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Emerging Frontiers in Concussion - Sessions 3: Emerging Research in Concussion
Doctors R.J. Elbin, Alicia Sufrinko, and Anthony Kontos review topics on the consequences of continuing to play following a concussion and the emerging finding on evidence behind patient-centered concussion care.
Upon completion of this activity, participants should be able to:
- Implement early treatment and management strategies for patients who continue to play with concussion, which will result in improved recovery outcomes.
- Educate patients and youth sport stakeholders on the consequences of continuing to play through a concussion, which will improve recovery outcomes in youth sport athletes.
- Discuss the importance of removal from play as a contributing risk factor for prolonged recovery with patients, which will encourage patients not to continue to play with concussion and seek medical treatment immediately following injury.
- Describe the role that preexisting sleep problems play in outcomes following concussion
- Identify family history as a risk factor for migraine post concussion.
- Describe neurocognitive impairments and recovery outcomes in patients with convergence insufficiency following concussion
- Describe the role of risk factors and profiles in conceptualizing concussion clinical research.
- Analyze emerging evidence for risk factors and clinical profiles in relation to patient care.
- Examine new evidence that rest may not be the best treatment strategy for all patients.
- Asken, B. M., McCrea, M. A., Clugston, J. R., Snyder, A. R., Houck, Z. M., & Bauer, R. M. (2016). "Playing Through It": Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Train, 51(4), 329-335. doi: 10.4085/1062-6050-51.5.02
- Kontos, A. P., Elbin, R. J., Lau, B., Simensky, S., Freund, B., French, J., & Collins, M. W. (2013). Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. American Journal of Sports Medicine, 41(7), 1497-1504. doi: 10.1177/0363546513488751
- McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R. J., . . . Turner, M. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine, 47(5), 250-258. doi: 10.1136/bjsports-2013-092313
- Sufrinko, Alicia, et al. "The effect of preinjury sleep difficulties on neurocognitive impairment and symptoms after sport-related concussion." The American journal of sports medicine (2015): 0363546514566193.
- Pearce, Kelly L., et al. "Near point of convergence after a sport-related concussion measurement reliability and relationship to neurocognitive impairment and symptoms." The American journal of sports medicine 43.12 (2015): 3055-3061.
- Blume, Heidi K. "Headaches after concussion in pediatrics: a review." Current pain and headache reports 19.9 (2015): 1-11.
- Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular and ocular motor screening (VOMS) assessment to evaluate preliminary concussion: Preliminary findings. Am J Sports Med; 2014; 42(1), 2479-86.
- Pearce KL, Sufrinko AS, Lau BC, Henry LC, Collins MW, Kontos AP. Relationship of near point of convergence to cognitive impairment and symptoms following sport-related concussion. Am J Sports Med; 2015; 43(12), 3055-61.
- Root JM, Zuckerbraun N, Brent D, Kontos AP, Hickey R. History of somatization is associated with prolonged recovery from concussion. Peds; 2016; Epub ahead of print.
Drs. Elbin and Sufrinko have reported no relevant relationships with proprietary entities producing health care goods or services.
Dr. Kontos has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- Grant/Research Support: GE-NFL Research Contract to Pitt
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 (0.1) continuing education units (CEU) which are equivalent to 1 contact hour.
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Release Date: 12/16/2016 | Last Modified On: 12/16/2016 | Expires: 12/16/2017
Before I get started I want to send out a thank you for having me to come and present these data, Dr. Collins, Dr. Okonkwo and Dr. Kontos and the rest of the programming committee.
And really to follow-up that last talk is quite a task, but for my talk I really want you all to think about the other end of the injury. So athletes are on the field, they get a concussion, what should they do? What should the athletic trainer, the supervising sports medicine professional do at the time? You know in detecting a concussion and having these athletes report their concussions, and removing athletes from play has been at the forefront of maybe the first line of prevention. It's been certainly a topic in the literature and also in the medial. And so we've conducted a study actually evaluating that. So is it really bad to keep playing with a concussion? It makes sense, we all think it is; but as Dr. Kontos alluded to until now we don't really have any - we haven't had any data to look at outcomes between kids that remove themselves or are removed or kids that hey, I didn't tell anyone, I kind of got hit pretty well in the first quarter but finished it, it was a pretty important game, but how do they look later on?
So a little bit of background. International Consensus Statements in the pasta couple of years all recommend and there is unanimous agreement on this, it's also legislative now for the immediate removal from play following suspected concussion. And why? Well the reason is we mitigate the risk of the catastrophic outcomes right, and we also lessen or think about the compromised neurometabolic consequences that are happening in the brain that Dr. Mehan alluded to earlier. We can mitigate that with immediate removal. The athlete is not getting hit in the head anymore, the athlete is not running anymore, not being physically exerted, immediate removal from play. Okay, it is recommended in International Consensus Statements and in current guidelines. However, removal from play involves on detecting symptoms, some observable overt sign of the injury, right? So what are we doing? We are educating athletes. We are educating coaches. We are taking the approach that if we can increase education maybe we can - maybe some of these athletes will take themselves out of the game, or we can identify some of the overt signs of the injury, such as on field dizziness, etc. However still more than half of these injuries we estimate go unreported.
So the current culture of concussion in sports, there has been some money thrown at this to change this whole culture. And you know what are the headlines here? So here is just an interesting headline, and for those of you that can't see it I'll briefly read it. Don't Tell Coach, Playing Through Concussion is the headline of this media release. And real quick, nausea sensitivity to bring lights, headache, this athlete knew right away that the helmet to helmet hit during practice had given him a concussion, his 5th in fact. So he knew just want to do. He reasoned that since only 10 days remained in the season he was both the team captain, he was a senior, he would tough it out and he would play. He's played through worse concussions.
And we see this in the media, right, we see this message right or these examples. And so this whole idea of playing through pain and injury that is pervasive throughout sport, the badge of honor when we keep going right, we can see this in hockey right now, we see this in the NBA finals. So this whole idea of playing through pain and injury doesn't really apply for brain injuries right? If you think about that, if we actually call concussion what it is, a brain injury, that's an interesting conversation to have with your head coaches those of you who are on the field. Stop calling this injury a concussion and start calling it a brain injury and see what kind of reaction you get, it's really an interesting little task there. So and what we are learning from some of the educational work is we are increasing concussion knowledge but we are not changing behavior. We are not changing reporting behaviors.
So what motivated this study, this is an interesting little story. As I was Dr. Kontos' post-doc down in the lab here before I took my position in Arkansas I was sitting in the lab one day and we had these posters, we had these posters around clinic, we had these posters in our lab, and this was one of the posters. It was a CDC poster and at the bottom if you can see it, it says it's better to miss one game than the whole season. I thought man, that sounds great doesn't it? But we've never had any data to really support this whole idea, right. It makes good logical sense but we really haven't had any data to really support this. So there's a theoretical and somewhat of a theoretical underpinning here. What may be happening if we keep continuing to play with concussion, even during the very acute minutes to even you know hours after injury what may be happening here?
So in going back to Dr. Mehan's talk we talked about the mismatch, the neurometabolic consequences that happen right after concussion, correct? And then in the literature if you look at some of the Vagnozzi work and also the Giza-Hovda paper they talk about this whole period of vulnerability, and this is that unmistakable sweet spot where we don't want especially younger athletes to sustain additional head impacts, right. This is where we find those very rare cases of catastrophic and chronic outcome. But the question that I had is what happens when we keep "playing" or exerting during this window of vulnerability? Does it change outcome? Does it make a difference, right?
So there was actually study in the past couple of months that was just published on this and the title was Playing Through It, Delayed Reporting and Removal from Athletic Activity, Asken and colleagues I think out of the University of Florida. And they went back to - now this was a college sample, they went back through medical records and they examined 70 or I'm sorry 97 college athletes and they looked at recovery time, right? They had 47 athletes that were removed from game, whether they removed themselves or whether they were removed by a sports medicine professional on the field: and then they also had 50 athletes in this sample that were not removed and here is what they found. College athletes that were not removed on average missed almost 5 more days than athletes that were removed, okay. They were also over 2 times more likely to have a prolonged recovery to which these authors defined a prolonged recovery as being longer than 8 days. Now depending on what literature you read some of the most recent findings indicate that recovery is a little bit longer than 8 days, okay, even up to 3 weeks depending on what type of multimodal assessment battery you use.
So there were some limitations to this study. First of all these authors and I commend their work you know as addressing this, there was a lack of data, there were no data supplied in this article to actually show what happens over time, you know, and is there some measurable outcome or deficits between these two groups throughout recovery? What do they look like at one week? what do they look like at two weeks? And in addition I wasn't particularly fond of how they defined prolonged recovery as being 8 days or longer and really the way that they did that was just a median split of the - so normal was defined as a recovery of less than 7 days, prolonged greater than 1week, okay.
So the purpose of our study was really to compare recovery time and related outcomes in youth sport athletes that were immediately removed and not immediately removed from play following concussion. And the questions that we had was you know first and foremost are the post-concussion neurocognitive symptoms and even vestibular recovery profiles different? Do these two groups of athletes demonstrate a different path to recovery, do maybe one group recovery and not the other at all? And here is a really important question, are the recovery times different?
And then finally this whole idea of removal from play status, we talk about it all the time but there really hasn't been any data to support whether or not it makes any bit of a difference. The CDC thinks it's important, it's on all the poster right. And it logically makes sense to all of us, practitioners and researchers about this injury, yeah, don't keep playing on a bran injury, pretty simple. But is this removal from play status a new risk factor that predicts recovery? And how does it stack up? So let me get to the nuts and bolts here of the study.
So this was a prospective study, we saw patients or we recruited patients out of the clinic, we had data at baseline, so pre-injury data. We also pulled their data from one week following injury, so 1 to 7 days and then we saw them again 8 to 30 days post-concussion, so they were seen 3 times. We had 95 athletes and you could see the age range there, 12 to 19 years. They were all recruited from our clinic here in Pittsburgh. They were all research registry participants, they were all diagnosed within 7 days of their first clinical visit. So no one was outside of that 1 week window, we saw them in clinic approximately 1 week following injury. And none of these athletes had a prior brain injury within the previous 3 months, and we also excluded anyone with learning disability or ADHD diagnosis.
Some of the measures that we used, so what did we want to look at and compare these two samples on? Well first of all we constructed a new form that basically we wanted to categorize patients on very strict criteria whether or not they were removed from play. Okay, and I'll talk a little bit about that. We also had a neurocognitive assessment. We examined so neurocognitive performance, we also examined post-concussion symptoms and we also examined symptom provocation and impairment on a brief vestibular/oculomotor assessment to which you will all get more information about the VOMS tomorrow with Ann Mucha's talk. And then most importantly we looked at recovery time, so how many days from injury until they received medical clearance, how long did it take them to get better and get back out onto the field?
So here is a little bit about the Removal from Play Intake Form, it's important you kind of know how we categorized these patients into groups. So we first had a clinical interview and this was corroborated from parent and also the referring sports medicine professional. We got injury related information on this interview, and we asked them some questions. The first question was can you recall the moment or event when you realized you might have sustained your concussion? If an athlete told us no, I'm not really sure, they weren't in the study. Okay, so we constrained this sample and did the best job that I think we could have done in getting a really, a well controlled sample here. And we even used words like did you get your bell rung, so on and so forth. Did you experience any concussion symptoms or have any changes in mental status? they had to tell us yes, I experienced the symptom, okay. Or I did experience - I was confused, I was disoriented, then they are still in the study, they are still in the recruitment process. And then we asked them were you removed from play yes or no? So if they answered yes to all of those questions and they dictated what group they were put in so we could follow them through clinic.
Some of the outcome measures, so all of these patients did complete a computerized neurocognitive batter to which many of us in here are familiar with, it gives us outcome scores of memory and speed, reaction time. It also has history, demographics as well as symptoms inventory. In addition we gave them a brief vestibular-/oculomotor screening tool which is again you all will see more about this tomorrow, those of you who are not familiar with the VOMS. This is comprised of 5 components of various head and eye movements and really what we are looking at here and also near point convergence distance, we are looking at symptom provocation. So when you make your head move while your eyes stay gazed and fixated does this give you symptoms? Does it make your headache worse? Does it make fogginess, so on and so forth. So we were looking at symptom provocation on a very brief 5 minute vestibular and ocular motor screening tool. In addition we defined recovery time as the total number of days from date of injury to medical clearance. All of these athletes, or I'm sorry these patients had to be symptom free at rest and also completing a physical exertion test prior to receiving medical clearance. And you can see that there.
So all athletes presented to clinic between September 2014 and December, so this was the 2014 fall athletic season. All athletes were seen within one week and had a second visit approximately one week later within that 8 to 30 day range. Okay you can see the standard clinical evaluation here in order so all the athletes completed the post-concussion symptom scale, they then completed neurocognitive testing, they had a clinical interview and a vestibular/oculomotor assessment.
So what did we look at here? So some of the questions again just to not get into the nitty-gritty statistical approach here I'll show you the data. Are the post-concussion neurocognitive and symptom recovery profiles different? So we did some means comparisons analyses to look at the two recovery curves are they different and do they interact at each time, okay. Are recovery times different? And then most importantly we wanted to know is removal from play status a new risk factor, is it something that we should key in on because some of my work is understanding you know, and Dr. Collins talks a lot about this from time to time, and you know what is the average time to recovery? You know we think that around 80% of these athletes get better around 3 weeks and we are still getting more data on this. But there is this 20% that represents this miserable minority, this chronic sample. And part of my research agenda and some of my focus is to understand what risk factors predict that group because that really informs and targets early treatment where we can get to these patients sooner rather than later. Why are we waiting 3 weeks before we do something for kids that don't get better?
So here are the results. We had 35 athletes, so 69 athletes actually met criteria, we actually I think had 130, so we threw out quite a number of cases based on our exclusion criteria. 35 were in the removed group, 34 were in the played group and I tested the equivalence of these two groups very rigorously. I looked at where it was football represented in one group and not the other. I categorized this collision sports represented in one group and the good new is no, there was equal representation of collision in helmeted sports in both of these groups, so we can't say any differences because we had a large sample of football players in one group and not the other. Athletes in the removed group, so these athletes were taken out of the game for whatever reason did not participate in any practice or game from the time of injury until they were seen in clinic. They had no additional exposure.
In addition athletes that stayed in the game whether they lied or they didn't know, it doesn't really matter at this point, they are in the clinic right. They continued to play and we had them self-report approximately how many more minutes did you stay in the game? What was your additional exposure? And on average a little over 24 minutes. Now of course that could differ depending on the sport which is a cited limitation of the study; but again we are just looking at this as a first examination.
So were the groups different in age? Did we have one group older than the other? No. There was no greater representation of females in either group. There was no greater representation of number of previous concussion, migraine diagnosis, headache diagnosis, anxiety, any kind of preexisting anxiety disorders. Family history of migraine was also equal between groups. Days until first clinical visit around 3, okay so they all got into clinic around 3 days post-injury between two groups. And also days until second clinical visit was also not different between groups. so that's good, right, that's good.
And then I wanted to know well is this just a representation of a more severe injury, right? so maybe the reason that one group came out is because they had a more severe injury. Well the way that we looked at that was we actually obtained data from some of the on field severity markers. So was loss of consciousness more prevalent in one group than the other? And you can see here what all we looked at. We also looked at on field markers of severity and on field symptoms to see if there were any differences between groups and we tested that, and there were no differences between groups. So I felt pretty confident as a researcher that we had pretty good group equivalency here. moving forward.
So take a look here and these are must some means across time. So we have baseline 1 to 7 days and 8 to 30 days for neurocognitive performance. The played group, those are the kids that stayed in the game, as you can see quite a different path. Pay attention to the red. So this was for verbal memory. We did have significant differences at each of these time points, not baseline though, so there was no baseline differences here. Visual memory same pattern. Processing speed, same pattern. Reaction time, now remember it's reverse scored so slower times are higher, so again we have the played group demonstrating significantly worse performance over time and through clinical visits, and again this was only up to 1 month following injury. And then their symptom scores, look at that. You can't draw a better graph than that. I didn’t' draw, these are really data, I'm not that type of researcher. But you know the kids in the played group didn't -they never got better in terms of even their symptom reporting, they never returned to baseline.
So what does their occulomotor performance, and again I apologize I didn't really have much time to get into the VOMS but looking at the groups and these are mean scores of just symptom provocation here, we had statistical differences across every component of this vestibular measure, even when controlling for baseline scores, okay. So these kids in sum, here's the take home point here, not only were they neuro-cognitively worse they are also worse on vestibular and ocular motor testing. Actually athletes that were not removed from play were almost 5 times more likely to have at least one of these components over clinical cutoffs, which you'll hear about clinical cutoffs later tomorrow.
Here is the important finding here. Kids that stayed in the game took over 40 days to get better whereas kids that were removed for whatever reason got better in 22 days. So if I'm a football coach wow I'm missing some games here, right. Athletes that continued to pay with concussion were over 8 times more likely to have a protracted recovery. So that's that chronic group that I alluded to. So maybe there is something here right, maybe there is something here about what an athlete and a coach can do just by being aware and actually doing something about signs and symptoms, okay.
And just kind of concluding, here is one of the questions that we followed up the study with, is removal from play a new risk factor for protracted recovery? So there have been some other risk factors that myself and Dr. Kontos and some other colleagues have looked at such as posttraumatic migraine, okay these certain symptom clusters that we think predict that 20% of people that take longer than 3 weeks to get better. On field dizziness is also another one, right. We've seen younger age and also female sex as being risk factors for poor recovery outcome in that chronic 20%.
So here is a model here looking at risk factors of on field dizziness following concussion. As you can see in the center here we have subacute posttraumatic migraine and also fogginess and my question was should we start to think about adding removal from play status in this figure? So if you look here I conducted a logistic regression and I put the variables that we had. So we looked at the contribution of these risk factors. So I compared removal from play status with age, sex and posttraumatic migraine. We didn't have enough concussion history to really look at that so I didn't put that in the model. These groups really did not have a high reporting of previous concussions. But here is the good news, the good news is removal from play status was the most robust predictor of protracted recovery even when considering the other influence of other risk factors.
So in summary, this is a real easy take home point, like don't play with concussion. How about that? I'm sure Homer Simpson could give this talk, right? So athletes who weren't removed from play and continued to play following concussion yeah they demonstrated a worse neurocognitive symptom recovery trajectory. It makes sense. Thank goodness, thank goodness, right.
And is this a consequence of this you know an exacerbation of the increased metabolic demand or an already injured brain? So it's not really good to keep running on a sprained ankle, well it's not good to keep running on a sprained brain. Sure. And these athletes take, you know take longer to recover from concussion and this I think absolutely should be a strong clinical educational message moving forward. We actually have some data to support some of the messages we've been preaching for the last couple of years, which is really exciting.
Now yes there are some limitations with this. It would have been great to have some helmet sensor data, right. So what's causing this, continued exertion right or potential additional head impacts, we didn’t have those data right. And even looking at somewhat of a dose response, so how much longer do you stay in, does that even make your recovery outcomes even worse. So unfortunately we didn't know - you know we didn't have data or any way to measure how much you know the exact physical exertion or any kind of sensor data accelerometer to actually look at well this athlete sustained an extra 10 impacts after his concussion or her concussion versus an athlete that was another 25.
So in conclusion you know I would like to thank my collaborators Dr. Sufrinko, Dr. Schatz , Dr. Collins, Dr. Kontos, Dr. French, also Dr. Burkhart who is here and you know hopefully these types of coaches that say boy you know back in my day we didn't get concussions, you know hopefully we are getting these types of folks out of the game. But thank you all so much for your attention.
I think that when most people think of sleep in the context of concussion you probably think of it as a symptom or a problem following concussion. I don't think a lot of clinicians think of it as potentially a risk factor, but Isa said why not look at it as a risk factor because we know that healthy individuals, especially our adolescents and young adults are quite at risk for not getting enough sleep or getting poor sleep. And even athletes, there is some research to suggest our high school athletes don't sleep as much because they are very busy. And we know that poor sleep is associated with a host of problems from mental health problems to cognitive academic problems to higher risk of obesity, type II diabetes in youth that don't sleep enough. So why not? If this is going to affect their overall health why not could it potentially be a risk factor for worse outcomes following concussion?
So we looked at 348 youth and collegiate sports athletes. You can see the age range is what you'd expect. Many more males and than females, and we had baseline data on these folks, ImPACT and PCSS and then we have 3 post-injury time points, 2 days, 5 to 7 and 10 to 14. And so by using their baseline data we characterized them into a sleep symptom group or those that had multiple complaints of sleep problems at baseline and then those who had absolutely no sleep complaints to kind of draw contrasts of two very different groups. So only 10% had multiple sleep problems.
Okay, and we did learn that athletes with preinjury sleep difficulties perform worse on verbal memory post-injury. It's important to note that actually at baseline they didn't look any different on their verbal memory, which may be surprising if you are familiar with the literature on baseline sleep, it's a really small but I don’t want to call it negligible but we do see some difference on baseline with kids that report very you know like less than 5 hours of sleep. But in this sample that wasn't you know thousands of people, we didn't have any statistically significant differences on baseline with any of their neurocognitive scores. So even though they were reporting they were having sleep problems they actually looked the same as the people that don't have sleep problems.
However after injury for verbal memory at 2 days post so - two days post you can see they dropped quite a bit more than their control counterparts there. They'd pop back up and they looked similar after that point. And it's also important to mention that we controlled for nonsleep symptoms, so these just aren't, going back to Anthony's talk, just people that are very somatic and have a ton of complaints. Even if you control for the other symptoms that are not related to sleep you still see this difference.
And then we see this also occurs with reaction time and it's probably more pronounced because it's all 3 time points that we see this difference. Again, no difference at baseline and reaction time higher, worse as we talked in prior, you saw the prior talk so they slow down a lot more than those athletes that do not have a history of reporting sleep problems. I think this is particularly interesting provided if you go to the sleep literature looking at what deficits we see with sleep problems being vigilance, attention, reaction time and reaction time had the most pronounced changes post-injury. So maybe coincidence, maybe actually because you are getting the effect of sleep in addition to concussion here. And then no surprise that the athletes with the preinjury sleep difficulties were more symptomatic both pre- and post-injury. This is their overall PCSS score but even if you look at just their sleep score too it gets much worse. And that's across time points.
So preinjury sleep difficulties may exacerbate neurocognitive impairment and symptoms following injury you know kind of like a diathesis stress model and essentially they may be more vulnerable to having worse sleep problems and that may show that they decline more. They may be more vulnerable to worse injury. There is a million different ways to conceptualize it and we don't know really what's going on yet. So I think that the take home message clinically we don't have any specific interventions but sleep hygiene if you may, you may want to really focus on these patients right off the bat and make sure that you are paying attention to their sleep and trying to educate and do anything you can so that they don't go down the path of having worse sleep.
And then further research is needed to determine if this is really a risk factor. You know the PCSS symptoms are nice, but that's certainly not going to diagnose a sleep disorder or tell you all that much about something that was measured in one moment of time. So I think it's a good start and something that's worthy of further investigating.
Okay, so we are going to move on to migraine. So personal history of migraine everyone in here knows is largely considered a risk factor for sustaining a concussion, like a primary risk factor and also a secondary risk factor for worse outcomes. There is not a whole lot of research as Anthony alluded to, but this is you know in the Consensus Statement this is something that a lot of clinicians believe. But I have the question is family migraine associated with poor outcomes following concussion? And I'm sure I'm not the only one in here that has seen a you know 16 year old you know soccer player female who comes in and mom is there and mom goes oh I have migraines, and it's just like she has a migraine, she needs a dark room, you know her siblings making noise is driving her crazy. It's just like a migraine. And so you know based on prior research with posttraumatic migraine we do know there is this type of profile, and you heard all about that earlier from Dr. Collins' talk. But essentially I want to know does having a family history of migraine serve as a catalyst for having a presentation that looks like a migraine post-injury? We know adolescence is a time where you are at risk for onset of migraine.
So we looked at 153 clinic patients that had a sport related concussion within the past 2 weeks, most of them were seen within the first week. The age was 12 to 18, so we definitely wanted that adolescent group. And we had many more males than females per usual. They were administered ImPACT, PCSS and VOMS and we defined the family migraine as a first degree relative with reported migraine diagnosis. And then the posttraumatic migraine diagnosis was based on you know a regular migraine diagnosis of headache with nausea and photo and/or phonophobia.
So we learned that family migraine history was associated with posttraumatic migraine symptoms on concussion. So those patients that had family history were 2.6 times more likely to present with the PTM symptoms at that first time point post-injury. So this broke down to over half being 57% of athletes with family history of migraine had posttraumatic migraine symptoms compared to only about a third of the athletes with no history.
Okay, but I wanted to go beyond this and we know that posttraumatic migraine is associated with all kinds of poor outcomes, longer recovery, worse performance in neurocognitive testing, especially memory and so on; but nobody has looked at how it really affects what we see with the vestibular screening. And I also wanted to look at the interaction between family migraine and posttraumatic migraine. Is posttraumatic migraine driving the impairments, is there a cumulative effect of having also a family history of migraine? It turned out there is only a main effect for PTM on ImPACT and PCSS, and as well as VOMS. So it doesn't much matter if you have a history of the family history of migraine in what you look like clinically but it does mater if you have the PTM profile and that symptom presentation. So there is no interaction for PTM and family history.
So summary, the family migraine history is associated with PTM symptoms following concussion suggesting perhaps a genetic predisposition for migraine that may serve as a catalyst or a trigger for onset of PTM. And only the presence of PTM rather than family migraine was related to the worse neurocognitive and vestibular and oculomotor outcomes. And again this is a good start but we don't know as much about you know recovery and outcomes as we should, we just know at this one time point what the differences are, so it would be very interesting to kind of follow this type of cohort across time and see how they recover if any differently.
All right, so we are moving on from risk factors to talking - primary risk factors to talking more about the injury related risk factors, presentations post-injury and how that looks with clinical outcomes. So I'm focusing on an oculomotor problem, near point of convergence which you'll hear a lot more about tomorrow with Dr. Steinhafel. You've probably hear some today already but you can see the little picture, they are measuring your point of convergence up there so often we use that little popsicle stick like target where the patient focuses with both eyes as they bring it in and you measure the convergence in centimeters at which point there is a deviation of the eye or the object splits into two. So just to give you that background for what I'm talking about.
And we wanted to know does this, does your convergence measurement play a role in your outcomes following concussion? So we looked at 78 clinic patients seen in a little bit of broad range here, 1 to 30 days. A lot of them were within about 10 days but up to a month and we had a wide age range, 9 to 24, definitely adolescent sample for the most part though 45 males and 33 females and they were administered 3 trials of the near point measurement. And then they also completed neurocognitive and symptom assessments, ImPACT and PCSS.
So we grouped them by convergence measurements. So those that had less than 5 cm were considered normal, and that was 57% of the sample. And then those with convergence insufficiency would be those greater than 5 cm, and that was the mean or the average of the 3 trials. So you can see this problem seems to be pretty common follow concussion.
So the first thing we wanted to know is this, is this reliable to measure in a concussion sample? In normal healthies you know the convergence measure it doesn’t change much but we definitely notice clinically that you get variable you know measurements with the convergence, groups that have convergence problems. And indeed that's what we saw with our research in that the bottom line, let's see here, these are people with normal near point of convergence so less than 5 cm, so it looks like they are about 1.8 and they stay at about 1.8, they don't really change. But at the top here you can see the adolescents that had the convergence insufficiency definitely it got worse as they were measured.
So the clinical outcomes, so the athletes with convergence insufficiency performed worse on neurocognitive testing and they were more symptomatic post-injury. So we did ANOVAs and they performed worse, the group that had the convergence insufficiency performed worse on verbal memory, visual motor speed and reaction time. And they had a greater total symptoms score.
Now we also did regressions where we controlled for age, but also for total symptoms score. We didn’t want to just say maybe these athletes are more severe injuries, and what we found when we did that was near points still contributed to reaction time even controlling for overall symptom severity. But no other composites were significant with the regression model.
So that was a good start and so more recently I wanted to look at this same type of patient across time. And interestingly enough we in clinic often think our patients with conversion insufficiencies recover, take longer time to recovery. When we actually crunched the numbers and again this is a little bit different of a sample because these were athletes within 7 days of injury, so we got them all very soon versus when you do 1 to 30 days you are going to get some chronic people that are just finally coming in because they've had symptoms for 3 weeks now right. And so this sample, it's not up here but they had a mean recovery time of about 3 weeks. So the normal of what we see but we didn't have any chronic individuals in this sample.
And they all looked the same at clearance you can tell. So even though we replicated this, had a very similar - actually all 3 composites we saw the first time were the same the next time regardless of when they were seen. Just if you had that convergence insufficiency you have this pattern of performance. And then they didn't differ on the recovery time either.
So athletes with convergence insufficiency have worse neurocognitive outcomes in the acute stage of injury. From a clinical standpoint personally and I think a lot of my colleagues we really pay attention to the academic accommodations we give this group. They do seem to struggle in school, they get very tired, they have problems focusing, a lot of problems in math, sometimes reading. They have real functional problems sometimes and so trying to reduce visual workload, trying to you know audio books, perhaps delaying tests or breaking them up, this kind of thing can be very helpful for this type, the trajectory of injury, or this profile.
It did not seem to play a role in recovery duration however I'm going to put the caveat of when appropriate treatment is available. So that sample I just showed you some of them if they needed were seen in vestibular therapy and may have been given exercises. So we don’t' know the natural recovery of the convergence, perhaps they would take longer to recover but at least here we are really good at getting them into treatment really early so when you treat it early most of them can recover in the same duration as someone without this problem. And then when athletes do fully recover from convergence insufficiency all of them were cleared, had normal convergence in the context of any preexisting, if any preexisting issues they'd still be cleared with that. But they either had normal convergence and normal scores on testing, so they look equivalent to athletes with and without - all athletes looked equivalent.
But we were really interested in is you know what factors influence these vestibular/ocular outcomes that we see as being so important following this injury. You know are there certain risk factors that might drive that particular clinical profile? And I hope as you are hearing all of this you are staring to connect the dots yourself in your own head and in your own practices as you leave.
So the VOMS and vestibular/oculomotor screening is a tool that came out or at least has been published in 2014, it's been in use here for about 4 or 5 years before that, at least in some derivation. And now what it focuses on is smooth pursuits, saccadic eye movements, near point convergence distance, visual motion sensitivity, that's the one on the bottom, and then a VOR reflex and we look at that horizontal as well as vertical. And the idea here is that we are kind of stirring up the vestibular system with the latter two and looking at what are the symptoms provoked by that. And then the earlier ones we are looking more at the oculomotor component and then that convergence insufficiency measure. And the idea is you are getting at symptom provocation here with the exception of the near point convergence distance. So that's ti, I'm done, Anne, didn't mean to steal too much.
So moving on, what did we learn? Well Mickey said you know a lot of the patients we see have this. How many? 60% have at least one of these things going on. The one that's the most common is the VOR, and in this case we only had the horizontal VOR for some reason in this particular data set, but that was the most common sort of impairment/symptom provocation we saw. Interestingly and importantly we see almost nothing in controls, only 9% of our controls report something that we would say would be like at some level of above zero, so they are almost literally at zero across the board, which is also important to know. We don't want a lot of false positives, right. That's good.
So we developed some cutoffs which some of you may have already heard. When we looked at this sample it wasn't 50/50 split so the actual probability to be considered concussed was 44%. So that's what it would look like in a pie graph. My advisor said never use pie graphs but I'm going to use them, okay. So when we get to an NPC distance of greater than or equal to 5 cm alone, and notice I said greater than or equal to, that's it, just that. What we do is we increase it 35%, so now we are about 79% accurate in identifying concussion.
Now throw that out the window and now let's look at symptom provocation. When we look just at that, if you are at a 2 or higher in symptom provocation we see a 50% increase to 94. We actually surprisingly didn't look at what happens when we combine them, we probably should have done that but we'll do that some other time.
So there are some good cutoffs, 2 for symptoms across each item, and 5 cm or above for the near point convergence. Is it balance? I always get this question, aren't you just measuring balance? Everyone always puts oh I'm doing a vestibular talk and then you look and they are talking about the BESS. Look at those wonderful correlations, they are nonexistent, they are not the same thing. In fact posture and stability across the board we are doing other research through NIH right now, there is nothing there as far its relationship to the vestibular component, they are totally different systems, totally different outcomes. That doesn't mean you drop them or one is more important, it means they are different so they are augmenting. So you should be doing both. The vestibular/oculomotor piece though hadn't been done up until recently so I think it's an important addition.
So here is what happens when we look at groups, and I'll thank R. J, Dr. Elbin for some data here, the high school big number there, 468 is from his sample in Arkansas. The colleges are athletes here in Pittsburgh through the DOD study, NCA DOD study. And then we have our original study of high school concussed. And what we see there is what? The high school kids with concussion are all above those cutoffs because they are concussed. And in contrast we see virtually nothing going on in our control both at the sort of early adulthood college age and in the addition at the high school age, so that's good right. We don't want to see them above that line because that would say you have false positives or something like that going on.
But we thought there might be a little bit more to it and we wanted to look at really like what is the false positive rate across these measures, and I'll highlight too. I know these numbers you are like oh my God which one am I supposed to look at? Those 2. Okay, so the first one on the left, 13% in our high school sample, VOR, that's the one where we receive the highest rates. So that means 87% across all of these evidence you are not seeing any positives, so 13% is sort of false positive rate if you will. When we look at the college it's 11% and interestingly it's down at near point convergence distances, that measure.
So we were interested in you know what is going on with that 13% and that 11%, why are they reporting that? So when we looked at our college age sample, so we are going to throw Dr. Elbin's sample out for this because we had a little bit better medical history and other data, that's what we wanted to look at. 89% reported zero cutoff, but there is this group here that had something going on, and some had a lot going on. We were like what is going on? Well 60% of them had motion sickness diagnosed. We had medical diagnosis for this in their records. So that was kind of a bell, we are like wait a minute what other factors might be influencing these VOMS because we want to be able to pull those people out so we don't get false positives when we use the VOMS clinically.
So when we look at this motion sickness is associated with a 7 1/2 times greater likelihood for basically a false positive at baseline on the VOMS. So you need to make sure you know whether or not these patients have a motion sickness history, and if you don't and they don't you ask some questions about do you get sick in the car? Does this make you sick, etc., etc? Do you not like shopping in the - you know scrolling the environment, do you not like walking down the hallway in school? Things like this right. And then at the end of the day we see this really, really strong relationship but not for near point convergence, just for the VOMS symptom provocation items.
So other factors that are relevant. Oh sex rears it's ugly head, I probably shouldn't say that out loud, it didn't sound right. But in all fairness here it is and guess what it's a risk factor again which you know is very specific again here to the VOMS. When we look at the near point convergence we don't see a lot going on and we don't see concussion history or migraine history being significant predictors at baseline. I'll come back to that when we look post-injury.
So what happens post-injury? And I'd like to acknowledge Melissa Wamble who is somewhere in this room in one of the corners I think, back in the corner here. She is doing some great work as our fellow here just about to exit in the next month or two. And she's really helped out looking at post-injury. So now we are looking at what about those factors I just mentioned on your post-injury VOMS, does that matter when you know we look at that? And lo and behold we see sex, on field dizziness at the time of injury, posttraumatic migraine and fogginess all being significant predictors of a higher vestibular/oculomotor score on the symptoms.
When we look at near point convergence distance it's a little bit different story but we still see 3 of them holding here, on field dizziness, posttraumatic migraine and fogginess. So those 3 are a pretty big deal but we actually are interested in which particular components of the VOMS are those affecting. Are they just across the board? Do they just make you higher on all VOMS items? Or are they very particular so you can kind of start to tie the dots together a little bit?
So sex really only played a role in that VOR component where you are doing fixation while you are moving the head. And then we see nothing again for concussion history across any of the individual items. Migraine history focused more on the saccadic eye movements and again on the VOR. Not terribly surprising, my wife has migraine history and I know when she had a concussion about a month and a half ago, which was really interesting to see firsthand the relationship between motion sickness, migraine history and a concussion. And she hated the VOMS. Sorry, Anne, she really did, it was brutal. But you know what was great is she improved very, very rapidly with therapy which you know is a whole other research study we need to do.
When we look at these secondary risk factors we see the same thing again across some other items here. So the on field dizziness what happened after the injury also drives whether or not you have these higher scores on the vestibular/oculomotor score. With the exception of concussion history and loss of consciousness we didn't see either one of those factors playing a role in any of this stuff. On the previous slide concussion history, LOC here.
PTM and fogginess, these patients are just kind of high across the board and what we are trying to do now is tease out, just pulling out that component of their global symptom factor if we can pull that out and look at them, just PTM. And that's really hard to do but we are trying to do it.
So in summary you know the VOMS plays - or VOMS scores can be affect4ed by these risk factors both in healthy populations, so some false positives associated particularly with motion sickness and with being female, and when we look at the post-injury we see some risk factors there as well. So we need to consider these, another set of questions along with somatization, sleep, we certainly have so much to do it's going to be like a 4 hour appointment but you get the idea here.
Now we are going to wrap up with what I think at least for me is kind of maybe I'm the researcher so of course this is all exciting, but this is the most exciting to me, the treatment phase and we are really moving our research into this area. It's hard to do, that's why you don't see a lot of published studies on treatment, they are very hard to do. it's hard to say we are not going to treat someone. We wanted to look at what happens when you compare like sort of a current approach, which is really prescribed rest within different groups. So if you look at one group versus another they all have concussion, do you end up with the same outcome when you prescribe rest of varying degrees to them?
I'm going to acknowledge here a couple of folks, Danny Thomas and then obviously my colleague here, Alicia Sufrinko. We are working on sort secondary data analysis in Danny's renal seminal piece of a randomized control trial looking at rest. What we want to do is determine which patients are getting better with rest, if any, and which are getting worse because we've written a few proposals suggesting that we think you really need to do different things with different patients, especially with regard to activity.
So these groups of patients are there were 60 males, 33 females, again this is PEDS ED, so we are talking about kids. Good population, you are seeing a lot of data from this. Five days strict rest , one group was randomly assigned to that. The other group is usual care which was kind of loosely defined as 2 days and a more progressive return to activity. And then the patients were compared on signs and symptoms only. Those were the two groups we did secondary analysis of. So we went back in the data and said what if we look at someone who has a higher organic or burden with the injury? So they had you know posttraumatic amnesia, loss of consciousness, disorientation, confusion, these very overt signs at the time of the injury versus those who only reported symptoms in the absence of any clinical sign of the injury.
So these are the data that you saw Noel present. And I'll just say that what we see here is that at 4 days we see the biggest difference. The group that gets prolonged rest is actually more symptomatic. They get more time to ruminate on their symptoms, you know all of these things that we've heard talked about today, contextual framing effect, nocebo, etc.
But now here is the kind of $50 question if you will, what about if we look at the group's signs versus the symptoms only group? Well if we look at the symptoms only group as evidenced by this lighter or gold line in wonderful Pitt Panther colors here, we see that that group actually got worse. They are the ones driving this. So if the symptoms only group is told to rest a lot they get worse. They actually do better when you tell them to rest over here a little bit less and kind of get your butt moving as fast as you can.
In contrast we see an opposite effect with the early signs group. So the symptoms group gets worse, the early signs group with the higher burden, you know there is a lot of different ways, more severity, you can think of this different conceptual ways, that group actually got a little bit better with that rest, and so that might be a group that we identify as maybe needing a little bit more of a break. My wife was a good example where she needed a couple of days, not a lot, just a couple of days of you are not going to work, you are not doing stuff but then immediately got into an active approach for her vestibular issues.
So in summary, prescribed rest may not be the best treatment for all patients as I think we are all starting to jump into, but we have to be careful about which patients we use it for and which patients we don't use it for. And so those with symptoms only rest was clearly problematic probably due to some somatization and other symptom issues. Patients with the signs may benefit from a little bit more rest, but we are not talking about cocoon, we are not talking about that approach, we are certainly not talking about dark rooms, no texting, just you know a little rest and then we move on. Questions to consider, and this is where we are going next, do active interventions are they more appropriate? Do they work better? If so when should we use them? How much? You know how often? And we need to match them with a profile so that we get the best outcomes, okay.
In conclusion overall here I think you are starting to get the idea that we have to ask a lot of questions of our patients to know how we can tie the risk factors to the clinical profiles to the hopeful treatment recommendations and outcomes. And also I think we need to be very judicious in how we use rest. I think right now we are all moving towards a more active approach, that's a good thing. And as we build more data hopefully we'll be able to be more specific about the when and the how much. And ultimately all of this hopefully will drive better patient care as we want to be evidence based as we move forward.
There is a bunch of people, many of whom you met out of the staff and the front that helped out with this, so I acknowledge them on this slide.