UPMC Physician Resources
Evidence-Based Management of Sports-Related Mild Traumatic Brain Injury: What are we Learning?
Dr. Micky Collins provides an overview on sports-related brain injury and what we are learning about sports in regards to mild traumatic brain injury.
Upon completion of this activity, participants should be able to:
- Discuss the biomechanics, pathophysiology, and neurocognitive recovery rates of sports-related mTBI
- Discuss appropriate assessment strategies for an in-office evaluation
- Discuss risk profiles and symptom patterns that predict more protracted recoveries
- Lau BC., Kontos AP., Collins MW., Mucha A., & Lovell MR. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med. 2011 Jun 28.
- Lau BC, Collins MW, Lovell MR. CutOff Scores in Neurocognitive Testing and Symptom Clusters that Predict Protracted Recovery from concussions in High School Athletes Neurosurgery. 2011 Aug 9.
- Lau BC, Collins MW, Lovell MR. CutOff Scores in Neurocognitive Testing and Symptom Clusters that Predict Protracted Recovery from concussions in High School Athletes Neurosurgery. 2011 Aug 9.
- Van Kampen DA, Lovell MR, Pardini JE, et al. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med 2006;34(10): 1630–5.Giza CC, Hovda DA. The pathophysiology of traumatic brain injury. In: Lovell MR, Echemendia RJ, Barth JT, Collins MW, editors.Traumatic Brain Injury in Sports. Lisse: Swets & Zeitlinger, 2004. p 45–70.
- Gaetz M. The neurophysiology of brain injury. Clin Neurophysiol2004;115:4–18.
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.
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Release Date: 6/25/2015 | Last Modified On: 10/19/2016 | Expires: 10/19/2017
Good morning. I appreciate the invitation to be here. I don't know if I've done Pediatric Grand Rounds before, I know I've done Trauma Grand Rounds, which was fairly recent. But this morning what I want to do is give an overview, a general overview on sports-related head injury. I want you to keep in mind that the information we learn in sports applies to MVAs, slip and falls, you know kids falling off bikes, etc. And I think sports actually is a very good laboratory to study mild traumatic brain injury and what we are learning in sports I think has really led the way from a research perspective about general mild traumatic brain injury. Kids have had head injuries in a lot of ways, and I think the information you are going to hear today you know it applies to the mild TBI group or the concussion group, those are synonymous terms, interchangeable terms.
So what I want to do this morning is really in a very general way I want to get a pointer here, hold on. In a very general way I want to discuss what we are learning about traumatic brain injury in sports, in mild TBI in terms of the biomechanics, in terms of the pathophysiology and also looking at what we are learning from a recovery rate standpoint and actually how we define recovery when we look at these athletes. I want to talk about how we do an appropriate in-office evaluation and when you send patients down to see us at Sports Medicine what are we doing with them? How are we evaluating them and what different tools are we utilizing to help quantify the injury in an evidence based way come up with appropriate parameters regarding recovery and treatment. I'm going to talk about the symptoms and we've done a lot of research looking at sort of who the miserable minority are in terms of the kids that don't do well and show you the evidence behind what signs and symptoms predict the kids that take the longest to recover. And then lastly I want to get into really talking about how we are starting to figure out that there is different types of concussions, not surprisingly, and too that we have really entirely different treatments, different recommendations for school, different recommendations for exertion, different physical therapies, different active approaches at managing the different types of concussions that we see because this is a very heterogeneic injury that presents in a myriad of different ways. And I think one of the problems to date has been sort of focusing on this injury as a one size fits all, you know here is a protocol for concussion. It doesn't work that way, it's a very complex disorder.
I do want to disclose before starting that I'm a codeveloper and Board member of ImPACT, that's a computer based tool that we've developed to help assess the injury. I will be talking about ImPACT generally. There are other very good tools out there in addition to ImPACT that we use ourselves. But I do want to disclose that financial conflict of interest.
Okay, so talking about the biomechanics of injury the word concussus literally translates from Latin to English to mean to shake violently. We think about our brain as an egg yolk inside an egg shell, there is essentially two different forces that will cause mild traumatic brain injury. One is a linear force, acceleration/deceleration. We've done a lot of work looking at these biomechanics and only about 14% of concussions at least at the NFL level will occur with what we feel to be linear acceleration/deceleration force. Here is a good example of acceleration/deceleration force.
And you know if we think about the brain as an egg yolk inside an egg shell and we talk about you know we've done a lot of research on helmets and we actually have found out that helmets don't do a really good job of preventing concussion if at all. Helmets do an excellent job of preventing a skull fracture, intracranial bleeds and once helmets were introduced the death rate from head injury in football was reduced dramatically. The morbidity rate probably has increased because now kids as you see in this video will use their heads as weapons and that's - and as long as that brain moves inside the skull that's what - that's what causes the pathophysiologic response that I'll describe and there's not a whole heck of a lot we can do to stop the brain from shifting inside the skull. Until we find a helmet that goes around the brain itself we are kind of in - it's not going to be too effective. We've looked at mouth guards, done research on mouth guards. Mouth guards are not effective at reducing the incidence or severity of concussion. The only thing we've found potentially being helpful is neck strength.
And I'll talk about that in a few but the second type of force we'll commonly see with concussion, actually more commonly seen with concussion is rotational trauma. About 86% of concussions at least at the NFL level are occurring from rotational injury rather than acceleration/deceleration. Please keep in mind that you cannot separate those forces out, even if you have what we feel to be a purely acceleration/deceleration injury there's very likely to be some rotational influences on that. We've done a lot of work recently looking at we can now measure rotational trauma, and we've done a study in hockey players as well as - we used to just be able to measure acceleration/deceleration but now we are able to look at rotational trauma. And this seems to be a little more deleterious in terms of not only causing concussion but perhaps a little longer outcome. Why would rotational trauma be more causative for a concussion than acceleration/deceleration trauma? Anybody?
Shearing I think is a good hypothesis. I think perhaps what I believe to be the main reason, and we haven't determined this empirically but it is because the athlete doesn't see the hit coming. If you are not prepared for a blow your neck muscles are loose, the forces stay on the head. If you are prepared for a blow and usually you are in acceleration/deceleration because you see the event, if you don't see the event coming and you get hit from the side those forces are going to stay on the head. What the neck does is it helps translate forces from the head through the neck into the body. And if you don't have that strong neck you don't have that strong bridge for forces. And we find that far less force causes concussion with rotational injuries that are sort of unexpected versus acceleration/deceleration. And that's really all it takes when an athlete is not prepared for the injury itself or for the blow.
And that's also why woodpeckers don't get concussions by the way. My six credits or ornithology is paying off, actually nine credits, sorry. But what we learn in the animal kingdom both in rams and in woodpeckers by the way, in the woodpecker there is actually a bone that connects the base of the skull to the shoulder blades, it's called an occipital condyle and that bone is placed there presumably for a reason. And if you watch a woodpecker hit a tree its acceleration/deceleration purely those forces translate through his little cranium into that bone and translates into the torso of the woodpecker and that's why we don't see woodpeckers falling out of trees you know concussed.
Okay, so what happens with concussion is pretty well understood at this point. I think the animal model that was employed in this research isn't the best animal models to study mild traumatic brain injury but with that being there is a fluid percussion model, with that being said what is thought to occur with concussion is this, when the brain moves inside the skull the membrane to the neuron or the cell gets stretched and potassium which is supposed to be intracellular will get leaked out into the extracellular space. And when potassium goes out of the cell there is an increased demand for glucose or energy. Okay, so that's step one. Step two is calcium which is supposed to be extracellular will leak across that stream, same stretched membrane into the cell and when calcium goes into the cell we actually get vasoconstriction. And so at the very time that the brain is emitting more energy we actually get reduced cerebral blood flow and henceforth less supply of energy. And what concussion is what we call a metabolic crisis to where the cell is starved for energy and taking that a step further what we don't want to do when kids are in this metabolic crisis is the first thing we don't want to do is what? Get hit in the head again, okay.
We've known and this has been shown in the animal model and it's certainly been shown in our research over and over and over again is that if the cell is not fully recovered from this, and the good thing about this is these cells will recover if managed properly we feel but if you are in this metabolic crisis and you have a secondary blow to the head it takes far less biomechanical force to produce far more significant morbidity and sometimes even worse morbidity, or mortality can occur. So what we - it's very critical as clinicians to understand that there is this window of vulnerability following a head injury, primarily as it relates to going back to sports because it's going to take a lot less force to cause this thing to get worse. We've got to make sure these kids are "recovered" before we put these kids back to sports. Now I'm going to talk about how we do that in a clinic setting and sort of the standards out there in terms of how we look at recovery and how we measure it. It's a complicated question but it's very important to answer that question explicitly when you are talking about return to sports. And we are also starting to realize pretty explicitly that it's not only return to sports it's return to learn, and we've got to make sure these kids are in the right lane as it relates to getting back to school because this metabolic crisis will affect cognition, it will affect a lot of different things.
Now what we've learned about concussion is that there is different types of injury and I'm going to talk about that, and really what I feel happens is when this metabolic crisis occurs in the brain we actually have certain systems in the brain that will become decompensated, okay. I'm going to talk about how that looks in terms of different clinical trajectories for concussion but we certainly see different permutations of this injury depending upon which systems are affected centrally in the brain. Keep that in mind.
So in terms of our areas of focus for mild traumatic brain injury or concussion first of all you don't know it's a mild traumatic brain injury until it's evaluated very carefully. CT scans and MRIs I think you guys do a phenomenal job at Children's, the best in the business for my money in terms of when to scan. I'm actually very pleased that I'm seeing less scanning over the last few, 4 or 5 years, I don't know if you agree with that, Bob. You know we certainly I think there is a lot more - you don't want to scan these kids if they don't need it, and that's a whole different lecture on when to scan, when not to scan but when I have a kid and I get called many times, my kid just fell down, hit their head, I live in Mt. Lebanon, I probably get a phone call every night from some parent calling and asking me send them to Children's if - you know if there is questions of concern because I think you guys do a pretty good job, really good job of that issue. You know but these imaging modalities are not going to pickup on concussion. You know we don't see this metabolic crisis with CT, we don't see it with MRI.
We are doing some pretty advanced imaging stuff, we look, we are doing high definition fiber tracking, we've got some interesting research going on there. We are doing spec, we've done FMRI, published on that extensively. There are some imaging modalities that have promise for measuring or looking at concussion but there is no image right now that I can say if I have a kid in my clinic with a concussion I'm not going to order a scan if I know it's a concussion because that information that is not ready for prime time, it's not telling us anything. We need more research in terms of that issue. That's my imaging talk. But really what we are dealing with as clinicians is this stuff and it's important to evaluate this stuff and make sure these kids are getting the right evaluation after the head injury because there is morbidity, folks, there is a lot of kids with problems with this stuff. But what we want to do, number 1, is prevent against cumulative effects of injury and the only way you can do that is by managing it effectively when you have one, make sure these kids are fully resolved. you can resolve - have less force causing an extensive injury, we can prevent all that. We can prevent kids from having symptoms that last a long time from this injury if it's managed well early on.
Now we have a lot of research looking into that empirically and we have actually some randomized controlled stuff that we are starting to look at, we just are on the verge of getting a grant not only the one that we are doing with you guys looking at rest, but we've also got some other sort of randomized controlled trial work looking, doing our treatment approaches with injury. We have a lot of research looking at this. But I can tell you anecdotally, qualitatively, empirically, you know experience-wise my goodness if you don't manage the stuff properly there can be a lot of problems and we can prevent those problems if it's treated correctly right out of the chutes. We can also appropriately determine clinical management about school, exertion, safe return to play. I think we are getting a lot better with that. And again we've got data coming down the pike on those issues. And most importantly we actually have these very targeted approaches at treating these different types of concussions that we see. I'm going to try to get into that a little bit if I'm not too much of a windbag this morning.
But return to play you know it's really important to make sure these kids are completely symptom free as it related to mild traumatic brain injury and that's when you can really avoid the poor outcomes from repetitive trauma. We've done a lot of research looking at how this injury breaks down phenomenologically okay, and here is a study we looked at what are the most common symptoms after a concussion. This is within 7 days of an injury. Not surprisingly headache is number one, that's the most common symptom following concussion in our athletes. The typical headache we’ll see with concussion it's usually a pressure event that gets worse as the day goes on because this is metabolic crisis. And if you can start to identify what is the trigger for the headache you can start to identify what type of concussion you are dealing with.
For example, if you have a headache, if a kid gets a headache working on the computer, reading what system do you think might be affected by the injury? The eyes, okay. And we see very strong ocular dysfunction in patients with mild traumatic brain injury, that's one of the types of concussions. If you have a patient that gets a headache walking down a busy hallway going into a busy cafeteria, riding in a car, when they are starting to workout and move dynamically what system would be affected then? Vestibular. And that's more centrally mediated. We are not talking the ear, we are talking deep in the brain. That system we've published extensive research showing that if you injure that you are more likely to have a worse outcome and you better be careful in rehabbing it too because there can be a lot of problems if you don't treat it the right way. So there is different types of triggers for the headaches and if you can start to identify what, where is the headache coming from as well as what other symptoms are associated with the headache you know if you get this slow, wavy dizziness that's probably a vestibular issue. If you get this frontal headache and fatigue it's probably an ocular issue. If you get a headache sitting on the couch watching TV guess what that is? Anxiety because there is no reason to get a headache watching TV from concussion, okay.
So we can start to identify like if I have a kid that comes in and they make - they are like yeah, I wake up in the morning, open my eyes and I get a really bad headache before I go to school. Why are you getting a headache before you go to school? Are you thinking, you know are you having a hard time turning your thoughts off? How did you know that? Because you shouldn't get a headache sitting up in bed and thinking about school, okay. The anxiety influence of this injury is ubiquitous and if I have a kid that is having symptoms due to that issue I am not giving them accommodations academically, I am not taking them out of school. I am working them out. I'm not telling them not to look in their phone okay. That increases anxiety. So you've got to be really careful about who you are dealing with as a child because you can create secondary pathologies. Guess what, if you nap all day long and you are stressed out and you are not working out what do you think happens? How about migraine? We see massive comorbidity of migraine in these patients that are mismanaged right out of the chute. We also see a lot of morbidity in clinicians that are too aggressive with this injury. You can't do that either. You know you've got to take the individual case and manage it individually with the right information, the right techniques, the right style. And I think it's very important to understand there are a lot of differences in how this injury presents.
Here is a factor analysis looking at concussion. This is the largest factor analysis that has been done where we looked at how the injury breaks down within 7 days of the injury and in the first 7 days we see this big gobbledygook of stuff, we kind of call it cognitive migraine fatigue. These - in patients, this is the classic symptoms they'll experience, feeling slowed down, tired, light and noise sensitive, foggy, difficulty remembering. And that's the primary cluster of symptoms we see and then secondarily we may have affective disturbance, somatic issues and sleep problems. But this is the sort of the money for the injury acutely within the first 7 days. We now have factor analysis work being done at like 2 and 3 weeks post-injury and we are starting to find there is different trajectories from these symptoms, and that's - I'll talk about that later.
So in very brief summary of my general overview in this injury you know there is no imaging technique or biomarker available to diagnose concussion. There are a lot of very smart people working on that. We've been looking for a biomarker for Alzheimer's disease for probably 5 decades, have we found one? Not really. There is a lot of work to be done before we come up with some biomarker for this injury. It's the brain after all. We should be working on that, but keep in mind it's not simple. There is really lack of well controlled prospective studies on long term outcomes. How many of you in this room have heard about chronic traumatic encephalopathy? Okay. That's - how many of you heard of Mike Webster, you know how many of have seen the movie League of Denial, how many of you have seen the stories on football players in the New York Times pretty much every day. If you go to the New York Times today you'll probably find a story on it. We don't - there is a lot of media speculation on that issue. We don't have long term studies determining if concussion in and of itself is what's causing that tauopathy. There is not a single study I can point to that definitively and scientifically states that concussion causes that problem. It could be steroids, it could be other issues, it could be concussion and steroids, it could be concussion and other issues. It could be base rates. There is so much we don't know about the long term effects of concussion if there are any at all. And I think from a scientific standpoint it drives me crazy as a guy who does this every day picking up the paper reading about this because what that does is it creates a lot of hysteria, it creates a lot of - I had an NFL guy yesterday I saw, played for the Green Bay Packers for 20 years or I'm sorry 15 years, 14 years, really like a hall of fame wide receiver and the guy comes in and basically is - thinks he has CTE and he's not - he doesn't have CTE he's depressed, like severely depressed, suicidal. And you know if we don't treat the depression the guy is probably going to kill himself. We need to understand there is other things that can cause problems in folks and thank goodness he saw me because - us, because I think we can treat that. I'm pretty sure of it. And he didn't think there was any help for himself. You know we've got to really careful with you now this information and what's out there.
To date there's been a lack of targeted clinical and treatment pathways, you know I'm going to talk about that. There is a lot of variability, tremendous variability in clinical management with this injury. You send your kids to one pediatrician, they are told to do nothing, don't work on your phone, don't do this, don't do that. You send your kid to another different clinician, and they put him back to play without doing the right evaluation. You know I think in Pittsburgh we are very lucky because it's a very well educated community on this issue. But that's not what's happening across the country, and there is a lot of I think poor management leading to very difficult outcomes in some of these kids.
Another issue is that rest does not cure all concussions. And we have a study actually I believe it's being reviewed today. Bob, myself, a guy named Anthony Contos and Noel Zucker Bron is an investigator on that where we are going to be doing a randomized controlled study hopefully looking at "rest" across 10 centers I believe, how many kids is it? It's a lot. What's the end Bob that we are proposing? Okay, so if we get this grant I'm going to be doing a pretty well controlled study looking at that issue, so stay tuned. But in my opinion rest certainly is not indicated in all your injuries. It is indicated maybe perhaps in some types but not in others. I think the media is driving public perception of this injury and one of the biggest problems is self report predicating return to play. I mean if you ask a 13 year old kid, better yet if you ask a 10 year old kid who cannot articulate anything about symptoms from head injury okay, it's very rare I see a 10 year old kid or a 9 year old kid with a headache. They don't - they have a hard time putting words to that. They don't understand that they are more irritable, they are tired. That's - irritability and fatigue are the two most common symptoms I see in you know little guys with head injury. The physical symptoms are not well articulated in that population.
But we need data to help with this. And really what I have to do in clinic all day long is this, how to recognize the moods of an Irish Setter because these kids all look alike and they really - there is not - if you see my waiting room you see a bunch of kids just sitting there straight up and like, I'm like what's wrong with you, you know? But then you get them into the room, the exam room and you look at them in certain ways and you do the right testing and you can really start to understand that there is a lot of morbidity and it's not like these kids have casts on their heads, it's a very difficult thing to conceptualize but I think once you understand how to look at it you can really start to identify perhaps these different problems that we see. And I welcome any of you by the way if you want to come spend a morning in clinic with me email me, I would love to have you. I think it's - how many of you have followed me in clinic? Anybody? I recognize you. But yeah, it's a good opportunity if you guys, I know you guys have all the time in the world but if you want to come over and see what we do I'd love to have you.
But this is where I work, it's at the UPMC Center for Sports Medicine, it's right across the Mon. I don't know how you guys drive here every morning by the way, it took me forever this morning. But basically we have a center, this is how many of you have been down to Sports Medicine? Okay. It's a nice place. It's a nice place, we have a whole floor devoted to concussion. We are on the second floor. We have a center, we have 11 exam rooms, we have a PT area, physical therapy, it's a pretty impressive place they built for us from the concussion standpoint. This is - but we work in orthopedics, that's Dr. Fu's office, that's a much nicer office than anyone else's. But basically our program consists of this; I'm a clinical neuropsychologist working in orthopedic surgery, there's got to be a joke in there somewhere. But that's what I am and that's what we do and it's actually worked out very well. We are sort of the primary folks that when the patient comes to - when you guys send the patients to us I will see them, we have 8 full time neuropsychologists. We have 18,000 patient visits a year to our clinic, 18,000. We have 35 faculty and staff. 20% of our patients are out of state, 1 in 5 patients that I see are out of state. We see very complicated cases from all over the country, sometimes all over the world coming to us from a lot of different places that are having a lot of problems with this injury and when the patients are sent to us we'll evaluate them, and I'll talk about what we do in our evaluation, but in the same building on the same day that we are there, and we actually have 6 sites around Pittsburgh now where we have this team in place. We have primary care sports medicine so when we need treatment we actually have those clinicians available right then and there to implement our treatment approaches. So primary care is part of our program, PMNR is part of our program and they are phenomenal. They do a lot of the musculoskeletal stuff. They also do medication management if indicated. They are a valuable resource.
Perhaps one of the most important parts of our treatment program is vestibular therapy. There is very good physical therapy to re-habituate the vestibular system. And I think at last count we had 22 or 23 vestibular therapists now around the city involved in our program where we refer patients to if needed. But they'll come to us first and then we'll refer to them and then we work together. We also have what we call exertional therapy, so with the vestibular system you actually have to re-habituate that system and we can only take them so far with vestibular therapy, what has to happen next is actually to do physical exertion where we do higher level movements and dynamic activities and we have full time exertion people, that's all they do is work our concussion patients out. In other words, with a large majority of our patients the only way you get them better is by getting them active, not by resting them. We actually have to re-habituate things to get these folks, kids better.
Radiology, Vicus Agarwal maybe you know him, he's in our program. He does a lot of our imaging if we need - if imaging needs to be done. Orthopedics, not surprisingly, is heavily involved. Neurosurgery, Joe Maroon, a lot of the other neurosurgeons are involved with our program. And also we have behavioral optometry as part of our program which is actually becoming more and more of a important role. We actually need to do physical therapy a lot of times to retrain the visual system after an injury if that is what's causing the problem. So that's our treatment team.
From an assessment standpoint we actually look at all of these things when we see a patient. Not just this, okay. So impact, neurocognitive testing is a really important tool but that's not the only thing I look at when I see a patient. We are also going to look at the vestibular system, the ocular motor system. Obviously we do a very good interview and if you come see me you are probably going to be working out pretty quickly because we are going to try to figure out where the system is breaking down so we can help identify the aberrant signal, where is it coming from? And by working patients out we actually can see where it's coming from and then help to retrain it. But when I see a patient this is what I'm doing from an assessment standpoint and that's really become or becoming, I mean that's the only way we really have to look at the injury is looking at all of these different component parts. And then most importantly knowing how to put those component parts together in to a meaningful clinical management protocol.
So what we do is we collect information from the interview, we've created a new screening tool, it's an exam looking at the vestibular ocular system, we're going to talk about that briefly. We then look at the computerized neurocognitive results which are very important but we put that all together and then we can establish diagnosis, prognosis, we can understand what type of concussion the patient has, and then we can come up with these very prescriptive individually based recommendations pertaining to academics, exertion level, treatment, return to play and then hopefully communicate back to the clinician that sent us the patient so we can work together to get these kids healthy.
So this is probably the most important slide I'm going to show you because this is what - all our new work is going to be - is based upon is that we've identified now 6 different clinical trajectories for the injury. And for every one of these different trajectories there is different risk factors. So for example if you have a patient with a history of car sickness, motion sensitivity you are more likely to have vestibular dysfunction after concussion. Concussion fights dirty, it's an energy problem so it's going to affect systems that are already sort of demanding a lot of energy so to speak. If you have a patient with a history of strabismus or a lazy eye you better look there. If you have patients with a history of learning disability you probably want to look here. Migraine, here. And for every one of these circles we actually have different neurocognitive test findings, we have different examination findings on our vestibular ocular screening. We have different treatments, we have different rehab approaches, different academic considerations, different medications if needed. There is a whole different approach to treatment based upon what circle you have.
Now of course it's very rare if some kid comes in with just one circle, usually it's this, this and this maybe or this, this and this. Or maybe it's all 6 of them. And you have to understand that there is also different permutations within each of these circles. So for an ocular problem we could see an exophoria, a convergence insufficiency. You can see ocular misalignment. You might difficult saccadic eye movements or pursuits. Each of those has different types of treatments and so what I'm trying to communicate to you is that this injury becomes very complex very quickly. And you - of course you are going to have completely different recommendations based upon these different injury permutations and different trajectories. But right now our research that we are doing is a lot of our imaging stuff is now looking at the injury this way, our treatment stuff is looking at the injury this way and quite frankly I think we need to look at exertion this way too because I can exert someone fully with this problem and they don't feel a thing. I exert someone with that problem and they are going to have trouble. And so it's very different outcomes based upon the different types of trajectories.
So from an in office evaluation standpoint we really look at these three things. I want to briefly talk about vestibular ocular screening. We've created a new exam called the VOMS, it's a horrible name I know, but it's the best we could come up with. It stands for Vestibular Ocular Motor Screening, we just validated this, it was just published and we have a lot of data coming out on it. And the next, we have 4 or 5 papers in review right now, but I'm not going to get into the specifics but what we do here is we are looking at smooth pursuits, saccadic eye movements, near point of convergence, vestibular ocular reflex, cancelling out that reflex. We've created standardized instructions, this exam takes 5 minutes to complete. We are looking at smooth pursuits, saccads, near point of convergence, VOR, VMS and that information we've been able, when you use this exam we actually find these are concussed patients within 7 days of an injury, these are controls. In short we see significant differences between concussing controls in a very robust way when you are looking at these different vestibular ocular motor functions. And patients that do these functions are reporting a lot more symptoms when we look at VOR than patients that don't have any concussion. And we've actually now determined that there is a 90% positive predictive rate that we actually can predict who is concussed and who is not. And so the sensitivity specificity exam is very impressive and we've never had an exam to measure concussion. A neurologic examination is very good to rule out CNS, you know more moderate and severe traumatic brain injury, a neurologic examination does nothing to measure concussion. We need to look at this injury in a different way. Once you rule out skull fractures and bleeds and all the intraparenchymal stuff that can occur and then you realize its concussion you need a different exam in how to look at it. And we are coming up with different approaches in terms of how to evaluate this injury.
We also have a lot more sophisticated tools to look at the vestibular ocular screening, I mean vestibular ocular motor functioning. So this is a screening exam, the VOMS, that takes 5 minutes. It's a very effective screening exam but then when we identify problems with those systems we actually have a lot more robust ways of examining that and we have something called a gait stability test where on this guy's head in an accelerometer and on the screen we actually flash up like an E that's turned left, right, up or down and we actually can, we have the patient move their head in horizontal or vertical ways and we can actually measure exactly at what velocity they are losing that target stimulus and how this injury affects dynamic acuity okay. It doesn’t affect your ability to see, it affects your ability to move your head to see. And so we can actually measure this very robustly. When I have a football quarterback come in to see me we have data on this test throughout the age range. I know what a 12 year old kid is supposed to look like on this, and as a quarterback you better be able to move your head and see down the field. And not only does that tell you the patient is still injured but it also tells you the patient is still vulnerable. And their performance is going to be affected.
So you know we have baseball players that come in, if you can't move your head and turn real fast and look at something you know we see baseball players all the time that have significant problems with performance. I saw a guy last year whose average went from like 310 lifetime hitter to like 220 because he couldn't see the ball when he moved his head. So there is a lot of functional implications of this injury and you've got to know how to rehab this stuff. But we can look at the ocular system and see if there is any misalignments, we can look at balance in very sophisticated ways. We also look at the eyes in very, very specific ways. If you use infrared goggles we actually can see the eye movements and nystagmus and convergence insufficiencies and convergent spasms and there is a lot of different ocular problems that we see from head injury and we can actually determine that a lot better when you use much more sophisticated ways of looking at it.
The last part of our evaluation that we do is computer based neurocognitive testing. ImPACT is a tool that was really primarily developed by Mark Lovell, Joe Maroon and myself and Mark was the primary guy. But this test, a lot of you have heard of this, it's the base - how many of you have heard of baseline testing? This test is implemented, I don't think there is any high school, many, there is probably less than a handful of high schools in Pittsburgh that aren't doing this. This is being used at I think 15,000 high schools now around the country, it's mandated in the NFL, NHL and Major League Baseball, bla, bla, bla. But this is the baseline testing that you hear about and what we do is we administer this test before the season starts. Athletic trainers play a huge role in that. If your kid goes to a school here it's very - and they play contact sports it's very likely they have a baseline. It's a web based tool. The athletic trainers play a huge role. We also have outreach programs, the Penn's Foundation have tested I don't know how many thousands and thousands of kids that are tested that way. It's used quite widely. And having a baseline is really helpful. When I see a kid it's particularly helpful in kids believe it or not with any preexisting ocular motor dysfunction because this test does a really good job of picking up on that. We see a lot of kids getting sent to us that were diagnosed with ADHD, they don't have ADHD, they have ocular motor issues. And we actually can treat that sometimes.
And that's very interesting what you see on the baseline data when we see these kids, and if you actually understand what to look at in the data you can start to identify some system problems. You know if you have a history of car sickness you are going to be affected on this test a little bit. Like if you - there is a lot of - you have to know how to look at this information to make sense of it. It's a lot of meat on the bone. But basically this tool is about 20 to 25 minutes, there is a symptom scale, there is 8 neurocognitive measures. There is basically there is validity checks built into the program, so you know about 7 or 8 years ago a kid came in and said yeah I just bombed my baseline so I don't have to do as well postinjury. I'm like well that's pretty smart, you know. And so we actually have created now ways of catching those kids where we are very good at that now. And they are not that smart, you know. But we actually have built in validity checks, but what as a clinician you have to know how to use this tool, it's critical because there is so much information in there and if you are not trained and you don't understand how to look at that information I don't know it can lead to a lot of mismanagement if you really don't understand how to look at the information.
But currently there is over 225 peer review papers on this since 2000, extensive data on validity, reliability, etc, etc. I'm going to - here's the typical protocol again baseline testing, head injury. We actually like to see these kids you know if possible within the first week of their injury, even 3 or 4 days post. We actually have a policy in our clinic, you call, we get you in within 3 days. We used to be have a hard time with that but we now have - we are a pretty well oiled machine. If you send a patient we are going to get this patient in very quickly, usually within 24 hours. And we actually like to see these kids because if you can identify what type of concussion they have early on you can actually affect management right away. And we are going to have some interesting research coming out showing that when we see kids early on they get better faster. And I think it's very important to understand that there is a lot of things you can do sort of out of the chutes with concussion where you can get these kids in the right set of situations academically, exertionally, socially where you can affect and expedite the sort of the recovery process. But basically that's our model.
I want to show you briefly the sensitivity specificity. This is a study that was done not by us, it was done - it looked at 81 concussed athletes, 81 matched, very carefully matched control. Within 3 days of an injury and these are athletes that are symptomatic. Okay so these are kids that 3 days postinjury are telling us they have symptoms of concussion. The discriminate function analysis did not look at symptoms, it just looked at the neurocognitive data in the concussed versus control group, okay, and of course sensitivity is what? Sensitivity is your ability to - the patient is injured when they have a concussion and you have deficits, and then specificity is in the control sample, there is no deficits right. You guys all understand that? And we found out that the testing has a 91.4% sensitivity and a 73.1% specificity. Now this is in patients that are having symptoms after an injury.
The interesting part of this study was looking at the sensitivity and specificity in patients that are not having symptoms. So these are patients within 3 days that on the field they were diagnosed as having concussion, but within 3 days they were telling the clinician that they had no symptoms at all from the head injury, okay. And then they looked at 37 carefully matched kids where they were diagnosed with a symptom score of 0 versus 37 matched controls that were not concussed. And what interestingly this study found is that the sensitivity and specificity was even better in kids that were telling us they were symptom free. In other words, this testing is important because these kids whether they are lying or whether they are not aware of the symptoms, or whether the right questions weren't asked who knows, but whatever it is you need to augment your evaluation with more objective measurements. And that is a big issue, especially as it relates to getting kids back to sports.
I wanted to briefly go over what predicts. So here is a study we did looking at over 2000 kids with concussion. I'm sorry 2000 kids, 134 of whom, we followed these for 3 years and in over 3 years 134 of these football players had a concussion. And then we measured their outcomes, okay prospectively. This is every kid in the sample and we found out that about - when you measure a recovery as being symptom free at rest, symptoms free with exertion and they demonstrate normal neurocognitive functioning about 40% of our football players get better in a week, 60% by week 2, 80% by week 3 and then 1 out of 5 kids took more than 3 weeks to recover. And that's why you can't cookbook this injury. If you tell a kid you can go back to play in a week you are missing 60% of your athletes dangerously. If you tell a kid to stay out 3 weeks you are going to be too conservative 80% of the time and not conservative enough 20% of the time. It's very important to evaluate this injury specifically for each kid.
You see this kid here, he got better in a day; this kid here took over a year you know to recover. So these kids up here are the ones that really struggled and our research in the last 5 years has really been trying to identify who these kids are up here, this 20% that take 3 or more weeks to recover. And I'm going to briefly show you some studies going over who those 20% are. You know we actually see - there is a lot of misperceptions about concussion. Here is an injury.
So that guy right there had a 5 minute loss of consciousness, he vomited, he was spine-boarded, taken to the emergency room, CT scan was done, it was normal. He spent the night in Kentucky, the next morning he flew to Gainesville and in 2 weeks they had a bye week the next week and in 2 weeks they were set to play LSU pretty much for the national championship. Pretty important player at the time. And long story short is he was evaluated by our team as well as the University of Florida team and we - it was like - it was a very thorough evaluation I can promise you because there was a lot riding on this. And we saw this guy probably a week after his injury, 7 days, and there was nothing wrong with him, zero, every single test we have was normal. Bit smile on his face like a politician, you know I mean he was totally normal. We put the guy back to play, he had no issues whatsoever. You wouldn't have expected that with a 5 minute LOC you know in someone that basically had that severe an on field presentation. And then we had this guy here who doesn't even look like he's severely injured.
So that guy did no loss of consciousness, no amnesia, no confusion, he was able to walk off the field on his own power. The athletic trainer was very good, took him out of play even though he was telling the athletic trainer he felt fine. That afternoon on the car ride back to his hotel or whatever he started feeling sick, foggy, kind of off. This guy took over a year to recover from that. Completely really pretty much ruined his career because was a you know free agent and didn't sign the big contract. He's back playing now and he's normal but it took a year. I saw this guy and it was forever to get him better from this. And the point I’m making is that what may be perceived as a severer injury early on actually those get better sometimes very quickly and the ones that seem innocuous and you bring them in the emergency room and the guy is like hey, how you doing? And you don't think there is much going on, 2 or 3 days later it can become a different story. And there is a lot of variability in outcomes and you've got to be really careful with that.
So we've done studies looking at what signs and symptoms predict the longest recoveries. And not to bore you too much with the details but here is a study, we looked at 176 male high school football players. They had baseline testing. We determined recovery, that they were back to normal. So we followed these 176 kids until they recovered from their concussion and then retrospectively we had very good records on field as to what symptoms these patients had and then we were able to analyze what signs and symptoms in the field predicted kids that took 3 or more weeks to recover, right. And this is the first time this study has ever been done. And we looked at actually 14 different on field signs and symptoms. We looked at headache, vision change, amnesia, retrograde posttraumatic, los of consciousness, confusion, balance problems, dizziness, nausea, vomiting, okay. We looked at 14 different signs and symptoms. There was one symptom reported by the patient that was 6.4 times more likely to result in a month or longer recovery relative to any other symptom in the field. And this is important for you guys as emergency, you know pediatricians or what have you, you know, what sign and symptom. For those of you - I've presented this before so don't raise your hand if you know the answer. But if you don't know the answer what would you guess to be the sign or symptom that best predicted outcomes, again 6.4 times more likely than any other sign or symptom to take a month or longer to recover?
Who said that? So he said dizziness, and he would be right, money, he was confident too actually. But if you have on field dizziness you are 6.4 times more likely than any other symptom to take a month or longer to recover, which is very interesting don't you think?
If you lost consciousness you were more likely to take a week or less recovery. And we've published multiple studies on this issue and it's reproducible. You lose consciousness for less than 30 seconds it does not predict outcome. And I know that everything in emergency medicine is predicated upon the LOC construct. Every textbook, my own textbooks I read when I was in school says oh if you lose consciousness it's a grade 3 concussion. I mean no, this is not the way in the injury works when you actually look at it empirically. Dizziness was number 1, the second symptom that best predicted poor outcome it looks like was headache, posttraumatic amnesia was 3, and you can read the numbers yourself.
But we've also done studies looking at what symptoms at 3 days predict poor outcome., okay, and we looked at 21 different symptoms in the office and this is a whole different sample. I'm going to spare you the methodology but we looked at all the common symptoms of concussion you know. I'll save you the time, but what symptom at 3 days post injury? All right, smarty pants over there. What symptom at 3 days post injury? What's that?
It's close but you are not right, no. Fogginess was okay. What the hell is fogginess, right? Fogginess is a symptom that I would describe as you feel kind of detached, one step behind yourself, disassociated. We've been able to identify fogginess as a symptom most likely arising from the vestibular system and when you are in a busy hallway for example and the vestibular system is not working properly that signal comes through aberrantly and the sensation you feel is a sensation of being one step behind, detached, disassociated. How many of you in this room have had a concussion? Okay. And how many of you clearly had that problem of fogginess? And how long did that take to get better, out of curiosity in the back there? Okay, sorry about that. But basically yeah, I mean that's kind of one that will - that's a hanger-oner okay. It's something that and you've got have it treated. If you don't have it treated it can be not so good.
But difficulty concentrating is number two. If you vomit at 3 days postinjury it strongly predicts long outcomes. If you vomit in the - on the field it doesn't. If you are dizzy again it predicts strongly at 3 days postinjury and you can read for yourself the rest of the symptoms. These are all affect sizes of larger than .8 which is a large affect size, all those symptoms listed.
We've also been able to determine on neurocognitive testing we have cutoff scores now that predict a month or loner of recovery. So if you come to see me and I give you this test and you show, and you score a 48 or lower on visual memory, I'm sorry 44 or lower that's an 85% chance you are going to take a month or longer to recover. That's pretty important information. And we are able to really get these kids stratified the right way by using the different exam findings that we gather. And this is empirically based, it's evidence based in terms of how we look at this stuff.
We've published all this work on who these patients are you know, the ones that take 3 or more weeks to recover. And you know to save you all the stuff, this is what we found from a research standpoint. If you are a high school kid you are more likely to take longer to recover than if you are a college athlete. If you are a high school kid you more likely take longer than a professional athlete. Why is that? We don't know, maybe because it's the developing brain, maybe it's due to glutamate which kids are more sensitive to glutamate and glutamate is involved in this pathophysiologically. Maybe it's neck strength, you know I don't know but kids take longer to recover, you've got to be really careful with that. That's been reproduced empirically, study-wise over and over again.
If you have a history of migraine that's the elephant in the room. You don't want to have migraine and get hit in the head because the Genie comes out of the bottle. And you've got to be really careful how you measure that. Learning disability, we published, that was actually the first thing we published in this and it still stands true. Girls have worse outcomes than boys. Why is that? anybody? Girls are 4 to 6 times more likely to have migraine, and migraine is a very strong risk factor and therefore girls are much more likely to have problems. We have a paper coming out looking at motion sickness and ocular dysfunction very strongly predicting poor outcomes. And then the on field symptoms.
So in summary what we know is that the outcomes are variable, there are certain presentations that predict the worst outcomes. You've got to make sure that acutely you are managing this carefully, getting them off the field and then getting them to the right clinician for evaluation. It's very important to get these kids treated. And you can read the rest of it.
I think the most exciting, some of the most exciting stuff we are doing right now is this trajectory model. You are going to hear a lot more about that. We are doing a lot right now, there is a lot in the works about replicating our program not only here in Pittsburgh but elsewhere. There is some exciting things going on with that and a lot of research coming out so I appreciate the time this morning and I may have time for a question or 2 or 3. Thank you very much, appreciate it.