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The Road to Recovery: The Impact of the Barrow Concussionand Brain Injury Center
Javier Cárdenas, MDBarrow Neurological Institute
Director, The Barrow Concussion Network
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History
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Traumatic Brain Injury
Physical
CognitiveBehavioral
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Traumatic Brain Injury
Physical
CognitiveBehavioral
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PhysicalBehavioralCognitive
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• Mission• To improve outcomes of those who
suffer from neurological injury through;• comprehensive, patient centered
care• collaboration• research
Barrow Concussion and Brain Injury Center
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Barrow Concussion and Brain Injury Center
Neurology
Psychiatry
Neuropsych BIAAZ
Neurorehab
Prevention
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Clinical Team
Neurology Neurorehabilitation
BIAAZ
Prevention
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Clinical Team
Neurology Neurorehabilitation
BIAAZNeuropsychology
PreventionPsychiatry Social Work
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Student Athlete Centered Care
Mom
PCP
Athletic Trainer Teacher
Dad
School Nurse
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Why a multidisciplinary model?
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Why a multidisciplinary model?
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Clinic algorithmWhen did TBI/
concussion occur?See in Neuro clinicGreater than 3
monthsLess than 3
months
Has the patient been evaluated by a neurologist or concussion specialist?
yes
no
See in Neuro clinic
Schedule acute injury clinic visit
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Consensus 2016• Berlin 2016• Published April 26, 2017• 11 Rs of Concussion Management
• Recognize a concussion • Remove from play• Re-evaluate: sideline and in clinic• Rest: 24-48 hours, then start physical (non-contact activity)• Rehab: Physical/vestibular, occupational/oculomotor, speech/cognitive• Refer: persistent symptoms (greater than 14 days)• Recovery: risk factors for prolonged recovery - initial presentation, migraine,
anxiety/depression• Return to school before Return to sport• Reconsider management of elite vs non-elite, children• Residual effects - Chronic traumatic encephalopathy• Risk reduction - education, high risk groups
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Rest
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Recovery:Metabolic needs after concussion
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Recovery
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Concussion Consequences
Physical
CognitiveBehavioral
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Concussion Consequences
Physical
CognitiveBehavioral
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Post-Concussive Symptoms
PhysicalBehavioralCognitive
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Physical Symptoms
• Headache - most common physical symptom. Acutely most like that of migraine (photophobia, phonophobia, etc)
• Dizziness - Second most common physical symptom. Poorly characterized. Postural vs vertiginous.
• Vision change- Convergence abnormalities, tracking, vestibular-ocular.
• *Sleep - hypersomnia, insomnia, generalized fatigue
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Behavioral Symptoms
• Irritability - most common behavioral symptom.
• Anxiety - tachycardia, panic attacks
• Depression - lack of motivation, late hypersomnia.
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Cognitive Symptoms
• Inability to focus - most common cognitive symptom.
• Memory - short term, not long term. Poorly characterized. When tested, most commonly a reflections of inattention.
• Slow processing speed - Increased time to comprehend and respond.
• Word finding - Mentally searching for words.
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Concussion Clinical Subtypes• Post-injury presentation of concussion
patients is not uniform.
• Cluster of symptoms/physical examinations findings may indicate a specific clinical phenotype
• Clinical subtypes of concussion may dictate:
• - Clinical recovery trajectory
• - Research Methods
• - Treatment
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Concussion Clinical Subtypes• Clinical subtype examples:
• Physiological: "Persistent symptoms and impairments caused by global impairment in cerebral metabolism."
• Disorder of cellular metabolism, cerebral blood flow, autonomic function.
• Clinical features: Headache exacerbated by physical or cognitive exertion.
• Examination findings: non-focal
• Treatment - initial rest followed by supervised exercise
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Concussion Clinical Subtypes• Vestibulo-ocular subtype
• Characterized by "symptoms and impairments caused by dysfunction of the vestibulo-ocular system."
• Disorder of the vestibular, oculomotor, and somatosensory systems
• Clinical features: Dizziness, vertigo, blurred/double vision, tracking difficulty.
• Examination findings: Impaired balance and gait, VOR, tracking.
• Treatment: Vestibular rehab, vision therapy, academic accommodations, light exercise.
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Concussion Clinical Subtypes• Cervicogenic Subtype
• Characterized by "symptoms and impairments caused by dysfunction of the cervical spine and somatosensory system."
• Disorder of proprioceptive information to the cerebellum, brainstem, and spinal cord.
• Clinical features: neck pain, occipital headaches, lightheadedness
• Exam findings: decreased neck ROM, paraspinous muscular tenderness, impaired head/neck position sense
• Treatment: Physical therapy
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Concussion Clinical Subtypes
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Concussion Clinical Subtypes• Cognitive/ fatigue subtype
• Characterized by fatigue, nonspecific headache, sleep disturbance exacerbated by cognitive or physical exertion.
• Physical examination is non-specific
• Cognitive testing demonstrates global impairment
• Treatment: initial rest with sleep hygiene, followed by gradual activity. Stimulants at times.
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Concussion Clinical Subtypes• Vestibular subtype
• Characterized by dizziness, nausea, overstimulation
• Examination - symptomatic with head movements, VOR suppression. Imbalance present in some.
• Treatment: Vestibular therapy.
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Concussion Clinical Subtypes• Ocular motor subtype
• Characterized by trouble with visual focus, frontal headaches, blurry vision, pressure behind the eyes. Symptoms exacerbated by computer screens.
• Examination findings: impaired convergence/ accommodation. Neurocognitive testing may reveal deficits in visual memory and reaction time.
• Treatment: Vision therapy
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Concussion Clinical Subtypes• Anxiety/mood subtype
• Characterized by anxiety, ruminating thoughts, hypervigilance, feeling overwhelmed, sleep disturbance.
• Examination: Vestibular/ ocular screening may be provoking.
• Treatment: Exercise regimen, structured sleep/ academics. Psychotherapy, pharmacology.
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Concussion Clinical Subtypes• Post-traumatic migraine subtype
• Characterized by headache with photophobia, phonophobia, nausea - exacerbated by stress, cognitive effort.
• Examination - vestiubulo-ocular screening may be provoking.
• Neurocognitive screening may demonstrate visual or verbal memory deficits.
• Treatment: pharmacology - tricyclics antidepressants, anticonvulsants, calcium channel blockers.
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Concussion Clinical Subtypes• Cervical subtype
• Characterized by neck pain and headaches.
• Examination demonstrates decreased range of motion and tenderness.
• Treatment: physical therapy, pharmacology -analgesics, anti-inflammatories, muscle relaxants.
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Critical Evaluation of Clinical Pathways
• Both groups demonstrate institutional bias.
• Both acknowledge vestibular and/or ocular subtype
• Both include cervicogenic subtype
• Physiologic subtype equivalent of migrainous subtype?
• One group includes mood subtype
• Neither group illustrates pathway for further evaluation and/or testing.
• Neither group demonstrates breakdown of subtypes in clinical setting.
• Both highlight need for validation of clinical subtype FOLLOWED by validation of clinical pathway.
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Subacute Management
• Red Flags
• Imaging - CTH
• Rest, Rest, Rest
• Physical rest
• Cognitive rest
• Anticipatory Guidance
• Fewer emergency room readmissions
• Students have better outcomes if teachers are aware of student's concussion
• Restraint!
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Recovery• Prolonged Recovery• Questions:
• Was the injury worse than a concussion?• Is there a physical or medical condition prolonging recovery?• Is there an emotional condition prolonging recovery?• Did the concussion exacerbate an underlying condition?
• Migraine• Anxiety• Depression• ADHD• Learning disability
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Chronic Management
• Imaging –
• MRI
• Non- contrast, GRE
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Post-traumatic headache• Concussion
• 90% have headache
• Patients with mild TBI were more likely to have headache than patients with moderate or severe TBI.
• Duration
• Days to weeks
• Problems
• Prolonged PCS
• Sleep
• Mood
• concentration
• Missed work/ school
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Post-traumatic Headache
• Acute phenotype is most like migraine• Chronic phenotype is most like tension-type headaches• Risk Factors:• female gender• history of migraine• family history of migraine• premorbid psychiatric disease• May present in isolation or part of PCS
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Headache Treatment• Headache comorbidities
• Analgesic overuse (rebound)
• Headache hygiene - caffeine, sleep, skipping meals
• Insomnia
• Imbalance
• Cognitive deficits
• Interventions
• Tricyclic anti-depressants
• Topiramate
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Cognitive Management• Cognitive Therapy
• Performed by speech therapists
• Duration varies
• School Accommodations
• Simplify/shorten directions.
• Give both oral and written directions.
• Increase allocated time.
• Provide frequent review.
• Establish rules and review frequently.
• Adapt test items for differing response modes.
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Postconcussive Syndrome• Three domains
• Somatic• Headache, fatigue, sleep disturbance, balance
• Emotional/ behavioral• Irritable, frustrated, depression, anxiety, personality changes
• Cognitive• Slowed thinking, distractibility, poor learning and memory
• Lasting up to 3 months• Most recover within weeks• Up to 15% can have long lasting or permanent symptoms
• Neuropsychological testing is often indicated
• Accommodations in the classroom are needed for those whose symptoms persist• Children perform better overall when their teacher is aware that they have suffered a
TBI
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Rehab
Physical
SpeechOccupational
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Physical
SpeechOccupational
Rehab
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Rehab
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Rehab
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Take Home Messages
• Multidisciplinary models of care are effective
• Treatment should be patient centered and individualized
• Patients should participate in their own recovery
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Take Home Message