UPMC Physician Resources
Emerging Frontiers in Concussion - Session 5: Moving Toward A Targeted Approach to Concussion Assessment and Active Rehabilitation: Clinical Profiles Treatment Model
Dr. Michael Collins discusses his findings that help establish targeted clinical pathways for concussion.
Upon completion of this activity, participants should be able to:
- Discuss targeted treatment approaches for the clinical profiles associated with sports related concussions.
- Conceptualize concussion as a heterogeneous entity
- Review assessment findings that help establish targeted clinical pathways for concussion.
- Med Sci Sports Exerc. 2016 May;48(5 Suppl 1):653. doi: 10.1249/01.mss.0000486961.75574.f0. Utility Of An Incongruent Visual, Cognitive-balance Dual Task To Assess Impairment In Athletes With Concussion: 2348 Board #2. Kontos AP1, Woolford J, McAllister-Detrick J, Sparto P, Collins MW, Furman J.
- Pediatrics. 2016 Sep;138(3). pii: e20160910. doi: 10.1542/peds.2016-0910. Removal From Play After Concussion and Recovery Time. Elbin RJ1, Sufrinko A2, Schatz P3, French J2, Henry L2, Burkhart S4, Collins MW2, Kontos AP2.
- Clin J Sport Med. 2016 Jul 1. [Epub ahead of print] Sex Differences in Vestibular/Ocular and Neurocognitive Outcomes After Sport-Related Concussion. Sufrinko AM1, Mucha A, Covassin T, Marchetti G, Elbin RJ, Collins MW, Kontos AP.
- Med Sci Sports Exerc. 2016 May;48(5 Suppl 1):985. doi: 10.1249/01.mss.0000487960.25488.fb. Utility Of An Incongruent Visual, Cognitive-balance Dual Task To Assess Impairment In Athletes With Concussion: 3556 June 4, 9: 45 AM - 10: 00 AM. Kontos AP1, Woolford J, McAllister-Detrick J, Sparto P, Collins MW, Furman J
Dr. Collins has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
Stockholder: Impact Applications, Inc.
All presenters disclosure of relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients is listed above. No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose.
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The University of Pittsburgh School of Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.01) continuing education units (CEU) which are equivalent to 1 contact hour.
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Release Date: 12/23/16 | Last Modified On: 12/23/16 | Expires: 12/25/17
All right I'm excited for the next part of - for this lecture you know because really this is where the rubber meets the road in terms of our treatment model for the injury and I want to lay down a conceptual framework for how we look at the injury, how we assess these different clinical profiles that we are starting to learn about and really talk conceptually about the assessment findings that lead to certain clinical profiles and then what treatments we feel are needed for the clinical profile that we see with concussion.
We are trying to create a model that creates a way of conceptualizing this in a much more targeted fashion to treat the problem. The question I ask as a clinician is where is the aberrant signal coming from? What's really going on? And if we can identify that aberrant signal or signals and match treatment to that aberrant signal I feel our outcomes can be far better. And we see that every day in our clinic. Keep in mind as I share this model with you and there is an evolving literature behind this model I'm going to share, there is really becoming a pretty strong evidence base to support what we are doing but we don't have randomized controlled trials, that's really the next step. And I think presenting the model in this fashion allows you, the audience, who haven't been here for a few years or you know it kind of shows you where at least our program is evolving to and how we are approaching this from a treatment standpoint.
I'm actually particularly excited that my fellows, I'm really excited, you know I've got Alex Taylor here from Boston and Jamie and I got Amy from Minnesota, her accents has grown dramatically since I've seen her last and a lot of my former fellows and others that are here today, and it's kind of exciting to get your feedback as to how you think we are evolving after hearing this lecture.
So I do want to disclose before starting here I'm a cofounder of ImPACT and I'm not really talking a lot about that but I do want to disclose that interest.
Okay, so the objectives of my lecture really is I feel these clinical profiles are the road map to this injury. And really understand the heterogeneity of concussion is absolutely essential to laying down a really organized approach at treating the problem. I'm going to talk about how our different assessment findings lead to establishing these different clinical profiles and then finally how clinical rehabilitation and treatment is really predicated upon these different profiles that we see. Now it's never as simple as saying there is one profile because there is not. You can - I'll get into this as we go. It's a complicated injury, I've got 30 minutes of crap boiled down into this parsimony, simplicity form. It's never as simple as one profile, there is usually multiple profiles going on but I'm going to lay out our model as we go here.
S yeah, I mean I think it's pretty intuitive you know for all of you in this room that this is a heterogeneic disorder. You know we have different psychological profiles, different biomechanics, we have different mechanisms of trauma. Different people really respond differently to trauma and boy is that the case in our clinic you know in terms of how variable outcomes can be. You know symptoms present across various forms: cognitively, sleep-wise, physically and really in terms of mood, and concussion is really - that's what makes sit fun. It's a complex heterogeneic problem that I think deserves more than a simple cookbook approach to managing it and frankly I think that's where the field has - I think we need to evolve beyond this sort of like you know rest and monitor approach, one size fits all kind of way of looking at concussion because it doesn’t work that way, it just doesn't. And you know the way we look at this injury is in a very complex heterogenic way and there is multiple reasons for that.
We've been doing this for quite a while at UPMC. It's a team effort, it's a multidisciplinary place that we've literally learned from each other and there is a lot of - a lot of people working together to make this successful. And our program which is housed in Sports Medicine and Orthopedic Surgery is very sports medicine model that we employ in our clinic. Our treatment model or really our program is really based upon this model. You know we get referrals from directly from Noelle in the Emergency Room, I think we are in their discharge instructions and we have a policy in our program that we have to see patients within 24 to 36 hours l- I think it's 72 hours but we see patients who are concussed in the morning coming into our clinic. We also see patients from all over the country that come in you know hears after repetitive trauma and so we really do run the gamut in terms of what patients we see in our clinic. We get referrals, we have very good working relationships with the pediatricians in the local area. Athletic trainers are absolutely essential to managing this injury. I think at UPMC we hire is it 90 of them or something, we cover over 60, 70 schools. Athletic trainers are the frontline of this injury and we have very strong collaborative relationships and you know they tell us what they see.
We have a policy in our program that we have to see the patient face to face. It's a brain injury, we are going to see them clinically and I think it's absolutely critical that that occurs because of the complexity of the injury. We also have complicated out of region referrals, that's happening more and more and you know up to 25% of our patients are out of region. And these are patients that come from various locals that have been living with this stuff for a long time. So we treat you know the acute patient but we also treat the chronic patient.
And in our model, and this isn't the case in every model but our model the neuropsychologist the point guard. It doesn’t' have to be the neuropsychologist but in UPMC is it. We have I think 7 attendings now or 8 attendings in our program, we have 6 clinics across Pittsburgh and each of our sites we have our treatment team located together and the neuropsychologist will do the initial evaluation, we will do the clinical interview, we will do vestibular/oculomotor screening, we'll do neurocognitive testing and we'll conceptualize the problem and conceptualize the treatment plan for the patient and determine return to play, etc. But in the same building as the neuropsychologist we also have the following professionals, primary care sports medicine is essential to our success, Kelly Anderson who you'll hear from tomorrow is part of our program, Mark Seiko is another primary care physician that's part of our program. We also have PM&R that I feel is a really well trained discipline to manage concussion, we wouldn't be as successful as we were if it weren't for their involvement and you know they do a lot of our neck stuff, they'll do injections if needed, medication management, etc.
I think perhaps the most important part of our program I feel is our vestibular and exertional therapists. That's the team that we take to our different sites. So when I see a patient in our clinic if we have a vestibular problem that's present we will actually on the same day start treating that patient typically, not always but sometimes. And we really bother the hell out of our therapists because we are like hey, can you squeeze this patient in? And usually they are very amenable to that, Cheri is smiling back there and shaking her fist at me.
But we in real time can start to treat the patient that we see. And we are becoming very aggressive in terms of applying treatments early on with this injury. Exertion therapists, for those of you not familiar with that term, that's our physical therapists who all they do is work patients out. And if you can find out where this injury is breaking down we can actually rehab it by exposing it. And really exertion, if you ask patients that go through our program what's the most important part of the treatment that occurred for you probably maybe 60% of them will say exertion. It's such a critical piece of what we do and Cara Troutman will be here to present that to you tomorrow. I don't think they would have gotten to that point doing exertion if it wasn't for our vestibular therapists, and usually that's the second thing they say or the first thing they say is that the vestibular therapy was very beneficial. But we are very hands on with our treatment. There are no dark rooms in our clinic as you'll learn. If you see me you are probably going to workout because again if we can find out where this thing is breaking down we can treat it.
Orthopedics and neurosurgery are critical, Dr. Maroon, David Okonkwo, I don't think we would be evolved as we are if it weren't for them and you know David coming on this way in the last 5 years has been amazing having him as part of our program, and really you know getting the biomarkers and the neuroimaging to correlate with what we are doing, we are working on it. And lastly behavioral neuro-optometry is an important critical component as well and you are going to hear that tomorrow as well, Dr. Nathan Steinhafel is our behavioral optometrist that we utilize most frequently. We have a few, but there is a lot of folks going through vision therapy in our program and you'll hear from that tomorrow.
But you know it sounds cliché but it really does take a village in terms of managing concussion. It's teamwork, it's learning from each other and I also want to make sure you hear me say that it doesn't have to be neuropsychology in the middle of this model, no one owns this field. And it could be neurology, PM&R, it could be primary care, it could be pediatrics, there is a lot of different folks that can be in the center there. In fact you know we had a meeting here recently in Pittsburgh and I'm going to talk about you know in my next lecture where we had a big meeting here in Pittsburgh and we heard form people from like Javier Cardenas down in Arizona and you know his model - we ended up doing the same thing but his model is different, he's got occupational therapy and speech therapy in there. You know I often, I feel like this is the Galapagos Islands you know, you evolve with what's around you and we are in sports medicine so that's our model. It doesn't have to be the same model across places, we are all trying to do the same thing. If you really listen to how we treat the injury when you listen to these different treatment programs across the country. Bill Mehan would be another great example, we are probably doing very similar things you know in terms of how we treat it.
In terms of how we assess this injury I can't stress enough how important it is that we approach this from a multi-tool comprehensive way. If you think we manage concussion with an impact report you are sorely mistaken, we don't. It's one piece of the puzzle. I know that's cliché too, but it's true. We use that data as a barometer as to what's going on. There is a lot of information in there that you can glean if you really know how to look at that stuff, different profiles with different data points, different severity levels with different data points. It helps us understand the different trajectories and you know is anxiety going on here? Is it migraine? Or is it vestibular? Is it ocular? The data tells me so much but it's got to be augmented with understanding the vestibular system and understanding the oculomotor system. And actually seeing your patient, talk to your patients and find out what's going on. Different symptoms beget different profiles, beget different treatments, beget different rehab approaches. Know your patients, know your tools, know how to put it together, very, very critical that you look at this injury in a comprehensive way.
And for us here in Pittsburgh exertion is a key component of our assessment. A lot of times I don't know entirely what's going on until I work the patient out. And you can actually when you really move up their dynamic activity you can see the problems. And we know how to do that in a way that we communicate it to each other, and I talk to Anne, Anne talks to Cara, they talk to me, we talk to Kelly Anderson, I mean if you follow me for a day in clinic I'm up and down the stairs and all day long we are communicating as a team. Absolutely essential that that occurs. Now not everyone has this okay, and I don't want to be presumptuous to think that every one of you have the ability to work in a multidisciplinary way because most of you don't. The model we have is I'm going to share with you what we do. I just think it's important to learn some of the pearls, the clinical pearls of wisdom that we are learning from this model.
So what we do is we put this information together, neurocognition, symptoms, oculomotor and vestibular and we do this mostly through the VOMS. The VOMS obviously is a screening tool you are going to hear more about. If there is a more extensive vestibular problem going on we'll - I'll send it down to Anne and she'll do her full evaluation. But once you put this information together you can establish a lot of different things. You know you can establish diagnosis, you can establish prognosis. You can't establish diagnosis without all of these tools together, you just can't do it. Neurocognitive testing is not a diagnostic tool, it's a tool. And neither is vestibular/oculomotor screening, you know it's got to be put together.
I think the most exciting - some of the most exciting things we've done is really start to establish prognosis. Like we understand which symptoms predict worse outcomes and which kids risk factors for poor outcomes, and you are going to hear so much data from Anthony regarding that issue. We really spend a lot of time on that issue. Most importantly this information we collect establishes our treatment protocol and it establishes the profiles that are playing out. And my treatment of the patient is going to be completely predicated upon what profile we are dealing with. And the treatments could vary tremendously depending on how we conceptualize the injury.
And for every clinical profile we have different academic considerations, we have different exertion considerations, different return to play considerations, different treatment considerations you know rehab considerations and specific return to play expectations and plans. So that's really our model in terms of how we assess the injury. And this is where we are going and have been and are evolving in terms of how we really start to think about concussion because I don't think about concussion in a homogenous way. When I come out of an exam room with my fellow and we are talking about the case we are like okay primary is vestibular, secondary is ocular, tertiary is anxiety you know and that's code for a whole different treatment than primary is anxiety versus tertiary is vestibular. It's completely different approaches that we would have depending upon primary, secondary, tertiary issues that are at play and this the language that we speak when we are in our clinic.
And for every circle we really have different risk factors, different symptoms, different treatments, different findings on impact or neurocognitive testing, different findings on VOMS and I'm going to break it down for you as to how we conceptualize this. I think most importantly we need to be evidence based as we move forward with our treatment model and it's becoming more and more so. Again we don't have randomized controlled trials at this point, that's really the next step. But there is an evolving literature supporting that this injury really presents itself in a heterogeneic fashion and that these different cognitive - clinical profiles mean something.
So let's now kind of switch gears in terms of how we conceptualize each of these different clinical profiles. And what I'm going to focus on for you is I'm going to go over 5 of 6 of these circles, I'm not going to talk about the cervical stuff because that's really not my expertise. We'll have Brian Hagan who is our PT extraordinaire with the neck, he's going to be presenting on that today or tomorrow I think; but I'm going to focus on these 5 circles and talk about for each circle what are the risk factors for that circle, what are the symptoms, what are the findings on neurocognitive testing, what are the findings on the VOMS and what are the treatments for each circle. Please understand, I can't stress it enough that it's very rare for a patient to come in with one profile, it's usually one on top of another. But there is not many cases where we don't say there is a primary, there is a bus driver, you know the primary trajectory versus the secondary trajectory, you know. So we will - there is always one leading the charge and again that's how we conceptualize things.
But for teaching's sake and the fact I have a half an hour to do this I'm going to try to do this in simple form and share with you what we are learning for each of these circles okay. So the first one I want to talk about is the vestibular system and vestibular, the vestibular profile in terms of this injury. We've learned a lot and you are going to hear a lecture tomorrow or today from Anthony that is going to show you how much data we have which is evolving rapidly in terms of what we are learning about this - about this type of profile. But we've learned that up to 60% of youth in sports, youth and adolescents experience vestibular symptoms following concussion and it's a pretty predominant concern that we see. If you are not treating this stuff you are probably missing it because it happens quite frequently in our patients. It doesn’t happen always, we have patients that don't have vestibular problems, many of them but it is a common type of problem that we see.
Now given that concussion is an energy crisis as Bill aptly went over this morning you know concussion fights dirty. And whatever you bring to the table that is works a little more laboriously than someone else usually that's the system that's going to be outed when you take a trauma to the head. And it really makes senses conceptually you know, what you bring to the table is what's going to become a problem if you have preexisting issues. And we are learning that pretty dramatically in our clinic. And for the vestibular problem patients that have a history car sickness and motion sensitivity Anthony is and us have just published a paper, I don't even though if it's out yet. Anthony, is it in press? I'm not sure, but we found that history of car sickness really does predict worse outcomes following this injury. And we actually ask that question quite commonly and one of the first questions I'll ask is do you have a history of car sickness because patients that have a history of car sickness seemingly have a blow to the head and will have this vestibular presentation much more commonly. And now we have data to support that.
But they symptoms that we'll commonly see from a vestibular problem is more of a slow and wavy kind of dizziness. If it's rapid and spinney dizziness we are typically thinking more peripheral vestibular, if it's slow and wavy we are thinking more centrally mediated systems. I'll let Anne talk about that much more extensively. But that slow wavy dizziness is kind of the hallmark of patients with a vestibular problem following concussion. They'll often feel foggy, kind of one step behind, detached. They may get nauseous particularly in cars, they may get nauseous with visual motion sensitivity in grocery stores and shopping centers and busy places. And we've also found there is a very strong proclivity for patients to become anxious that have vestibular dysfunction.
And I can't underscore that relationship enough to you is that we wonder if the vestibular system when it's affected physiologically triggers anxiety because these systems in the brain are very similar mediated. The emotional centers and the vestibular centers if you really look at deep brain structures we have a lot of synergies there between pathways. And patients that have a vestibular problem will then become anxious, and then when they become anxious they condition themselves not to feel the crap they feel when they have a vestibular problem right, because it's nausea, it's dizziness, it's that kind of crud feeling. And so patients will actually become more reclusive, they'll become avoiding busy places, they won't want to be social, they won't want to workout. And then all of a sudden you start adding that to anxiety and you can see pretty rapidly how someone can go down the rabbit hole, particularly when how do you treat a vestibular problem? Not rest, exposure, exactly the opposite. And so when I see a clinician that says you now a pediatrician or whatnot that says you know they sit in a dark room and don't do anything, don't use your phone, don’t use the TV, stay home from school 19 times out of 20 that patient is going to have a lot of anxiety. And I think it's mediated not only by the vestibular problem but by the way it's been managed. And it just feeds the problem you know. And that's a huge issue for us in our clinic because you are just not treating it the right way if you do that, this type of concussion that is.
So the question you want to ask is this a vestibular problem. I mean you can ask a lot, but do you become dizzy, foggy or experience a headache when taking notes in school, walking down hallways, being in grocery stores, being in car rides? And again because the vestibular system is - it's the job of the system is to interpret motion and movement right. The system is going to be affected when you workout dynamically. It may not be affected on a stationary bike and you know a treadmill, it's really when you start moving dynamically is when you start seeing the problems. And so our treatment model we don't really - we are going to move people dynamically. It goes way beyond a treadmill in terms of what we look at with this injury. We feel a lot of this injury is coming from the system and that you really have to stress the system dynamically to understand if there is problems.
Now on the VOMS of course you are going to pickup provocation with VOR, you know which is your ability to stabilize your vision when you move your head in both horizontal and vertical ways. Or you are going to pick it up when you have to inhibit vestibular induced eye movements with what we call visual motion sensitivity. Anne will be talking about that, but the VOR and VMS part of the VOMS is critical to understand if there is a vestibular component in the patient's presentation, okay. And we screen this in our clinic as neuropsychologists but I'm not going to do a thorough evaluation, I'm going to send it to my vestibular therapist for that.
On ImPACT we've learned that, and we need more data on this for sure, but we've really seen relationships between vestibular dysfunction and deficits on visual motor speed and sometimes reaction time on ImPACT. And you know if you look at an ImPACT report we are finding that when you see a score like this there seemingly is a pretty strong relationship between deficits in that domain and what we are seeing from a vestibular standpoint. So looking at the neurocognitive data can start to give you a glimpse of what's going on. And you know when I see a patient that has a history of car sickness, is female, you'll learn more about that from Anthony, is experiencing a lot of environmental sensitivity, they have visual motor speed deficit on ImPACT and they have increased provocation with VOR and VMS I mean that's pretty easy, guys, that's a vestibular problem you know. And you get that collaborating information and you can really start to understand how you are going to treat this. And you are not going to treat this patient with rest. If you do you are going to end up having a lot of problems I can promise you.
So what we do from a treatment standpoint depending upon the severity, depending upon you know we are starting to - do I send everyone to vestibular therapy a day after their injury if they have vestibular problems? No, of course not. You've got to be careful with the vestibular system because if you actually - if there is a migraine component to it underneath and you push that system too hard you are going to get migraine, which you don't want to do, okay. And if you push it too little you are not going to get them better. And so with this type of patient behaviorally we are going to really recommend regulation. You know I don't want them taking naps,, I want them regulated with their sleep. I want a bed time and a wakeup time. I want expose, recover. I want them to go to places that make them feel crappy and then recover. And depending upon a variety of factors I will refer these patients to vestibular therapy. If I see anxiety building quickly in my patient I'm going to get him down to Cheri or Anne immediately because we've got to start treating that, it's starting to set in. Okay, so anxiety is something where I'm going to say okay I'm gong to get them to vestibular therapy. I can tell you that without question we are becoming earlier and earlier and earlier in our treatments of this problem in our clinic, I think because we've become more confident in how to treat it. Our outcomes are getting better and so because of that we're going to be more aggressive in getting these patients into vestibular therapy.
And you know I also want to state, and I hope Anne talks about this, but you know all vestibular therapy isn't created equal. It's very important that I feel a neuro-vestibular therapist be involved with neurologic training because they really understand the nuances of this and you can get yourself in trouble a little bit if you don't understand the subtleties of what's going on. It's a field that's evolving and there is a lot of disparity in how it's treated from the vestibular standpoint frankly. Now when you do treatment of the vestibular system it's very common that you hit walls in one of three areas, and if you hit walls you may need pharmacology to help you get over those walls. And the three different types of walls that we hit in terms of vestibular therapy is anxiety, migraine and sleep. And if those problems are ongoing just if you are doing vestibular therapy and not seeing progress with the vestibular type of patient it's because of one of those three issues, mood, migraine or sleep. And sometimes you need pharmacologic support to help you with that. So for the sleep issues we'll often try Melatonin initially, if that doesn't work we may go a little more extensive. If it's migraine we'll often go with tricyclics and if it's you know anxiety we will often go with Clonazepam or even Zoloft sometimes depending on what you see. But Kelly Anderson is going to talk about this tomorrow in greater detail.
The second type of concussion that we or profile that we commonly is anxiety. And I put this next because there's such strong relationships between the vestibular system and the anxiety that we see in our patients. And you know there's been a pretty good literature coming out on this more and more. I don't know what it is, I don’t' know if it's the hysteria around concussion or if it's clinicians shutting kids down too much or if it's physiology but my God do I see a lot of anxiety with this injury you know. And I'm not going to make light of that, you know we can sort of like it's emotional and it's anxiety but boy is it a problem. It's you know this is a serious issue that needs to be treated. And we can kind of smile about it, anxiety is anxiety you know, but if you don't treat it you can find a lot of kids with a lot of problems in a lot of rabbit holes. And we see suicidality in these patients, emotionality. That's very serious and it's a problem that actually needs to be treated.
And if you don’t know how to treat anxiety you can - boy you can have some bad outcomes. And you teat anxiety by exposure, you don't treat it by rest. And you have to understand this, this profile is tricky; but the risk factors for anxiety is a person with a family history of it. You know I write this down the mom or dad of the child has a thick notebook and we might chuckle about that but it's so diagnostic, I don't think it's ever failed you know. Right? Another thing I've picked up when you walk into a room if the child looks at the parent before they answer a question it's - I mean there is tremendous anxiety. The dynamics there are powerful. I was talking to Joe Maroon last night at dinner about how when you walk in a room there is so much that happens and you can pickup on this stuff pretty quickly, there is a feeling you get you know. And it's something where I get that feeling a lot recently in my practice frankly.
You know another trait of anxiety is being very analytical. You know we joke about this but it's you know it's engineers. You know they are all anxious, I don’t know what the hell is all going on but they are. You now it's people from Cornell. Jo Fleisher, where are you? There she is, yeah. It's people from you know ivy league schools, it's the very analytical person. Not that you are anxiety Jo, I love you to death, she is my fellow. But we see a lot of folks from that university I might add.
But anyhow but the symptoms we'll see in our patients with anxiety is you know they are very ruminative, they can't turn their thoughts off, they are hypervigilant, they can't fall asleep, they can't stay asleep, anxiety attacks at night you know it really comes out at night because the frontal cortex is shutdown and that's when it sort of evokes. And you also see a lot of self-limiting behaviors in these patients where they will actually - if I walk into a room and the patient turns to see me and moves their shoulders like this instead of moving their head, it's an immediate cue that they are self limiting. If you walk in and see some sunglasses on a table or they've asked my MA to turn down the lights I mean are they sitting up there rigid like this it's anxiety you know and those are the things you've got to look for in your patients. And if you see that and there is a vestibular problem and if you don't activate these patients you are in trouble. You've got expose, recover is the way I look at it. You can't feed this, you can't enable this in your patients. And boy has that made it the one thing we've learned in our practice.
Some questions to ask, how often do you take inventory with your symptoms? Do you have a hard time turning your thoughts off? Do you become symptomatic when thinking about your symptoms? If I ever see a kid - if I see a kid that's watching TV and gets symptoms it's anxiety. You know I mean it's like you know maybe they've got a little VMS going on or maybe they you know have a little bit of - but it's usually anxiety you know. And if you enable that and kind of reinforce it it's just going to get worse. There is no patient I've ever told you can't watch TV, there is no patient I've ever told you can't use your cell phone, all right. There is no patient I've told you know don't - you know I want them to go to busy places, I want them to expose to places that make them feel it because that's how you get better from this stuff.
On the VOMS there is really two different things you have to look at on the VOMS. If the VOMS is normal with these patients, these anxious patients, that means you are going to really push them hard exertionally, all right. If the VOMS is abnormal or if it's sensitive I'm going to send down Anne and we'll do a more detailed evaluation and then we are going to treat the vestibular problem first or you know treat it and then attack the anxiety or do it concurrently. But you've got to be careful with that vestibular overlay with this patient because it's so critical you approach it the right way. Neuro-cognitively it's so critical to understand what to look at you know.
If you see this profile that's - and there is a lot of symptoms it's typically anxiety okay, because it's very hard to score it to 96 percentile on visual motor speed and have a vestibular problem, it just doesn’t happen okay. And this data can give you a really good understanding of how to approach this stuff. If you have a data point like this and there is a lot of symptoms and anxiety then there is probably a vestibular component. You want to be careful with those patients and make sure you screen for the vestibular stuff before you push them too hard exertionally. But if you have anxiety I'm going to get you busy, I'm going to get you moving.
How do you treat anxiety, and there is a lot of good research on this. You know psychotherapy can help, but really it's about expose, recover. If none of you have read this author you know he's done some really good work and it's really about - if you look at the literature on it, it's exposure that you've got to use to get them better. Depending on the vestibular component of the injury you've got to be more or less aggressive with your exertion. Look, if you've got a vestibular problem and you work some out and you get a migraine it's not going to kill them. You know I mean it's going to make them feel pretty crappy and maybe reinforce the anxiety I might add, but they are not going to die, you know. I mean we are going to push these patients you know, don't be afraid to push your patients. It's very important. And obviously the behavior regulation is our secret sauce. You know make sure in these patients you don't let them take naps, go to bed same time, wake up same time, expose, recover all day. Same time you eat your meals, you now hydrate a lot. Try to be regulated in your management and that of course helps with migraine too. If we run into major problems with anxiety we'll often go the SSRI route or sometimes go the benzo route and I'll let Kelly Anderson talk about that tomorrow.
All right the third type of profile that we see is oculomotor. And you know the ocular stuff is something that is - does play a role in our clinic and you know if you talked to me 3 years ago I would have said oh my goodness this is the next greatest thing, it's huge, it's big, and I still feel it's important but it's not any more important than any other circle okay. And we do see oculomotor problems here but we see a lot of oculomotor problems in people that are anxious, it doesn’t come from concussion it comes from anxiety you know. We see a lot of oculomotor problems with this injury for sure but that's the thing I'm trying to relay to you is you can't manage concussion with one tool or one thing or one circle, it's all of these things you've got to look at. And this is as important as other circles but it's no more important than other circles.
Now you know this along with vestibular function is common follow concussion or you know our research shows that 42 to 69% of concussed adolescents at least will have oculomotor issues following a concussion, that was done by Kelly Pearce, one of our fellows. And Tina Master has done some work on this as well. But this here, you've got to be careful with this, it's a little different animal. And of course the oculomotor system is tied to the vestibular system so if you really affect one you may affect the other. You've got to be mindful of that, but we do see patients with isolated oculomotor deficits that don't have any of those circles going on. And quite frankly it's, that case takes the longest to treat sometimes but it's the easiest case to conceptualize because people with oculomotor problems if it's isolated they are going to get frontal headaches, they are going to get more headaches when they do their school work, math, science, they are going to be really tired at the end of the day. And you are going to be able to see it in the VOMS typically with near point convergence measurement, accommodation measurement and you know and it's just so coherent.
And on neurocognitive testing they almost always have problems, ImPACT is really good at picking up on this all right. If you have scores that are grossly impaired and the patient is putting forth good effort and you understand the raw data, it's very likely they are not going to look real good on neurocognitive testing because ImPACT is an oculomotor exam right. You know you are taking on a computer and the computerized neurocognitive tests are particularly good at picking up on this type of concussion. And you see grossly impaired scores, you are going to typically - and the oculomotor stuff is not far behind. And also on neurocognitive testing we will often see that their encoding with information is worse than their, or you don't see memory problems you see problems with taking information in. You know memory is three things, it's encoding, consolidation and retrieval. And if you have an oculomotor problem you are going to have problems taking information in rather than retrieving it. And if you see this profile in neurocognitive testing with the Immediate trial, see this guy he's at 6 and 6, he's 12 and then the delay trial 6 and 9, is 15, he's actually remembering more than he took in, that's a sure sign of someone with an oculomotor problem because it's really about taking information in and that's what the oculomotor system affects. Understood? And you are going to see that both across verbal memory and design, word memory and design memory.
But the questions to ask of your patients usually oculomotor stuff is more frontal with the headaches. They'll feel a pressure behind the eyes, they get - their eyes feel heavy. They'll end up feeling really tired and patients that have very circumscribed problems with math and science you've got to look at that because that's really where the system is breaking down. On the VOMS you are going to pick it up sometimes in Pursuits and Saccades, not always, but you know near point and convergence anything greater than 5 cm is typically a sign of problems unless it's preexisting which we do see a lot of that. And again you are going to see this type of neurocognitive profile.
Now how do we treat oculomotor issues? Well a lot of times we'll start with vestibular therapy because our vestibulare therapists do a really good job with oculomotor dysfunction and they will try vestibular therapy early on sometimes. But if there's a big exophoria, 20 cm or greater, if their recovery is off, their accommodation is way off, if they have an ocular misalignment you know it's pretty - I'll send the patient down to see our vestibular people and they have - Anne is going to go over the test that she looks at with this stuff, but it's pretty obvious when they need vision therapy. And then we'll pull in Dr. Steinhafel at that point and say all right, the Hof, you know we call the Hof, he's like the wolf in pulp fiction, you know he cleans up all the messes. But you'll meet him tomorrow. But Steinhafel will come on the scene and really help out with these patients.
Now interestingly when there is circumscribed and focal oculomotor problems patients can workout until they are blue in the face and not feel anything. And so I see patients that come in, they have all these symptoms in school and academic based stuff, and they've been told to do nothing and I see an isolated oculomotor problem and I'm like this is easy, let's get you moving, man. Let's get you downstairs and get you working out. And these patients won't feel a thing and they come back, they are like oh my God thank you for letting me workout. I've done nothing. And remember and I'd like to hear Anne and Nate Steinhafel's comments on this but there is a very strong relationship between oculomotor dysfunction and anxiety too. Anxiety can evoke through the oculomotor system, anxiety can evoke through m migraine, anxiety can evoke through a lot of different things. And don't you know don't forge the role that plays in the system as well. It's very important. And so a lot of times we work patients out with this problem and they get better like really quickly because they get rid of their anxiety. Okay?
All right the fourth type of profile is cognitive fatigue and I call this one the white lion because it's very impressive when you see it but you don't see it a whole lot. And I think it's changed over time. There used to be a lot of this in patients that I saw because they pushed, patients pushed too hard back when I started doing this, a long time ago. And no one cared about concussion you know, and I think if you reflect back on those early years with Mark and Joe and you know in early 2000s we were probably seeing way more of this back then because everyone just pushed through concussion. And when you push through concussion I think the consequence of that is this problem, cognitive fatigue.
And this is the hardest one to treat for us, guys, and I get a little worried when I see this one. Worried meaning there is no easy treatment for it, okay. And I'm going to talk about that, but cognitive fatigue happen s lot in our NFL guys, it happens a lot in our professional athletes that are just animals you know and they are just - they are not feelers, they just go out there and bang heads all day and don't really feel it and you know keep playing through it. And this one is an interesting one to me but you know fatigue, let's define what cognitive fatigue is. You know we see for some reason we are seeing that a history of learning disability or ADHD may pose a risk for this. Don't know, it's not been researched totally.
But the symptoms we'll commonly see from cognitive fatigue is a lot of you know low energy at the end of the day, they may or may not have sleep problems, they just feel worn out. These are usually the patients that have gone back to work like and just pushed through this and you know haven't really taken breaks and just kind of pushed too hard. Theoretically I think these are the patients that kind of re-habituated the vestibular and oculomotor systems on their own and didn't do a real good job of it. And they overdid it. That's how I look at this problem. Because they can self re-habituate right. But I think there may be consequences if you don't do it the correct way I guess is how I conceptualize this.
And you know on the VOMS sometimes because they've sort of re-habituated this you don't see a lot of remarkable findings in the VOMS. They may have even like re-habituated the oculomotor system but we will see problems more with memory than encoding in these patients. So these are patients who take information in but then forget it later on. And the profile is a little different on neurocognitive testing. See how there is 12 and 12 and the 7 and8? I meant this kind of cues me into this might be going on. And you just see their performance worsen over the course of the tests. You see the 3 letters test is really off, average count, average counted correctly, they are just sort of minimally to moderately compromised on neurocognitive testing and they have more problems with memory than they do retrieval. And they are tired all the time and you know sometimes there is emotional stuff that they just plow through, it's worrisome when you see that. Sometimes there is sleep problems when you see it.
How do you treat it? Well good luck. You know I mean it's something where we might be able to do some breaks, and this is where we've had some success with Amantadine. And I'm going to tell you 6 years ago if you came to watch me at this lecture we talked a lot about Amantadine, we rarely use Amantadine anymore really, rarely. I don't know, Anne, how many patients do we use Amantadine with? When we use meds probably about 10% of the patients now maybe?
One in ten.
One in ten, yeah, I think that's right. And so you know Amantadine is not going to really help unless it's this type of problem going on. And again you've got to hit the target that you are trying to treat right, and this is the type of patient that could benefit form a neuro stimulant. And then cognitive rehab in protracted cases and you know we don't do that a whole lot, cognitive rehab, but in patients that have cognitive fatigue I think it can be very helpful in some of those patients.
All right, the last trajectory I'm gong to talk about is migraine. Very important to understand this what we call posttraumatic migraine. And for the neurologists in the room you know it's we conceptualize it maybe a little - I don't know this is how we look at this. You know by definition these patients will have a headache with nausea and/or light or noise sensitivity, meets International Headache Society guidelines for migraine. They typically these headaches may occur in the morning, we see that a lot more. They can be intermittent, they can be severe. Sometimes they have an aura, sometimes they do not. But these patients are typically very dysregulated. These are patients that have come to us, they've been in dark rooms for a long time and then patients get migraine when they are not working out, when they are stressed out, when they regulated with their diet or hydration. And so sometimes - we see a lot more migraine in patients that have been treated very badly with the behavioral management stuff you know that these are kids that end up evoking migraine. And we think there is a vulnerability to this in patients recovering from concussion. And a lot of times this is not only migraine but you see vestibular migraine, you know dizziness and things associated with the migraine.
You know on the VOMS you can see provocation with this group and you can see a clean profile. I think that's critical. when you do a VOMS with a migraineur and if that is non-provocative you know what I'm doing with a patient? I'm working them out heavy. I saw a patient recently who came to me and had a 7 out of 10 headache, had had an injury a couple of days before, had dysregulated things. Came to me this week I think I saw this patient, and he comes in, he's gout a 7 out of 10 headache, pressure you know, nausea, light/noise sensitivity. I do the VOMS, it's totally normal. I'm like go down and see Cara Troutman. I walked him down to see Cara Troutman and we pushed that patient so hard and the patient's headache went away, whisk, gone. You know not that it happens all the time but don't be afraid to workout patients, you know especially if they fit this profile without migraine and vestibular.
So you know on ImPACT we'll and we published a paper on this, we see with migraine neurocognitive testing we'll often see problems with verbal and visual memory for whatever reason. And if there's a vestibular component you'll see problems with visual motor speed deficits as well. How do we treat this? Regulation is huge, you know regulated sleep, hydration, diet, exercise, stress. We may need to go medications you know tricyclics or sometimes others, and I'll let Dr. Anderson talk about that.
So really in summary you know what we see is people bring certain things to the table when they get hit in the head. They get hit in the head, we have these different problems that can arise and your treatments are going to be really predicated upon what problem occurs. And you know I kind of put this together late last night. I was just thinking you know with this conference stuff it's always time for reflection right you know. I'm like how have we evolved as a program? And I frankly don't know. I was talking to Tom Frenaught this morning, where are you? And you know you haven't come down here for a few years, we were chatting this morning and I don't know what's different now versus what we did 3 years ago. We live it every day, I just don't know. So I try to put on paper what I think are the most important things we are seeing with this injury right now and what we are learning and what may be different that we've seen over the last few years I think we are really focusing on these clinical profiles. I think it's essential to think like that. This is my bias, but that's how I feel about it.
I can't tell you how important teamwork is. It's so critical to work with a team. I'm not going to treat vestibular problems, I'm not a vestibular therapist all right, I'm not going to exert someone, I'm not a PT that does that. I'm going to rely on someone to do that for me. It really takes communication between really well trained people to provide the optimal care that we hope we are getting. You know, know your tools, know your patient, know how it all fits together You know they've got problems with verbal or visual memory, there is a family history of migraine, you know the patient is exhibiting a certain presentation that's going to be a totally different treatment than someone that has a vestibular problem you know. And it's going to be - it's so important to understand how this all fits together.
The secret sauce is really the right amount of activity, it's behavioral regulation and matching the right treatment to the right problem. I mean that's it in a nutshell. Find out where the aberrant signal is coming from, figure out what it is and treat it. We have treatments for all of this stuff guys, it's not the bogy man, this is something that's manageable.
Expose and recover are words to live by. I do not rest my patients, I let them expose, I let them recover. And that's a big different than what's written out there internationally. Know how to treat anxiety and migraine because they are ubiquitous. If you don’t know how to treat those things you probable shouldn't be doing this stuff because they are everywhere. And it's really important. And really it's about process not protocol. There is not a protocol that's going to manage concussion for you, there is a process you have to understand and conceptualize in this injury in approaching each case individually. That's how I feel about it. And where the problems in the field are occurring is we are trying to come up with these protocols that take care of everyone. I feel badly for the - how many university folks do we have here, college people? You know I feel bad to have to write protocols to manage this because how are you going to do that? You can't manage concussion with a protocol, and the NCAA is requiring you to have a protocol and if you work outside the protocol you get in trouble, right? How do you do that? I don't know.
You know and that's my next point, you know don't be afraid to think and practice outside the consensus box. That might worry some of you because of the medical/legal implications of that, but if you are using International Consensus Statements only to manage concussion you are probably not managing it very well because what we are talking about here is not what's in those Consensus Statements and hopefully that Statement this year will add to the depth of this. I don't know.
And lastly, concussion is treatable, I think that is so critical to understand. All of the stuff I've presented today to you is a treatable problem. Thank you very much for your time.