Welcome, everyone, to the final live day of the 2020 AAPMNR Virtual Annual Assembly. This session is our live session on concussion evaluation, clinical tools, and evidence-based applications for all patient ages and clinical settings. Thank you for coming this morning, bright and early, depending on where you are on a Sunday. My name is Stephanie Tao. I am an assistant professor and also the medical director of the adaptive sports medicine program at UT Southwestern. I completed fellowships in both pediatric rehab and sports medicine. I practice both PEDS rehab and sports medicine at Children's Health and at Scottish Rite Hospital for Children and see a lot of patients with concussion in my practice. I'm excited to bring this fantastic session to you all today and introduce our amazing panel of faculty who also practice a good amount of concussion in their practice. First up, we'll have my co-session director, Dr. Andrew Gordon, who's a fellow of the AAPMNR and currently works in private practice with U.S. Physiatry and also serves as faculty for the National Capital Sports Medicine Consortium. He's a former president of the AAPMNR Resident Physician Council, now known as the Physiatrist and Training Council, and now serves on the AAPMNR Evidence, Quality, and Performance Committee. He did his physiatry residency at the Johns Hopkins Hospital and primary care sports medicine fellowship at MedStar Georgetown University Hospital, National Rehab Hospital. He has provided medical coverage for several DC metro area collegiate and professional sports teams, as well as elite distance running events and has substantial experience in both academic and private practice environments during concussion management. I'm also proud to have Dr. Kathleen Bell on our presentation today. She's the chair of the Department of PMNR at UT Southwestern Medical Center and holder of the Kimberly Clark Distinguished Chair in Mobility Research. She graduated from Temple University Medical School in Philadelphia, Pennsylvania, and completed residency at the University of Washington in Seattle, Washington, and completed an NIHR, which is now NIDILRR, Switzer Fellowship. Her research interests and publications have centered on treatment and outcomes for traumatic brain injury, including self-management techniques, post-traumatic headache, sleep disorders, and exercise after TBI. Her current interests include concussion, sleep disorders after TBI, and autonomic nervous system after concussion. She has been funded as an investigator on grants from NIH, NIDILRR, the Department of Defense, PCORI, and the CDC since 1998. Dr. Bell is currently a past president of the AAPMNR, the co-director of the Texas Institute for Brain Injury and Repair, and an investigator for the North Texas Concussion Registry and co-PI for the North Texas TBI model system. And last but not least, I'm also proud to introduce Dr. Mary Dubon, who's a pediatric rehab medicine and pediatric sports medicine physician at Harvard Medical School in Boston Children's and Spalding Rehab Hospital, and is an assistant fellowship director of the Pediatric Rehab Medicine Fellowship Program at Spalding and Harvard. She completed her internship at St. Vincent Hospital and Healthcare Center, did her PMNR residency at the Rehab Institute of Chicago, which is now known as Shirley Ryan Ability Lab and Northwestern University, and then subsequently completed her Pediatric Rehab Fellowship at the University of Washington and Seattle Children's, and then her sports fellowship at the Ann and Robert H. Lurie Children's Hospital of Chicago at Northwestern University. She is board certified in PMNR, pediatric rehab medicine, sports medicine, and brain injury medicine. Here are the disclosures for our speakers, otherwise there are no other disclosures. Just some housekeeping to pose questions to the faculty. Please type questions in the Q&A field on the left side of your screen. If you want to direct the question to a specific speaker, please also type who you would like to direct that to. I will be monitoring the chat throughout the presentation, and I will address all questions during the Q&A at the end of our session. And if you don't see the Q&A box on the left, you can also bring it up with the question mark icon on the bottom of your screen. As a reminder, you can earn CME for attendance in this session, and your participation has been recorded. Due to high volume, it may take up to 48 hours for all data to be transferred to your Academy online account. For those attending the annual assembly in real time, the Academy recommends claiming your CME beginning Wednesday morning to ensure all of your participation has been accurately transferred. All sessions will be recorded and made available on demand until January 31st, 2021. Visit the Member Resource Center if you have questions. Please also complete an evaluation for this session as your feedback on the evaluation does help the Program Planning Committee outline content for future annual assemblies. So please ensure to give suggestive content. All sessions will be recorded and made available. So we do have a poll question that we would like to ask. So please let us know which of the following patient populations you see in your clinical practice. And I'll give a minute for everyone to just respond to this. And this is just helpful for us to know who's in the audience today. Okay, let's close the poll. See the results. Okay. So it looks like the majority who are on live with us today see adult patients with concussion, with some of us also seeing some pediatric patients with concussion as well. Wonderful. All right. Here's our learning objectives for today. We'll be describing the evidence behind various concussion evaluation clinical tools, including in what context and setting it is most appropriate to use each tool. And then what age group the evaluation tool is valid. And then also the sensitivity and specificity if it's known for that concussion evaluation tool. And then lastly, we'll be also describing various concussion evaluation techniques via the video demonstration if that's available. So I'm happy to introduce started with Dr. Andrew Gordon. Thank you, Dr. Tao. Good morning, everybody. I'd also like to thank Dr. Duvall and Dr. Bell for joining us today in this session and the Academy for facilitating this as well as every one of you out there for joining us on a Sunday morning. So hope everyone's staying safe. I'll be talking this morning about gold standard concussion tools and adults have no disclosures. And, you know, briefly, when we talk about concussion, what we want to do is basically when looking at a patient assess their level of consciousness, assess, you know, their physical stability before going on to using more specific concussion tools and assessment algorithms that could be useful in taking care of the patient. Apologize for the small writing here, but basically this goes down and talks about whether the cervical spine can be cleared. If it can be, then you don't have to send them to the hospital. You can also talk about whether the patient has prolonged loss of consciousness. Once, you know, level of consciousness is established, you then move the patient over to the clinic or sideline for evaluation and then, you know, look for any obvious mental status changes and then move along toward more specific concussion evaluation tools. Where assessment tools are concerned, none are exclusively effective. Combining assessment tools will increase the sensitivity and specificity of your evaluation. So we break this down into five general types of assessment tools. The first are symptom checklists, which are more subjectively reported by the patient. Neuropsychological tests, which can be conducted by pen and paper or over a computer. Postural stability testing in concert with a focused physical exam. Then there's more rapid sport sideline assessment tools for those participating in sport or those who need a more rapid assessment of whether they've had a concussion or not. And then more specific hospital and clinical assessment tools in combination with imaging. So when considering symptom checklists, they can be useful for diagnosis and monitoring recovery. They allow concussion patients to self-report symptoms easier and it can aid in clinical decision making throughout recovery. And so basically break down the select signs and symptoms of concussion into four basic areas. There's emotional, there's cognitive, there's sleep that's very important, and also somatic and physical aspects of symptoms. And there are a number of different examples of symptom checklists that are used. These are the most widely used, including the concussion resolution index, the concussion symptom inventory, graded symptom checklist, the head injury scale, McGill abbreviated concussion evaluation, the neurobehavioral symptoms inventory, the post-concussion symptom scale, and the Rivermead post-concussion questionnaire. These are widely used, they're quick, they're easy, they're cost effective. They mostly have good sensitivity and allow athletes to self-report symptoms. Physicians should be aware that when using such checklists like these, again, it's not to be used exclusively for the diagnosis of concussion. Symptoms can also be delayed or not even be reported. So again, it's not a complete assessment. And some more complex tools, which we'll talk about later, have some of these checklists actually embedded in them. An example of such a checklist is the post-concussion symptom scale. This particular one is embedded within a computerized neurocognitive testing package called IMPACT, and it has 22 different symptoms that are rated from a scale of 0 to 6. And from that, there's an index score that's combined with the rest of the computerized neurocognitive testing to give a bigger picture of where the patient is in terms of having a concussion. So moving on to neuropsychological tests, identification and tracking of cognitive deficits is what we try to accomplish with this. And the validation of these tests is very variable, and the evidence often can be subjective based on what, you know, what you're reading and so forth, because some of these are more rigorously defined, others are not. It can assist return to activity or return to play decision-making. It helps evaluate individuals with prolonged symptoms. There really is no consistent consensus as to which neuropsychological test is best. Again, there are sideline neuropsychological evaluations, rapid evaluations you can do versus written pen to paper and computer-based. And these typically assist memory, attention, and reaction time. And the post-injury data is typically more useful if you have a pre-injury baseline. You often have this in athletes in high school, collegiate, and professional sports. However, you know, patients in car accidents and so forth aren't really going to have that, so unless they've had a concussion before. So when you think about neuropsychological symptoms in recovery, headache is very common. It's often the most reported symptom, and it's associated with higher levels of post-concussion symptoms including memory dysfunction and decreased reaction time. Those with headache also are more likely to have retrograde amnesia and are five times more likely to have mental status changes greater than five minutes after concussion. Concussed athletes with post-traumatic migraine, they have the most post-injury impairment with significant decreases in visual memory, verbal memory, processing speed, and reaction time at least four days post-injury. And another thing you're assessing during these neuropsychological tests is actual fogginess. It's very common for concussed patients to report to you in clinic that they feel foggy after a few days, weeks, and months, and so forth. As time goes on, the fogginess tends to get more important, and this is related to decreased performances in memory, reaction time, and processing speed. So this is a list of different neuropsychological tests that can be used. Again, there's a very long list here, and the evidence for this is variable. Again, we're looking to assess memory, reaction time, and processing speed. As an example, I am going to point out the impact test. This is very commonly used. It is actually an FDA-approved medical device for both the adult and the pediatric versions, and it assesses together verbal memory, visual memory, visual motor speed, reaction time, impulse control, and together with the total symptom score, it comes up with a cognitive efficiency index. Now, they've been able to compact impact so that it's also used on a sideline, on an iPad. Again, you know, the evidence for a lot of these are variable, so, you know, I don't necessarily advocate for one type of neuropsychological test over the other. It's only a piece of the puzzle, but, you know, this is the kind of thing that's commonly used in clinic. I also like to talk about, when we consider assessment tools, a strong-focused physical exam. A focused neurologic exam can reveal more severe mild traumatic brain injury, and I urge everybody to not forget the neck. Always clear the C-spine and look for neck sprains, myofascial pain, signs of instability, occipital neuralgia, look for symptoms that could be coming from the neck or, you know, the base of the head as opposed to, you know, your more traditional concussive symptoms. In particular, when it comes to examining the patient, the vestibular ocular motor screening is proven to be sensitive. And we also, when we consider assessment tools, you know, in combination with the focused physical exam, postural stability testing. Again, more beneficial in combination with other assessment tools and evidence variable. The main postural stability test that we use in addition to the vestibular ocular motor screening or the VOMS is the BESS, the balanced error scoring system. This has low to moderate accuracy and limited sensitivity, yet strong specificity for concussion diagnosis. In terms of monitoring recovery, again, it's another piece. A modified version of this is embedded in the SCAT-5, which I'll talk about shortly. And again, this is something that I'll discuss in a minute here. But going back to the vestibular ocular motor screening, it's broken down into five discrete exam parts. The first is the smooth pursuits, then horizontal vertical saccades, near-point convergence, vestibular ocular reflex, and visual motor sensitivity test. In smooth pursuits, the examinee follows a slow-moving target to try to provoke symptoms. With horizontal vertical saccades, the patient is trying to move the eyes quickly between targets without provoking headache or fogginess or other symptoms like that. In near-point convergence, basically, a target is moved closer and closer and closer toward your nose, and if the patient has double vision greater than or equal to six centimeters from the nose, the test is abnormal. Then there's a vestibular ocular reflex, which is the ability to stabilize patient's vision as the head moves while staying focused on a target. And then finally, visual motion sensitivity is used to assess whether a patient can suppress vestibular-induced eye movement. I find myself using this, you know, whether inpatient or outpatient. Number five is a little harder to do with inpatients who might be stuck in a bed and have multiple trauma, but most of these are widely applicable to patients, you know, ranging from inpatient trauma to outpatient clinic. With regard to the balance error scoring system, this is a pretty cheap test to do. Just have to have the foam pad that you can see in the last three pictures over here that the patient is standing on. And basically what you do is for 20 seconds in each of these poses, you have to try to stay as still as you can while you have your eyes closed. And errors include moving your hands off your hips, opening your eyes, stumbling or falling, flexion beyond 30 degrees of the hip, lifting of the forefoot or the heel off the testing surface, and remaining out of the proper testing position for greater than five seconds. And, you know, if you make multiple errors at once, it only counts as one error. But within 20 seconds, if you have at least 10 errors, then you stop counting. And as you can see on the right here, you can have a minimum score of zero and a maximum score of 60. I see. So moving on to sport sideline assessment tools, there's the standardized assessment of concussion and the SCAT-5. And Dr. Dubon is going to talk more about the SCAT-5 in kids. The standardized assessment of concussion is validated for junior high and older with emergency department version validated only in adults. And again, this talks a lot about more symptoms and so forth. The SCAT-5 has both on-field and off-field components to its evaluation. And I'll leave this for Dr. Dubon to talk more about. Then there are hospital assessment tools that include the standardized assessment of concussion. And one that I like to use in clinic a lot is the acute concussion evaluation. There are two versions of this that were developed, one for the emergency department and the other more so for the clinic. And the emergency department one is obviously briefer. The clinic version dives deeper into activity risk factors and more red flags. So again, it's evidence-based and is a good way to bring structure to your concussion evaluation and outpatient clinic in addition to the rest of your assessment and testing. And a comment on imaging, there is one scale that can be used in adults. It's the Canadian CT head injury trauma rule. This was actually developed by the same doctor who developed the adequate ankle rules for anyone in the musculoskeletal and sports medicine world and basically go down the checklist and you can determine whether you need to do imaging or not in concussion patients. And as a final word, you know, Dr. Bell will probably get more into the future of assessment tools and the cutting edge, but we can do all of this now effectively on a contraption like this, where this is monitoring a patient's EEG. It's connected to a device that a patient can do cognitive evaluation on and also literally fill out the SCAT evaluation. And it's wonderful how far we've come. There are also biomarkers that can be used to detect brain injury in patients. And taken together, we've come a long way in terms of being able to assess concussion in evidence-based manner in adults. And with this, I'm gonna pass the baton over to Dr. Dubon and we'll take questions at the end. Thank you. Hi, everyone. Thanks so much, Dr. Gordon. So Dr. Gordon gave a great overview of lots of concussion tools. Now I'm gonna be talking specifically about the pediatric population and kind of a trend here is we need a bit more evidence, I think, for all of this, but certainly for pediatrics. So for those of you who are joining today who are pediatric rehab doctors or pediatric sports medicine doctors or are sports medicine doctors or general physiatrists who see kids, you know that the literature for kids is a lot less than the literature is for adults. And so certainly we take a lot from the adult literature and apply it to children, but certainly just the biggest take-home point, I think, from my talk is just that we need more literature, we need more information about the utility of these tools and what we need to do for specific age groups. Because certainly a concussion in an eight-year-old might be different than a concussion in a 13-year-old, right? And so that's something that I think all of us who see concussion in kids definitely see. Now, in terms of gold standard and where you wanna look to in the literature, if you're just getting into concussion management or you're just looking for a really good article, you're gonna wanna look for the consensus guidelines. So there's an international conference on concussion that happens every number of years, and this is from the most recent one in Berlin in 2016. And that's really where you get a lot of really good information. They have experts that join together, they look at the evidence, and then they put together these guidelines. So that's usually what I kind of look to first and foremost, and then I'll look to see if there's literature since then that kind of builds upon that. So if you haven't read this article, I definitely would recommend doing so. So this is just a little information from that article. And so from that article, they did a really nice job of if it was something that was new since the last international guidelines, they italicized it. So it made for a really nice read if you're familiar with the last guidelines and you just wanna get updated information, this will give you that pretty clearly. And so some of the things that they mentioned is for adults, the normal length of symptoms is up to two weeks. But again, as we always say in pediatrics, kids are not just little adults, things are different when you're talking about a growing and developing brain. And so the normal length of symptoms was determined to be up to four weeks. Now, I think there does still need to be more evidence to kind of show this, to expand upon this, to adjust this over time, if this is something that is not thought to be the case, because I think it was a combination of them looking at literature, but also expert opinion. Some other important things to note, if you're not familiar with taking care of kids with concussion, a big thing that we think about is kids want to get back to their sport and they wanna get back to their sport ASAP. And so you cannot return someone to sports before returning them to school. So they have a chart for return to school and a chart for return to sport. And it's just important that you don't start doing the sport specific pieces of the return to sport before the kid is completely back to school. So you wanna be asking during your visits, okay, I know at last visit I gave you these modifications, have you been using these modifications? Have you, you know, and like, are they still getting extra time on tests? Have they not been taking tests? If all those things are still the case, you wanna make sure they start doing those things before you start getting them back to sport. And then in terms of another thing that came from this was the child's scat number five. And so if you're familiar with the scat, you would have known about the scat three, and then it skipped four to go to five because it was the fifth guidelines. And so they decided just to make everything number five, just to make it clean moving forward. And so this is the graduated return to sport. And so they don't want, they want athletes to spend at least 24 to 48 hours in each step before going to the following steps. So there is that rest period that happens at first, and that's 24, 48 hours. And then you can start going to light aerobic exercise pretty quickly. That's something that has really changed over the past, you know, 10 years or so in sports medicine, because we know that we don't wanna just keep people completely in boxes, but we also don't wanna get them back to contact activity right away either. So I always think about it thinking, gosh, when, you know, we see patients with moderate or severe traumatic brain injury, we're not just keeping them in bed constantly. We do wanna rehab them too. So just having people do like light walks, you know, a couple of days out of injury has been found to be helpful. And then this is the graduated return to school strategy as well. So people call it return to learn or return to school. And so you wanna make sure kids are completely returned to school before you start doing that sport specific return. So again, the Child SCAT-5 also was the, was one of the things that came out of this meeting. And I know that Dr. Gordon briefly mentioned it. So I'm gonna go through it a little bit here. So it has, you know, the immediate things that you do when you're on the sideline, right? You wanna look for the red flags. You wanna make sure that you don't need to be calling for, you know, an ambulance immediately, right? You're gonna look either on video or you're gonna look in person to see if you see things that are just making you kind of, you know, concerned about what's going on with the athlete. And then we're all familiar with the Glasgow Coma Scale. And obviously this is something that's gonna be important for you to be doing with the athlete, sorry, there as well. So you're gonna be looking to see if it looks like there's a more catastrophic injury that's going on here. That's gonna be your first and foremost. For those of you who've done sideline management before, whether it's football or whatever sport you see a bad hit, you know that the first thing going through your mind is what just happened. And you wanna kind of do that initial assessment. You wanna look for cervical spine assessment as well. Now, the second part of the SCAT is really, okay, things have calmed down and you have the ability to kind of pull the athlete aside and you're able to do some neurocognitive testing to do further assessment or the athlete comes into your office and the athlete is clearly days, weeks, whatever out from injury is stable. And so it's kind of a more of a neurologic assessment. So I'm gonna ask them some general questions about their history of concussion. And then you're going to indicate if this is baseline or post-injury. So a lot of high school athletes and some local programs, not all, will actually do baseline testing. And so it is somewhat valuable to have baseline testing. It doesn't necessarily mean that you need the baseline testing in order to diagnose a concussion by any means, but it can be helpful for when you're like getting closer towards the tail end and you're not sure if this person's balance is off because their balance is off at baseline or if their balance is off because of concussion. And so that I do find a little bit valuable at times to have baselines, though again, it's not necessary. And so then, sorry for the small font, but I definitely recommend if you are gonna be seeing pediatric athletes with concussion that you should be looking to the SCAT and to the McCurry article, or even if it's non-athletes with concussion, I would also recommend that as well. So this is a symptom scale. And so what's nice about this one, and it has it in child-friendly language and parent-friendly language. And so if you're in clinic, you can give it to both and kind of compare, which can be valuable. And then it has some neurocognitive testing as well in terms of memory and concentration. And they put quite a lot in here. In this version of the SCAT, they actually said it takes no less than 10 minutes, which is a long time. So this was kind of something that there was a lot of conversation about after it came out because, well, if you're in the middle of a boxing match and you have to come out for 10 minutes, like that's kind of like a big deal, or if it's wrestling, that's a big deal too, because there's kind of like time restrictions there. So there's also the space restrictions as well in terms of, you have to, as a sideline provider, make a determination of concussion efficiently, but also you wanna make sure that you're thoroughly addressing everything that you need to address to kind of make that determination. And so they did really make it clear that there needs to be adequate space, there needs to be doing this in kind of a relaxed resting position, and there needs to be the ability to do a 10-minute assessment to help you make that determination. Now, for many athletes, you might make that determination pretty quickly. And I think that it's always better to stay on the safer side of things. One of my concerns with this in the pediatric population is just that I don't have a good sense when I'm working with seven-year-olds of how many digits backwards they should be doing, right? Like, I don't really have a great sense of that baseline, and we don't really have anything in the literature that makes it clear that, okay, a child that's at this reading level should be able to do X, Y, Z. And so this is where anyone who's listening, who's interested in this kind of stuff, we really need research in this area to help us be able to make the best care for our patients, because sometimes it is hard to tell what is baseline, what is age, what is concussion. And then just some questions in terms of neurologic screening, just to see, in general, how the patient's doing. And then there's the modified BESS, which I know Dr. Gordon mentioned as well, which is really valuable as well, and that gives a good balanced test. And that's something that I definitely, I utilize this, honestly, in the office and the clinic as well. And they talk about, too, about how the SCAT itself, you add in gait assessment, you add in something like the VOMS, you add in some visual ocular testing into that, you add in some speed reaction time testing, and that makes all of it much more valuable in a clinical setting to actually follow somebody post-injury. And then, of course, you have your delayed recall as well. And then it basically kind of talks you through how you make your decision with that. But certainly, I think that it's important for sideline docs to keep in mind, if you see something that makes you concerned that there was a concussion, there's any signs of it, or, gosh, that was just a hard hit, it is absolutely always safer to just keep the athlete out, because, as we know, symptoms can develop 24 hours later, 48 hours later, and it's certainly always better safe than sorry. And so this is something that I like to point out, too, because I mentioned that sometimes I have a hard time with the younger individuals with concussion, is like, you know, parents would be like, well, I don't know if they ever would be able to do that, or, you know, if we do months of the year, and they're like, they don't know the months of the year forward, and they're like, well, I don't know the months of the year forward, unless backwards, and that's always something I test first. So I'll make some modifications based on that, but it does make it hard, I think, sometimes to analyze, because we don't have great data of this age group, or that age group, how things look different. But this was an interesting study that I thought was really valuable, too, is that not everyone has a zero on their concussion symptoms score when they have absolutely, you know, nothing else going on. So if you don't have a concussion, it doesn't mean that you have zero headaches, or you're not tired, and all those other things. So it's just a good read, another thing out there, just to show that, you know, on average, people did have more than one symptom as well. So not to wait for it to be zero. One question I like to ask in clinic a lot is, what percent better do you think you are? You know, if 100% is you feeling yourself the day before your concussion, and 0% is when you felt the worst during your concussion, what percent better do you feel? And if people, you know, it tends to kind of give me a really good litmus test. Again, not a validated thing, but if people are saying 75%, okay, great. Next visit's like 80%, you know, and they'll kind of be honest with you. I think that that has added some value to things for me as well. And then this is another good article that's kind of recent from last year, and it just kind of, it speaks to one of the points that the McCurry article did say, hey, we need symptom profiles among the patients at different ages. And it's interesting, because in terms of the symptom profiles and domains, they're actually pretty similar. There weren't really statistical differences between the ages. And so, again, in the interest of time, don't have time to go through all the results of it, but I do think that that's another good article, good read to think about. So with that, I'm going to pass it along to Dr. Bell to finish it up here for us. Thanks. I appreciate being asked to be on this panel today. Thank you, Dr. Toh, for asking me to do so. And I'm going to endeavor to stay in the middle of this little window here. Let me make one point before I start, because it's going to be pertinent to things that I talk about, and I think it's kind of a wind up from what Dr. Gordon and Dr. DuBon were saying. There's a lot of reference to what we know about adults. And let me point out that what we know about adults is what we know about adult athletes. And we know very, very little about non-athlete adults. So particularly, we know very, very little about patients in that category for whom the incidence of brain injury is rising the fastest, and that's people over the age of 60. So, kind of keep that in mind as we're going along, and maybe Dr. Toh will have a session next week or a session next year in Nashville about the aging person with a concussion, because I think that, again, we know even less about them than we know about children. All right, so what I thought I would do today, talking about future possibilities for diagnosis in concussion, and there's a lot of work going on in a lot of areas, and I decided I was just going to skip imaging entirely. The reason being, I think that the work done in imaging is really incredibly valuable in teaching us more about what the real biomechanics and what the biophysiology is of concussion. But the truth is, we're not going to send all of our patients with a concussion off for an MRI, diffusion tensor imaging, because that's just way out of line for most people. So I decided I would concentrate on things that theoretically you might be able to do in an office setting as time goes along. And I wanted to try to stay as objective as possible, so I kind of eliminated things like neuropsychological examinations, which actually in many ways are our gold standard, at least of brain function at this point, went on in a classic way and not necessarily went on in a computerized manner. But we're going to kind of talk about some little more objective things. So don't freak out too much about this graph. There's not going to be a test given afterwards. And all I really wanted to do was demonstrate a little bit about talking about the autonomic nervous system. And it's a universality in the nervous system. So if you look at this kind of simplified version of the central autonomic nervous system, you'll see that we're talking about starting way out in the frontal, prefrontal cortex, all the way towards exiting the brain to the peripheral autonomic system. So there's a lot of the brain that's integrated with the autonomic nervous system, which is why it may give us a really nice window to look at in terms of brain dysfunction. So remember that the autonomic nervous system basically characterizes a couple of things. One is the brain-heart network. So it really is the modulation of cardiovascular activity, which allows us to have a window into brain function. The other thing that is connected to this is also there's a modulation of autonomic nervous system by respiratory function as well. So we can have alteration of autonomic nervous system function by depth or rate of breathing. And that's because it's affecting the concentration of carbon dioxide. And the carbon dioxide is of course then affecting things like the blood vessel circumference and the arterial pressures. Also, there are things that feed into this such as the baroreflex circuit, which goes through the nucleus tractus solitarius. And remember the one thing that's not on this slide is the endocrine system and its interface in the autonomic nervous system, including the sympathetic medullary system and the hypothalamic pituitary adrenal axis as well that are all involved in the stress response, which is of course the response of the autonomic nervous system. Let me also point out to you on this particular slide, the boxes that are grayed out are actually areas of the brain that are very highly involved in emotional reactions. And so think about this when you're thinking about people perhaps with more persistent symptoms that the autonomic nervous system is very active in the prefrontal cortex, in the amygdala, which is highly involved in emotional output and in the medial refe nucleus. So it's a very complex system, but it does give us some windows to look at, which is really cool. So this is another way now to look at the peripheral autonomic nervous system and what the interface is between the central and the peripheral system. So if you look at the bottom, you'll see that you're looking at the autonomic structures in the brain and the brainstem as kind of your controller of what's going on in the peripheral autonomic nervous system. And then you have your actuators and your actuators are basically heart frequency and also the stroke volume that's emitted from the heart contraction and also the peripheral resistance in the arterioles. The other thing then that you see on the other side are the sensors that basically contribute again to regulation of the autonomic nervous system, including the baroreceptors, which are contained primarily in the aortic arch. So how can we measure sympathetic nervous activity from the autonomic nervous system? Well, there are a number of ways we can do this that are relatively simple. So we can look at things like beat to beat arterial blood pressure. We can look at blood pressure tone and subsequent blood flow. We know that after severe traumatic brain injuries, that there's an exaggerated sympathetic neural activity, which we see in things like sympathetic storms and dysautonomia. And there's no reason to suspect that in, you know, milder brain injuries that we're not seeing some of this as well. So there appears to be some uncoupling of the autonomic nervous system and cardiovascular control after a brain injury. And the question is, to what degree do we see that in concussion? So you can study this with things like heart rate variability, pupillary dynamics, arterial pulse waves. There are a lot of ways that you can intervene in the autonomic nervous system so that you can look at reactions to perturbation using things like eye pressure, valsalva maneuvers, hand grip tests, squatting, face cooling, or breathing a variety of gases. So lots of different ways that you can study this. So let's, I wanted to just go over a couple concepts with heart rate variability because I, you know, sometimes you get to reading these papers and the question is what the heck are they talking about in terms of heart rate variability. So most often measured by chest strap in research areas because it tends to be a little bit more accurate than wristbands. So there are two things that you can look at in terms of heart rate and also intervals between the RR waves or other aspects of the heart, the EKG output. So you can look at the time domain and you can look at the frequency domain and they're measuring slightly different things. So the time domain you can look at the heart rate at any point in time or the intervals between successive complexes, as I was saying. And as I mentioned, there's lots of different ways that you can intervene to perturb this so that you can see what the reaction is. And some of the things that you might see are, you know, how long it takes for something to react to a perturbation. And that's what we might need to see in things such as mild traumatic brain injury. And there's also the frequency domain in which there's a power spectral analysis done of the heart rate. And that can give us some information as to whether there's more kind of sympathetic tone or parasympathetic tone going on that's affecting the heart rate variability. So high frequency domain typically will reflect the efferent vagal flow and the low frequency domain will more give you the sympathetic flow or a combination of parasympathetic sympathetic flow. Now, there's still a lot of, I mean, this is really at a research level right now, heart rate variability. There's lots of work being done on this right now, but, you know, we're looking at mostly papers that have 10, 20, 30 subjects there, and they're almost all collegiate athletes. So we don't know a whole lot about this yet, but it's really very interesting. So we have conflicting evidence, but it's clear that the autonomic nervous system is disturbed after mild TBI. It's absolutely clear, especially when a perturbation is used to look at the response rate of heart rate variability. It persists well beyond the expected recovery period of three weeks, well beyond. We've been able to document abnormalities in autonomic nervous system responses up to three months after a concussion in subjects who are healthy, young, collegiate athletes. So, again, I always like to say, so think of what's happening in your 60-year-old in a car accident that has a concussion. Okay. And there's some interesting things we've also been able to see. For instance, that doing some cognitive work, mild cognitive work actually seems to improve heart rate variability back towards normal. So, you know, something, again, really interesting to think about. One of the other things that we've been looking at in terms of abnormalities after concussion is things like cerebral blood flow. So we and other laboratories have been using transcranial Doppler ultrasound to look at cerebral blood flow. And, again, I bring this up here because this is something that, again, can eventually, if it proves, you know, if we can get guidelines set up, is something that can actually be done in an office setting. We have, again, and we and other laboratories have noted that there really are disruptions in regional cerebral blood flow that have been noted in concussed athletes. Even, you know, eight days after injury, we're still seeing abnormal blood flow in healthy 20-year-olds. Makes you pause and think about what we're doing in terms of returning people to activity. So I'm going to move on now to talk about another aspect of the autonomic nervous system, which is pupillary reaction, and talk a little bit about pupillometry. So let me talk for a minute about the pupillary light reflex, just to give a little refresher on how it works. Remember, pupillary light reflex is a bilateral pupillary constriction in response to light, which is shown in either eye. Light shown in one eye is detected by the retina, projects the information through axons, which are on the ipsilateral optic nerve to the optic chiasm, at which time half of the neurons switch over to the other side. So you have half going ipsilateral and half going contralateral. So some of these axons then enter the upper brainstem in bilateral pre-tectal nuclei. Now, axons from each of these nuclei then project a short distance to synapse in the edinger-westfall nuclei, which contain parasympathetic pre-ganglionic parasympathetic neurons. Then axons from these go back to the ipsilateral oculomotor nerve, and they synapse in the ciliary ganglion, which have post-ganglionic parasympathetic neurons. So again, kind of summing everything up, what we're seeing is that constriction of the pupils, again, is a parasympathetic phenomenon, and dilation of the pupils is a sympathetic phenomenon. So kind of keep that in mind as we're going through here. So hold on a second. Okay, great. So what we know about pupilometry, it's kind of really exciting, and I think it's something that we're going to see in the future that we're really going to be able to use in this population. But there are relatively few studies at this point in concussion. There's a few in blast-injured populations, and I would definitely posit that that is not a typical concussion population. There are a few in more severe TBI, and there are a few in some cross-sectional cohorts. But there's not a lot of information on this. It's very easy to do, which is pretty cool. And there's been one study this year, which is probably the largest study that's come out so far, on 98 concussed athletes between the ages of 12 and 18 years, and 134 controls. This was done approximately 12 days post-injury, and eight out of the nine metrics in this study were significantly different between the concussed group and the non-concussed group. Now, what don't we know about pupilometry? We don't know about the trajectory of abnormalities. We don't really know about the correlation with symptoms. We don't really know the correlation with other biophysiological or other biomarkers. We don't really know the meaning in more severe TBI, and we certainly don't know what the interaction is with other disease states. And I keep coming back to older adults. Do other eye problems have an issue? Do other, say, microvascular white matter disease have any kind of bearing on the measurements of this stuff? Don't know that yet. Okay, now we're going to do like a two-minute review of serum biomarkers. So, remember with serum biomarkers that there are three areas that they're reflecting. They're reflecting the rupture of the blood-brain barrier, they're reflecting trauma to the neuron or the axon, and then they're reflecting the response to that trauma, which is neuroinflammation. And the things that are involved are the neuron itself, the axon, the glial markers, and the cytoplasm. So, in terms of blood-brain barrier biomarkers, probably the best known is the S100B, which is probably the one that's also been the most studied. Now, there have definitely been some studies that have reflected the presence of S100B elevations in concussed populations in emergency room populations. The problem with the S100B is it doesn't, it's not very specific. It's pretty sensitive, but not very specific to concussion, which kind of limits its use as a biomarker. But still, the question is, might it be useful in combination with other biomarkers? Then when you get into the neuronal and axonal injuries, again, I'm going to kind of fly over this. Things like tau enameloid protein are probably later indicators at this point of injury because tau protein and amyloid proteins form complexes when injury exists in neurons or axons and can be detected at that point. But we still don't really know what the real activity is of tau enameloid post-injury and far post-injury, let alone early on in concussion. Now, UCHL1, the ubiquitin, I'm going to say the rest of it, is very highly expressed in neuronal cytoplasm, which is why it's called ubiquitin. And indeed, there has been one FDA-approved biomarker combination, which is on the market. It's the Banyan biomarker, which is a combination of UCL1 and GFAP, glial fibrillary acidic protein. Now, what that does is it is useful for detecting the presence of blood in the brain. It is not useful for detecting the presence of concussion. The other limitation about using, and this is a limitation for all serum biomarkers, is when do you get them? Because the timescale for presence and absence of abnormalities in serum biomarkers is going to depend on when the actual injury was. So as you can imagine, the blood-brain barrier rupture proteins and perhaps some of the early neuronal axonal injury proteins will be useful earlier on, and then later there might be other aspects. So I'm just going to mention again GFAP here, which seems to have a higher accuracy than the S100B, and it's probably at this point probably the most promising acute indicator of abnormality in serum biomarkers. I'm going to mention myelin basic protein a little bit, because that is a delayed onset axonal injury marker. And that may actually be useful for looking at perhaps trajectory of recovery from concussion at some point in time. And then inflammatory biomarkers, the interleukins primarily. Now again, inflammatory biomarkers are generally going to be somewhat delayed, probably at least 24, 48, 72 hours afterwards. And some people have prolonged inflammatory biomarkers. And again, the meaning of this is still being sorted out. But there does seem to be some association between elevated inflammatory proteins and poor clinical outcomes eventually. I threw the genetic markers in here, right, just to have them on the slide so you could see them, but we're not going to talk about them again. So again, all of this not really ready for prime time yet. But I tried to choose the most promising things that I think will be there. I know there are a number of hopefully large studies that are going to be going on, certainly of kids and teenagers over the next couple of years that are going to do some work with phenotyping children. But there's a lot of work to be done in this. And it'll be a lot of fun if some of us want to get together and do some studies on this. Thanks a lot. Now I'm going to toss it back to Stephanie. All yours, Stephanie. Awesome. Thank you, everyone, for a wonderful, wonderful panel of presentations. So just some quick reminders. We're going to move into our Q&A now. Again, the Q&A, I've seen some questions pop up. Just because we're short on time, I've tried to address most of the questions, but we'll address the remaining ones here as time allows. And then if you don't see the Q&A on your left, again, you can click that question mark, question at the, sorry, the icon at the bottom of your screen. And so if we could pull up all of our panelists now. Okay. So the first question, and Kathy, just to save time, Dr. Dubon and Dr. Gordon, I've been texting to you to see if we know answers to this. And so we're leaving some questions for you that we didn't know the answer to. Do you know if a sixth edition consensus statement is coming out? Because I know they usually do come out every four years. Dr. Jason Lee asked that, and you're right. Have you heard anything? Because I know, Dr. Bell, you're very internationally involved with brain injury. I'm not involved, however, with the higher levels of sport concussion. So I honestly don't know. And I think it's probably going to be held in the Zoom country, this next one, probably not in Berlin. But no, I don't know, honestly. Less time for travel, but at least out of all this, we can collaborate better, so more easily. Dr. Bob Rinaldi asked, are there telehealth models in place that allow physicians to monitor multiple sidelines simultaneously with athletic trainers on-site assisting? And so Dr. Gordon and Dr. Dubon and I were texting about this, since we see it more on the sports side, so we do a lot of sports coverage. And a lot of the athletic trainers are often limited to the sidelines, and so don't do as much telemed. Dr. Bell, I don't know if you've had, because I know with our context group of athletic trainers, have you had any interactions with any of the athletic trainers doing telehealth or anything? We've done some robotics with, we've done robotics. We've done a little bit of early pilot work using kind of some virtual evaluation tools for the sidelines, so that, for instance, the physician can back up a trainer using some virtual stuff. I can't remember if that's actually been published yet. So no, but Bob, I think there's absolutely no reason that, for instance, once we get some good guidelines, for instance, with things like perhaps heart rate or pupillometry and things like that, no reason that can't be done at a distance and somebody calling the shots, you know, at home somewhere. So yeah, I think that's really going to be, that's going to be the future of all of this. Yeah, for sure. And I know Dr. Gordon also brought up that some of the neurocognitive testing could also easily be done remotely over telehealth as well. And then another question we had here, let's see, for Dr. Bell, I've seen a few young women with post-concussion syndrome, especially young women separately diagnosed with POTS post-injury. What do you think about this? Could this be related to dysautonomia? Do you think this diagnostic labeling is appropriate? Sometimes we are trying to get patients to be more active and the cardiologists are recommending less activity. So setting the right recommendation can be challenging. Oh, yeah. This is just kind of a messy, messy thing right now. Do I think that there are some abnormalities? Obviously, I think there are abnormalities in the autonomic nervous system, which could certainly, certainly result in some lag time in terms of, you know, managing arterial pressures. Honestly, the only things that I've really seen in the long run cure POTS are getting someone to go on a very staged increase in activity to get their tolerance levels back up again. And again, you know, we've seen, we've certainly seen from some early pilot studies that it's not bad for people to have some cognitive and some physical activity to help return the nervous system back to its normal function. And there's absolutely no evidence that it's going to hurt someone in the long run to do that. Hard to convince people of that though. And just a little bit on, you know, POTS as well, just wanted to add something. So I actually had a patient, a teenager, like a 14, 15-year-old female who was a soccer player, had multiple concussions and ended up with autonomic instability. And the way that we got her back to play, back to soccer and to collegiate soccer was with activity and graded therapy, like Dr. Bell is saying. So right on the mark. You know, and let me also say, I just, I just said that we have used some beta blockers as well. Now, now that sounds a little odd in a way, but sometimes it's this, it's this, you know, instability in management and then anxiety. So I've actually successfully used beta blockers in some of my younger patients, which seems to kind of kill two birds with one stone, and it doesn't hurt for headaches as well. It's kind of the aspirin of brain injury. Yeah, that's true. Another question here. I see students with asymmetric pupils within 48 hours for which I've been sending for imaging. Would you do so if no other focal neurologic findings? Since this is related to your talk, Dr. Bell, do you want to tackle that one? If I saw somebody with a neurologic sign, they would be in a CT scanner. Yes. Yes. That's a, that's a hard yes from me. I don't know about you guys. Agreed. Unless mom and dad could say, oh, that was always been like that now. Yeah. I think you always have to think about the things that you're most worried about and make sure that, you know, the autonomic instability can definitely be a component, but you need to rule out other concerning things first. Maybe Dr. Dubon can answer this one. Are there age-related norms for return to exercise or mental work? I wish. I mean, I think that that's definitely something that we need more out there. One of the things when I was thinking through the McCurry thing was like, oh gosh, I would love to be a fly on the wall in these conversations because I think a lot of it, I do think there was a decent amount that was expert opinion for the pediatric perspective of things. And there's definitely more and more research coming out, but age-specific stuff I haven't seen. And I think that that, in my opinion, is something that we really need to work on. I would point out that there was a consensus statement that's either published now or been published that's led by Noah Silverberg that got together a really huge group of people to look at signs and symptoms and kind of what they would do on the basis of signs and symptoms. So you might keep an eye out for that. Sorry. No, Dr. Gordon, anything else you wanted to add? No, I'm good. Thanks. This delay is crazy, right? I know. I know. I think we've answered all the other questions on here. I did try my best to answer other questions. I know there was an interesting question about adaptive and para-athletes or athletes in wheelchairs. And that's the topic of interest of, I think, most of the speakers on here and definitely much needed in research. I will say there have been some studies out there looking at the King-Devik. I know others have looked at the VOMS. I don't know if I've seen the published data yet. But then there's a bunch of people out there looking at trying to gather a lot more data on our athletes with disabilities. Of course, it's a complicated topic because I think we often lump athletes with disabilities together when they, depending on their underlying etiology and the severity of their impairment and symptoms can also manifest differently for concussion. And so every individual, again, it's the entire clinical picture and you have to kind of piece all the different puzzle pieces together. So not a simple answer, but I think it's important to look at So not a simple answer. And I think to that point too, Stephanie, is also what about athletes with intellectual disability because at baseline there are cognitive impairments. So that's been a whole other area that really needs a lot more research as well. Yeah. All right. Well, we are getting the message that we need to wrap up. So thank you, everyone, for attending our session. Thank you for our speakers for a wonderful job and enjoy the last day of our session. I mean, of the conference. Take care.

AAPMNR Virtual Annual Assembly

concussion evaluation

clinical tools

evidence-based applications

patients of all ages

Dr. Stephanie Tao

Dr. Andrew Gordon

Dr. Kathleen Bell

Dr. Mary Dubon

gold standard concussion tools