Concussion Current Research and Best Practice
David Brooks MD Dip Sport Med CIME
Clinical Services Manager WorkSafeBC
November 20 2015 Nanaimo Brain Injury Society
Dr Brooks background experience- MTBI
Research thesis on concussion in young ice hockey players 1999
Computerized neuropsych testing of 100rsquos of hockey players 2000-2010
Consultation to professional and amateur athletes on concussion Medicolegal consultations non-sports head injury consults (falls MVAs)
Work with VAC and RCMP on injured soldierspolice officers
Peer reviewer on head injuries Clinical Journal of Sports Medicine British Journal of Sports Medicine
httpsenwikipediaorgwikiConcussion -accessed Sept 215
3
Goals
1 Understand the basics of TBI and touch on some of the more complex issues eg PTSD anxiety depression PCS
2 Understand some of the difficulties in diagnosing and managing these cases
3 Whatrsquos new in the research literature
Prepare to be amazed and probably confused
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Dr Brooks background experience- MTBI
Research thesis on concussion in young ice hockey players 1999
Computerized neuropsych testing of 100rsquos of hockey players 2000-2010
Consultation to professional and amateur athletes on concussion Medicolegal consultations non-sports head injury consults (falls MVAs)
Work with VAC and RCMP on injured soldierspolice officers
Peer reviewer on head injuries Clinical Journal of Sports Medicine British Journal of Sports Medicine
httpsenwikipediaorgwikiConcussion -accessed Sept 215
3
Goals
1 Understand the basics of TBI and touch on some of the more complex issues eg PTSD anxiety depression PCS
2 Understand some of the difficulties in diagnosing and managing these cases
3 Whatrsquos new in the research literature
Prepare to be amazed and probably confused
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
httpsenwikipediaorgwikiConcussion -accessed Sept 215
3
Goals
1 Understand the basics of TBI and touch on some of the more complex issues eg PTSD anxiety depression PCS
2 Understand some of the difficulties in diagnosing and managing these cases
3 Whatrsquos new in the research literature
Prepare to be amazed and probably confused
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Goals
1 Understand the basics of TBI and touch on some of the more complex issues eg PTSD anxiety depression PCS
2 Understand some of the difficulties in diagnosing and managing these cases
3 Whatrsquos new in the research literature
Prepare to be amazed and probably confused
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Prepare to be amazed and probably confused
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
mTBI in the Canadian Forces Does Afghanistan Change Things
LCol Rakesh Jetly MD FRCPC
Directorate of Mental Health
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Canadian LAV (Nyala light armoured vehicle)
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
2 Baseline neurocognitive testing should
not be done until more rigorous research
has validated the use of these tools in a
military operational setting Until such
time clinicians may use neurocognitive
testing to determine the presence and
magnitude of any impairment and to follow
the clinical course of any impairment
identified
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
3 The DVBIC clinical practice guidelines
and algorithms for mTBI in theatre should
be adopted [26] with some modification
for the purpose of evaluating fitness for
duty in those who may have sustained a
mTBI in an operational setting (Appendix
2)
bull A major modification was the removal of the
recommendation for detailed neurocognitive
testing in the algorithm applicable to the
Role 3 facility
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
7 A systematic approach should be adopted for the
management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance
to patients with a history of head trauma
Consider chronic subdural haematoma in patients with chronic headache after head trauma
Post-traumatic headache responds to the usual
approach for chronic headache disorders
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Promote Protect and Heal
Promouvoir proteacuteger et gueacuterir
Recommendations from CF working group
bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion
-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms
-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se
-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Biomechanical Injury Translation
Coup
site
Contre-
Coup
site
Force vector
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Biomechanical Injury Rotation amp Angular Acceleration
Rotation vector
Force vector
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Biomechanical Injury Diffuse Axonal Injury (Silver 2003)
Pre-Injury
Acute Injury
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
TBI Produces Cognitive Emotional Behavioral and Physical Disturbances
Brain Injury
Impaired Attention Memory
Disturbance Language
Impairment Executive
Dysfunction Intellectual Loss
Irritability Rage
Depression Anxiety
Agitation Aggression
Disinhibition Apathy
Sleep Disturbance Headaches
Visual Problems DizzinessVertigo
Seizures Motor Problems
Cognitive Disturbance
Behavioral Disturbance
Emotional Disturbance
Physical Disturbance
(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
mTBI Definition
bull Loss of consciousness of less than 1 hour and
bull Post-traumatic amnesia of less than 24 hours and
bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Glasgow Coma Scale
Severity GCS AOC LOC PTA Imaging
Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg
Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs
gt24 hrs lt7 days
Pos or Neg
Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos
21
GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors
Self-
Expectation
mTBI
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Demographic
Characteristics
Medical
Iatrogenesis
Litigation
Iatrogenesis
Acute
Symptoms Chronic
Symptoms
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Intelligence
Level
Coping
Abilities
Social
Support Coping
Abilities
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Problems with ldquomTBIrdquo as diagnostic term
bull Sounds scary
bull Applies to both immediate injury and long-term consequences
bull Gets confused with more severe forms of TBI
bull mTBI itself varies in severity (and consequences)
bull ldquoConcussionrdquo may be a better word
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Natural History of Civilian mTBI
bull Populations most studied
bull Serious athletes (pre- and post-)
bull Road traffic accident victims other trauma
bull Full recovery in the vast majority of patients within weeks to months
bull Less recovery after 3 months
24
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Causes of Symptoms Seen after mTBI
bull Short-term symptoms are likely directly due to brain trauma
bull Long-term symptoms are ldquomore complexrdquo
bull Rare in concussed athletes
bull Not uncommon in civilian trauma victims
bull Not overly specific to brain injury
bull Psychosocial factors are very important
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Frequency of PCS Symptoms following a MTBI
bull Poor concentration 71
bull Irritability 66
bull Tired a lot more 64
bull Depression 63
bull Memory problems 59
bull Headaches 59
bull Anxiety 58
bull Trouble thinking 57
bull Dizziness 52
bull Blurry or double vision 45
bull Sensitivity to bright light 40
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Neuropsych Testing for mTBI Evaluation
bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable
bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly
bull CBT is probably helpful for those with persistent concerns regardless of test results
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Imaging Tools ndash Old School to Cutting Edge
bull Plain Radiographs
bull Computed Tomography (CT)
bull MRI with standard anatomic sequences
bull Gradient Echo (Blood sensitive) MRI
bull Diffusion Tensor Imaging
bull Spectroscopy
bull fMRI
bull Perfusion Imaging
bull Quantitative techniques
28
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
GE 3T MRI Scanner
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Tractography
Superior view color fiber maps Lateral view color fiber maps
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
SPECT Brain Perfusion after mild TBI
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Management of MTBI
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Management of Sensory Disturbance
bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist
bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)
bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries
bull Driving can be an issue
bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist
bull No Etoh
33
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Post Traumatic VertigoDizziness
Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone
Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks
BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development
Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic
Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo
Mechanisms of Vertigo
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Post Traumatic VertigoDizziness
Mechanisms of non-vertiginous dizziness is often cervical
bull Aberrant afferent input from positional proprioceptors in C- spine
bull Overstimulation of cervical sympathetic nerves
bull Compromised vertebral arterial flow Probably rare
Mechanisms of Vertigo
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Pharmacologic choices for mild TBI
bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety
bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo
bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue
bull Topamax 25mg to 100mg qd if headaches remain intractable
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Cognitive Evaluation of mild TBI
Vulnerable domains to TBI
Attention
Working memory
Processing speed
Reaction time
Not associated with gross deficits of intelligence and memory
Findings can be confused with those of pain syndromes and medication effects as well as psychological illness
May be helpful in differentiating TBI from alternative diagnosis
Neuropsychological Testing
37
Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Lessons learned from mild TBI patients
Family physicians have pleotropic effects
Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first
Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI
The human brain is ldquoplasticrdquo
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Recent research
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al
bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome
bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome
bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Waljasrsquo paper (contrsquod 2 )
bull One-week RTW status rates after mTBI vary widely in the literature
bull A Greek study showed the rate was 84 in a very mildly injured population
bull New Zealand study 82 returned in the first week post-injury
bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks
bull The percentages returning to work by 1 month also varied widely across studies from 25-100
bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Waljas paper contrsquod 3
bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates
bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity
bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]
bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)
bull MRI was performed 3 weeks post injury including SWI
42
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems
In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI
The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
44
They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment
The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue
Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014
45
299 articles reviewed relating to MTBI prognosis
Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al
This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS
The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression
Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS
Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Continued 47
Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also
Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias
Treatments Education and reassurance exercise and return to activity
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI
Neuropsychologiy 2014 Karr et al
key points made The average prognosis remains positive but a subgroup of
patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)
Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment
However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)
Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head
Trauma Rehabil 2013 Leddy et al
10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months
Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues
fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to
restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but
that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil
2014 Prodan et al
Study of veterans with TBI
Coated platelet levels are markedly and persistently elevated in patients with mTBI
The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and
Cook
Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck
Only one small study has been done to suggestive effectiveness (Schneider 2014)
No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al
Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players
Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Diffusion tensor imaging findings are not strongly associated with
postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al
bull To examine the relation between diffusion tensor imaging (DTI) of
the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)
bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury
RESULTS The MTBI group reported more postconcussion symptoms than
the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures
CONCLUSIONS These data do not support an association between white matter
integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Recent VGH Grand Rounds- Dr David Koo Physical Medicine
Whats New in the Diagnosis and Management of Concussion (mild TBI)
bull Key Points made
bull He felt concussion was a subset of mTBI ie at the lower range
bull Noted that the patient may incorporate the memories of observers to form their own impressions
bull Symptom baselines present in non concussed groups eg college students chronic pain and depression
54
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Koo Rounds 2
bull Diagnostic accuracy improvements
bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical
bull SWI MRI scans shows hemosiderin persist about 5 years post TBI
bull High rate of questionable lesions on 3 T MRI
bull SPECT scanning failed to differentiate clearly
bull DTI is best tool to detect DAI
bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)
55
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
VGH Koo Rounds 3
bull He said 85 should get better within 4 weeks and this should be the message
bull Anxious individuals tend to overmonitor their symptoms
bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity
bull PCS incidence reported as 10-15 after a single mTBI
bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014
56
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Koo 4
bull Causes of PCS-Neurobiological vs psychogenic vs
bull MRI in some showed a smaller cingulate gyrus 1 year later
bull Several cases of post-mortem diagnoses of DAI
bull Apo E4 influence
bull Levin 2001 showed higher rates of depression and PTSD after 3 months
57
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
VGH Koo Rounds 5
bull Treatment
bull Early education of critical importance
bull Treat depression and anxiety primarily ie treat what you can treat
bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar
bull He advocated early CBT within 6 weeks if indicated
58
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59
Koo Rounds 6
bull Pharmacology-numerous possibilities
bull He noted a recent study in press using amantadine
bull Increased use in US including stimulants
bull SSRIrsquos if appropriate in my view
bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise
bull Attempt to normalize life asap with early RTW
bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate
bull Mentioned brainstreamsca for patient education
bull Use of early responsive concussion clinics
59