24/05/16 - Home | University of Waterloo · PDF file24/05/16 4 Sport Concussion ... notes: mechanism of injury (“tell me what happened”?): ... K G |UJQWNF PQV DG NGHV CNQPG CPF

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Traumatic Brain Injury What is it and what can we do with it?

Goals

•  Etiology and epidemiology of TBI •  Acute TBI management •  TBI recovery, Return-to-Play/Life •  Short and long term consequences of TBI

•  Repetitive injury, post-concussion syndrome, chronic traumatic encephalopathy

•  TBI and the vision system •  Clinical assessment of TBI

Traumatic Brain Injury (TBI)

•  Acquired brain injury caused by external mechanical forces •  Direct impact or blow to •  Rapid acceleration or deceleration •  Blast waves •  Projectiles or penetrating injuries

•  Loss of consciousness is not required •  Predominantly functional damage

•  Structural damage may or may not be present

1.  Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368

Causes of TBI

Sports (20%) Biking (15%)

Medical (10%)

Violence (10%)

Work Place Accidents (10%)

Diving (5%)

Motor Vehicle Accidents (30%)

1)  http://www.biaww.com/stats.html 2)  http://www.cdc.gov/traumaticbraininjury/get_the_facts.html

Falls (40%)

Unknown / Other (19%)

Struck by / against (16%)

Motor vehicle

traffic (14%)

Assaults (11%)

Pathophysiology of TBI •  Biomechanical brain injury characterized by the

absence of gross anatomic lesions •  Ionic and neurotransmitter perturbations that disrupt

normal cellular function

•  Efflux of K+ from cells •  Influx of Ca2+ to cells

•  Excessive glutamate release

•  Ca2+ impairs function •  Glucose metabolism •  Free radicals

•  Ca2+ and free radicals •  Mitochondrial

dysfunction

•  Recurrent injury •  Apoptosis and

necrosis of cells

1.  Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368 2.  Prins M, et al. (2013) Disease Models & Mechanisms 6: 1307-1315 (Note: synaptic terminal image

adapted from this manuscript)

TBI Classif icat ion Eyes Verbal Motor

4 = Spontaneous 3 = To sound 2 = To pressure 1 = None

5 = Orientated 4 = Confused 3 = Words 2 = Sounds 1 = None

6 = Obey commands 5 = Localising 4 = Normal flexion 3 = Abnormal flexion 2 = Extension 1 = None

Glasgow Coma Scale •  Severe: <9 •  Moderate: 9-12 •  Mild: 13-15

•  Concussion is a mild form of mild TBI

1.  Prins M, et al. (2013) Disease Models & Mechanisms 6: 1307-1315 2.  glasgowcomascale.org

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TBI prognosis •  Depends on the severity of the injury

•  Moderate and severe injuries depend on length of coma, age, extent of trauma •  Prognostic calculators

•  Mild injuries •  Children: recovery in 2-3 months •  Adults: recovery in 3-12 months

•  Influenced by age, acute injury rest, life stressors, previous injuries

•  Sports injuries tend to heal faster •  Under reporting symptoms?

1.  Carroll L et al. J Rehabil Med 2004: Suppl. 43: 84-105 2.  http://www.tbi-impact.org/?p=impact/calc 3.  http://www.brainandspinalcord.org/prognosis-of-a-tbi/

The si lent epidemic… •  TBI occurs in 500 (per 100 000) people yearly

•  18,000 people a year in Ontario •  Leading cause of death and disability for

Canadians <35years •  Kills more children <20years than everything else

combined •  11,000 deaths and 6,000 permanent disabilities every

year •  465 people suffer a brain injury daily

1 person is injured every 3 minutes

1.  http://www.biaww.com/stats.html

The si lent epidemic… •  2.5 million most common causes in adults

emergency department visits, hospitalizations and deaths in 2010 related to TBI •  Emergency visits have increased 70% since 2001

•  Hospitalizations have increased 11%; deaths 7%

•  Concussion affects 823.7 per 100,000 annually •  Young children (5-14yrs) have the highest rates of

concussion •  Sports and bicycle accidents

•  Falls and MVA in adults

1.  Center for Disease Control and Prevention

138 people die from injuries that include TBI daily

The economics of TBI •  Annual direct cost $302 million (2009)1

•  Direct cost $98 million; indirect cost $2.4 billion (2009)2

•  Cost per case3

•  Mild: $33,284 to $35,954 •  Moderate: $25,174 to $81,153

1.  Runge JW. (1993) Emerg Med Clin North Am 11(1): 241–253 2.  Schulman J, Sacks J, Provenzano G (2002) Inj Prev 8(1):47–52 3.  McGregor K, Pentland B (1997) Soc Sci Med 45(2):295–303 4.  Humphreys I et al (2013) Clinicoecon Outcomes Res 5: 281-287

TBI and the Mil i tary

•  Most prevalent U.S. warfighter injury between 2000-20101 •  Over 300,000 in DoD alone

from 2000- August 20142

1.  Capo-Aponte et al., Military Medicine 2012 2.  Defense and Veterans Brain Injury System

TBI and Sports

•  1 in 5 sports related injuries are head injuries

•  Between 1997-2007 ER visits for concussion •  DOUBLED 8-13 year olds •  TRIPLED among older children •  DOUBLED in 8-19 year olds in

basketball, soccer, football despite participation declining

1.  http://www.biaww.com/stats.html 2.  http://www.clearedtoplay.org/concussion-information/concussions-by-the-numbers

http://radio.foxnews.com/wp-content/uploads/2012/09/9-18-head.jpg

http://www.scientificpsychic.com/fitness/AntonioRodrigoNogueiraVsRandyCouture.jpg

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Concussion Prevalence •  Vision screenings of UW varsity athletes

•  September 2013 – September 2015 •  305 athletes from 17 sports

•  Individual athletes: •  Curling, cross-country, track & field, volleyball, squash, badminton, tennis, figure

skating, baseball, golf, tennis •  Teams:

•  Rugby, soccer, ice hockey, field hockey, football, basketball

Concussion Prevalence •  28.2% of athletes self-reported having a previous concussion

(overall) •  28.1% men, 29.5% women

0

5

10

15

20

25

30

35

40

45

Football Basketball Volleyball Ice Hockey Soccer Rugby Field Hockey

Mens Womens

Concussion and Vision

•  No difference in mean refractive error •  With concussion

•  OD: -0.03 / -0.55 x 99 (BS = -0.30) •  OS: -0.08 / -0.54 x 82 (BS = -0.35)

•  Without concussion •  OD: -0.24 / -0.60 x 94 (BS = -0.54, p=0.25) •  OS: -0.26 / -0.58 x 92 (BS = -0.53, p=0.38)

Concussion and Vision

•  Last eye exam

0

5

10

15

20

25

30

35

40

<1 yr 1-2 yrs 2-3 yrs >3yrs Never

No Concussion Concussion

Acute Injury Presentat ion •  Sensory symptoms:

•  Photophobia, blurry vision, tinnitus, noise sensitivity, nausea, sensitivity to smell

•  Somatic symptoms: •  Headache, dizziness, balance impairments,

reaction time impairments, fatigue, sleep disturbances

•  Behavioural changes: •  Anxiety, irritability, restlessness, frustration

•  Cognitive changes: •  Poor memory, poor concentration, depression,

impaired judgment

Acute Injury

•  Athletes should be immediately removed from play

•  Glasgow Coma Scale, Sideline SCAT 3 protocol, King-Devick test •  GP, emergency room, sports medicine clinics

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Sport Concussion Assessment Tool 3

SCAT3 Sport ConCuSSion ASSeSment tool 3 | PAge 1 © 2013 Concussion in Sport Group

What is the SCAT3?1

the SCAt3 is a standardized tool for evaluating injured athletes for concussion

and can be used in athletes aged from 13 years and older. it supersedes the orig-

inal SCAt and the SCAt2 published in 2005 and 2009, respectively 2. For younger

persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed

HQT�WUG�D[�OGFKECN�RTQHGUUKQPCNU�� +H� [QW�CTG�PQV�SWCNKƂ�GF��RNGCUG�WUG� VJG�5RQTV�Concussion recognition tool

1. preseason baseline testing with the SCAt3 can be

helpful for interpreting post-injury test scores.

5RGEKƂ�E�KPUVTWEVKQPU�HQT�WUG�QH�VJG�5%#6��CTG�RTQXKFGF�QP�RCIG����+H�[QW�CTG�PQV�familiar with the SCAt3, please read through these instructions carefully. this

tool may be freely copied in its current form for distribution to individuals, teams,

groups and organizations. Any revision or any reproduction in a digital form re-

quires approval by the Concussion in Sport Group.

NOTE: the diagnosis of a concussion is a clinical judgment, ideally made by a

medical professional. the SCAt3 should not be used solely to make, or exclude,

the diagnosis of concussion in the absence of clinical judgement. An athlete may

have a concussion even if their SCAt3 is “normal”.

What is a concussion?

A concussion is a disturbance in brain function caused by a direct or indirect force

VQ�VJG�JGCF��+V�TGUWNVU�KP�C�XCTKGV[�QH�PQP�URGEKƂ�E�UKIPU�CPF���QT�U[ORVQOU�UQOG�examples listed below) and most often does not involve loss of consciousness.

Concussion should be suspected in the presence of any one or more of the

following:

- 5[ORVQOU�G�I���JGCFCEJG���QT - 2J[UKECN�UKIPU�G�I���WPUVGCFKPGUU���QT - +ORCKTGF�DTCKP�HWPEVKQP�G�I��EQPHWUKQP��QT - #DPQTOCN�DGJCXKQWT�G�I���EJCPIG�KP�RGTUQPCNKV[���

Sideline ASSeSSmenT

indications for emergency management

noTe: A hit to the head can sometimes be associated with a more serious brain

injury. Any of the following warrants consideration of activating emergency pro-

cedures and urgent transportation to the nearest hospital:

- Glasgow Coma score less than 15

- Deteriorating mental status

- potential spinal injury

- progressive, worsening symptoms or new neurologic signs

Potential signs of concussion?

if any of the following signs are observed after a direct or indirect blow to the

head, the athlete should stop participation, be evaluated by a medical profes-

sional and should not be permitted to return to sport the same day if a

concussion is suspected.

Any loss of consciousness? Y n

“if so, how long?“

Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y n

Disorientation or confusion (inability to respond appropriately to questions)? Y n

loss of memory: Y n

“if so, how long?“

“Before or after the injury?"

Blank or vacant look: Y n

Visible facial injury in combination with any of the above: Y n

SCAT3™

Sport Concussion Assessment Tool – 3rd edition

For use by medical professionals only

glasgow coma scale (gCS)

Best eye response (e)

no eye opening 1

eye opening in response to pain 2

eye opening to speech 3

eyes opening spontaneously 4

Best verbal response (v)

no verbal response 1

incomprehensible sounds 2

inappropriate words 3

Confused 4

oriented 5

Best motor response (m)

no motor response 1

extension to pain 2

#DPQTOCN�ƃ�GZKQP�VQ�RCKP� 3

(NGZKQP���9KVJFTCYCN�VQ�RCKP� 4

localizes to pain 5

obeys commands 6

glasgow Coma score (e + v + m) of 15

GCS should be recorded for all athletes in case of subsequent deterioration.

1

name &CVG���6KOG�QH�+PLWT[�Date of Assessment:

examiner:

notes: mechanism of injury (“tell me what happened”?):

Any athlete with a suspected concussion should be removed

From PlAy, medically assessed, monitored for deterioration

K�G��|UJQWNF�PQV�DG�NGHV�CNQPG��CPF�UJQWNF�PQV�FTKXG�C�OQVQT�XGJKENG�until cleared to do so by a medical professional. no athlete diag-

nosed with concussion should be returned to sports participation

on the day of injury.

2 maddocks Score3

“I am going to ask you a few questions, please listen carefully and give your best effort.”

/QFKƂ�GF�/CFFQEMU�SWGUVKQPU���RQKPV�HQT�GCEJ�EQTTGEV�CPUYGT�

9JCV�XGPWG�CTG�YG�CV�VQFC[!� 0 1

9JKEJ�JCNH�KU�KV�PQY! 0 1

9JQ�UEQTGF�NCUV�KP�VJKU�OCVEJ! 0 1

9JCV�VGCO�FKF�[QW�RNC[�NCUV�YGGM���ICOG! 0 1

Did your team win the last game? 0 1

maddocks score of 5

/CFFQEMU�UEQTG�KU�XCNKFCVGF�HQT�UKFGNKPG�FKCIPQUKU�QH�EQPEWUUKQP�QPN[�CPF�KU�PQV�WUGF�HQT�UGTKCN�VGUVKPI�

259

group.bmj.com on March 13, 2013 - Published by bjsm.bmj.comDownloaded from

SCAT3 Sport ConCuSSion ASSeSment tool 3 | PAge 2 © 2013 Concussion in Sport Group

CogniTive & PhySiCAl evAluATionBACkground

name: Date: examiner: 5RQTV���VGCO���UEJQQN� &CVG���VKOG�QH�KPLWT[�

Age: Gender: m F

Years of education completed: Dominant hand: right left neither

How many concussions do you think you have had in the past? 9JGP�YCU�VJG�OQUV�TGEGPV�EQPEWUUKQP! How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury?

Y n

Have you ever been diagnosed with headaches or migraines? Y n

&Q�[QW�JCXG�C�NGCTPKPI�FKUCDKNKV[��F[UNGZKC��#&&���#&*&! Y n

Have you ever been diagnosed with depression, anxiety or other psychiatric disorder?

Y n

Has anyone in your family ever been diagnosed with any of these problems?

Y n

Are you on any medications? if yes, please list: Y n

SCAT3 to be done in resting state. Best done 10 or more minutes post excercise.

SymPTom evAluATion

3 how do you feel? “You should score yourself on the following symptoms, based on how you feel now”.

none mild moderate severe

Headache 0 1 2 3 4 5 6

“pressure in head” 0 1 2 3 4 5 6

neck pain 0 1 2 3 4 5 6

nausea or vomiting 0 1 2 3 4 5 6

Dizziness 0 1 2 3 4 5 6

Blurred vision 0 1 2 3 4 5 6

Balance problems 0 1 2 3 4 5 6

Sensitivity to light 0 1 2 3 4 5 6

Sensitivity to noise 0 1 2 3 4 5 6

Feeling slowed down 0 1 2 3 4 5 6

Feeling like “in a fog“ 0 1 2 3 4 5 6

“Don’t feel right” 0 1 2 3 4 5 6

&KHƂEWNV[�EQPEGPVTCVKPI 0 1 2 3 4 5 6

&KHƂEWNV[�TGOGODGTKPI 0 1 2 3 4 5 6

Fatigue or low energy 0 1 2 3 4 5 6

Confusion 0 1 2 3 4 5 6

Drowsiness 0 1 2 3 4 5 6

trouble falling asleep 0 1 2 3 4 5 6

more emotional 0 1 2 3 4 5 6

irritability 0 1 2 3 4 5 6

Sadness 0 1 2 3 4 5 6

nervous or Anxious 0 1 2 3 4 5 6

Total number of symptoms (Maximum possible 22)

Symptom severity score (Maximum possible 132)

Do the symptoms get worse with physical activity? Y n

Do the symptoms get worse with mental activity? Y n

self rated self rated and clinician monitored

clinician interview self rated with parent input

overall rating: if you know the athlete well prior to the injury, how different is VJG�CVJNGVG�CEVKPI�EQORCTGF�VQ�JKU���JGT�WUWCN�UGNH!�

Please circle one response:

no different very different unsure 0�#

4 Cognitive assessmentStandardized Assessment of Concussion (SAC) 4

orientation (1 point for each correct answer)

9JCV�OQPVJ�KU�KV!� 0 1

9JCV�KU�VJG�FCVG�VQFC[!� 0 1

9JCV�KU�VJG�FC[�QH�VJG�YGGM!� 0 1

9JCV�[GCT�KU�KV!� 0 1

9JCV�VKOG�KU�KV�TKIJV�PQY!�(within 1 hour) 0 1

orientation score of 5

immediate memory

List Trial 1 Trial 2 Trial 3 Alternative word list

elbow 0 1 0 1 0 1 candle baby ƂPIGT

apple 0 1 0 1 0 1 paper monkey penny

carpet 0 1 0 1 0 1 sugar perfume blanket

saddle 0 1 0 1 0 1 sandwich sunset lemon

bubble 0 1 0 1 0 1 wagon iron insect

Total

immediate memory score total of 15

Concentration: digits Backward

List Trial 1 #NVGTPCVKXG�FKIKV�NKUV

4-9-3 0 1 6-2-9 5-2-6 4-1-5

3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8

6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3

7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6

Total of 4

Concentration: month in reverse order (1 pt. for entire sequence correct)

Dec-nov-oct-Sept-Aug-Jul-Jun-may-Apr-mar-Feb-Jan 0 1

Concentration score of 5

8 SAC delayed recall4

delayed recall score of 5

Balance examination&Q�QPG�QT�DQVJ�QH�VJG�HQNNQYKPI�VGUVU�

(QQVYGCT�UJQGU��DCTGHQQV��DTCEGU��VCRG��GVE��

/QFKƂGF�$CNCPEG�'TTQT�5EQTKPI�5[UVGO�$'55��VGUVKPI5

9JKEJ�HQQV�YCU�VGUVGF�(i.e. which is the non-dominant foot) left right

6GUVKPI�UWTHCEG�JCTF�ƃQQT��ƂGNF��GVE�� Condition

Double leg stance: errors

Single leg stance (non-dominant foot): errors

tandem stance PQP�FQOKPCPV�HQQV�CV�DCEM�� errors

And / or

Tandem gait6,7

time (best of 4 trials): seconds

6

Coordination examinationupper limb coordination

9JKEJ�CTO�YCU�VGUVGF� left right

Coordination score of 1

7

neck examination:range of motion tenderness upper and lower limb sensation & strength

Findings:

5

Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion.

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group.bmj.com on March 13, 2013 - Published by bjsm.bmj.comDownloaded from

Injury

Glasgow Coma Scale

Memory

Symptoms

Cognitive Function

Motor Function

Delayed Recall

1. (2013) Br J Sports Med 47: 259

K ing-Devick

•  3 reading cards •  Record total time to

read all three •  Record number of

errors made •  Take a baseline

•  Worse than baseline = injury

1.  http://kingdevicktest.com

Average: 39.2 ± 7.7s Range: 24.3 to 101.2s

Median: 38.5s *UW Varsity Athletes 2013-2015

Acute Injury Management •  Cognitive rest!

•  Nothing but eating, sleeping and walking for a minimum of 7 days / until symptoms resolve •  No TV, texting, reading, computer use •  Discontinue work / school

•  When symptoms resolve, begin a return-to-play/life protocol

Return to Play

•  Return to play protocol (5-7 days) •  Gradual return to activity, monitoring for return of

any symptoms •  Ex: light aerobic exercise, sport specific exercise,

non-contact training drills, full contact practice, return to play

•  If symptoms return, you revert back to an “acute” status

•  ImPACT, ANAM, King-Devick •  Need to return to baseline values

ImPACT •  Immediate Post-Concussion Assessment

and Cognitive Testing •  Scientifically validated computerised concussion

evaluation system •  Measures symptoms, verbal and visual memory,

processing speed and reaction time

1.  www.impacttest.com

ANAM •  Automated Neuropsychological

Assessment Metrics •  Developed by the DoD, USA •  Measures speed and accuracy of attention,

memory and thinking ability •  Neurocognitive assessment of TBI

1.  Defense and Veterans Brain Injury Center, www.dvbic.corg

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Short Term Consequences of TBI •  Concussion cells enter peculiar state of

vulnerability following injury •  Initial injury increases the risk of repetitive

injuries •  Especially high risk populations – military, sports

•  Second insult during acute phase can result in irreversible cell damage due to swelling

•  Second Impact Syndrome

1.  Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368

Second Impact Syndrome •  Consists of:

•  Athlete suffering post-concussive symptoms •  A second head injury within several weeks

•  Before the first injury has healed

•  Diffuse cerebral swelling and brain herniation can be fatal •  50% of “second impact syndrome” incidents

result in death

1.  Bey T, Ostick B (2009) Western Journal of Emergency Medicine 10(1): 6-10

Post-Concussion Syndrome •  Persistence of any mTBI symptoms for >30days

•  May be exasperated following exercise or other stressful event

•  50% of patients report symptoms for up to 3 months •  10% -15% of patients report symptoms for > 1year •  Symptoms may never go away completely

•  Cannot be predicted by injury severity

1. Spinos P et al. (2010) J Trauma 69(4): 789-794

Qual i ty of Li fe •  11 – 30% suffer depression following injury

•  3x more likely to be depressed with >3 TBI •  Fatigue is more severe and prevalent in TBI •  Many people miss work and/or loose their

jobs following moderate to severe TBI •  Students often miss school

•  Health-related quality of life scores lower in TBI •  Mild, moderate, severe, repetitive •  Adults, children •  Can persist for years after injury

1.  Guskiewick K et al. (2007) Medicine & Science in Sports & Exercise 39(6): 903-909 2.  Andelic N et al. (2008) Acta Neurologica Scandinavica 120(1): 16-23 3.  Cantor J et al. (2008) Journal of Head Trauma Rehabilitation 23(1): 41-51 4.  Dijkers M (2004) Archives of Physical Medicine and Rehabilitation 85(Supplement 2); 21-35 5.  Stancin T (2002) Pediatrics 109(2): e34 6.  Emanuelson I (2003) Acta Neurologica Scandinavica 108(5):332-338

Neurodegeneration •  TBI, particularly repetitive mTBI increases

the risk of: •  Mild cognitive impairment •  Dementia •  Alzheimer's •  Parkinson's •  Psychiatric syndromes •  Altered brain function

•  Issues tend to occur earlier than non-TBI •  May be genetic risk factors

•  APOE-e4 genotype and Alzheimer’s (Odds Ratio 3.3) •  APOE-e4 may influence concussion recovery / PCS also

1.  Guskiewicz K et al. (2005) Neurosurgery 57(4): 719-726 2.  Mortimer JA et al. (1991) Int J Epidemiol 20:S28-S35 3.  Kiraly M, Kiraly S (2007) The Scientific World Journal 7: 1768 – 1776 4.  De Beaumont L et al. (2009) Brain 132: 695-708

Chronic Traumatic Encephalopathy •  Neurodegenerative disease of the young

•  Irritability, impulsivity, aggression, explosivity, depression, short-term memory loss, heightened suicidality, cognitive impairment, executive dysfunction

•  Begin 8-10 years after mTBI •  CTE must be diagnosed post-mortem

•  Global prevalence is unknown •  Estimated 17% of repetitive mTBI develop CTE •  But… 90% of all CTE cases occur in athletes

1.  Omalu B (2005) Neurosurgery 57(1): 128-134 2.  McKee A (2013) Brain 136: 43-64 3.  Gardner A et al. (2014) Br J Sports Med 48:84-90

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Headache

Dizziness

Fatigue

Poor memory Poor concentration

Irritability Depression

Sleep disturbances

Impaired judgment Frustration

Restlessness

Sensitivity to noise

Blurry vision

Double vision

Light sensitivity

Nausea Tinnitus

Balance impairments

Poor coordination

Difficulty tracking objects

Trouble focusing

Sensitivity to smells

Trouble reading

Reduced reaction time

Eye strain

TBI and Visual Function •  60 – 75% TBI have subjective visual complaints

•  Common: General vision disturbances, headaches, focusing issues, light sensitivity, reading difficulties, distress from moving objects, concentration difficulties, issues with spatial attention, difficulty tracking objects, pain with eye movements •  Also issues with balance, gait initiation, reaction times,

visuomotor coordination •  Less common: blurry vision, dizziness, double vision,

confusion, staring behaviour, VA loss, VF loss, anisocoria, ocular trauma, issues with dark adaptation

1.  Ciuffreda KJ et al (2007) Optometry 78: 155-161 2.  Brahm K et al. (2009) Optom Vis Sci 86(7): 817-825 3.  Goodrich G et al. (2013) Optom Vis Sci 90(2): 105-112

Common vision problems Normal Population Post-Concussion

Convergence Insufficiency 2 – 15% (up to 33%) 42%

Accommodation Insufficiency 2 – 15% (up to 62%) 38%

Alignment Problems (Strabismus) 2-5% 25%

Eye Movement Problems 20% 25-50% (up to 90%)

1.  Ciuffreda KJ et al (2007) Optometry 78: 155-161 2.  Brahm K et al. (2009) Optom Vis Sci 86(7): 817-825 3.  Goodrich G et al. (2013) Optom Vis Sci 90(2): 105-112 4.  Leat, S et al. (2013) IOVS 54(5): 3798-3805 5.  Cacho-Martinez, P et al. (2010) J Optom 3: 185-197

Cl inical Assessment of TBI •  Three-part assessment

•  Case history •  Structural assessment •  Functional assessment

Case History •  Important to establish an injury

timeline •  Date of injury •  Onset of symptoms •  Chronicle recovery, symptoms,

treatments, triggers •  Current symptoms

•  Determine circle of care •  GPs, Sports Medicine, Physiotherapy,

Massage, Chiropractors, Chiropractic Neurology, Vestibular Rehabilitation, Psychology, Counselor

Structural Assessment •  Similar to a routine OVA

•  Visual Acuity •  Static high contrast, contrast sensitivity

•  Refraction •  Ocular Alignment

•  Cover tests with comitancy (D / N) •  Ocular Health

•  Pupils •  Anterior segment exam •  Dilated fundus exam

•  Visual Field

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Functional Assessment •  Oculomotor Control

•  Broad H, pursuits, saccades •  Accommodative Function

•  Amplitudes of accommodation •  Accommodative facility •  MEM

•  Vergence Function •  NPC •  Fusional reserves •  Vergence facility

•  Light sensitivity •  Tint trials

•  Global Function •  Stereopsis, King-Devick, balance

TBI in cl inical pract ice •  May 2014: University of Waterloo, Sports

Vision Clinic opened •  Dedicated to providing comprehensive vision

care to all athletes •  Sport-specific vision assessments, performance

enhancement vision training, concussion management

Purpose: •  Evaluate the incidence of concussion-related visits •  Determine the prevalence of concussion-related

vision problems

TBI in cl inical pract ice Method: •  Retrospective analysis of patient charts •  May 2014 – August 2015

•  37% of all patient visits are related to concussion •  n=11 post-concussion patients, with medical

referrals •  13 to 44 years of age •  2 weeks to 9 months post injury •  History of 1 to 5 lifetime concussions

TBI in cl inical pract ice •  Patients report 5.4 symptoms in the past 6

months •  Confusion, poor memory, feeling of getting ‘dinged’,

feeling of getting ‘bell rung’ •  Headaches, balance problems, nausea, dizziness,

tinnitus, blurry vision •  Symptoms worse with physical activity = 90% •  Symptoms worse with cognitive activity = 80%

TBI in cl inical pract ice

0

20

40

60

80

100

Headach

es

"Pressur

e in Head

"

Neck Pain

Nausea/

Vomitin

g

Dizzine

ss

Blurred

Vision

Balance

Problem

s

Sensitiv

ity to L

ight

Sensitiv

ity to N

oise

Feeling

Slowed

Down

"Don't Feel

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Hard to

Concent

rate

Feeling

"In a F

og"

Troubl

e Rem

ember

ing

Fatigue/

Low Ener

gy

Confusi

on

Drowzin

ess

Troubl

e Falli

ng Asle

ep

More Emotio

nal

Irritabi

lity

Sadness

Nervous

/anxio

us

None Mild Moderate Severe

%

TBI in cl inical pract ice Diagnosis: •  Photophobia = 18% •  Accommodative dysfunction

•  Suspected = 46% •  Confirmed = 10%

•  Vergence dysfunction •  Suspected = 36% •  Confirmed = 27%

•  Refractive error = 18%

Management: •  Monitor = 18% •  Computer-based VT = 36% •  Conventional VT = 27% •  Spectacle Rx = 10% •  Nothing (healthy) = 10%

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Case 1: AR •  22 y/o male, football player •  C/C: residual vision sx following mTBI

•  Has issues when moving/navigating complex visual environments – feels vision is uncomfortable

•  Stationary weightlifting, school & work okay; running/jumping are bad

•  Physio has given balance an vision exercises (pursuits, saccades, tracking objects on cluttered background)

•  Injury: October 2014 •  Hit in practice, played for 1 week after and then took 3

weeks off

March 2015 Case 1: AR •  VA (unaided)

•  OD 6/4.5-1, OS 6/4.5-2, OU 6/4.5 •  CT (unaided)

•  (D) Ortho (N) 2 Exophoria •  Refraction

•  OD +0.50 / -0.50 x 180 •  OS +0.75 / -0.75 x 165

•  King-Devick •  50.1s, 0 errors

•  Stereoacuity •  50sec of arc

•  NPC •  TTN, TTN, 2/4cm

•  Vergence Facility 15cpm •  Amplitude of Accommodation

•  14D OD, OS •  Accommodative Facility

•  OD 5cpm OS 5cpm OU 8cpm

March 2015

Case 1: AR May 2015

•  VA (aided) •  OD 6/4.5-2, OS 6/4.5-2, OU 6/4.5

•  CT (aided) •  (D) Ortho (N) 4 Exophoria

•  King-Devick •  44.2s, 0 errors

•  Stereoacuity •  40sec of arc

•  NPC •  TTN, TTN, TTN

•  Vergence Facility 35cpm •  Amplitude of Accommodation

•  14D OD 12.5 OS •  Accommodative Facility

•  OD 30.5cpm OS 23.5cpm OU 22cpm

•  Symptoms are much improved •  Occasional vision cramps/discomfort when playing football without Rx •  Has tried not wearing specs some days, and feels visual comfort is

worse without them

Case 2: GD •  25 y/o male, hockey player •  C/C: headaches, constant pressure in the head

(worse with TV & reading), light sensitivity following mTBI •  Also tinnitus, bouts of dizziness and trouble sleeping •  Physio has given some balance exercises •  GP signed him off work one year (May 2015)

•  Injury: November 2015, Dx mTBI June 2015 •  At least 2 previous concussions

October 2015

Case 2: GD October 2015

•  VA (unaided) •  OD 6/4.5-3, OS 6/4.5-2, OU

6/4.5-1 •  CT (unaided)

•  (D) Ortho (N) 3 Exophoria •  Stereoacuity

•  50sec of arc •  NPC

•  6/11, 6/11, 6/10

•  Vergence Facility •  Unable to fuse BI or BO

•  Amplitude of Accommodation •  OD 8D OS 7D

•  Accommodative Facility •  OD 7cpm OS 7cpm OU 1.5cpm

November 2015

•  King-Devick •  46.6s, 0 errors

•  Cycloplegic Refraction •  OD +1.50 / -1.00 x 005 •  OS +1.50 / -0.75 x 170

Case 2: GD February 2016 March 2016 April 2016 May 2016

Hx - No longer getting extra pressure at near; adapted to Rx in 1 week; no other change in Sx

- Sx improving gradually; more good days then bad; started Vitamin D, B12

- Sx improving gradually; bad days are less bad

- Sx improving; started full time work, no change in Sx with work; sleeping better

VA OD 6/4.5-3 OS 6/4.5 OU 6/4.5

OD 6/4.5-2 OS 6/4.5 -1 OU 6/4.5-1

OD 6/4.5-2 OS 6/4.5 OU 6/4.5

OD 6/4.5-3 OS 6/4.5-2 OU 6/4.5-1

Stereo 40 seconds 30 seconds --- 20 seconds

Amps OD 8D OS 7D OD 8D OS 8D OD 8D OS 7.5D OD 7D OS 7D

NPC 6/10, 6/10, 6/11 6/8, 6/8, 6/8 7/11, 7/11, 7/11 5/7, 6/9. 7/9

AF OD 8cpm OS 10cpm OU 3cpm

OD 11cpm OS 10cpm OU 8.5cpm

OD 6cpm OS 5.5cpm OU 5.5cpm

OD 14.5cpm OS 14.5cpm OU 12.5cpm

VF 15cpm 7.5cpm 11.5cpm 18.5cpm

KD 46.7seconds 36.7seconds 38.6seconds 33.3seconds

Rx Near-Far Hart charts OU, Brock string – primary and other

Add OD, OS Hart charts, Bug on a string

Continue exercises, try for longer duration

Taper VT

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Management of TBI •  Address any ocular health issues first •  Prescribe full refractive correction

•  Allow time for adaptation •  May need an additional reading Rx or tint

•  Vision therapy can be beneficial for some functional losses •  Progression is slower

1. Ciuffreda KJ, et al. (2008), Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry, 79;18-22.

Cl inical Pearls for TBI

•  Patient symptoms tell you a lot about how they are healing •  All symptoms, not just visual ones

•  Prioritise your tests and use multiple visits

•  Simple interventions can have a big impact •  Breaking symptom cycles

•  You are not alone! •  Circle of care

What can we do? •  Ask about head injury in high risk patients •  Careful examination paying attention to refractive

and BV issues •  Education is key to preventing repetitive injuries!

•  Unified message across health professions

Let’s play an active role in assessment, return to play decision making and rehabilitation of our

TBI patients!

Thank you! •  Student researchers in Vision & Motor Performance Lab •  Dr. Michael Cinelli, Wilfred Laurier University •  Mr. Robert Burns, Waterloo Warriors Athletic Therapy •  Ms. Robyn Ibey, Waterloo Sports Medicine Clinic •  Dr. Robin Duncan, Dr. Eric Roy, Dr. Ewa Niechwiej-Szwedo,

University of Waterloo Kinesiology •  University of Waterloo, School of Optometry & Vision Science Funding sources •  Propel Centre for Population Health Impact

•  Waterloo Chronic Disease Prevention Initiative, 2014 •  Canadian Optometric Education Trust Fund

•  2014, 2016 •  American Optometric Foundation

•  Beta Sigma Kappa Research Fellowship, 2014