A new model for the diagnosis and treatment of concussion Changing the Game A new model for the diagnosis and treatment of concussion Dr Niamh Lynch March 2nd 2019

The Concussion Network Features of the student population What is concussion? What has changed? What is ImPACT? What is VOMS? Case studies

The Developing Brain

The Developing Brain

The Developing Brain Metabolic costs and evolutionary implications of human brain development Christopher W. Kuzawaa et al, PNAS 13010–13015, doi: 10.1073/pnas.1323099111

The Concussed Brain The new neurometabolic cascade of concussion. Giza CC1, Hovda DA. Neurosurgery. 2014 October ; 75(0 4): S24–S33. doi:10.1227/NEU.0000000000000505.

The Concussed Developing Brain Higher background metabolic rate Increased metabolic demand Decreased cerebral blood flow Vulnerable to second impact syndrome

So what’s new?

So what’s new?

The Concussion Network Clear pathway for children and adults with concussion Four centres at present Cork, Waterford, Galway, Mayo Dublin service will begin soon

Pathway to Care

Pathway to Care

Pathway to Care

ImPACT: Baseline and Post Injury What is ImPACT? What does baseline and post injury mean? What does it look like? How does it help? Who provides ImPACT?

What is ImPACT? A computerised neurocognitive assessment Verbal Memory Visual Memory Visual Motor Speed Reaction Time Impulse Control

What is ImPACT? IS a tool to determine recovery from injury IS a tool to help manage concussion (eg return to study, return to exertion, return to play) IS a tool to help communicate post-concussion status to coaches IS NOT a substitute for medical evaluation/treatment

What does baseline and post-injury mean? Baseline: A ‘preseason physical for the brain’ There is a wide range of ‘normal’ cognitive function Assesses normal function for the individual child/ athlete Post-injury test is administered after the child/athlete sustains a suspected concussion Post injury tests compared with baseline for that individual inform treatment decisions and return to play/learn

Baseline Testing Pre season Computerised, takes 30 minutes Baseline- what is my normal? (Everyone different, normative data, existing conditions-ADHD, dyslexia etc) If concussed, follow- up testing to quantify injury and track progress

Baseline Testing

Baseline Testing

Baseline Who can administer baseline test? Anyone who is appropriately trained: coach, school nurse, volunteer Currently available in Affidea centres in Ireland How often? Every 2 years

Percentile Ranges Superior/Very Superior 90 – 99th % ile High Average Low Average 16 – 25th % ile Poor (Borderline Impaired) 6 – 15th % ile Impaired < 5th % ile Average Low average High average Poor Superior Very superior Impaired

Baseline: What does it look like?

Post-injury test: What does it look like?

How does ImPACT Help? Sensitivity and Specificity of ImPACT Computerised Neurocognitive Testing Schatz P, Sandel N. Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, 2012 Study summary…. “The current results demonstrate that ImPACT is a useful, valid tool as part of a comprehensive post concussion evaluation. Regardless of whether athletes are candid regarding the presence of post concussion symptoms, performance on neurocognitive testing can identify neurocognitive deficits with 91 to 95% sensitivity”

Pre-season 1-3 Days Supervised at School Or clinic Remove From Play Baseline Testing Concussion First Follow-Up Follow-up Testing as needed Pre-season 1-3 Days Supervised at School Or clinic Remove From Play Evaluation Return to Play 27

ImPACT without Baseline Individual’s normative data is unknown Are there pre-existing conditions? Dyslexia, ADD, learning difficulties, colour blindness Some information from academic performance- A, B or C student

Case Study 1 14 yr old F Camogie injury Dizzy, headaches Memory-migraine, VMS- vestibular, RT-ocular

Case Study 1

Case Study 2 16 yo M Rugby collision Dizzy, headache, poor sleep, anxiety (pressure to achieve in rugby) NPC 8cm Melatonin Exercise program

Case Study 2

Case Study 3 14 yo F Camogie Fall onto back of head Dizzy but played on Headaches, fatigue, nausea, anxiety, napping ++ Bgd dyslexia

Case Study 3

Conclusion Concussion is a treatable injury! There are lots of types of concussion-each has different treatment There is a treatment pathway available VOMS helps define concussion type Baseline and post-injury ImPACT testing helps tailor treatment