clinical profiles and recovery trajectories conference...

10/24/2018

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Aimee Custer, PsyD, LP

Clinical Sports Neuropsychologist

Clinical Profiles and

Recovery TrajectoriesConcussion Management

Disclosures

• I have no disclosures

The following slides are property of Aimee Custer, PsyD. Do not duplicate in

any way without written permission.

Objectives

• Identify emerging clinical trajectories and

corresponding treatment options

• Review emerging research on trajectories

• Explain the importance of a comprehensive

approach to concussion management

• Describe variations in behavioral

modifications, social/physical restrictions, and

vocational accommodations for each

trajectory

History

Collins, Kontos, Reynolds, Murawski, Fu. KSSTA; 2014.

Collins, Kontos, Okonkwo et al., Neurosurg; 2016

• University of Pittsburgh

Medical Center (UMPC)

Model

• 18 years of clinical

experience and research

Physiologic, vestibulo-ocular and Cervicogenic

Ellis, M., Leddy, J., & Willer, B., (2014). Brain Injury

Targeted treatments

Ellis, M., Leddy, J., & Willer, B., (2014). Brain Injury

10/24/2018

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Growing Agreement that Concussion Involves

Different Clinical Profiles/Subtypes

Collins, Kontos, Okonkwo,

et al., Neurosurg; 2016

“Concussions are

characterized by diverse

symptoms and impairments

in function resulting in

different clinical profiles and

recovery trajectories.”

Injury Characteristics


SAMPLE DETAILS• N=1,438• High School/University Athletes• 1-7 Days Post-Concussion

DifficultyConcentrating

DifficultyRemembering

Sensitivity to Light/Noise

Dizziness

Foggy

HeadacheDrowsiness

Slowed Down

Fatigue

SadnessMore Emotional

Nervous

Sleep Less

Trouble Falling Asleep

Vomiting

Numbness

Factor Analysis: Post Concussion Symptom Scale

Kontos, Elbin, Schatz, Covassin, Henry, Pardini, Collins; AJSM, 2012

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/FATIGUE

POST-TRAUMATIC

MIGRAINE

ANXIETY/

MOOD

CERVICAL

Clinical Profiles Trajectories Determined by:

Clinical Interview

� Constitutional risk factors

� Symptom clusters

� What questions to ask?

Vestibular-Ocular Screening

� Provocative or not?

� Specific findings help determine level/type

of exertional activity

Computerized Neurocognitive Testing

� Specific cognitive profiles for specific clinical

trajectories

Treatment Management

� Behavioral Management

� Therapy and/or Medication considerations

� Vocational considerations

Findings lead to individually determined treatment

and rehabilitation plan


Anxiety

• Excessive and persistent worry and/or fear about everyday

situations that is difficult to control.

• Patients may be unable to accurately characterize their

feelings of anxiety. May manifest as:

– Nervousness

– Somatic symptoms

– Cognitive rumination

– Avoidance, Fear of injury

– Feeling overwhelmed

– Restlessness, Agitation

– Difficulties concentrating

Anxiety

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Secondary characteristics

• Inactivity

• Academic stress

• Increased “rules” or restrictions

• Reduced social activities

• Reduced energy/tolerance for stress

• Removal of coping mechanisms

• Pressure from Parents or Coaches

ANXIETY/

MOODAssessment

• Risk factors: Personal or FHx of anxiety, Hx of psychiatric meds

• CNT: Limited to no deficits, high symptom score

• VOMS: Normal or mildly provocative; unusual symptoms; more

symptom provocation with vestibular overlay

Treatment Considerations

• Education

• Regulated Schedule

• Academic Accommodations?

• Limited restrictions

• Vestibular Consult/Therapy

• Supervised Exertion Therapy

• Psychology and/or Medications

Collins MW, Kontos A, et al, KSSTA, 2014Elbin RJ, Schatz P, et al, Curr Treat Options Neurol, 2014

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/FATIGUE

POST-TRAUMATIC

MIGRAINE

ANXIETY/

MOOD

CERVICAL

Clinical Profiles Trajectories Determined by:

Clinical Interview










trajectories








Vestibular Dysfunction

• 50% report vestibular symptoms post-concussion

• 43% experience balance impairments

• Central versus Peripheral

• Symptoms:

– Dizziness

– Nausea; motion sickness

– Fogginess

– Environmental sensitivities

– Unstable vision

– Difficulty focusing, remembering

– Anxiety

Collins MW, Kontos A, et al, KSSTA, 2014Reynolds E, Collins MW, et al, Neurosurgery, 2014

Assessment

• Risk factors: Motion Sickness, Vestibular Disorder, Hx of anxiety

• CNT: Deficits in visual motor speed

• VOMS: increase in symptoms with gaze stabilization and visual motion

integration

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• Education, especially w/ comorbid anxiety or migraine

• Appropriate academic accommodations

• Expose/Recover

• Vestibular Therapy

• Guided exertion therapy – dynamic exertion protocol

• Medications

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/FATIGUE

POST-TRAUMATIC

MIGRAINE

ANXIETY/

MOOD

CERVICAL

Clinical Profiles

Trajectories Determined by:

Clinical Interview










trajectories








Ocular

• Smooth Pursuits: tracking a moving object

• Saccades: rapidly changing line of sight and focusing object (i.e., reading)

• Convergence: binocular vision; simultaneously focusing a single object

• Vestibular-Ocular Reflex: holds image steady during rotational head

movements

• Eye and Head Movements: interaction of eye movements, head

movements, and VOR to change line of sight (i.e., gaze)

Assessment

• Risk factors: Personal of family hx of binocular dysfunction

• CNT: Deficits in visual memory and reaction time

• VOMS: fixation loss with pursuits, Saccadic deficiencies,

Convergence Insufficiency, irregular eye movements, eye strain



• Vestibular Therapy or Occupational Therapy- Emphasis on ocular-motor exercises

• Vision Therapy of Therapeutic Lenses - Behavioral neuro-optometrist. Can include both office and home

based activities

• Dynamic Physical Exertion Protocol - Isolated Binocular Dysfunction does not typically result in symptoms

with dynamic exertion

• Behavioral Management- Limit visual based tasks (i.e., reading, iphone, computer use)

- Academic/Work Accommodations

• Pharmacological- Limit OTC to reduce risk of rebound headaches

- Limited options; stimulants sometimes beneficial

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/ FATIGUE

POST-TRAUMATIC

MIGRAINE

ANXIETY/

MOOD

CERVICAL

Clinical Profiles


Clinical Interview










trajectories








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Cognitive Fatigue

Cognitive Complaints

• Concentration (attention, distractibility)

• Memory (forgetfulness, repeating oneself)

• Processing Speed (difficulties with

multitasking, slowed)

• Mental Fogginess (one step behind)

COGNITIVE/

FATIGUE

Fatigue Complaints

• Tiredness with cognitive or

physical exertion

• Decreased endurance and/or

energy levels

• Decreased tolerance for stress

Additional Symptoms• Dull, generalized headache

• Headache that worsens throughout day

• Sleep disruption/change

• Mood related consequences

Assessment COGNITIVE/

FATIGUE

• Risk factors: Hx of LD or ADHD

• CNT: global suppression of scores, multiple in low average range

• VOMS: Typically normal, Saccades and NPC fatigue across trials


Behavioral Management• Breaks from cognitive activity throughout the day

• Temporarily adjust academic schedule to allow for rest periods

• Modified work/school schedule

Exertion Therapy• Monitored exertional progression

Cognitive Therapy • For cases of protracted recovery

Pharmacological Intervention• Neuro-stimulants; sleep aids

• Caffeine

COGNITIVE/

FATIGUE


CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/FATIGUE

POST-TRAUMATIC

MIGRAINE

ANXIETY/

MOOD

CERVICAL


Clinical Interview










trajectories







Clinical Profiles


Post-Traumatic Migraine

• Headache with light or noise sensitivity and/or nausea that

worsens with exertion, caused by traumatic injury to the

head

• Research indicated that PTM is associated with cognitive

deficits and protracted recovery

• Headaches present upon wakening, intermittent

throughout day

• Can be accompanied by dizziness, visual changes,

environmental sensitivities, secondary cognitive difficulties

Kontos, A, Elbin, R.J., Lau, B, et al., Am J Sports Med, 2013

Assessment

• Risk factors: PHx/FHx Migraine, comorbid anxiety, female sex

• CNT: Deficits in Verbal and Visual Memory

• VOMS: Typically normal; possible headache provocation. Dizziness

or nausea provoked with vestibular overlay

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• Behavioral management

– Regulated sleep, diet, hydration, exercise, stress

• Stress management

• Academic Accommodations

• Pharmacological considerations/supplements

• PT considerations

– Neck

– Exertion


Profile Combinations

• Primary Secondary Tertiary

Thank You!

References:• Collins, M.W., Kontos, A.P., Reynolds, E. et al. Knee Surg Sports Traumatol Arthrosc (2014) 22:

235. https://doi.org/10.1007/s00167-013-2791-6

• Collins, M.W., Kontos, A., Okonkwo, D.O., Almquist, J., Bailes, J. et al., (2016). Concussion is

treatable: Statements of agreement from the targeted evaluation and active management

(TEAM) approaches to treating concussion. Neurosurgery, 79(6): 912-929.

• Elbin, R. J., Schatz, P. Lowder, H. B., & Kontos, A. (2014). An empirical review of treatment

and rehabilitation approaches used in the acute, subacute, and chronic phases of recovery

following sport related concussion. Current Treatment Options in Neurology, 16: 320.

• Ellis, M.J., Leddy, J.J., & Willer, B. (2014). Physiological, vestibule-ocular and cervicogenic

post-concussion disorders: an evidence-based classification system with directions for

treatment. Brain Injury, 1-11.

• Kontos, A., Elbin, R. J., Lau B., et al. (2013). Posttraumatic migraine as a predictor of recovery

and cognitive impairment after sport-related concussion. American Journal of Sports

Medicine, 41(7): 1497-1504.

• Kontos, A., Elbin, R.J., Schatz, P., Covassin, T., Henry, L., Pardini, J. Current treatment (2012). A

revised factor structure for the post-concussion symptom scale: baseline and postconcussion

factors. American Journal of Sports Medicine, 40: 2375-84.

• Photos that are not cited are public domain Commons.Wikimedia

• Special Thank You to Dr. Micky Collins and Dr. Anthony Kontos for data provided

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