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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
Double: 0.076 Single: 0.109 Tandem: 0.133
Double: 0.024 Single: 0.070 Tandem: 0.044
Double: 0.064 Single: 0.063 Tandem: 0.068
Balance Score (Eyes Closed)
Double: 0.069 Single: 0.859 Tandem: 3.043
Double: 0.049 Single: 0.369 Tandem: 0.212
Double: 0.035 Single: 0.299 Tandem: 0.17
Double: 0.047 Single: 0.24 Tandem: 0.132
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