: A Multidimensional & Interdisciplinary Approach Jacob E. Resch, Ph.D., ATC Department of Kinesiology Exercise Sport and Injury Laboratory University of Virginia
Disclosures: Sponsors: Biocore LLC Study: Investigation of a Novel Mouthguard Sensor Study: Muscle response to Non-injurious head impact Defense Advanced Research Projects Agency Study: Warfighter Analytics using Smartphones for Health National Athletic Trainers Association Foundation Study: The Impact of Athletic Trainers on the Incidence, and Outcomes for Sports Related Injuries in High School Athletes Vista Life Sciences Study: Ahead Normative Data
Objectives Describe the epidemiology of sport concussion Review the pathophysiology, clinical presentation and clinical recovery associated with concussion Discuss evidence-based practices for the management of sport concussion Identify key stakeholders within and outside of the medical community to assist with management of sport concussion
Who are Certified Athletic Trainers? Athletic Trainers are health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions - National Athletic Trainers Association
Psychologist Physician Nutritionist Strength Coach EMT Athlete Health ATC Care Administrator Exercise Physiologist Physical Therapist
National Athletic Trainers Association Position Statements
Total Number of mtbis Based on Emergency Department Visits 1 million 0 Roozenbeek et al, 2013
Estimated Global mtbi Incidence Rate (per 100,000 people) Based on Emergency Department Visits 500 0 Roozenbeek et al, 2013 Center of Disease Control, 2017
Sport Incidence Rate by Gender Resch et al, 2017
Mechanisms of Injury Assault, 11% Pedal Cycle, 3% Other Transport, 2% Suicide, 1% Sport 19% Struck by/against, 19% Other, 7% Unknown, 9% MVA, 20% Life 81% Falls, 28% No mechanism Assault/homicide, 9% specified, 7% Self-harm, 0% Unintentional injury, 7% Struck by/againt Something, 17% Sport 17.0% Life 83.0% MVAs, 13% Falls, 47% Langlois et al, 2006 Taylor et al, 2013 2006 2013
A sport-related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include: Direct hit to the head, face, neck or elsewhere on the body Typically results in the rapid onset of short-lived impairment of neurological function that resolve spontaneously. Neuropathological changes largely reflect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies Results in a range of clinical signs and symptoms that may or may not involve the loss of consciousness. Resolution of clinical and cognitive features typically follow a sequential course. However, in come cases symptoms may be prolonged. The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries or other conditions. - McCrory et al, 2017
Articles (#) Disclosures 5th International CIS Conference 250 200 150 * * * 100 50 0 Topic Included Articles (#) Reviewed Articles (#) * Qualitative analysis Schneider et al, 2017 Kamins et al, 2017 Iverson et al, 2017 Davis et al, 2017 Makdissi et al, 2017 Manley et al, 2017 Emery et al, 2017
Unemployment Rate in the United States Since 2005 (The Great Recession) Lakosh, 2017
Neurometabolic Cascade of (Supply vs. Demand) Figure 1. (A) CT Scan (B) MRI (C) PET (D) fmri Giza & Hovda, 2014
Choosing a Clinical Measure of
A Multidimensional Approach Cognitive Impairment Symptoms Somatic Behavioral Cognitive Sleep Balance McCrory et al, 2017 Resch et al, 2017
Clinical Measures Time Interval R ICC Authors Sideline Measures Variable.04 -.52.02 -.97 Valovich McLeod et al, 2006 Galetta KM et al, 2011 Putukian et al, 2015 Eddy et al, 2018 Neurocognitive Measures 1 day / 2 years.15 -.88.11 -.94 Barr, 2003 Segalowitz et al, 2007 Register-Mihalik et al, 2012 Cernich et al, 2007 Resch et al, In Press Falleti et al, 2006 Straume-Naesheim et al, 2005 Collie et al 2003 Broglio et al, 2007 Schatz, 2009 Elbin, 2011 Resch et al, 2013 Nakayama et al, 2014 Gualtieri et al, 2006 Resch et al, 2017 Balance Measures 2 days / 58 days.70.35 -.93 Wrisley et al, 2007 Tsang et al, 2004 Warren et al, In Preparation Valovich-McLeod et al, 2006 Ross et al, 2011 Symptom Scales / Checklists 50 days.55 Valovich-McLeod, 2012
Clinical Measure Sensitivity Specificity Reference Sideline Measures 80% - 94% 76% - 91% Barr et al, 2001 Valovich McLeod et al, 2006 McCrea et al, 2005 McCrea M et al, 2003 Valovich McLeod et al, 2004 Naunheim et al, 2008 Grubenhoff JA et al, 2010 Putukian et al, 2016 Eddy et al, 2018 Broglio et al, 2018 Neurocognitive Measures 1% 95% 69.1% - 100% Schatz et al, 2006 Broglio et al, 2007 Van Kampen, 2006 Resch et al, 2016 Schatz et al, 2012 Register-Mihalik et al, 2012 Makdissi et al, 2010 Nelson et al, 2016 Nelson et al, 2018 Broglio et al, 2018 Balance Measures Symptom Measures 29% - 72.5% 77% - 91% Broglio et al, 2007 Broglio et al, 2008 Resch et al, 2016 Register-Mihalik et al, 2012 Broglio et al, 2018 82% - 89% 85% - 100% Valovich-McLeod, 2012 Resch et al, 2016 Nelson et al, 2018 Broglio et al, 2018
The Great Glass Wall Clinical Measures of Sport Limited Clinical Utility Current Gold Standard Gold Standard 1998 2018
If it has become cheaper to produce a new invention, this suggest we are using our information wisely and are forging it into knowledge. If it has become expensive, this suggest that we are seeing signs in the noise and wasting our time on false leads. - Nate Silver
Clinic Based Measures (Biofluids)
ATC UVa Protocol Baseline Symptoms Patient Reported Outcome Measures (PROMS) Neurocognition Balance SCAT3/5 Other Measures Post-Injury Primary Survey ABCDE DCAPSBTLS Secondary Survey Symptoms SCAT3/5 Other Measures Imaging?
Lost in Translation? How can communication be increased between the field and the emergency department?
Total Athletes (%) Disclosures 100 90 80 Symptoms of NCAA Student-Athletes (N = 1670) 70 60 50 40 30 20 10 0 Wasserman et al, 2016
McCrory et al, 2017
Nelson et al, 2018
SCAT3 Limitations Practice effects Sensitivity (Broglio et al, 2014/2018) Gender Dehydration Fatigue Comorbid injuries Testing Environment Age Baseline Values (Guskiewicz et al, 2013) (McCrea, 2001) McCrea, 2001
Diduch et al, 2016
Diduch et al, 2016
The Case For Neuroimaging? Bonow et al, 2017
The Case For Neuroimaging? Bonow et al, 2017
UVa Protocol Baseline Post-Injury Post-Injury (< 7 days) Symptoms PROMS SCAT3/5 Other Measures Imaging? ATC MD
Parental Recall of Discharge Instructions n = 99 Thomas et al, 2018
Concussed athletes High School (337 male, 68 female) College (86 male, 3 female) Clinical < 7 days for high school and college aged studentathletes University of Virginia Males (8 days) Females (9 days) Nelson et al, 2016
UVa Protocol Symptoms PROMS Baseline Post-Injury Post-Injury (< 7 days) Symptom Free RTP Protocol Stage 2 Return to Learn ATC MD ATC
UVa Protocol McCrory et al, 2017
Return-to-School Considerations Medical note, not medically binding Academic Academic adjustments Based on symptom phenotype Transient, not permanent Academic accommodations Prolonged recoveries Individualized Education Plan (IEP) 504b plan Williamson et al, In Press
Return-to-School Strategy McCrory et al, 2017
Williamson et al, In Press S P O R T S C H O O L
UVa Protocol Symptoms PROMS Sub-symptom Threshold Exercise (> X) Baseline Post-Injury Post-Injury (< 7 days) Symptom Free RTP Protocol Stage 2 Symptom Free Assessment Symptoms PROMS Neurocognition Balance RTP Protocol Stages 3-5 ATC MD ATC NP/PT MD
Interventions? Physical Rest Cognitive Rest McCrory et al, 2012 Broglio et al, 2014
When Should We Intervene? Sport concussion recovery 90% < 10 days (Nelson et al, 2016) Immediate recognition Protracted recovery (10+ days) Depression & Anxiety Post-concussion syndrome 3+ symptoms for 3+ months Exercise as Medicine Buffalo Treadmill Test 30+ day recovery (Asken et al, 2018) (Leddy et al, 2010) Multidimensional Approach (Gagnon et al, 2016) 28+ day recovery Sport-specific exercise Coordination exercises Visual Imagery
Symptom Score 7.9 weeks 6.8 weeks Time Point Gagnon et al, 2016
Prescription: F: < 6 days/wk I: 60% THR or 80% mthr T: Treadmill, Cycle, Multidimensional T: > 20 minutes Implementation:?? Duration:?? Outcomes: Improved QoL Decrease symptom burden Gagnon et al, 2016 Leddy et al, 2018 Leddy et al, 2017
Does Clinical Match? =
Cerebral blood flow High School and collegiate student-athletes Concussed (n = 18) Control (n = 19) Symptom scale, SAC, BESS, ANAM, ImPACT Baseline (p <.05 [1/5]) 24 hours post-injury (p <.05 [4/5]) 8 days post-injury (p <.05 [1/5]) Arterial Spin Labeling 24 hours post-injury 8 days post-injury Wang et al, 2016
Figure. Fatality rates from traumatic brain and spinal cord injuries among high school and college football players United States, 2005-2014 Mueller et al, 2016
Washington Post 2016
The Future of Sport Diagnostics Prognostics Theranostics (Broglio et al, 2007) (Register-Mihalik et al, 2011) (Resch et al, 2016) (Meehan et al, 2014) (Lau et al, 2011) (Resch et al, 2015) (Silverberg et al, 2015) (Howell et al, 2016) Symptom phenotypes?
The Future of Sport Athlete
Document Disclosures Current Practice Guidelines (n = 44) None AAP Unsure AAN CDC AMSSM Berlin (CISG) NATA 0 5 10 15 20 25 Respondants (#)
Personnel Implementation Equipment Documentation Communication Emergency Department Transportation Venue Location
Considerations for the ED Healthcare Team Be knowledgeable about the signs and symptoms of sport concussion and its caveats Effectively communicate with ancillary healthcare providers (e.g. athletic trainers and EMS) to prepare for the arrival of a patient Rule out spinal, head, and other traumatic injuries Verbally educate patients, parents/guardians, caretakers about the signs and symptoms of concussion and red flags that warrant further care. Clearance from a sport-related concussion requires follow-up evaluation and cannot be reliably predicted at the time of injury Diduch et al, 2016 Thomas et al, 2018
Thank you! Questions? @jeresch jer6x@virginia.edu