Professor Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program Clinical Profile and Targeted Treatment of Concussion Disclosures ID: 776702
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Slide1
Micky Collins, PhDUniversity of Pittsburgh Medical CenterProfessorDepartment of Orthopaedic SurgeryDepartment of Neurological SurgeryProgram Director, UPMC Sports Concussion Program
Clinical Profile and Targeted Treatment of Concussion
Slide2Disclosures
I am a co-founder and shareholder of
ImPACT
Applications, Inc.
I am co-author of the book,
“Concussion: A Clinical Profiles Approach to Assessment and Treatment”
I have been (during the previous 12 months) supported in part by research grants and contracts to the University of Pittsburgh from the sources listed to the right:
Slide3Objectives
Provide an overview for a clinical profile/subtype model for concussion. Present data showing the clinical criteria associated with each concussion clinical profile. Discuss active and targeted treatment approaches for each profile of concussion.
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Slide4Collins, Kontos, Reynolds, Murawski, Fu. KSSTA; 2014.Collins, Kontos, Okonkwo et al., Neurosurg; 2016
“
Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.”
Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-
TraumaticMigraine
Anxiety/
Mood
Cervical
Slide5Exercise CBT Psychotherapy Medication
Vestibular RehabilitationExercise
Vision TherapyOrthoptics
Manual TherapyExerciseInjectionAcupunctureBiofeedbackMedicationSurgery
Structured RestExerciseMedication
Exercise Behavioral Regulation Relaxation/Biofeedback CBT/Trigger Modification Medication
“Matching targeted and active treatments to clinical profiles may improve recovery trajectories following concussion.”
Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-
TraumaticMigraine
Anxiety/
Mood
Cervical
Slide6Building Evidence for Characterizing Criteria for Concussion Clinical Profiles
The information contained in this Presentation is protected by copyright and/or other intellectual property laws and is considered proprietary by UPMC. The information embodied in this document is strictly confidential and may not be modified, copied, published, disclosed, distributed, displayed or exhibited, in either electronic or printed formats, without the prior written consent of UPMC. © 2017 UPMC. All rights reserved.
Kontos
, Collins et al.
Current Sports Medicine Reports
, 2019.
Slide7Purpose
Determine the frequency of the different primary clinical profiles in a concussion specialty clinic patient cohort.
Determine which clinical profiles are most likely to co-occur.
Establish empirically defined clinical criteria for each clinical profile.
Slide8Study Overview
De-identified review of 188 patient clinical charts from two UPMC concussion clinic sites between October 1, 2017-Nov 4, 2017.M Age= 21.9 (SD= 13.8, Range 10-40) yrs; Female= 54% (n= 103)Time since injury=What characterizes patients with the primary profile from patients with other profiles?Chi-square analyses with odds ratios (OR) for characteristics Logistic Regression w/adjusted ORs
Kontos
, Collins et al.
Current Sports Medicine Reports
, 2019.
Slide9Determining and Prioritizing Clinical Profiles
Profile(s)?
Vestibular
Anxiety/
Mood
Migraine
Primary= Vestibular
Secondary= Migraine
Tertiary= Anxiety/Mood
Slide10How often does each clinical profile occur?
The information contained in this Presentation is protected by copyright and/or other intellectual property laws and is considered proprietary by UPMC. The information embodied in this document is strictly confidential and may not be modified, copied, published, disclosed, distributed, displayed or exhibited, in either electronic or printed formats, without the prior written consent of UPMC.
© 2017 UPMC. All rights reserved.
Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-
TraumaticMigraine
Anxiety/
Mood
Cervical
Slide11Results: Primary Clinical Profiles (N = 188)
Kontos
, Collins et al.
Current Sports Medicine Reports
, 2019.
Slide12Which profiles co-occur?
The information contained in this Presentation is protected by copyright and/or other intellectual property laws and is considered proprietary by UPMC. The information embodied in this document is strictly confidential and may not be modified, copied, published, disclosed, distributed, displayed or exhibited, in either electronic or printed formats, without the prior written consent of UPMC.
© 2017 UPMC. All rights reserved.
Vestibular
Anxiety/
Mood
Ocular
Vestibular
Anxiety/
Mood
Post-
TraumaticMigraine
Slide13Co-occurring Profiles(N=141)
OR= 5.7 (95%CI= 2.4-13.5),Chi-square= 15.8, p<.001
Vestibular
Migraine
Ocular
Cognitive/ Fatigue
Primary
Secondary
OR= 3.5 (95%CI= 1.5-8.0),
Chi-square= 7.6, p=.006
Primary
Secondary
Vestibular
Migraine
OR= 11.2 (95%CI= 3.8-33.5),
Chi-square= 21.2, p<.001
Primary
Secondary
Migraine
OR= 4.3 (95%CI= 1.2-6.5),
Chi-square= 4.3, p=.04
Primary
Secondary
Anxiety/
Mood
Kontos
, Collins et al.
Current Sports Medicine Reports
, 2019
.
Slide14Which characteristics best identify each clinical profile?
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Slide15Concussion
Ocular
Vestibular
Cognitive/
Fatigue
Post-Traumatic
Migraine
Anxiety/
Mood
Cervical
Collins MW,
Kontos
A, et al,
KSST
Concussion Clinical Profiles
:
Vestibular
Collins, Kontos, Reynolds,
Murawski
, Fu.
KSSTA
.
15
Slide16Vestibular Clinical Profile
Clinical Findings:
PCSS + for dizziness and/or imbalance
Current symptoms:Dizziness, dizziness with movement or change of positions, symptoms in busy environmentsCurrent motion sensitivityVOMS – increase in symptoms beyond baseline with VOR/VMS Medications: meclizine, Dramamine, vestibular suppressantsNeurocognitive deficits with visual motor speed (data not in current analysis)
Risk Factors:Personal history of motion sicknessPersonal history of vestibular disorderComorbid migraineComorbid anxiety disorder
Vestibular
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Slide17Dizziness with Movement and Discomfort in Busy Environments Associated with Vestibular Profile
χ2=19.72, p<.001, Nagelkerke R2= .19
BSEWaldpAdj OR95% CIDizziness.264.350.57.451.300.66-2.59Dizziness w/Movement0.92.337.84.0052.511.32-4.77Discomfort in Busy Env1.05.445.69.022.861.21-6.76Current Motion Sens0.68.373.28.071.970.95-4.09Positive VOMS VOR0.55.362.31.131.720.85-3.48Positive VOMS VMS0.47.391.51.221.610.75-3.44
Pts w/Dizziness w/Movement were 2.5x more likely to have vestibular profilePts with Discomfort in Busy Environments were 2.9x more likely to have vestibular profile
χ2=39.38, p<.001, Nagelkerke R2= .18
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Slide18Vestibular Clinical Profile Targeted Treatment Recommendations
Vestibular therapy
Retraining and re-habituation
Targeted
VOR, VMS focused therapies
Environmental Exposures
Targeted exertion therapy
Medications- only if chronic and strong anxiety or migraine overlay
Slide19Concussion
Ocular
Vestibular
Cognitive/
Fatigue
Post-
TraumaticMigraine
Anxiety/
Mood
Cervical
Concussion Clinical Trajectories
:
Post-Traumatic Migraine
Collins, Kontos, Reynolds,
Murawski
, Fu.
KSSTA
.
19
Slide20Migraine Clinical Profile
Clinical Findings:
PCSS + for HA and light and/or noise sensitivity; HA and nausea
Current symptoms: HA Upon WakingHA and nauseaHA with light/noise sensitivity Motion sicknessCurrent medications for migraine prevention/rescue meds and/or anti-nauseaNeurocognitive deficits with verbal and visual memory (data not in current analysis)
Risk Factors:Personal history of migrainePersonal history of motion sicknessFamily history of migraineComorbid anxiety disorderFemale gender
Migraine
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Slide21Headache @ Waking and w/Nausea Associated with Migraine Profile
χ2=19.72, p<.001, Nagelkerke R2= .19
BSEWaldpAdj OR95% CIHeadache @ Waking1.30.3514.09<.0013.671.86-7.24Headache w/Nausea0.93.2910.62.0012.531.45-4.42HA w/Light or Noise1.30.290.19.671.130.65-1.99Per Hx Motion Sick.0.44.302.10.151.540.88-2.79Fam Hx Migraine0.38.281.87.171.450.85-2.50
Pts with HA @ Waking were 3.7x more likely to have migraine profilePts with HA w/Nausea were 2.5x more likely to have migraine profile
χ2=42.15, p<.001, Nagelkerke R2= .17
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Slide22Migraine Clinical Profile Targeted Treatment Recommendations
Behavioral regulation-No naps/strict sleep schedule, exercise, reduced stress, regulated diet/hydration
Exertion therapy
If vestibular component-Vestibular Rehabilitation
Medications- only if chronic
Abortive and/or Preventative migraine, anti-anxiety medications
Slide23Concussion
Ocular
Vestibular
Cognitive/
Fatigue
Post-Traumatic Migraine
Anxiety/
Mood
Cervical
Concussion Clinical Trajectories
:
Ocular
Collins, Kontos, Reynolds,
Murawski
, Fu.
KSSTA
.
23
Slide24Ocular Clinical Profile
Clinical Findings:
PCSS + for vision problems
Current symptoms:
Blurry vision, diplopia, eye strainDifficulty reading or performing visual activitiesHA triggered specifically by visual activity VOMS – NPC > 5cm or abnormal convergence notedNeurocognitive deficits with reaction time and visual memory (not in current analysis)
Risk Factors:Personal and/or family history of eye muscle surgery, strabismus, amblyopia, or other ocular diagnosisPrescribed reading glasses before age of 30Past participation in vision therapy and/or prescribed prism lenses.
Ocular
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Slide25Male Gender, Blurry/Diplopia, Difficulty Reading and NPC Distance Associated with Ocular Profile
BSEWaldpAdj OR95% CIMale Gender1.47.566.81.0094.351.44-13.15Blurry, Diplopia, Eye Strain1.27.516.11.013.561.45-4.42Difficulty Reading1.49.606.26.014.440.65-1.99NPC >5cm2.34.6712.27<.00110.390.88-2.79
Males were 4.4x more likely to have ocular profilePts w/Blurry, Diplopia, Eye Strain were 3.6x more likely to have ocular profilePts w/Difficulty Reading were 4.4x more likely to have ocular profilePts w/NPC >5cm were 10.4x more likely to have ocular profile
χ2=45.24, p<.001, Nagelkerke R2= .39
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Slide26Oculo-motor Clinical Profile Targeted Treatment Recommendations
Oculo-motor exercises via vestibular therapy
Behavioral Optometry and Vision therapy in more protracted or severe cases
Oculo-motor exposures and re-habituation
If isolated oculo-motor issue-allow full non-contact exertional activity
Slide27CONCUSSION
OCULAR
VESTIBULAR
COGNITIVE/
FATIGUE
POST-TRAUMATICMIGRAINE
ANXIETY/
MOOD
CERVICAL
CONCUSSION CLINICAL TRAJECTORIES:
Anxiety
Collins, Kontos, Reynolds,
Murawski
, Fu.
KSSTA
.
27
Slide28Anxiety/Mood Clinical Profile
Clinical Findings:
PCSS + for irritability, nervousness, sadness, feeling more emotional; symptom report across all domains
Current symptoms: Anxiety/depression, worry, difficulty turning off thoughts, ruminationSadness, limited social interaction Current psychiatric or mood medicationsCurrent psychiatry, psychotherapy Normal or inconsistent findings on neurocognitive testing (Data not in Analysis)
Risk Factors:Personal and/or family history of psychiatric issuesPsychiatric/mood medications taken in pastComorbid migrainePresence of significant life stressor
Anxiety/
Mood
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Slide29Every characteristic on the preceding slide was a significant univariate predictor of the anxiety/mood profile...reflecting the complicated presentation of this profile.
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Slide30Anxiety/Depression, Worry, and Sadness
Sx Associated with Anxiety/Mood Profile*
BSEWaldpAdj OR95% CIAnxiety/Depression Sx1.55.3421.17<.0014.742.44-9.19Worry, Difficulty Turning off Thoughts, Rumination Sx1.44.3814.77<.0014.242.03-8.85Sadness, Lim. Social Interact1.10.427.00.0083.021.33-6.84
Pts w/Anxiety/Depression were 4.7x more likely to have anxiety/mood profilePts w/Worry and related Sx were 4.2x more likely to have anxiety/mood profilePts w/Sadness/Loss of Interest were 3x more likely to have anxiety/mood profile
χ2=138.30, p<.001, Nagelkerke R2= .48
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Slide31Anxiety Clinical Profile Targeted Treatment Recommendations
Behavioral regulation
Exercise and Exertion Therapy
Social and environmental exposures
Cognitive-behavioral psychotherapy
Anti-anxiety medication if needed
Slide32Concussion
Ocular
Vestibular
Cognitive/ Fatigue
Post-
TraumaticMigraine
Anxiety/
Mood
Cervical
Concussion Clinical Profiles
:
Cognitive Fatigue
Collins, Kontos, Reynolds,
Murawski
, Fu.
KSSTA
.
32
Slide33Cognitive/Fatigue Clinical Profile
Clinical Findings:
PCSS + for items: feeling slowed down, difficulty concentrating, difficulty remembering.
Current symptoms: Cognitive complaintsAbsence of HA upon waking and increases with activity throughout dayNeurocognitive: low test results (<16th%) on 2 out of 4 cognitive composite areas
Risk Factors:ADD/ADHDOther learning disabilityHas not modified work or activity schedulePlayed through injury
Cognitive/Fatigue
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Slide34Male Gender and 2+ CNT Scores <16% Associated with Cognitive Fatigue Profile
χ2=19.72, p<.001, Nagelkerke R2= .19
BSEWaldpAdj OR95% CIMale Gender1.24.506.15.0133.451.29-9.172+ CNT Scores <16% 1.64.588.30.0045.341.71-16.67W/out Modified Activity or Work1.751.112.50.1145.770.66-50.64
Males were 3.5x more likely to have cognitive-fatiguePatients with 2+ CNT scores <16% were 5.3x more likely to have cognitive-fatigue
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Slide35Cognitive Fatigue Clinical Profile Targeted Treatment Recommendations
Structured breaks during day
Regulated exercise
Regulated sleep
Cognitive Rehab??
Stimulant medications if chronic
Slide36CP-Screen Items by Profile (23 items)
Anxiety/Mood (5)Migraine (5)Vestibular (5)Ocular (5)Cognitive-Fatigue (3)Feeling sadHeadache (HA) when you wake upDizziness when you move your headTrouble focusing your eyes while readingFeeling more tired at the end of the dayDifficulty turning off your thoughtsHA with nausea/upset stomachDifficulty or discomfort in busy environmentsBlurry or double visionTrouble remembering thingsConstantly thinking about your symptomsHA with sensitivity to light or noiseFeeling motion sickEye strain during visual activitiesIncreased HA following cognitive activityFeeling nervous or anxiousVisual aura with or without HAFeeling or sensation of slow wavy dizzinessDifficulty/HA when looking at phone or computer screenFeeling more stressed than usualIncreased HA with physical activityFeeling of fast spinning dizziness (vertigo)Frontal HA
Kontos
, Collins et al. Neurosurgery, In Press
.
Slide37Next Steps: Randomized Controlled Trials (RCT) for Distinct Clinical Profiles
Slide38Concussion
Ocular
Vestibular
Cognitive/
Fatigue
Post-Traumatic
Migraine
Anxiety/
Mood
Cervical
RCT: Concussion Clinical Profiles
Vestibular
38
Slide39Randomized Controlled Trial (RCT) of Precision Vestibular Treatment following Concussion
Collins, Kontos, MuchaRandomized controlled trial to determine the effectiveness of precision, vestibular therapy for reducing recovery time and impairment in patients with vestibular clinical profilesCompare 50 adolescent patients <10 days post-injury with vestibular clinical profiles given: 1) Vestibular Therapy, or 2) Standard of Care Behavioral ManagementClinical outcomes measured at 2 and 4-weeks post-treatment
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Slide40Comparison of Recovery Status
Controls (n=21)VestibularTreatment (n=19) Odds Ratio (OR)95% Confidence Interval (CI) pRecovered by 2 weeks- # (%)5%32%9.2 1.0 – 85.80.03Recovered by 4 weeks- # (%)20%48%8.6 1.2 – 20.20.01
Comparison of Participants in Control and Vestibular Treatment Groups Recovered by 2- and 4-weeks Post-enrollment (N=50).
Vestibular Treatment group was 9.2x more likely to be recovered by 2-weeks and 8.6x more likely to be recovered by 4-weeks than Controls.
Conclusions
Concussions involve different clinical profiles.Active treatments for concussion should be targeted and driven by clinical profiles.Behavioral regulation is key and early activity is indicated.Research is forthcoming on effectiveness and timing/dosing of treatments.Treatment of concussion is about process not “protocol.” Educate Your Athletes…Concussion is treatable!
Slide4242
Thank you!
For more information:
collinsmw@upmc.edu