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 Micky Collins, PhD University of Pittsburgh Medical Center  Micky Collins, PhD University of Pittsburgh Medical Center

Micky Collins, PhD University of Pittsburgh Medical Center - PowerPoint Presentation

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Micky Collins, PhD University of Pittsburgh Medical Center - PPT Presentation

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

clinical vestibular anxiety profile clinical vestibular anxiety profile concussion mood cognitive ocular migraine profiles fatigue collins post kontos current

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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

Slide2

Disclosures

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:

Slide3

Objectives

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.

3

Slide4

Collins, 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

Slide5

Exercise 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

Slide6

Building 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.

Slide7

Purpose

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.

Slide8

Study 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.

Slide9

Determining and Prioritizing Clinical Profiles

Profile(s)?

Vestibular

Anxiety/

Mood

Migraine

Primary= Vestibular

Secondary= Migraine

Tertiary= Anxiety/Mood

Slide10

How 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

Slide11

Results: Primary Clinical Profiles (N = 188)

Kontos

, Collins et al.

Current Sports Medicine Reports

, 2019.

Slide12

Which 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

Slide13

Co-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

.

Slide14

Which characteristics best identify each clinical profile?

14

Slide15

Concussion

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

Slide16

Vestibular 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

16

Slide17

Dizziness 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

17

Slide18

Vestibular 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

Slide19

Concussion

Ocular

Vestibular

Cognitive/

Fatigue

Post-

TraumaticMigraine

Anxiety/

Mood

Cervical

Concussion Clinical Trajectories

:

Post-Traumatic Migraine

Collins, Kontos, Reynolds,

Murawski

, Fu.

KSSTA

.

19

Slide20

Migraine 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

20

Slide21

Headache @ 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

21

Slide22

Migraine 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

Slide23

Concussion

Ocular

Vestibular

Cognitive/

Fatigue

Post-Traumatic Migraine

Anxiety/

Mood

Cervical

Concussion Clinical Trajectories

:

Ocular

Collins, Kontos, Reynolds,

Murawski

, Fu.

KSSTA

.

23

Slide24

Ocular 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

24

Slide25

Male 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

25

Slide26

Oculo-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

Slide27

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/

FATIGUE

POST-TRAUMATICMIGRAINE

ANXIETY/

MOOD

CERVICAL

CONCUSSION CLINICAL TRAJECTORIES:

Anxiety

Collins, Kontos, Reynolds,

Murawski

, Fu.

KSSTA

.

27

Slide28

Anxiety/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

28

Slide29

Every characteristic on the preceding slide was a significant univariate predictor of the anxiety/mood profile...reflecting the complicated presentation of this profile.

29

Slide30

Anxiety/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

30

Slide31

Anxiety Clinical Profile Targeted Treatment Recommendations

Behavioral regulation

Exercise and Exertion Therapy

Social and environmental exposures

Cognitive-behavioral psychotherapy

Anti-anxiety medication if needed

Slide32

Concussion

Ocular

Vestibular

Cognitive/ Fatigue

Post-

TraumaticMigraine

Anxiety/

Mood

Cervical

Concussion Clinical Profiles

:

Cognitive Fatigue

Collins, Kontos, Reynolds,

Murawski

, Fu.

KSSTA

.

32

Slide33

Cognitive/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

33

Slide34

Male 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

34

Slide35

Cognitive Fatigue Clinical Profile Targeted Treatment Recommendations

Structured breaks during day

Regulated exercise

Regulated sleep

Cognitive Rehab??

Stimulant medications if chronic

Slide36

CP-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

.

Slide37

Next Steps: Randomized Controlled Trials (RCT) for Distinct Clinical Profiles

Slide38

Concussion

Ocular

Vestibular

Cognitive/

Fatigue

Post-Traumatic

Migraine

Anxiety/

Mood

Cervical

RCT: Concussion Clinical Profiles

Vestibular

38

Slide39

Randomized 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

39

Slide40

Comparison 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.

Slide41

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!

Slide42

42

Thank you!

For more information:

collinsmw@upmc.edu