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Concussion:AnEvidence-BasedApproachtoOptometricManagement
JacquelineTheis,OD,FAAOOptometry’sMeeHng2017
WashingtonDC
• Training
– BSBiochemistry–BucknellUniversity– OD–UCBerkeleySchoolofOptometry– Residency–BinocularVision,Neuro-Optometry,VisionTherapy–UCBerkeleySchoolofOptometry
• Current– Director,ClinicChief–UCBerkeleySportsVisionClinic
• ClinicalCareandResearchforVisionProblemsinConcussion– ClinicalInstructor–UCBerkeleySchoolofOptometry– ClinicalResearchFunding–UCRegents,NIHSBIR– Neuro-Optometrist–KaiserPermanente
Background
FinancialDisclosures
– C.LightTechnologies• ClinicalResearchConsultant
Goals/GeneralOutline• TraumaHcBrainInjury
– Grades– Pathophysiology
• Concussion– Whatdoweknow?– Whatdowenotknow?– Challengesindiagnosis– Sequelae
• Visualproblemsa_erconcussion– Permanentvs.Transient– Literaturereviewofmostprominentdisorders– FuturedirecHonsforthefield– Howtomanageinaprimaryvs.aterHarycareseang– Roleofvisiontherapy
GlasgowComaScale(GCS)● MotorResponse
○ (4)WithdrawsfromnoxioussHmuli○ (1)NoResponse○ (2)ExtensorResponse○ (3)AbnormalFlexion○ (5)LocalizestonoxioussHmuli○ (6)Obeyscommandsfully
● VerbalResponse○ (1)Nosounds○ (2)IncomprehensibleSounds○ (3)Inappropriatewordsandjumbledphrases
○ (4)Confused,yetcoherentspeech○ (5)Alertandoriented
● EyeOpening○ (1)Noeyeopening○ (2)Eyesopentopain○ (3)Eyesopentospeech○ (4)Spontaneouseyeopening
• LevelofTBI– Mild(13-15)
• +/-lossofconsciousness<30min• Normalneuroimaging
– Moderate(9-12)• Lossofconsciousness>30min,<24hrs• Normal/abnormalneuroimaging
– Severe(3-8)• Coma• Normal/abnormalneuroimaging
– VegetaHve(<3)
TeasdaleG,JennemB.AssessmentofComaandImpairedConsciousness:ApracHcalscale.Lancet304,81-84.VossJ,ConnollyJ,SchwabK,ScherA.Updateontheepidemiologyofconcussion/mildtraumaHcbraininjury.CurrPainHeadacheReports.2015;19(7):32.
TraumaHcBrainInjury
• PrimarytraumaHcbraindamage– Mechanicalforces→HssuedeformaHonATthemomentofinjury– Directdamagetobloodvessels,axons,neurons,glia,etc– Diffuseaxonalinjury(DAI)/vascularinjury(DVI)– FocalInjury
• Vascular(intracerebral,subdural,extradural,subarachnoidinjury)• Axonalinjury• Contusion• LaceraHon
• SecondarytraumaHcbraindamage– ComplicaHonofprimarydamage– Ischemicandhypoxicdamage,cerebralswelling,increasedintracranialpressure,infecHon,etc
ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida
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Concussion-Controversyovera“DefiniHon”
• RepresentstheimmediateandtransientsymptomsoftraumaHcbraininjury(TBI)– Vague– Noinsightsintounderlyingpathophysiology
– DoesnotdisHnguishdifferentgradesofseverity
– Doesn’treflectnewinsightsintopersistentsymptoms
• ThereisalackofdataANDconfusionindefiniHonandterminology.
McCroryP,MeeuwisseWH,DvorakJetal.Consensusstatementonconcussioninsport:the5thInternaHonalConferenceonConcussioninSportheldinBerlin,October2016.BrJSportsMed2017;51:838-847.
ImagefromMarHnLJ.Avisualguidetoconcussionsandbraininjuries.Webmd.comAccessedApril15,2017.hmp://www.webmd.com/brain/ss/slideshow-concussions-brain-injuries
Concussion-Controversyovera“DefiniHon”
McCroryP,MeeuwisseWH,DvorakJetal.Consensusstatementonconcussioninsport:the5thInternaHonalConferenceonConcussioninSportheldinBerlin,October2016.BrJSportsMed2017;51:838-847.
“Asportrelatedconcussion(SRC)isatraumaHcbraininjuryinducedbybiomechanicalforces.SeveralcommonfeaturesthatmaybeuHlizedinclinicallydefiningthenatureofaconcussiveheadinjuryinclude:• SRCmaybecausedbyadirectblowtothehead,face,neckorelsewhereonthe
bodywithanimpulsiveforcetransmimedtothehead• SRCtypicallyresultsintherapidonsetofshort-livedimpairmentofneurological
funcHonthatresolvesspontaneously• However,insomecases,signsandsymptomsevolveoveranumberof
minutestohours.• SRCmayresultinneuropathologicalchanges,buttheacuteclinicalsignsand
symptomslargelyreflectafuncHonaldisturbanceratherthanastructuralinjuryand,assuch,noabnormalityisseenonstandardstructuralneuroimagingstudies
• SRCresultsinarangeofclinicalsignsandsymptomsthatmayormaynotinvolvelossofconsciousness
• ResoluHonoftheclinicalandcogniHvefeaturestypicallyfollowsasequenHalcourse
• However,insomecases,symptomsmaybeprolonged.”
Imagefrom:LienJ.PediatricConcussionandothertraumaHcbraininjuries.Medscape.com.AccessedApril15,2017.hmp://reference.medscape.com/features/slideshow/pediatric-concussion
EpidemiologyofConcussion• CDC2010-2.5millionpeoplewenttoERforTBIbasedonICD9data
– 75%mTBI– UnderesHmatesinceonlyincludes
thosewhopresentedtotheERandhadarelevantdiagnosHccode(Voss)
• PediatricpopulaHon– 173,285<19yononfatalconcussion
annually2001-2009– Increasefrom153,375to248,418
• Mostcommonmechanism–Falls• HighRiskPopulaHons
– Military– Athletes
• 1.6-3.8millionSRCsannually• 5.8%ofallcollegiateinjuries,
8.9%ofhighschoolinjuries
www.cdc.gov/traumaHcbraininjuryGesselLM,FieldsSK,CollinsCL,DickRW,ComstockRD.ConcussionsamongUnitedStateshighschoolandcollegiateathletes.JAthlTrain2007;42:495-503
CommonDiagnosHcTestsforConcussion
• Self-reportSymptomChecklists• BriefcogniHveassessment
– SAC– SCAT-5
• BalanceTests– TGT– BESS
• ComputerBasedNeuropsychologicalTests
– ImPACT– CogSport– Headminder
LimitaHons/DifficulHesinConcussionDiagnosisandManagement
• SubjecHvenatureofdiagnosis– SymptomScales– IntenHonallowbaselinescores
• Incompleteunderstandingofpathophysiology
• Lackofdata• Variabilityamongphysicians
• NostructuralinjuryonconvenHonalneuroimaging
• AdvancedneuroimagingcanshowfuncHonal/structuraldamageBUT$$andnotreadilyavailable
• Under/overreporHngofsymptoms
• Under/overdiagnosis• EvolvingdefiniHon
• McCroryP,MeeuwisseWH,DvorakJetal.Consensusstatementonconcussioninsport:the5thInternaHonalConferenceonConcussioninSportheldinBerlin,October2016.BrJSportsMed2017;51:838-847.
• HarmonKG,DreznerJA,GammonsM,etal.AmericanMedicalSocietyforSportsMedicineposiHonstatement:concussioninsport.BrJSportMed2013;47:15-26.
• KimparaH,IwamotoM.MildtraumaHcbraininjurypredictorsbasedonangularacceleraHonsduringimpacts.AnnBiomedEng2012;40:114-26.
• ZhangL,YangK,KingA.AproposedinjurythresholdformildtraumaHcbraininjury.JBiomechEng2004;126:226-36.• ReillyP,BullockR.HeadInjury2ed:PathophysiologyandManagement,CRCPress2005TaylorandFrancis,Florida
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Whydoesdiagnosismamer?
hmp://www.bu.edu/cte/about/what-is-cte/
Transient??
ChronicTraumaHcEncephalopathy• 1928-Dr.HarrisonMartland-“PunchDrunk”boxers• DemenHaPugileisHca/TraumaHcEncephalopathy
– Cerebralatrophyincaseseriesof15• Late1980s-Robertsetal(18)
– DiffuseB-amyloidplaques– 3Clinicalstages
• 1)AffecHvedisturbancesandpsychoHcsymptoms• 2)Socialinstability,psychiatricsymptoms,memoryloss,developmentofparkinsonism
• 3)GeneralcogniHvedysfxn,pyramidaltractdisease• Casereports-NFLplayers(8.9)
– LossofpigmentinsubstanHanigra– Cerebralatrophy– DiffuseB-amyloidplaques*– Neurofibrillarytangles– Tau-posiHveneuriHcthreadsinneocorHcalareas
MartlandHS.PunchDrunk.JAmMedAssoc.1928:91:1103-7CorsellisJA,BrutonCJ,Freeman-BrowneD.TheA_ermathofBoxing.PsycholMed1973:3:270-303RobertsGW,AllsopD,BrutonC.Theocculta_ermathofboxing.JNeurolNeurosurgPsychiatry.1990:53:373-8
CTEConHnued• DefiniHon(s)vary
– ConsequenceofmulHplemTBIvs.severeTBIvs.repeatsub-mTBI– NeurodegeneraHvediseaseassoc.w/repeHHveTBI– ProgressivecogniHve,motorandmooddecline
• CharacterisHcs– Clinicalsigns:
• Memorydisturbance,confusion• Behaviorchanges(depression,suicidalideaHon,poorimpulsecontrol,shorttemper
withaggression)• Parkinsonism,gaitabnormaliHes• SpeechabnormaliHes
– Pathologicalsigns:cerebral/temporallobeatrophy,ventriculomegaly,enlargedcavumseptumpellucidumwithfenestratedseptum,extensivetau-immunoreacHvepathology,?B-amyloiddeposiHon
– DefiniHveDiagnosisonlymadepostmortem• Diagnosisofexclusion
MeehanW,MannixR,ZafonteR,Pascual-LeoneA.ChronictraumaHcencephalopathyandathletes.Neurology2015:85:1504-11
LiteratureSupport?• CaseReports
– (+)AthleteswithpreviousrepeHHveheadtraumadevelopmooddisorders,headaches,cogniHvedifficulHes,suicidalideaHon,difficulHeswithspeechandaggressivebehaviorlaterinlife(CTE)
– Sub-concussiveblowscauseclinical/pathophysiologicalfindings• (-)NotallathletesthatparHcipateincontactsportsgetCTE• (-)TherearepeoplewhohaveCTEsigns/symptomsthatneverhadpreviousrepeHHveheadtrauma
• AssociaHonvs.CausaHon• LACKofprospecHvedata!
MeehanW,MannixR,ZafonteR,Pascual-LeoneA.ChronictraumaHcencephalopathyandathletes.Neurology2015:85:1504-11
RoleofEyesinConcussionDiagnosisandManagement:
1)Objec>vebiomarkerforbraindysfunc>on
2)Treatmentofconcussion
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VisualPathwaysintheBrain
Post-ConcussiveVisualSignsandSymptoms
• CurrentlyScreened– DoubleVision– BlurredVision– LightSensiHvity
• InAddiHon/Actuality– ReadingDifficulHes– Eyestrain/FaHgue– Eyefocusingproblems– EyeTrackingProblems– Vision-DerivedNausea– VisualInamenHon– VisualAnxiety/Crowding
LaukkanenH,ScheimanM,HayesJR.Braininjuryvisionsymptomsurvey(BIVSS)quesHonnaire.OptomVisSci.2016;94(1):43-50.
AfferentVisualPathway
Imagefrom-HannulaDe,SimonsDJ,CohenNJ.ImagingimplicitpercepHon:promiseandpi{alls.NatureRevNeurosci.2005;6:247-255/
AfferentVisualPathway–CNII Post-ConcussionVisualSigns
OcularHealth• TraumaHcIriHs• TraumaHcOpHcNeuropathy• ReHnalchanges• CommoHoReHnae• ReHnalTear/Detachment
PupilFindings• Afferent
– IncreasedaverageconstricHonlatency
• Efferent– ParasympatheHc
• SloweraverageconstricHonvelocity
– SympatheHc• Decreasedpupillarydiameter• SlowerpeakdilaHonvelocity
• Anisocoria?
ThiagarajanP,CiuffredaK.Pupillaryresponsestolightinchronicnon-blast-inducedmTBI.BrainInjury.2015;29(12):1420-1425
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Photophobia-LightSensiHvity
E5ology??–Photophobiapathway?
• OcularPhotophobia– IriHs
• Flashlighttest• Asymmetric
– Pupilproblems– DryEye
• NeurologicalPhotophobia– TBI– Migraines
• Pharmacologic
Management• SunglassesoutsideOKAY• Sunglassesinside–TRYTOAVOID
– WearingdarkglassesindoorsàdarkadaptaHonofthereHnaàaggravaHonoflightsensiHvity
• Visors/Hats• MildTints
– Wavelengthmamers
KatzBJ,DigreKB.Diagnosis,pathophysiology,andtreatmentofphotophobia.SurvOphth.2016;61:466-477
VisualSignsitmaybeMOREthanaConcussion
• Pupils– Dilated/Fixed– APD– Anisocoria
• ReducedBCVA• VisualFieldDefects• CranialNervePalsy• OcularHealthProblem
– OpHcnerveedema,pallor,etc
EfferentVisualPathwayCNIII,IV,VI,ParasympatheHc,SympatheHc
-EyeMovements
Imagefromhmp://what-when-how.com/neuroscience/the-cranial-nerves-organizaHon-of-the-central-nervous-system-part-4/
VesHbulo-oculardysfuncHoninpediatricsport-relatedconcussion(SRC)
• RetrospecHvereviewofallpaHentswithacuteSRC(presenHng30daysorlesspostinjury)andPCS(3ormoresymptomsforatleast1month)referredtoamulHdisciplinarypediatricconcussionprogramfrom9/2013-7/2014
• Methods-ClinicalHx,Physical,PCSS,VOD– VODComplaint(dizziness,blurredvision,etc)+Sign(Abnormal
pursuits,saccades,VOR)• Results-n=101,age14.2+/-2.3years,76.2%withacuteSRC(n=77)and
23.8%withPCS(n=24)– MeanduraHonofSxwas40daysforptsw/acuteSRCandVODvs.21
daysforacuteSRCwithoutVOD.• Conclusions:EvidenceofVODinacuteSRCandPCS.VODwasasignificant
riskfactorfordevelopmentofPCS
EllisMJ,CordingleyD,VisS,ReimerK,LeiterJ,RussellK.VesHbulo-oculardysfuncHoninpediatricsports-relatedconcussion.JNeurosurgPediatr2015:16:248-255
WhatDeterminesConcussionResoluHon?
• BalanceRecovery<7days• SymptomScores5-14days• CogniHveRecovery7-21days• OculomotorRecovery21-28days
OtherFactors
LiHgaHonWorker’sCompensaHonIndividualMoHvaHon(Athlete,Military)AgeGenderConcussionHistoryPremorbidFactorsInjurySeverityType/TimingofTreatment
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaHonandAcHveManagement(TEAM)ApproachestoTreaHngConcussionMeeHngHeldinPimsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
RoleofEyesinConcussionDiagnosis:VOMS(Ves>bular/OcularMotorScreening)
AssessmentVes>bular/OcularDomainsAssessed
1. SmoothPursuit2. HorizontalandVerHcalSaccades3. Convergence4. HorizontalandVerHcalVOR5. VisualMoHonSensiHvity
• 61%ofadolescentconcussedathletesreportedsymptomprovocaHona_eratleast1VOMSitem
• AllVOMSitemswereposiHvelycorrelatedtothePCSS(PostConcussionSymptomScale)totalsymptomscore
• VOMSwasnearly90%accurateinidenHfyingpaHentswithconcussionfromcontrols
MuchaA,CollinsMW,ElbinRJ,etal.AbriefvesHbular/ocularmotorscreening(VOMS)assessmenttoevaluateconcussions:preliminaryfindings.AmJSportsMed2014;42:2479-86.
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VOMSConHnued…• WomenhavehigherVOMSscoresthenmales(Sufrinko2017)• SymptomprovocaHon/clinicalabnormalityassociatedwithalldomains(except
convergenceandaccommodaHon)candelayrecoveryHmea_erSRCinyouthandadolescents(Anzalone2017)
• VOMSdoesNOTprovokevesHbularsymptomsinhealthyadolescents(Yorke2017)• VOMSmeasuresuniqueaspectsofvesHbular-ocularfuncHonotherthanthose
measuredintheBESS(BalanceErrorScoringSystem)orKD(King-DevickTest)withgoodreliability(Yorke2017)
• Incollegiateathletes,VOMShadahighinternalconsistencywithan11%false-posiHverateatbaseline–mostlyfemaleorhistoryofmoHonsickness(Kontos2016).
AnzaloneAJ,BlueimD,CaseT,McGuffinT,PollardK,GarrisonJC,JonesMT,PavurR,TurnerS,OliverJM.AposiHveVesHbular/OcularMotorScreening(VOMS)isassociatedwithincreasedrecovertyHmea_ersports-relatedconcussioninyouthandadolescentathletes.AJSM2017;45(2)474-479KontosAP,SufrinjoA,ElbinRJ,PuskarA,CollinsMW.ReliabilityandassociatedriskfactorsforperformanceontheVesHbular/OcularMotorScreening(VOMS)toolinhealthycollegiateathletes.AJSM2016;44(6):1400-1406SufrinkoAM,MuchaA,CovassinT,MarcheaG,ElbinRJ,CollinsMW,KontosAP.SexdifferencesinvesHbular/ocularandneurocogniHveoutcomesa_ersport-relatedconcussion.ClinJSportMed2017;27:133-138.YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesHbular/OcularMotorScreeningandassociaHonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.
YorkeAM,SmithL,BabcockM,AlsalaheenB.ValidityandreliabilityoftheVesHbular/OcularMotorScreeningandassociaHonswithcommonconcussionscreeningtools.SportsHealth.2017;9(2):174-180.
Pursuits
Saccades
Imagefrom:KrauzlisRJ.RecasHngtheSmoothPursuitEyeMovementSystem,JNeurophysiology.2004;91(2):591-603
NormalSmoothPursuits
AbnormalPursuits(i.e.SaccadicIntrusions)
Symptoms:DifficulHesreading,nauseawithvisualmoHon,difficulHesscrollingonascreen
NormalSaccades
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AbnormalSaccades–Hypometric/Hypermetric
Symptoms:DifficulHesreading,difficulHes“tracking”,losingplacewhilereading,re-reading
Calhasreallygreatathletes.Theyare
smartandenjoygoingtoclassandto
pracHce.Whentheyarenotonthe
fieldtheyareinthelibrary.
Calhasreallygreatathletes.Theyare
smartandenjoygoingtoclassandto
pracHce.Whentheyarenotonthe
fieldtheyareinthelibrary.
King-Devick• n=219• Post-seasonKDscores
werelower(bemerthanpre-seasonscores-mildlearningeffect
• n=10concussions-significantworseningfrombaseline5.9sec
• RemovefromPlay/SidelineAssessmentTool
• Requiresbaseline
GalemaKM,BrandesLE,MakiK,etal.TheKing-Devicktestandsports-relatedconcussion:studyofarapidvisualscreeningtoolinacollegiatecohort.JNeurolSci2011;309:34-39.
DEMNormedfor6-13yearoldsCanassessvisualprocessing
speed/RANversushorizontaltracking/binocularvision
NotknownoutsideofOptometry
• n=9,7dayspost-concussion• n=9,age,sexmatchnormal
volunteers• FixaHon,Reflexivesaccades,anH-
saccades,memoryguidedsaccades,self-pacedsaccades
• fMRI-widespreadincreasedacHvaHonofmulHplebrainareasfollowingconcussioninresponsetooculomotortasks
– LongerlatencyHme,worseposiHonerrors,fewernumberofself-pacedsaccades
JohnsonB,ZhangK,HallemM,SlobounovS.FuncHonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73
fMRIofAcuteOculomotorDeficitsinConcussedAthletes
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Post-ConcussionVisualSigns
• Eyemovements– Difficultymaintainingfocus– Hypometric/HypermetricSaccades– SaccadicIntrusionsonPursuits
• Cogwheelpursuits–someHmesgazespecific• Nausea/SymptomprovocaHonwithpursuits
– SymptomprovocaHonwithVOR• ReducedVORAcuity
AccommodaHon• WhentheeyechangesrefracHvepowerbyalteringtheshapeof
thelenstofocusonobjectsatdifferentdistances• ie–Howtheeyefocusesonthings
AccommodaHvePathway
Imagefromhmp://what-when-how.com/neuroscience/the-cranial-nerves-organizaHon-of-the-central-nervous-system-part-4/
Post-ConcussionVisualSigns
• AccommodaHon– AccommodaHveInsufficiency– AccommodaHveInfacility– AccommodaHveSpasm
AccommodaHveInsufficiency AccommodaHveInfacility
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AccommodaHveSpasmConvergence/Divergence
Distance Near
Divergence
Convergence
NPC(NearPointofConvergence)VergencePathway
GamlinP.NeuralMechanismsfortheControlofVergenceEyeMovements.AnnNYAcadSci.2002Apr;856:264-72
Post-ConcussionVisualSigns
• Vergence– GrossConvergenceInsufficiency– VergenceDysfuncHon– VergenceInfacility
ConvergenceInsufficiencyVergenceDysfuncHon
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Post-Concussion/HeadInjuryVisionProblems
• n=220individualswithTBI(n=160)orCVA(n=60)• ComputerbasedqueryinclinicalpopulaHon2000-2003• Results:MajoritywitheitherTBI(90%)orCVA(86.7%)manifestedanoculomotor
dysfuncHon
CiuffredaKJ,KapoorN,RutnerD,SuchoffI,HanME,CraigS.OccurrenceofoculomotordysfuncHonsinacquiredbraininjury:aretrospecHveanalysis.Optom2007:78:155-61
TBIandVisualConsequencesinaMilitarypopulaHon
• RetrospecHveanalysisofeyeexamrecordsof50NBRand50BRTBIpaHentsatPAVANeuro-RehabilitaHonHospital
• Results:65%ofNBRandBRTBIpaHentsreportedvisionproblems,Readingcomplaintsin50%
• HighratesoflightsensiHvity,saccadicdysfuncHon,accommodaHvedysfuncHonandconvergenceinsufficiency
GoodrichGL,FlygHM,KirbyJ,ChangCY,MarHnsenGL.MechanismsofTBIandVisualConsequencesinMilitaryandVeteranPopulaHons.OptomVisSci2013:90:105-12
Percentageofpa5entswithoculomotordeficitsPercentageofpa5entswithsubjec5vevisualandreadingcomplaints
Visual-EvokedNausea VisualMoHoninDailyLife
Visual-VesHbularMoHoninSport HigherOrderVisualProcessing
Imagefrom:hmp://www.nmr.mgh.harvard.edu/mkozhevnlab/?page_id=663
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VisualAmenHonandVisualProcessing
GilbertC,LiW.Top-downinfluencesonvisualprocessing.NatureRevNeurosci.2013;14:350-363RaffoneA,SrinivasanN,vanLeeuwenC.TheinterplayofamenHonandconsciousnessinvisualsearch,amenHonalblinkandworkingmemoryconsolidaHon.PhilTransRSocB.2014:369.
VisualCrowding(Simultanagnosia)
VisualCrowdinginDailyLife PrescribedAccommodaHons/AdvocaHons
• VisualMoHonSensiHvity/VisualCrowding– Removalfromgym/danceclass,band/orchestra,schoolassemblies
– Doublespacedtext,increasedfontsize,lineguides• OculomotorDysfuncHon
– Delaytests/quizes– Reduceamountofhomework– IncreaseHmeontests/assignments
• Plannedbreaks– Notetaker
• TEMPORARYMODIFICATIONS
DirecHonsforthefuture?
ConcussionManagement?• Classically
– 80-90%ofsymptomaHcconcussionsresolvewithin7-14daysa_erinjury• IssymptomresoluHonindicaHveofcompleterecovery?• Longtermsideeffects/braindamagefromconcussionyettobedetermined?
– Isittransient?• MorerecentstudiesquesHonifconcussionrecoverytakeslonger~3-4weeks?
• DoesreturningtoacHvitysoonerspeeduporslowdownrecovery?
● KieferAW,FossKB,RechesA,GaddB,GordonM,RushfordK,LauferI,WiessM,MyerG.BrainnetworkacHvaHonasanovelbiomarkerforthereturn-to-playpathwayfollowingsport-relatedbraininjury.FrontNeur2015;6:3-5.
● MooreR,HillmanC,BroglioS.ThepersistentinfluenceofconcussiveinjuriesoncogniHvecontrolandneuroelectricfuncHon.JAthlTrain2014;49:24-35.
● HenryL,ElbinRJ,CollinsMW,MarcheaG,KontosA.Examiningrecoverytrajectoriesa_ersport-relatedconcussionwithamulHmodalclinicalassessmentapproach.Neurosurgery2015:1-9
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ConcussionManagement
CurrentApproachtoTx• NosamedayReturn-to-Play
(RTP)• Needtobeclearedby
PhysicianforRTP• Prescribedphysical/cogniHve
restunHlasymptomaHc• AccommodaHonsatschool/
work• Progressivesymptom-based
aerobicexerHon-basedRTP
Limita5ons• LimitedguidanceonacHve
treatment• Limitedevidencefor
effecHvenessofprescribedrest– Norandomizedcontrolled
trials• LackofdefiniHonof“rest”• Recoveryisinfluencedby
severityofinjury,typeandHmingoftreatment
Wait–soRestisGood…orisit??Pros
• RestdecreasesexposuretoaddiHonalimpacts
• PhysicalandcogniHveacHvityexacerbatesymptomsposHnjury,prolongingrecovery
• 1-weekperiodofrestdecreasedSxandincreasedcogniHvescoresin60%ofpaHents– Evenwhenusedseveralweeks/
monthsa_erinjury• IniHalbriefrestmaybebeneficial
Cons• Youcanavoidcontactwithoutavoiding
allacHvity• PhysicalandcogniHveacHvitydonot
worsenpathophysiologicalinjuryorcauseaddiHonalharm
• NoassociaHonbetweenprescribedrestanddecreaseorSxorrecoveryHme
• PaHentswithhighestandlowestlevelsofacHvityhadworseoutcomes– Toolimleortoomuchrestmaydelay
recovery• Whattype,howlong–sHllTBD• Prolongedrestcanleadtosocial
isolaHon,anxiety,lossofacademic/workstanding
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaHonandAcHveManagement(TEAM)ApproachestoTreaHngConcussionMeeHngHeldinPimsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
TEAMApproachtoConcussion-2015• Mul5disciplinaryAssessment
– ReviewmechanismofInjury– Relevantmedicalhistory– SymptomChecklist– NeurocogniHveScreening/
NeuropsychologicalEvaluaHon– BalanceAssessment– VesHbularScreening/
ExaminaHon– OculomotorFuncHon
Screening/ExaminaHon– NeurologicalEvaluaHon– CervicalSpineEvaluaHon– PsychologicalEvaluaHon– Neuroimagingprn
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaHonandAcHveManagement(TEAM)ApproachestoTreaHngConcussionMeeHngHeldinPimsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.
TEAMApproachtoConcussion-2015
• Concussionsareatreatableinjury– MoreacHve/targetapproachesarebemerthanprescribedrestalone
• AcHveRehabilitaHon– VesHbularTherapy– Oculomotor/VisionTherapy– BehavioralTherapy
CollinsM,KontosA,OkonkwoD.etal.StatementsofAgreementfromtheTargetedEvaluaHonandAcHveManagement(TEAM)ApproachestoTreaHngConcussionMeeHngHeldinPimsburgh,October15-16,2015.Neurosurgery.Dec2016;79(6):912-929.BroglioSP,CollinsM,WilliamsRM,MuchaA,KontosA.CurrentandemergingrehabilitaHonforconcussion:areviewoftheevidence.ClinSportsMed.2015;34(2):213-231
RoleforVisionTherapy?• n=220individualswithTBI(n=160)orCVA
(n=60)• ComputerbasedqueryinclinicalpopulaHon
2000-2003,selectedthosewhocompletedoptometricVTprogramTBI(n=33),CVA(n=7)
• Results:90%ofTBIand100%withCVIhadtreatmentsuccess
– Marked/totalimprovementinatleast1primarysymptomandatleast1primarysign
– ImprovementsremainedstableatretesHng2-3monthslater
CiuffredaKJ,RutnerD,KapoorN,SuchoffI,CraidS,HanME.VisiontherapyforoculomotordysfuncHonsinacquiredbraininjury:AretrospecHveanalysis.Optom2008:79:18-22.
Post-ConcussionVisionExam• AfferentVisualPathway
– VisualAcuity• Crowded/Isolated• VORacuity(DynamicAcuity)
– Pupils– ConfrontaHonVFs
• Eyemovements– FixaHon– Saccades– Pursuits– VOR– NumberReadingTest(KD,
DEM)• OcularPosture–CoverTest• EOMs
• AccommodaHon– MonocularNPA– MonocularFlippers– MonocularMEM
• Vergences– NPC– VergenceRanges– VergenceFacility
• OcularHealth– Adnexa/OrbitalExam
• Exophthalmometry– AnteriorSegment– PosteriorSegment
*AlotofyourexamisprovingtoyourselfthatthereisONLYaconcussiongoingon!
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13
Optometry’sRole?
• PressingneedforobjecHvediagnosHctoolsforconcussionassessmentthatarestraigh{orwardtoadminister
• CurrentresearchinusingeyemovementsandoculomotorfuncHonforsensiHveandobjecHvebiomarkersofcerebraldysfuncHon– Canwetrackconcussionwiththevisualsystem??
• ManagementofPost-Concussion/HeadInjuryVisionProblems
HeitgerMH,JonesRD,MacLeoda.D,SnellDL,FramptonCM,AndersonTJ.Impairedeyemovementsinpost-concussionsyndromeindicatesubopHmalbrainfuncHonbeyondtheinfluenceofdepression,malingeringorintellectualability.Brain2009;132:2850-70.JohnsonB,ZhangK,HallemM,SlobounovS.FuncHonalneuroimagingofacuteoculomotordeficitsinconcussedathletes.BrainImagingBehav2015;9:564-73.
OptometricManagementPrimaryCare
• Vergence(Ranges,NPC,Facility)• AccommodaHon(NPA,Facility)• DEM• Crowding(crowdedacuitysymbols)• Rx
– Focusing/vergenceissues– Sunglasses
• Reassurance
Ter5aryCare-PCS• ComprehensiveBinocularVisionAssessment
• VisualPerceptualSkillsAssessment
• VisionTherapy• VesHbulo-OculomotorTherapy
AcHveparHcipaHoninmulHdisciplinarycare!
ClinicalPearls
• Thevisualsystemiscommonlyaffectedinconcussion
• Themajorityofvisualproblemsself-resolvea_erconcussionin3-4weeks,butsomepaHentsmayneedacHvetherapyforfullrecovery
• OptometryhasaroletofillinthemulH-disciplinarymanagementofconcussion
• Whenindoubtrefertoacolleague!
Thankyou!QuesHons?
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injury:aretrospecHveanalysis.Optom2007:78:155-61• CiuffredaKJ,RutnerD,KapoorN,SuchoffI,CraidS,HanME.VisiontherapyforoculomotordysfuncHonsinacquired
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AddiHonalSlidePhotoReferences• Slide7-hmp://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/arHcles/health_tools/
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– hmp://ishiharatest.blogspot.com/2011/03/ishihara-color-blindness-test.html– hmps://usherposiHve.wordpress.com/category/blindness/– hmp://www.glaucoma.org/uploads/eye-anatomy-2012_650.gif
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