28/05/16 · 28/05/16 2 Repetitive TBI Consequences • Post-concussion syndrome • Second Impact Syndrome • 50% are fatal • Chronic Traumatic Encephalopathy • 90% of cases

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Management of Special Populat ions Athletes

•  Disclosure Statement •  Exploring commercialisation of moV&,

V&MP Vision Suite •  No other commercial interests / disclosures

Goals

•  Risks associated with TBI in athletes •  Athlete mentality and how this affects TBI

management •  Clinical assessment of TBI in athletes

Sports Related TBI

Sports (20%) Biking (15%)

Medical (10%)

Violence (10%)

Work Place Accidents (10%)

Diving (5%)

Motor Vehicle Accidents (30%)

1)  http://www.biaww.com/stats.html 2)  Center for Disease Control, USA 3)  Guskiewicz K et al (2003) JAMA 209(19)

•  Second leading cause of TBI in 15-24 year olds

•  Leading cause of TBI in 5-14 year olds

•  Rate of emergency room visits has risen 57% between 2001 and 2009

•  Estimate 300,000 sport-related concussions occur annually in USA

Repeti t ive TBI in Athletes

•  28.2% of athletes self-reported a previous TBI (UW Varsity athletes)

•  20% of high school athletes report one TBI •  Highest rates: boys football (47%), girls

soccer (8%) •  Girls have a higher rate (RR 1.7, 95% CI 1.4 –

2.0) •  6.5% have more than one TBI a year

•  91.7% occurred in 10 days; 75% in 7 days (football)

1.  Moser RS, Schatz P, Jordan BD (2005) Neurosurgery 57(2):300–306 2.  Guskiewicz K et al (2003) JAMA 290 (19) 2549-2555 3.  Marar M et al (2012) Am J Sports Med 40(4): 747-755

•  Athletes with multiple TBIs •  Report more symptoms

•  HA most common •  7.7x more likely to have poor memory •  Slowed recovery (>1 week)

•  30% with ≥3 vs. 14.6% with 1 TBI •  Suffer from depression

•  1-2 TBI: 1.5x more likely •  ≥3 TBI: 3x more likely

•  More likely to commit suicide

Repeti t ive TBI Consequences

1.  Iverson G et al (2004) Brain Injury 18(5): 433-443 2.  Guskiewicz K et al (2003) JAMA 290 (19) 2549-2555

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Repeti t ive TBI Consequences •  Post-concussion syndrome •  Second Impact Syndrome

•  50% are fatal •  Chronic Traumatic Encephalopathy

•  90% of cases are athletes •  Alzheimer's, dementia pugilistica

1.  Guskiewicz KM et al. (2007) Medicine and Science in Sports and Exercise 39(6):903–909 2.  Oquendo MA et al. (2004) Journal of Nervous and Mental Disease 192(6):430–434 3.  Brenner LA, Ignacio RV, Blow FC (2011) Journal of Head Trauma and Rehabilitation 26(4):257–264 4.  Graham R et al. Eds (2014) Sports Related Concussion In Youth; Improving the Science, Changing the Culture

Rowan’s Law – Canada •  First concussion legislation in Canada

•  Making concussion awareness mandatory in Ontario’s curriculum

•  Promotion of an annual Brain Day awareness campaign

•  Better tools for coaches and players to identify and treat concussions

•  Expert advisory committee to Ontario’s Premier

•  Implement Ontario specific recommendations

http://rowanslaw.ca

cbc.ca

The Athlete Mental i ty •  Highly motivated •  Highly Dedicated

•  Average high school athlete – 10+ hours •  Average provincial athlete – 20+ hours

•  Sport defines their identity •  What the eat, how much they sleep, what

they watch on TV •  Sacrifice time with family and friends to train

•  The sport and the team are everything

www.thepeterboroughexaminer.com

The Athlete and (TBI)Injury •  Loss of identity

•  Loss of social networks and support •  Loss of physical activity

•  Retirement due to multiple TBIs •  Distress and reduced quality of life

•  Similar to other severe athletic injuries

•  Social support is important for psychological recovery

1.  Caron JG et al. (2013) Journal of Sport and Exercise Psychology. 35(2):168–179 2.  Kuehl MD et al. Clinical Journal of Sports Medicine 20(2):86–91 3.  Graham R et al. Eds (2014) Sports Related Concussion In Youth; Improving the Science, Changing the Culture 4.  Clement D, Shannon VR (2011) Journal of Sport Rehabilitation 20(4):457–470 5.  Bianco T. (2001) Research Quarterly for Exercise and Sport 72(4):376–388

The Athlete and (TBI)Injury •  Pressure to perform

•  Norm is to play through injuries •  Stigma: lacking toughness

•  Pressure is applied athlete’s entire support group

•  Coaches, teammates, parents •  Pressure is also applied by athlete

•  Big games, playoffs, starting rosters, scouts, scholarships, careers

•  Motivation to succeed

1.  Safai P (2003) Sociology of Sport Journal 20(2):127–146 2.  Young K, White P, McTeer W. (1994) Sociology of Sport Journal 11(2):175–194 3.  Graham R et al. Eds (2014) Sports Related Concussion In Youth; Improving the Science, Changing the Culture

The Athlete and (TBI)Injury •  Invisible injury

•  TBIs are defined entirely on symptoms •  No bumps, bruises, broken bones or swelling

•  No casts, crutches or braces in rehab •  Athletes look “normal”

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Return to Play •  Athletes want to return to high-risk

environments •  Sport cannot be modified for athletes to

play with injury

Risk of Re-Injury •  Athletes are more likely to be re-injured

•  1 TBI = 1-2x increased risk •  2 TBI = 2-4x increased risk •  3 TBI = 3-9x increased risk

1.  http://www.concussiontreatment.com/concussionfacts.html 2.  Guskiewicz K et al (2003) JAMA 290 (19) 2549-2555

Risk of Re-Injury

Number of Previous Concussions

Numb

er of

Athl

etes

•  28 Athletes (M Hockey, W Hockey, W Basketball) •  17 (60.7%) had previous concussions •  8 (28.6%) had multiple previous concussions

0

2

4

6

8

10

12

0 1 2 3 4

Total Men Women

Safe Return to Play •  Currently “safe” when symptoms resolve

•  Complete return to play protocol without symptoms

•  ImPACT or other baseline testing is normal •  No symptoms ≠ healthy

•  Balance deficits still present •  “Athletes aren’t quite right”

1.  Powers K, Kalamar JM, Cinelli M (2014) Gait Posture 39(1):611-4 2.  Personal conversation with Head Athletic Therapist, UW

Assessing of TBI in Athletes •  Three-part assessment

•  Case history •  Structural assessment •  Functional assessment

•  Additional testing •  King-Devick •  Balance •  Reaction time •  Motion anticipation •  Dynamic visual acuity

All TBI Patients

King-Devick, Balance •  King-Devick

•  Reading speed with increasing visual difficulty

•  Total time + total errors •  Balance

•  Measure of stability •  Eyes open, eyes closed

•  BESS test, King-Devick Balance, Wii boards

Baseline: 44.1 ± 8.73s (Errors: 0.10 ± 0.35)

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Reaction Times •  Amount of time needed to see a visual

stimulus and respond with a motor action •  Simple reaction time – single stimulus •  Choice reaction time – multiple stimuli •  Stimuli can be central or peripheral

•  SVT board (Australia), Dynavision, FitLight, Wayne Saccadic Fixator, BATAK light board

Visual-Motor Reaction Time •  Baseline Assessment

•  4 protocols •  Central •  Central Go / NoGo •  Peripheral •  Peripheral Go / NoGo

•  4 tests / protocol •  1 x practice •  3 x timed

20

Baseline = (Timed1 + Timed2 + Timed 3) 3

1.  Dalton K, Willms A. (2015) Optom Vis Sci 92: E-abstract 155026.

21

0

100

200

300

400

500

600

700

800

900

Central Peripheral

static individual dynamic team dynamic

Aver

age R

eact

ion

Tim

e (m

s)

Visual Motor Reaction Time

1. Dalton, K, Cinelli, M, Khaderi, K and Willms, A. (2014) Optom Vis Sci 91: E-abstract 145134.

Central

Peripheral

Central = 478.2 ± 99.7 (range: 315.7 to 969.7) Peripheral = 780.7 ± 127.2 (range: 571.3 to 1142.0)

506.8 480.8 470.0

810.4 828.4 751.8

Motion Anticipat ion •  Initiation of a complex motor movement in

response to the anticipated position of a moving target

•  Bassin anticipation timer, tachistoscope, strobe glasses

Coincidence Anticipation

23

-40

-30

-20

-10

0

10

20

30

40

50

60

0 5 10 15 20 25 30 35 40 45

Constant Error

Absolute Error

•  Baseline Assessment •  Constant speed – incremental increase

•  5 x 5mph •  5 x 10mph •  5 x 15mph •  5 x 20mph •  5 x 25mph •  5 x 30mph •  5 x 35mph •  5 x 40mph

1.  Dalton K, Willms A (2016) Optom Vis Sci 93: Submitted to AAO 2016

Dynamic Visual acuity •  Measure of visual acuity with movement

•  Moving optotypes •  Wayne Robot Rotator •  moV&, V&mp Vision Suite (UW)

•  Moving person •  inVision

•  Dynamic acuity is worse than static

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The biggest chal lenge •  Population norms are not available for

these tests •  Standardized methods have not been used

•  Need pre-injury “baselines” to establish normal function

•  Can still monitor recovery using tests though

Case 1: RR •  23 y/o female, field hockey player •  C/C: vision sx following multiple mTBI

•  Physiotherapist recommended that she have her vision checked out

•  Daily headaches, difficulty focusing, discomfort and nausea with extreme gazes, pressure in head, sensitivity to light & sound, dizzy when stands to quickly

•  Wants to get better quickly •  National Team training camp over Christmas •  Full time training in early 2016

December 2015

Case 1: RR •  Early October 2015 - First mTBI

•  Quick turn, hit another player’s head •  Felt immediately nauseous and dizzy •  Finished the game and kept training

•  “Only 2 weeks left in the season anyway” •  Late October 2015 – Second mTBI

•  Quick turn, hit another player’s shoulder •  Hugely symptomatic – head throbbing •  Stopped physical activity, continued work and school

•  Mid-November 2015 •  Went back to practice 2 weeks after 2nd injury •  Head throbbing, symptoms exploded

•  FINALLY decided to tell someone and get care

December 2015 Case 1: RR

•  VA (unaided) •  OD 6/4.5, OS 6/6, OU 6/4.5

•  CT (unaided) •  (D) Ortho (N) 2 Exophoria

•  Refraction (post-dilation) •  OD plano 6/4.5 •  OS +0.25 6/6

•  Amplitude of Accommodation •  OD 8.0D OS 8.0D

•  Accommodative Facility •  OD 11cpm OS 10cpm OU 13cpm

•  Stereoacuity •  25sec of arc

•  NPC •  6/9cm x 3

•  Vergence Facility •  4.5cpm

•  Oculomotor control •  Pursuits & saccades – moderate

accuracy; discomfort esp. with extreme left gazes

December 2015

Case 2: RR December 2015 January 2016 February 2016 March 2016

King-Devick 35.8s , 0 errors 34.3s, 0 errors 37.2s, 0 errors 32.2s, 0 errors

Balance Score (Eyes Open)

Double: 0.046 Single: 0.094 Tandem: 0.061




Balance Score (Eyes Closed)





Reaction Time Central: 422.0ms Peripheral: 694.9ms

Case 2: JA •  13 y/o female, soccer player •  C/C: Feels she no longer needs her bifocal

•  Reads through top of glasses or without glasses •  Back at school, some light sensitivity, HA’s 4-5 days/week •  Vision tracking & VOR exercises from chiropractic

neurologist •  Injury: April 2015

•  Previous Injuries: •  September 2012, May 2013, May 2014

•  Tried soccer in November 2015, symptoms returned immediately

•  Weightlifting also triggers symptoms, doing yoga and some biking

February 2016

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Case 2: JA •  VA (aided)

•  OD 6/6+2, OS 6/6+2, OU 6/4.5-1 •  CT (unaided)

•  (D) 2 Exophoria (N) 4 Exophoria

•  Refraction •  OD: -6.00 / -0.50 x 165 •  OS: -6.50 / -0.25 x 160

•  Stereoacuity •  20sec of arc

•  Vergence Facility •  12cpm

•  Amplitude of Accommodation •  OD 14D OS 14D

•  Accommodative Facility •  OD 10cpm OS 9cpm OU 8cpm

February 2016 Case 2: JA

•  VA (aided) •  OD 6/4.5-1, OS 6/4.5-1, OU

6/4.5-1 •  NPC

•  TTN x 3 •  Amplitude of Accommodation

•  OD 12.5D OS 12.5D

•  History •  Happy without bifocal •  HA’s 3-4 days a week, go away

quickly •  Doing VT and more cardio

training (cycling) •  Sick last 2 weeks so

inconsistent lately •  Thinking of starting soccer again

next week (just light training)

March 2016

Cl inical Pearls for Athletes

•  It is NOT “just a game”

•  Honesty is crucial for building trust •  Even if it means saying “I don’t know”

•  Athletes are super motivated •  Numbers help them focus on progress •  Keep journals – compete with themselves

•  Positive reinforcement •  Help them see their own success!

•  You are not alone! •  Work with therapy teams

Thank you! •  Student researchers in Vision & Motor Performance Lab •  Dr. Michael Cinelli, Wilfred Laurier University •  Mr. Robert Burns, Waterloo Warriors Athletic Therapy •  Ms. Robyn Ibey, Waterloo Sports Medicine Clinic •  Dr. Robin Duncan, Dr. Eric Roy, Dr. Ewa Niechwiej-Szwedo,

University of Waterloo Kinesiology •  University of Waterloo, School of Optometry & Vision Science Funding sources •  Propel Centre for Population Health Impact

•  Waterloo Chronic Disease Prevention Initiative, 2014 •  Canadian Optometric Education Trust Fund

•  2014, 2016 •  American Optometric Foundation

•  Beta Sigma Kappa Research Fellowship, 2014

Documents

28/05/16 · 28/05/16 2 Repetitive TBI Consequences • Post-concussion syndrome • Second Impact Syndrome • 50% are fatal • Chronic Traumatic Encephalopathy • 90% of cases