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Traumatic Brain Injury What is it and what can we do with it?
Goals
• Etiology and epidemiology of TBI • Acute TBI management • TBI recovery, Return-to-Play/Life • Short and long term consequences of TBI
• Repetitive injury, post-concussion syndrome, chronic traumatic encephalopathy
• TBI and the vision system • Clinical assessment of TBI
Traumatic Brain Injury (TBI)
• Acquired brain injury caused by external mechanical forces • Direct impact or blow to • Rapid acceleration or deceleration • Blast waves • Projectiles or penetrating injuries
• Loss of consciousness is not required • Predominantly functional damage
• Structural damage may or may not be present
1. Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368
Causes of 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) http://www.cdc.gov/traumaticbraininjury/get_the_facts.html
Falls (40%)
Unknown / Other (19%)
Struck by / against (16%)
Motor vehicle
traffic (14%)
Assaults (11%)
Pathophysiology of TBI • Biomechanical brain injury characterized by the
absence of gross anatomic lesions • Ionic and neurotransmitter perturbations that disrupt
normal cellular function
• Efflux of K+ from cells • Influx of Ca2+ to cells
• Excessive glutamate release
• Ca2+ impairs function • Glucose metabolism • Free radicals
• Ca2+ and free radicals • Mitochondrial
dysfunction
• Recurrent injury • Apoptosis and
necrosis of cells
1. Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368 2. Prins M, et al. (2013) Disease Models & Mechanisms 6: 1307-1315 (Note: synaptic terminal image
adapted from this manuscript)
TBI Classif icat ion Eyes Verbal Motor
4 = Spontaneous 3 = To sound 2 = To pressure 1 = None
5 = Orientated 4 = Confused 3 = Words 2 = Sounds 1 = None
6 = Obey commands 5 = Localising 4 = Normal flexion 3 = Abnormal flexion 2 = Extension 1 = None
Glasgow Coma Scale • Severe: <9 • Moderate: 9-12 • Mild: 13-15
• Concussion is a mild form of mild TBI
1. Prins M, et al. (2013) Disease Models & Mechanisms 6: 1307-1315 2. glasgowcomascale.org
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TBI prognosis • Depends on the severity of the injury
• Moderate and severe injuries depend on length of coma, age, extent of trauma • Prognostic calculators
• Mild injuries • Children: recovery in 2-3 months • Adults: recovery in 3-12 months
• Influenced by age, acute injury rest, life stressors, previous injuries
• Sports injuries tend to heal faster • Under reporting symptoms?
1. Carroll L et al. J Rehabil Med 2004: Suppl. 43: 84-105 2. http://www.tbi-impact.org/?p=impact/calc 3. http://www.brainandspinalcord.org/prognosis-of-a-tbi/
The si lent epidemic… • TBI occurs in 500 (per 100 000) people yearly
• 18,000 people a year in Ontario • Leading cause of death and disability for
Canadians <35years • Kills more children <20years than everything else
combined • 11,000 deaths and 6,000 permanent disabilities every
year • 465 people suffer a brain injury daily
1 person is injured every 3 minutes
1. http://www.biaww.com/stats.html
The si lent epidemic… • 2.5 million most common causes in adults
emergency department visits, hospitalizations and deaths in 2010 related to TBI • Emergency visits have increased 70% since 2001
• Hospitalizations have increased 11%; deaths 7%
• Concussion affects 823.7 per 100,000 annually • Young children (5-14yrs) have the highest rates of
concussion • Sports and bicycle accidents
• Falls and MVA in adults
1. Center for Disease Control and Prevention
138 people die from injuries that include TBI daily
The economics of TBI • Annual direct cost $302 million (2009)1
• Direct cost $98 million; indirect cost $2.4 billion (2009)2
• Cost per case3
• Mild: $33,284 to $35,954 • Moderate: $25,174 to $81,153
1. Runge JW. (1993) Emerg Med Clin North Am 11(1): 241–253 2. Schulman J, Sacks J, Provenzano G (2002) Inj Prev 8(1):47–52 3. McGregor K, Pentland B (1997) Soc Sci Med 45(2):295–303 4. Humphreys I et al (2013) Clinicoecon Outcomes Res 5: 281-287
TBI and the Mil i tary
• Most prevalent U.S. warfighter injury between 2000-20101 • Over 300,000 in DoD alone
from 2000- August 20142
1. Capo-Aponte et al., Military Medicine 2012 2. Defense and Veterans Brain Injury System
TBI and Sports
• 1 in 5 sports related injuries are head injuries
• Between 1997-2007 ER visits for concussion • DOUBLED 8-13 year olds • TRIPLED among older children • DOUBLED in 8-19 year olds in
basketball, soccer, football despite participation declining
1. http://www.biaww.com/stats.html 2. http://www.clearedtoplay.org/concussion-information/concussions-by-the-numbers
http://radio.foxnews.com/wp-content/uploads/2012/09/9-18-head.jpg
http://www.scientificpsychic.com/fitness/AntonioRodrigoNogueiraVsRandyCouture.jpg
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Concussion Prevalence • Vision screenings of UW varsity athletes
• September 2013 – September 2015 • 305 athletes from 17 sports
• Individual athletes: • Curling, cross-country, track & field, volleyball, squash, badminton, tennis, figure
skating, baseball, golf, tennis • Teams:
• Rugby, soccer, ice hockey, field hockey, football, basketball
Concussion Prevalence • 28.2% of athletes self-reported having a previous concussion
(overall) • 28.1% men, 29.5% women
0
5
10
15
20
25
30
35
40
45
Football Basketball Volleyball Ice Hockey Soccer Rugby Field Hockey
Mens Womens
Concussion and Vision
• No difference in mean refractive error • With concussion
• OD: -0.03 / -0.55 x 99 (BS = -0.30) • OS: -0.08 / -0.54 x 82 (BS = -0.35)
• Without concussion • OD: -0.24 / -0.60 x 94 (BS = -0.54, p=0.25) • OS: -0.26 / -0.58 x 92 (BS = -0.53, p=0.38)
Concussion and Vision
• Last eye exam
0
5
10
15
20
25
30
35
40
<1 yr 1-2 yrs 2-3 yrs >3yrs Never
No Concussion Concussion
Acute Injury Presentat ion • Sensory symptoms:
• Photophobia, blurry vision, tinnitus, noise sensitivity, nausea, sensitivity to smell
• Somatic symptoms: • Headache, dizziness, balance impairments,
reaction time impairments, fatigue, sleep disturbances
• Behavioural changes: • Anxiety, irritability, restlessness, frustration
• Cognitive changes: • Poor memory, poor concentration, depression,
impaired judgment
Acute Injury
• Athletes should be immediately removed from play
• Glasgow Coma Scale, Sideline SCAT 3 protocol, King-Devick test • GP, emergency room, sports medicine clinics
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Sport Concussion Assessment Tool 3
SCAT3 Sport ConCuSSion ASSeSment tool 3 | PAge 1 © 2013 Concussion in Sport Group
What is the SCAT3?1
the SCAt3 is a standardized tool for evaluating injured athletes for concussion
and can be used in athletes aged from 13 years and older. it supersedes the orig-
inal SCAt and the SCAt2 published in 2005 and 2009, respectively 2. For younger
persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed
HQT�WUG�D[�OGFKECN�RTQHGUUKQPCNU�� +H� [QW�CTG�PQV�SWCNKƂ�GF��RNGCUG�WUG� VJG�5RQTV�Concussion recognition tool
1. preseason baseline testing with the SCAt3 can be
helpful for interpreting post-injury test scores.
5RGEKƂ�E�KPUVTWEVKQPU�HQT�WUG�QH�VJG�5%#6��CTG�RTQXKFGF�QP�RCIG����+H�[QW�CTG�PQV�familiar with the SCAt3, please read through these instructions carefully. this
tool may be freely copied in its current form for distribution to individuals, teams,
groups and organizations. Any revision or any reproduction in a digital form re-
quires approval by the Concussion in Sport Group.
NOTE: the diagnosis of a concussion is a clinical judgment, ideally made by a
medical professional. the SCAt3 should not be used solely to make, or exclude,
the diagnosis of concussion in the absence of clinical judgement. An athlete may
have a concussion even if their SCAt3 is “normal”.
What is a concussion?
A concussion is a disturbance in brain function caused by a direct or indirect force
VQ�VJG�JGCF��+V�TGUWNVU�KP�C�XCTKGV[�QH�PQP�URGEKƂ�E�UKIPU�CPF���QT�U[ORVQOU�UQOG�examples listed below) and most often does not involve loss of consciousness.
Concussion should be suspected in the presence of any one or more of the
following:
- 5[ORVQOU�G�I���JGCFCEJG���QT - 2J[UKECN�UKIPU�G�I���WPUVGCFKPGUU���QT - +ORCKTGF�DTCKP�HWPEVKQP�G�I��EQPHWUKQP��QT - #DPQTOCN�DGJCXKQWT�G�I���EJCPIG�KP�RGTUQPCNKV[���
Sideline ASSeSSmenT
indications for emergency management
noTe: A hit to the head can sometimes be associated with a more serious brain
injury. Any of the following warrants consideration of activating emergency pro-
cedures and urgent transportation to the nearest hospital:
- Glasgow Coma score less than 15
- Deteriorating mental status
- potential spinal injury
- progressive, worsening symptoms or new neurologic signs
Potential signs of concussion?
if any of the following signs are observed after a direct or indirect blow to the
head, the athlete should stop participation, be evaluated by a medical profes-
sional and should not be permitted to return to sport the same day if a
concussion is suspected.
Any loss of consciousness? Y n
“if so, how long?“
Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y n
Disorientation or confusion (inability to respond appropriately to questions)? Y n
loss of memory: Y n
“if so, how long?“
“Before or after the injury?"
Blank or vacant look: Y n
Visible facial injury in combination with any of the above: Y n
SCAT3™
Sport Concussion Assessment Tool – 3rd edition
For use by medical professionals only
glasgow coma scale (gCS)
Best eye response (e)
no eye opening 1
eye opening in response to pain 2
eye opening to speech 3
eyes opening spontaneously 4
Best verbal response (v)
no verbal response 1
incomprehensible sounds 2
inappropriate words 3
Confused 4
oriented 5
Best motor response (m)
no motor response 1
extension to pain 2
#DPQTOCN�ƃ�GZKQP�VQ�RCKP� 3
(NGZKQP���9KVJFTCYCN�VQ�RCKP� 4
localizes to pain 5
obeys commands 6
glasgow Coma score (e + v + m) of 15
GCS should be recorded for all athletes in case of subsequent deterioration.
1
name &CVG���6KOG�QH�+PLWT[�Date of Assessment:
examiner:
notes: mechanism of injury (“tell me what happened”?):
Any athlete with a suspected concussion should be removed
From PlAy, medically assessed, monitored for deterioration
K�G��|UJQWNF�PQV�DG�NGHV�CNQPG��CPF�UJQWNF�PQV�FTKXG�C�OQVQT�XGJKENG�until cleared to do so by a medical professional. no athlete diag-
nosed with concussion should be returned to sports participation
on the day of injury.
2 maddocks Score3
“I am going to ask you a few questions, please listen carefully and give your best effort.”
/QFKƂ�GF�/CFFQEMU�SWGUVKQPU���RQKPV�HQT�GCEJ�EQTTGEV�CPUYGT�
9JCV�XGPWG�CTG�YG�CV�VQFC[!� 0 1
9JKEJ�JCNH�KU�KV�PQY! 0 1
9JQ�UEQTGF�NCUV�KP�VJKU�OCVEJ! 0 1
9JCV�VGCO�FKF�[QW�RNC[�NCUV�YGGM���ICOG! 0 1
Did your team win the last game? 0 1
maddocks score of 5
/CFFQEMU�UEQTG�KU�XCNKFCVGF�HQT�UKFGNKPG�FKCIPQUKU�QH�EQPEWUUKQP�QPN[�CPF�KU�PQV�WUGF�HQT�UGTKCN�VGUVKPI�
259
group.bmj.com on March 13, 2013 - Published by bjsm.bmj.comDownloaded from
SCAT3 Sport ConCuSSion ASSeSment tool 3 | PAge 2 © 2013 Concussion in Sport Group
CogniTive & PhySiCAl evAluATionBACkground
name: Date: examiner: 5RQTV���VGCO���UEJQQN� &CVG���VKOG�QH�KPLWT[�
Age: Gender: m F
Years of education completed: Dominant hand: right left neither
How many concussions do you think you have had in the past? 9JGP�YCU�VJG�OQUV�TGEGPV�EQPEWUUKQP! How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for a head injury?
Y n
Have you ever been diagnosed with headaches or migraines? Y n
&Q�[QW�JCXG�C�NGCTPKPI�FKUCDKNKV[��F[UNGZKC��#&&���#&*&! Y n
Have you ever been diagnosed with depression, anxiety or other psychiatric disorder?
Y n
Has anyone in your family ever been diagnosed with any of these problems?
Y n
Are you on any medications? if yes, please list: Y n
SCAT3 to be done in resting state. Best done 10 or more minutes post excercise.
SymPTom evAluATion
3 how do you feel? “You should score yourself on the following symptoms, based on how you feel now”.
none mild moderate severe
Headache 0 1 2 3 4 5 6
“pressure in head” 0 1 2 3 4 5 6
neck pain 0 1 2 3 4 5 6
nausea or vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred vision 0 1 2 3 4 5 6
Balance problems 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like “in a fog“ 0 1 2 3 4 5 6
“Don’t feel right” 0 1 2 3 4 5 6
&KHƂEWNV[�EQPEGPVTCVKPI 0 1 2 3 4 5 6
&KHƂEWNV[�TGOGODGTKPI 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
trouble falling asleep 0 1 2 3 4 5 6
more emotional 0 1 2 3 4 5 6
irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
nervous or Anxious 0 1 2 3 4 5 6
Total number of symptoms (Maximum possible 22)
Symptom severity score (Maximum possible 132)
Do the symptoms get worse with physical activity? Y n
Do the symptoms get worse with mental activity? Y n
self rated self rated and clinician monitored
clinician interview self rated with parent input
overall rating: if you know the athlete well prior to the injury, how different is VJG�CVJNGVG�CEVKPI�EQORCTGF�VQ�JKU���JGT�WUWCN�UGNH!�
Please circle one response:
no different very different unsure 0�#
4 Cognitive assessmentStandardized Assessment of Concussion (SAC) 4
orientation (1 point for each correct answer)
9JCV�OQPVJ�KU�KV!� 0 1
9JCV�KU�VJG�FCVG�VQFC[!� 0 1
9JCV�KU�VJG�FC[�QH�VJG�YGGM!� 0 1
9JCV�[GCT�KU�KV!� 0 1
9JCV�VKOG�KU�KV�TKIJV�PQY!�(within 1 hour) 0 1
orientation score of 5
immediate memory
List Trial 1 Trial 2 Trial 3 Alternative word list
elbow 0 1 0 1 0 1 candle baby ƂPIGT
apple 0 1 0 1 0 1 paper monkey penny
carpet 0 1 0 1 0 1 sugar perfume blanket
saddle 0 1 0 1 0 1 sandwich sunset lemon
bubble 0 1 0 1 0 1 wagon iron insect
Total
immediate memory score total of 15
Concentration: digits Backward
List Trial 1 #NVGTPCVKXG�FKIKV�NKUV
4-9-3 0 1 6-2-9 5-2-6 4-1-5
3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8
6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3
7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6
Total of 4
Concentration: month in reverse order (1 pt. for entire sequence correct)
Dec-nov-oct-Sept-Aug-Jul-Jun-may-Apr-mar-Feb-Jan 0 1
Concentration score of 5
8 SAC delayed recall4
delayed recall score of 5
Balance examination&Q�QPG�QT�DQVJ�QH�VJG�HQNNQYKPI�VGUVU�
(QQVYGCT�UJQGU��DCTGHQQV��DTCEGU��VCRG��GVE��
/QFKƂGF�$CNCPEG�'TTQT�5EQTKPI�5[UVGO�$'55��VGUVKPI5
9JKEJ�HQQV�YCU�VGUVGF�(i.e. which is the non-dominant foot) left right
6GUVKPI�UWTHCEG�JCTF�ƃQQT��ƂGNF��GVE�� Condition
Double leg stance: errors
Single leg stance (non-dominant foot): errors
tandem stance PQP�FQOKPCPV�HQQV�CV�DCEM�� errors
And / or
Tandem gait6,7
time (best of 4 trials): seconds
6
Coordination examinationupper limb coordination
9JKEJ�CTO�YCU�VGUVGF� left right
Coordination score of 1
7
neck examination:range of motion tenderness upper and lower limb sensation & strength
Findings:
5
Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion.
260
group.bmj.com on March 13, 2013 - Published by bjsm.bmj.comDownloaded from
Injury
Glasgow Coma Scale
Memory
Symptoms
Cognitive Function
Motor Function
Delayed Recall
1. (2013) Br J Sports Med 47: 259
K ing-Devick
• 3 reading cards • Record total time to
read all three • Record number of
errors made • Take a baseline
• Worse than baseline = injury
1. http://kingdevicktest.com
Average: 39.2 ± 7.7s Range: 24.3 to 101.2s
Median: 38.5s *UW Varsity Athletes 2013-2015
Acute Injury Management • Cognitive rest!
• Nothing but eating, sleeping and walking for a minimum of 7 days / until symptoms resolve • No TV, texting, reading, computer use • Discontinue work / school
• When symptoms resolve, begin a return-to-play/life protocol
Return to Play
• Return to play protocol (5-7 days) • Gradual return to activity, monitoring for return of
any symptoms • Ex: light aerobic exercise, sport specific exercise,
non-contact training drills, full contact practice, return to play
• If symptoms return, you revert back to an “acute” status
• ImPACT, ANAM, King-Devick • Need to return to baseline values
ImPACT • Immediate Post-Concussion Assessment
and Cognitive Testing • Scientifically validated computerised concussion
evaluation system • Measures symptoms, verbal and visual memory,
processing speed and reaction time
1. www.impacttest.com
ANAM • Automated Neuropsychological
Assessment Metrics • Developed by the DoD, USA • Measures speed and accuracy of attention,
memory and thinking ability • Neurocognitive assessment of TBI
1. Defense and Veterans Brain Injury Center, www.dvbic.corg
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Short Term Consequences of TBI • Concussion cells enter peculiar state of
vulnerability following injury • Initial injury increases the risk of repetitive
injuries • Especially high risk populations – military, sports
• Second insult during acute phase can result in irreversible cell damage due to swelling
• Second Impact Syndrome
1. Signoretti S et al. (2011) PM&R 3(10): Supplement 2, S359-S368
Second Impact Syndrome • Consists of:
• Athlete suffering post-concussive symptoms • A second head injury within several weeks
• Before the first injury has healed
• Diffuse cerebral swelling and brain herniation can be fatal • 50% of “second impact syndrome” incidents
result in death
1. Bey T, Ostick B (2009) Western Journal of Emergency Medicine 10(1): 6-10
Post-Concussion Syndrome • Persistence of any mTBI symptoms for >30days
• May be exasperated following exercise or other stressful event
• 50% of patients report symptoms for up to 3 months • 10% -15% of patients report symptoms for > 1year • Symptoms may never go away completely
• Cannot be predicted by injury severity
1. Spinos P et al. (2010) J Trauma 69(4): 789-794
Qual i ty of Li fe • 11 – 30% suffer depression following injury
• 3x more likely to be depressed with >3 TBI • Fatigue is more severe and prevalent in TBI • Many people miss work and/or loose their
jobs following moderate to severe TBI • Students often miss school
• Health-related quality of life scores lower in TBI • Mild, moderate, severe, repetitive • Adults, children • Can persist for years after injury
1. Guskiewick K et al. (2007) Medicine & Science in Sports & Exercise 39(6): 903-909 2. Andelic N et al. (2008) Acta Neurologica Scandinavica 120(1): 16-23 3. Cantor J et al. (2008) Journal of Head Trauma Rehabilitation 23(1): 41-51 4. Dijkers M (2004) Archives of Physical Medicine and Rehabilitation 85(Supplement 2); 21-35 5. Stancin T (2002) Pediatrics 109(2): e34 6. Emanuelson I (2003) Acta Neurologica Scandinavica 108(5):332-338
Neurodegeneration • TBI, particularly repetitive mTBI increases
the risk of: • Mild cognitive impairment • Dementia • Alzheimer's • Parkinson's • Psychiatric syndromes • Altered brain function
• Issues tend to occur earlier than non-TBI • May be genetic risk factors
• APOE-e4 genotype and Alzheimer’s (Odds Ratio 3.3) • APOE-e4 may influence concussion recovery / PCS also
1. Guskiewicz K et al. (2005) Neurosurgery 57(4): 719-726 2. Mortimer JA et al. (1991) Int J Epidemiol 20:S28-S35 3. Kiraly M, Kiraly S (2007) The Scientific World Journal 7: 1768 – 1776 4. De Beaumont L et al. (2009) Brain 132: 695-708
Chronic Traumatic Encephalopathy • Neurodegenerative disease of the young
• Irritability, impulsivity, aggression, explosivity, depression, short-term memory loss, heightened suicidality, cognitive impairment, executive dysfunction
• Begin 8-10 years after mTBI • CTE must be diagnosed post-mortem
• Global prevalence is unknown • Estimated 17% of repetitive mTBI develop CTE • But… 90% of all CTE cases occur in athletes
1. Omalu B (2005) Neurosurgery 57(1): 128-134 2. McKee A (2013) Brain 136: 43-64 3. Gardner A et al. (2014) Br J Sports Med 48:84-90
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Headache
Dizziness
Fatigue
Poor memory Poor concentration
Irritability Depression
Sleep disturbances
Impaired judgment Frustration
Restlessness
Sensitivity to noise
Blurry vision
Double vision
Light sensitivity
Nausea Tinnitus
Balance impairments
Poor coordination
Difficulty tracking objects
Trouble focusing
Sensitivity to smells
Trouble reading
Reduced reaction time
Eye strain
TBI and Visual Function • 60 – 75% TBI have subjective visual complaints
• Common: General vision disturbances, headaches, focusing issues, light sensitivity, reading difficulties, distress from moving objects, concentration difficulties, issues with spatial attention, difficulty tracking objects, pain with eye movements • Also issues with balance, gait initiation, reaction times,
visuomotor coordination • Less common: blurry vision, dizziness, double vision,
confusion, staring behaviour, VA loss, VF loss, anisocoria, ocular trauma, issues with dark adaptation
1. Ciuffreda KJ et al (2007) Optometry 78: 155-161 2. Brahm K et al. (2009) Optom Vis Sci 86(7): 817-825 3. Goodrich G et al. (2013) Optom Vis Sci 90(2): 105-112
Common vision problems Normal Population Post-Concussion
Convergence Insufficiency 2 – 15% (up to 33%) 42%
Accommodation Insufficiency 2 – 15% (up to 62%) 38%
Alignment Problems (Strabismus) 2-5% 25%
Eye Movement Problems 20% 25-50% (up to 90%)
1. Ciuffreda KJ et al (2007) Optometry 78: 155-161 2. Brahm K et al. (2009) Optom Vis Sci 86(7): 817-825 3. Goodrich G et al. (2013) Optom Vis Sci 90(2): 105-112 4. Leat, S et al. (2013) IOVS 54(5): 3798-3805 5. Cacho-Martinez, P et al. (2010) J Optom 3: 185-197
Cl inical Assessment of TBI • Three-part assessment
• Case history • Structural assessment • Functional assessment
Case History • Important to establish an injury
timeline • Date of injury • Onset of symptoms • Chronicle recovery, symptoms,
treatments, triggers • Current symptoms
• Determine circle of care • GPs, Sports Medicine, Physiotherapy,
Massage, Chiropractors, Chiropractic Neurology, Vestibular Rehabilitation, Psychology, Counselor
Structural Assessment • Similar to a routine OVA
• Visual Acuity • Static high contrast, contrast sensitivity
• Refraction • Ocular Alignment
• Cover tests with comitancy (D / N) • Ocular Health
• Pupils • Anterior segment exam • Dilated fundus exam
• Visual Field
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Functional Assessment • Oculomotor Control
• Broad H, pursuits, saccades • Accommodative Function
• Amplitudes of accommodation • Accommodative facility • MEM
• Vergence Function • NPC • Fusional reserves • Vergence facility
• Light sensitivity • Tint trials
• Global Function • Stereopsis, King-Devick, balance
TBI in cl inical pract ice • May 2014: University of Waterloo, Sports
Vision Clinic opened • Dedicated to providing comprehensive vision
care to all athletes • Sport-specific vision assessments, performance
enhancement vision training, concussion management
Purpose: • Evaluate the incidence of concussion-related visits • Determine the prevalence of concussion-related
vision problems
TBI in cl inical pract ice Method: • Retrospective analysis of patient charts • May 2014 – August 2015
• 37% of all patient visits are related to concussion • n=11 post-concussion patients, with medical
referrals • 13 to 44 years of age • 2 weeks to 9 months post injury • History of 1 to 5 lifetime concussions
TBI in cl inical pract ice • Patients report 5.4 symptoms in the past 6
months • Confusion, poor memory, feeling of getting ‘dinged’,
feeling of getting ‘bell rung’ • Headaches, balance problems, nausea, dizziness,
tinnitus, blurry vision • Symptoms worse with physical activity = 90% • Symptoms worse with cognitive activity = 80%
TBI in cl inical pract ice
0
20
40
60
80
100
Headach
es
"Pressur
e in Head
"
Neck Pain
Nausea/
Vomitin
g
Dizzine
ss
Blurred
Vision
Balance
Problem
s
Sensitiv
ity to L
ight
Sensitiv
ity to N
oise
Feeling
Slowed
Down
"Don't Feel
Right'
Hard to
Concent
rate
Feeling
"In a F
og"
Troubl
e Rem
ember
ing
Fatigue/
Low Ener
gy
Confusi
on
Drowzin
ess
Troubl
e Falli
ng Asle
ep
More Emotio
nal
Irritabi
lity
Sadness
Nervous
/anxio
us
None Mild Moderate Severe
%
TBI in cl inical pract ice Diagnosis: • Photophobia = 18% • Accommodative dysfunction
• Suspected = 46% • Confirmed = 10%
• Vergence dysfunction • Suspected = 36% • Confirmed = 27%
• Refractive error = 18%
Management: • Monitor = 18% • Computer-based VT = 36% • Conventional VT = 27% • Spectacle Rx = 10% • Nothing (healthy) = 10%
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Case 1: AR • 22 y/o male, football player • C/C: residual vision sx following mTBI
• Has issues when moving/navigating complex visual environments – feels vision is uncomfortable
• Stationary weightlifting, school & work okay; running/jumping are bad
• Physio has given balance an vision exercises (pursuits, saccades, tracking objects on cluttered background)
• Injury: October 2014 • Hit in practice, played for 1 week after and then took 3
weeks off
March 2015 Case 1: AR • VA (unaided)
• OD 6/4.5-1, OS 6/4.5-2, OU 6/4.5 • CT (unaided)
• (D) Ortho (N) 2 Exophoria • Refraction
• OD +0.50 / -0.50 x 180 • OS +0.75 / -0.75 x 165
• King-Devick • 50.1s, 0 errors
• Stereoacuity • 50sec of arc
• NPC • TTN, TTN, 2/4cm
• Vergence Facility 15cpm • Amplitude of Accommodation
• 14D OD, OS • Accommodative Facility
• OD 5cpm OS 5cpm OU 8cpm
March 2015
Case 1: AR May 2015
• VA (aided) • OD 6/4.5-2, OS 6/4.5-2, OU 6/4.5
• CT (aided) • (D) Ortho (N) 4 Exophoria
• King-Devick • 44.2s, 0 errors
• Stereoacuity • 40sec of arc
• NPC • TTN, TTN, TTN
• Vergence Facility 35cpm • Amplitude of Accommodation
• 14D OD 12.5 OS • Accommodative Facility
• OD 30.5cpm OS 23.5cpm OU 22cpm
• Symptoms are much improved • Occasional vision cramps/discomfort when playing football without Rx • Has tried not wearing specs some days, and feels visual comfort is
worse without them
Case 2: GD • 25 y/o male, hockey player • C/C: headaches, constant pressure in the head
(worse with TV & reading), light sensitivity following mTBI • Also tinnitus, bouts of dizziness and trouble sleeping • Physio has given some balance exercises • GP signed him off work one year (May 2015)
• Injury: November 2015, Dx mTBI June 2015 • At least 2 previous concussions
October 2015
Case 2: GD October 2015
• VA (unaided) • OD 6/4.5-3, OS 6/4.5-2, OU
6/4.5-1 • CT (unaided)
• (D) Ortho (N) 3 Exophoria • Stereoacuity
• 50sec of arc • NPC
• 6/11, 6/11, 6/10
• Vergence Facility • Unable to fuse BI or BO
• Amplitude of Accommodation • OD 8D OS 7D
• Accommodative Facility • OD 7cpm OS 7cpm OU 1.5cpm
November 2015
• King-Devick • 46.6s, 0 errors
• Cycloplegic Refraction • OD +1.50 / -1.00 x 005 • OS +1.50 / -0.75 x 170
Case 2: GD February 2016 March 2016 April 2016 May 2016
Hx - No longer getting extra pressure at near; adapted to Rx in 1 week; no other change in Sx
- Sx improving gradually; more good days then bad; started Vitamin D, B12
- Sx improving gradually; bad days are less bad
- Sx improving; started full time work, no change in Sx with work; sleeping better
VA OD 6/4.5-3 OS 6/4.5 OU 6/4.5
OD 6/4.5-2 OS 6/4.5 -1 OU 6/4.5-1
OD 6/4.5-2 OS 6/4.5 OU 6/4.5
OD 6/4.5-3 OS 6/4.5-2 OU 6/4.5-1
Stereo 40 seconds 30 seconds --- 20 seconds
Amps OD 8D OS 7D OD 8D OS 8D OD 8D OS 7.5D OD 7D OS 7D
NPC 6/10, 6/10, 6/11 6/8, 6/8, 6/8 7/11, 7/11, 7/11 5/7, 6/9. 7/9
AF OD 8cpm OS 10cpm OU 3cpm
OD 11cpm OS 10cpm OU 8.5cpm
OD 6cpm OS 5.5cpm OU 5.5cpm
OD 14.5cpm OS 14.5cpm OU 12.5cpm
VF 15cpm 7.5cpm 11.5cpm 18.5cpm
KD 46.7seconds 36.7seconds 38.6seconds 33.3seconds
Rx Near-Far Hart charts OU, Brock string – primary and other
Add OD, OS Hart charts, Bug on a string
Continue exercises, try for longer duration
Taper VT
24/05/16
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Management of TBI • Address any ocular health issues first • Prescribe full refractive correction
• Allow time for adaptation • May need an additional reading Rx or tint
• Vision therapy can be beneficial for some functional losses • Progression is slower
1. Ciuffreda KJ, et al. (2008), Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry, 79;18-22.
Cl inical Pearls for TBI
• Patient symptoms tell you a lot about how they are healing • All symptoms, not just visual ones
• Prioritise your tests and use multiple visits
• Simple interventions can have a big impact • Breaking symptom cycles
• You are not alone! • Circle of care
What can we do? • Ask about head injury in high risk patients • Careful examination paying attention to refractive
and BV issues • Education is key to preventing repetitive injuries!
• Unified message across health professions
Let’s play an active role in assessment, return to play decision making and rehabilitation of our
TBI patients!
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