Rehabilitation and Treatment of Sports Concussion: What are we Learning? Micky Collins, Ph.D. University of Pittsburgh Medical Center Associate Professor Department of Orthopaedic Surgery Department of Neurological Surgery Director UPMC Sports Concussion Program Disclosure Statement Micky Collins, PhD is Vice President, Chief Clinical Officer, and Co-Founder of ImPACT Applications, a computerized neurocognitive test battery designed to assess sports concussion and Mild Traumatic Brain Injury. Objectives Present data pertaining to acute and subacute predictors of outcome following sports concussion. Discuss models of care in assessment/treatment of sports concussion. Discuss role of vestibular screening and vestibular rehabiliation in evaluation and treatment of sports concussion Present outcome study on use of Amantadine for treating post-concussion syndrome. 1
100 90 80 70 60 50 40 30 20 10 0 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED N=134 High School Male Football Athletes 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+ All Athletes No Previous Concussions 1 or More Previous Concussions Predicting Protracted Recovery Following Sports Concussion: Syndrome: What are we Learning? Established (?) Constitutional Risk Factors For More Complicated Recovery Age - Field, Lovell, Collins et al. J of Pediatrics, 2003 - Pellman, Lovell et al. Neurosurgery, 2006 Migraine History & Symptoms - Mihalik, Pardini, Collins, Lovell et al, J Neurosurgery, 2006 Learning Disability - Collins, Lovell et al, JAMA, 1999 Repetitive Concussion? - Collins, Lovell et al, Neurosurgery, 2004 - Guskiewicz et al, CJSM, 2003 Gender? - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009 2
Which Acute and Sub-Acute Symptom Profiles Predict Protracted Recovery? Which 0n-Field Symptoms Predict Protracted Recovery? Lau B, Kontos A, Lovell MR, Collins MW, Data Under Review Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in High School Football Players? 176 Male HS Football Players (Mean Age = 16.2 years) Athletes had baseline computerized testing and were revaluated within 3 days of injury. All followed until clinical recovery (Mean = 4.1 evaluations) Within RCI of baseline for neurocognitive/symptom scores 32% of sample required < 7 days until recovery (N =56) Rapid Recovery (Mean = 4.9 days) 39% of sample required 7-14 days until recovery (N = 68) 17% of sample required > 21 days until recovery (N = 31) Protracted Recovery (Mean = 33.2 days) 12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21) MANOVA used to determine differences between rapid/> 3 week recovery ATC s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, etc) Lau B, Kontos A, Lovell MR, Collins MW, Data Under Review 3
Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from Sports Concussion **p<.01 On-Field Marker N Chi 2 P Odds Ratio 95% Confidence Interval Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42 Retrograde Amnesia 97.120 0.729 1.179 0.46-3.00 Confusion 98.114 0.736 1.164 0.48-2.82 LOC 95 2.73 0.100 0.284 0.06-1.37 On-Field Symptom N Chi 2 P Odds Ratio 95% Confidence Interval Dizziness** 98 6.97 0.008 6.422 1.39-29.7 Headache 98 0.64 0.43 2.422 0.26-22.4 Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63 Visual Problems 97 0.62 0.43 1.400 0.61-3.22 Fatigue 97 0.04 0.85 1.080 0.48-2.47 Balance Problems 98 0.28 0.59 0.800 0.35-1.83 Personality Change 8 0.86 0.35 0.630.023-1.69 Vomiting 97 0.68 0.41 0.600 0.18-2.04 The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive. Lau, Kontos, Collins, Lovell, Data Under Review On-Field Symptom Summary Brief LOC (<30 sec) not predictive of subacute or protracted outcomes following sports-concussion (Collins et al 2003) Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery (Collins et al 2003) On-Field dizziness best predictor of protracted recovery and post concussion syndrome Etiology of dizziness? Migraine variant? Central Vestibular Dysfunction? Peripheral Vestibular Dysfunction? Cervico-genic? Psychiatric? Need clinical tools/physical examinations to better assess dizziness construct UPMC Sports Concussion Program 2010 Physical Vestibular/Balance Exam (Furman, Mucha, Collins Lovell et al) Screen for Vestibular Abnormalities Concussion Program P hysical Exam: A. Ocular Motor/Vestibulo-Ocular a. Abnorm al Pursuits? ------------------------------------ b. Abnorm al Saccades? ---------------------------------- c. Abnorm al Convergence (<6 cm )? ------------------ d. Any observable nystagm us? ------------------------ e. Blurring/dizziness with VOR (focus on ------------ stationary object while moving head side to side)? B. Balance Screen: a. Rom berg Eyes Open < 30 sec or unsteady------ b. Rom berg Eyes Closed < 30 sec or unsteady---- c. Tandem Romberg Eyes Open < 30 sec or unsteady -------------------------------------------------- d. Tandem Rom berg Eyes Closed < 20 sec -------- (unless age >50) e. Compliant Foam Eyes Open < 30 sec or unsteady -------------------------------------------------- f. Compliant Foam Eyes Closed < 30 sec or unsteady -------------------------------------------------- g. Tandem gait unsteady--------------------------------- Possibly central vestibular disorder, particularly if a, b, or c abnormal Abnormality on any item suggests a balance disorder Modified 10/04/10 4
Which Subacute Symptoms Predict Protracted Recovery? Lau B, Lovell MR, Collins MW; Pardini J; AJSM 2009 (3):216-21 108 concussed high school football players Athletes had baseline computerized neurocognitive testing and were revaluated within 3 days of injury (Mean = 2.2 days) All followed until clinical recovery Within Reliable Change Score of baseline for neurocognitive/symptom scores 43.5% of sample recovered < 10 days = Quick Mean = 5.9 Days 56.5% of sample required >10 days until recovery = Protracted Mean = 29.2 Days MANOVA conducted on which individual symptoms and neurocognitive domains predicted quick versus protracted recovery Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21 Current Symptoms Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems (blurry or double vision) 5
2 FOGGY DIFF CONC VOMIT DIZZY NAUSEA HEADACHE SLOWNESS BALANCE LIGHT SENS NOISE SENS NUMBNESS 1.5 1 0.5 0 Expressed as Effect Sizes (Cohen s D). Only includes symptoms with large (greater than.80) effect sizes. Sample is composed of 108 male HS football athletes. It is like going from a high definition TV world to standard TV world Feeling one step removed from my surroundings It is like my vision is impaired, but it isn t Feeling like I am underwater Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual 6
Variables Classification Z-Score (Simple vs. Complex) Fogginess Cognitive 4.3* Difficulty Concentrating Cognitive 2.46 Vomit Migraine 2.391* Dizziness Migraine 2.09 Nausea Migraine 1.96 Headache Migraine 1.71 Slowness Cognitive 1.53 Balance Migraine 1.53 Light Sensitivity Migraine 1.52 Noise Sensitivity Migraine 1.52 Numbness Migrainei 1.46 Trouble Sleeping Sleep 1.231* Visual Problems Migraine 0.97 Difficulty Remembering Cognitive 0.93 Sleeping Less Sleep.52 Drowsiness Cognitive 0.5 Fatigue Cognitive 0.48 Emotional Neuropsychiatric 0.37* Irritability Neuropsychiatric 0.3 Sadness Neuropsychiatric 0.09 Nervousness Neuropsychiatric -0.03 Sleeping More Cognitive -0.05 *Symptoms with the largest contributions to differences between quick and protracted recovery in each symptom factor. ImPACT yields summary composite scores for: -Verbal Memory - Visual Memory - Reaction Time - Visual Motor Speed Neurocognitive Summary Scores SCORES PREDICTIVE OF PROTRACTED RECOVERY (Greater than 10 days to Recovery) Deficit in Reaction Time Best Predicts Protracted Recovery 0-0.2-0.4-0.6-0.8-1 REACTION TIME PROCESSING SPEED D=.838 (Large) p <.001 D=.663 (Medium) p<.001 VISUAL MEMORY VERBAL MEMORY D=.466 (Medium) p<.01 D=.221 (Small) p<.05 N = 108 Effect Sizes compare quick recovery to protracted recovery groups. (Cohen s D) 7
The UPMC Sports Concussion Program Department of Orthopaedic Surgery The UPMC Sports Concussion Program Pediatric Practices ATC from Contracted Schools Emergency Departments UPMC Concussion Program (Neuropsych) Primary Care Physicians Parents /Schools Parents / School PM & R Vestibular / Physical Therapy Neuro Radiology Orthopaedic Surgery Neuro Surgery Sports Concussion / mtbi Clinic Pediatric Practices ATC from Contracted Schools Emergency Departments PMR, Sports Med, Neurology, Pediatrics, Ortho, etc. Primary Care Physicians Parents /Schools Parents / School Neuropsych Neuro Radiology Vestibular / Physical Therapy Orthopaedic Surgery Neuro Surgery 8
Key Personnel-UPMC Concussion Program Neuropsychology Point guard of program PMR Medication/medical management Athletic Training Vestibular Therapy Physical Therapy Exertional training/therapy Secondary referral sources Sports Medicine/Primary Care Neuroradiology Neurosurgery Neurology Over 10,000 Patient Visits per Year UPMC Typical Evaluation Detailed Clinical Interview Vestibular Screening Computerized Neurocognitive Testing Same day patient feedback Severity of Injury? Prognosis for Recovery? Neuroimaging indicated? Level of Physical Exertion Allowed? Level of Cognitive Exertion Allowed? Academic Accommodations? Return to Play? Communication to ATC, Team Physician, Referring Physician, etc. 100 90 80 70 60 50 40 30 20 10 0 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED N=134 High School Male Football Athletes 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+ All Athletes No Previous Concussions 1 or More Previous Concussions 9
Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual Vestibular Screening and Vestibular Rehabilitation ti of Post- Concussion Syndrome Vestibular Screening: Physical Examination Ocular-Motor: Smooth Pursuits ( H-Test ) Saccades (Vertical/Horizontal) Any dizziness, blurriness, over/under shoots? Vestibular-Ocular: Gaze Stability (focus on stationary ti object while moving head side to side/up and down) Vertical/Horizontal Any observable nystagmus, provocative dizziness/bluriness, slowed movements? Convergence In high school/college aged athletes, near point < 6-8 cm Balance Examination Romberg, Compliant Foam-eyes open/eyes closed 10
UPMC Vestibular Screening Evaluation FURMAN, MUCHA, COLLINS, LOVELL ET AL 2010 Screen for Balance/Vestibular Abnormalities Concussion Program Physical Exam: A. Ocular Motor/Vestibulo-Ocular a. Abnormal Pursuits? ------------------------------- No b. Abnormal Saccades? ---------------------------- No - No c. Abnormal Convergence (<6 cm)? ------------- No d. Any observable nystagmus? ------------------- No e. Blurring/dizziness with VOR (focus on ------- -----stationary object while moving head side to side)? B. Balance Screen: a. Romberg Eyes Open < 30 sec or unsteady- No b. Romberg Eyes Closed < 30 sec or No unsteady---- c. Tandem Romberg Eyes Open < 30 sec or No unsteady --------------------------------------------- No d. Tandem Romberg Eyes Closed < 20 sec --- (unless age >50) e. Compliant Foam Eyes Open < 30 sec or No unsteady --------------------------------------------- f. Compliant Foam Eyes Closed < 30 sec or No unsteady --------------------------------------------- No g. Tandem gait unsteady---------------------------- Modified 10/04/10 Possibly central vestibular disorder, particularly if a, b, or c abnormal Abnormality on any item suggests a balance disorder Pursuits- H-Test Saccades-Horizontal and Vertical 11
Gaze Stability-Horizontal/Vertical Convergence A. Romberg (Feet Together) 1. Eyes Open 2. Eyes Closed 3. Arms Folded/Shoes on ok 4. Abnormal if cannot do for 30 seconds or excessive sway 12
B. Foam Cushion/Feet Together 1. Eyes Open 2. Eyes Closed 3. Arms folded/shoes on - ok 4. Abnormal if cannot do for 30 sec. or excessive sway C. Tandem Stance 1. Eyes Open/Arms Crossed Abnormal if < 30 sec or unsteady 2. Eyes Closed/Arms Crossed Abnormal if <20 sec (unless age >50) D. Tandem Walk Abnormal if unsteady or unable 13
Pharmacologic Treatment of Post- Concussion Syndrome Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual 14
Somatic Symptoms Headaches Prophylaxis Propranolol* Verapamil* Amitriptyline* Escitalopram (Lexapro) Sertraline (Zoloft) Vestibular Therapy Emotionality SSRIs Escitalopram (Lexapro) Sertraline (Zoloft) Therapy Sleep Disturbance Melatonin Trazodone Cognitive Symptoms Neurostimulants Amantadine* Methylphenidate* Atomoxetine (Strattera)* NOTE: *Off-label use Evidence for the Use of Amantadine as a Pharmacological Treatment following Concussion Camiolo-Reddy, Collins, Lovell, Sabini, Twichell, Kontos, In review. Amantadine for Cognitive Symptoms and Neurocognitive Function How it works: Presynaptically facilitates the release of Dopamine and inhibits reuptake Anti-viral, Parkinson s s Disease Theoretically Improves: Arousal, Vigilance, Processing Speed, General Cognitive Functioning 15
Study Overview Subjects 1. 25 male (n=11) and female (n= 14) concussed adolescents, and 2. 25 male (n=11) and female (n=14) age-, sex-, and concussion Hx-matched controls Groups Treatment =100mg of amantadine 2x/day (200mg total per day) Concussed Controls= evaluated and treated conservatively without medication Computerized neurocognitive scores and symptoms Demographics Total Amantadine Controls T-test M SD M SD M SD t P Age (yrs) 15.54 1.42 15.68 1.44 15.40 1.41 0.70 0.49 Concussion 0.68 1.17 0.56 0.92 0.80 1.38-0.72 0.47 History (#) Injury to 26.18 36.70 26.16 28.16 26.24 44.21 -.01 0.99 first-test (days) Injury to 47.64 57.10 48.88 41.85 46.40 70.00 0.15 0.88 Post-tx test (days) Groups were Similar ImPACT and Symptom Scores for Amantadine and Control Groups (N= 50) Amantadine Control Pre Post Pre Post M (SD) M (SD) M (SD) M (SD) Wilk s λ F η 2 p Symptoms (#) 37.08 11.80 23.00 14.28 0.84 8.71 0.16.005 (20.81) (11.79) (18.59) (16.24) Verbal Memory 72.52 86.16 84.92 87.32 0.87 7.35 0.14.009 (% correct) (20.76) (9.13) (7.57) (10.18) Visual Memory 61.92 76.68 70.08 78.72 0.96 2.14 0.04 0.30 (% correct) (16.37) (14.16) (9.14) (14.62) Visual Processing 33.20 38.20 36.60 39.91 0.98 0.79 0.02 0.38 Speed (#) (9.95) (9.13) (7.06) (7.69) Reaction Time 0.66 0.56 0.60 0.56 0.92 3.97 0.08 0.05 (sec) (0.16) (0.13) (0.11) (0.10) 16
Comparison of symptoms from pre- to posttest for the amantadine (n= 25) treatment and matched control (n= 25) subjects (p<.05). Comparison of Verbal Memory scores from pre- to posttest for the amantadine (n= 25) treatment and matched control (n= 25) subjects (p<.05). Conclusion Tentative support for the efficacy of amantadine as pharmacological treatment for intractable patients (i.e., >3 weeks) following concussion Corroborates anecdotal support Study Limitations: Sample size No placebo group Future: Double-blind randomized control trial of the efficacy of amantadine following concussion in a sufficiently large sample to corroborate the current study s findings 17
Thank You collinsmw@upmc.edu 18