1. 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

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

3. The Developing Brain

4. The Developing Brain

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

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

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

8. So what’s new?

9. So what’s new?

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

11. Pathway to Care

12. Pathway to Care

13. Pathway to Care

15. 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?

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

17. 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

18. 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

19. 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

20. Baseline Testing

21. Baseline Testing

22. 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

23. 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

24. Baseline: What does it look like?

25. Post-injury test: What does it look like?

26. 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”

27. 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

28. 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

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

31. Case Study 1

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

33. Case Study 2

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

35. Case Study 3

36. 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