Modern concussion management paradigm: Todays complexities and - - PowerPoint PPT Presentation

Modern concussion management paradigm: Today’s complexities and tomorrow’s solutions

Jason P. Mihalik, PhD, CAT(C), ATC

Associate Professor, Department of Exercise and Sport Science Co-Director, Matthew Gfeller Sport-Related TBI Research Center @jmihalik79

Disclosures

Chief Science Officer

“It’s not dangerous to play with a

• concussion. You’ve got to

sacrifice for the sake of the team. The only way I come out is on a stretcher.”

Cumulative risks for youth athletes

S hould kids be playing contact or collision sports?

0% 10% 20% 30% 40% 50% 60% Valovich McLeod, 2008 Register-Mihalik, In Progress

"Concussion" "Bell Ringer"

Concussion evidence

PubMed search string “sport concussion” on 12/07/17

500 1000 1500 2000 2500 3000

Number of “sport concussion” publications in PubMed

Concussion: A multifaceted condition

Traumatic Brain Injury

Cognition Concussion history Postural stability Mechanism

• f

injury Physical exam Symptomatology Knowledge, Attitudes, Behaviors Treatment

Concussion evaluation

Standardized concussion protocol

Preseason Baseline

• Symptom
• Mental status
• Balance
• Neurocognition

Injury

• Evaluation
• Symptom
• Mental status
• Balance

Clinical Follow-up

• Asymptomatic
• Cleared for

progression

• Cleared for full

RTP

Symptoms by Bucket

Bucket Match Symptom Com.

• 1. Headache

Com.

• 2. "Pressure in Head"

Com.

• 3. Neck Pain

Com.

• 4. Nausea or Vomiting

Bal./Mot.

• 5. Dizziness

V-V

• 6. Blurred Vision

Bal./Mot.

• 7. Balance Problems

V-V

• 8. Sensitivity to Light

V-V

• 9. Sensitivity to Noise

Monitor

• 10. Feeling Slowed Down

Monitor

• 11. Feeling like "in a fog"

Com.

• 12. "Don't feel right"

Cog.

• 13. Difficulty Concentrating

Cog.

• 14. Difficulty Remembering

Monitor

• 15. Fatigue or Low Energy

Cog.

• 16. Confusion

Monitor

• 17. Drowsiness

Monitor

• 18. Trouble Falling Asleep

Monitor

• 19. More Emotional

Monitor

• 20. Irritability

Monitor

• 21. Sadness

Monitor

• 22. Nervous or Anxious

Com=Comfort Bucket Cog=Cognitive Bucket V-V=Visual Vestibular Bucket Bal./Mot=Balance/Motor Bucket Monitor=Activity that does not fit in activity bucket but should be monitored for change (as should all symptoms)

Concussion evaluation

Longitudinal perspective on concussion

ACUTE INJURY REPETITIVE CONCUSSION LONG-RANGE OUTCOME

True Incidence, Risks, Latent Pathophysiology?

~30-50 yrs

Need for prospective, longitudinal, population-based studies

Courtesy of Dr. Michael McCrea

Courtesy of Dr. Michael McCrea

Phase 1- Symptom Control*

• 1st Session –

relaxation/control of symptoms (manual therapy, massage, etc)

• Each session after –

Comfort + 1 bucket activity around impairment Phase 2 - Impairment Reduction

• Relaxation/control of

symptoms- 1-2 activities from the same bucket around with continuing to increase complexity in that bucket/area Phase 3 – Activity Integration Relaxation/control of symptoms as needed, can continue to add 1 new area to address

• f impairment with

each session Phase 4 – Recovery Acceleration

• Relaxation/contorol
• f symptoms, can

continue to add 1 new area per session and increase complexity of existing areas – including divided attentions tasks Phase 5 – Sport Specific Applications

• Continue to add new

areas and increase complexity as needed

• Activities should

include divided attention tasks and be sports-specific

Multidimensional Intervention Progression Framework

Active Rehab + Graded Exertion Progression

Active Rehab Group Only

• We expect that each session will last 15-20 minutesminutes, regardless of phase

Cognitive Techniques Balance Techniques Visual Techniques Dual-Task Techniques

Simple Math 1+2; 3+1 Stroop Say yes if color the same as the word – BLUE N-Back State if the letter you see is the same as the

• ne you immediately

saw before- A  B  A A Serial 7s Count backwards from 100 by 7: 71421, etc Foam EC: DL, SL, Tandem Bosu Ball Gaze Stability Ball Toss Pencil-Push Rocker Board + Stroop Bosu/Dynadisc lunges + COWAT

Identify at- risk players Intervention Reduce risk

Safer football, taught from inside the helmet

Neuroimaging: Structural and clinical sequences Plasma/serum biomarkers Vision & sensory performance Standard TBI clinical measures

Imaging the Brain for Chronic Effects

• Diffusion Tensor Imaging (DTI)

Matthew Gfeller Center

Jason P. Mihalik, PhD, CAT(C), ATC

Matthew Gfeller Sport-Related TBI Research Center jmihalik@email.unc.edu 919.962.2573 http://tbicenter.unc.edu @jmihalik79