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ERIN REYNOLDS, PSY.D: I have a lot of information to give you. I was trying to figure out the best information for this group. And what I decided on is a general overview of the state of affairs and where we're moving in terms of concussion management. We move rapidly in my field. So I'm going to go through a lot of information, probably too quickly. And if there's any questions at the end, you can feel free to contact me. And I can send you articles or go into anything else more in depth. We'll see how much time I have at the end for questions.

OK, so some quick disclosures. I'm not going to talk too much about the impact test today. We use the impact test in all of our assessments. It's a computer-based neurocognitive test. I'm a paid consultant for that group. I am going to present about a meeting that we had last October, it's called the team meeting. And it was underwritten by both the NFL and UPMC. So I'll tell you more about that in a little bit. Our objectives, I want to describe the current status of concussion care.

We're going to go over some new clinical profiles and targeted active approaches to treating the injury. I'm going to go over the key statements of agreement from that team meeting. And we're going to do a brief overview of some emerging evidence. So the current approach to managing concussion is really all over the map. We use that word managing very loosely. Our group here in Pittsburgh is the largest clinical and research group in the country. And we manage concussion very differently than maybe if some of you see this injury in your own practices.

We have over 17,000 patient visits a year, so we see a lot of concussion. And when you see this injury over and over, you become a little bit more comfortable being a bit more aggressive in your treatment. And so you'll see what I'm talking about today. But the word management when you talk about concussion can mean a lot of things to many different people. And part of the issue is, our pendulum has really swung. And this has happened in our lifetimes. This has happened in my lifetime.

We went from really minimizing the injury and just like saying, brush it off. Get back in the game, you know, you're fine. How many fingers am I holding up? To now, I mean, I have so many parents that joke in my office about wanting to bubble wrap their kids or having them wear a helmet all day. And it's funny. They make light of it. But people are really scared of this injury. Parents are afraid of it. Coaches are afraid of it. And our student athletes are afraid of it.

So we've really gone from one extreme to the other in terms of how we're thinking about this injury. So last year, UPMC commissioned Harris poll. And the idea here was to get a general idea of what the public's perception of concussion was. The entire Harris poll is published on our website. So our website is rethinkconcussions.com and the entire document is there for the public to review.

But some of the interesting statistics that came out. 24%-- so this is over 2,000 United States adults-- 24% think a concussion will change their life forever. 72% believe that damage to the brain from a concussion is permanent. And 25% of parents said they will not allow their kids to play contact sports because of concussion. And so for me, I strongly believe that concussion's a treatable injury. That's why I'm in this field. I treat concussion all day long and I return kids back to play. And I do so very confidently that they're safe to go back to play.

So these numbers, to me and my colleagues, really stand out. And so our mission right now is we need to change this conversation. Because what I see in those numbers is a lot of fear and a lot of misunderstanding of everything that we've learned about this injury in the last decade. These are some of the current consensus statements that are out there about how to manage concussion. And the one common theme is that they're all over the place.

Nobody really agrees. There is no general consensus on how to appropriately manage this injury. The only similarity here is that everyone seems to agree if someone sustains an injury, they should not go back to play that day. But that's it. After that, it's a free for all. So a couple of years ago, one of our post-doctoral fellows was sitting in our research lab. And there was a poster on the wall that said, it's better to remain out of one game than to remain out of the whole season. And he said, I wonder if that's true.

And it turned into this really great study that was just published in pediatrics. So he took two groups of kids, one which had sustained an injury, came out of play immediately when they had some symptoms. And another group where they played through. So some of them played through for a few minutes. Some of them play through for the whole game. And we wanted to see, is there a difference? Does this affect recovery time when you come out of play?

And sure enough, those who stayed in play and didn't come out right away were almost six times more likely to have a protracted recovery, so more than three weeks. So we have that part right. If there's an injury, you should stop playing. You shouldn't push further. The foundation of our recovery, for years, has been built on this idea of rest. So I don't know how many of you would have a patient come into your office who sustained a concussion, but I'm just curious by a show of hands.

Let's say I walked into your office and I said I was playing in my adult volleyball league last night. I took a ball to the head. I have a headache. I'm dizzy. I'm nauseous. You think I have a concussion. How many of you would tell me to go home and rest? I mean, it's fair. That's what-- you're not feeling well. Go home and rest. And that's OK. That's all right. You know, I got injured last night go, home and rest.

But what happens is we have kids coming into our office and adults who have been resting for a very long time. So we need to get a hold of that. So our management of concussion has always been based on this idea of rest. And the idea behind this, it makes sense. We know that concussion is a metabolic injury. When someone sustains a concussion, there's a metabolic exchange in their brain. And their brain starts that healing process. So there's increased metabolic demand with decreased energy that results in this energy crisis.

That's why people are so tired in that first week after a concussion. They have all these symptoms layered on top of each other. The idea behind rest is that any physical or cognitive activity is essentially going to steal energy away from that healing process. So we want the healing process to be as efficient as possible. We want to preserve our energy. The other piece of that is we don't want someone to play through an injury because while you're concussed, you're more vulnerable to a new injury. So it's going to take less biomechanical force to reinjure you.

The problem with this is there's very little empirical research to support the idea of rest. There are a few studies, but it's very limited. And there's some methodological flaws in this research. So we've always based this idea of physical and cognitive rest without a strong empirical base to support it. This document in 2013 came out of the National Research Council report on concussions in sport. And they basically said, there's little evidence regarding this.

So here we are basing this whole field on this idea of rest. And we start scratching our heads, well, why are we doing this? Where's the evidence that says this is the correct thing to do? The issue is that we left treatment out of the equation. Part of the reason for this is treatment has really come around in the last decade, maybe. I came to Pittsburgh in 2012, and the way we were treating the injury from 2012 to 2016 has evolved. So this has all happened very rapidly. The last five to 10 years has seen enormous growth in the way that we're understanding the injury, in the way that we're implementing our treatment practices.

So now we have to start thinking about things a little bit differently because of what we know. So this meeting that I spoke about earlier occurred last October in Pittsburgh. It's the first meeting of its kind to focus on treatment. So there are consensus meetings that happen every few years in our field in which experts get together and they talk about, well, how are we going to define the injury? And what are the criteria for return to play? And it's a very scientific meeting.

And we wanted to talk about treatment. So this meeting was chaired by Dr. David Okongwu, neurosurgery, Dr. Micky Collins, who's our clinical director, and Dr. Anthony Contoso who is a research director at Sports Concussion. There were 37 multi-disciplinary participants on the clinical side. And then we also had 19 guests from other organizations. So I just put some up there. You can see it was a pretty wide range outside of the medical specialties. We wanted to get everyone's input. And it's important for you to know, these were not just people who think like we think.

So we had guests from Boston that are publishing research on CTE. We had folks across the country who have differing opinions than we do on how to manage this injury. And we wanted to bring everyone together. We had group discussions, large group discussions like this. And then we had small breakout groups where we really got into some of these issues. And the outcome of this meeting is a white paper, which is essentially 17th statement agreements that has been in review for many, many months. It should be published very soon. I've been told it's in proofs. It's going to come out in neurosurgery.

And there's 17 statements of agreement in that paper that are designed to provide best clinical practice summary agreements. So I'm not going to go through all 17 because I simply don't have time. But I'm going to go through a number of them so you can get an idea of what this very diverse group was able to agree upon.

So the first one regarding evidence for rest. There is limited empirical evidence for the effectiveness of prescribed physical and cognitive rest with no multi-site trials for prescribed rest following concussions. So that one was pretty easy, because we have the literature. We can go to the literature and see what's out there. And the multi-site trials is a very interesting piece because that doesn't exist-- concussion is a hard injury to do randomized controlled trials on. everyone wants to be treated. Nobody wants to go in the no treatment group.

So we have to think about gathering data little bit different with concussion. The role of rest. Prescribed physical and cognitive rest may not be an effective strategy for all patients following concussion. You can see, we definitely had some folks that weren't entirely bought in on this. And so we had to really push this a little bit with some of them. And you can see, we have documents that taking athletes out of their sport, out of their livelihood, taking them away from their team, they get depressed. They get anxious.

We see a lot of this with our college athletes and our high school athletes. Passive managements or telling someone just to rest for an extended period of time, this creates other issues. And once someone starts to have anxiety, that's going to play into their concussion recovery and that's going to prolong the recovery. There are a number of studies that look at the negative effects of rest. So we know that we can see worsening mood.

If you take a middle school kid off their basketball team, that means they're not going to be with their friends four nights a week. They're not going to be doing the team events. They may be missing school. They're going to feel left out. This doesn't mean you should put them back to play right away but you have to have some consideration of how to keep them in their social circle and their academic circle to feel included. We know that when we keep people on rest, they become hyper-vigilant and they focus on their symptoms. And that's when we get the somaticizers, so the folks that come into your office with chronic stomach aches and GI problems and there's no medical cause for it.

We see this with concussion. We see folks who are dizzy because they've had a vestibular problem and that goes away because we treat it. And then they're anxious. And that's causing dizziness. And it's a cycle. An interesting study in 2014, Noel Zuckerbron at Children's Hospital Pittsburgh is an emergency room physician. She took two groups that came in through the ED with concussions. And one, their discharge instructions said rest for 24 hours and gradually return back to normal activity.

And the other said strict rest for five days.

And sure enough, when they did their recheck in about a week, those who were told to strict rest for five days had a higher symptom profile than those that were told to gradually return back to sport or to activity. So we had this contextual framing effect that we see. Strict brain rest, what we now refer to as cocoon therapy, is not indicated and may have detrimental effects on patients following concussion. This is probably most disturbing that we didn't have 100% consensus, because cocoon therapy at this point is just-- I feel it's just antiquated.

So this is the idea, you know, this is cocoon therapy. We see this a lot with our migrainers. We have folks who come in with a history of migraine. And they say, when I get a migraine once a month, I go home and I draw the curtains. I make it dark and quiet and cool and I go to sleep. My migraine goes away. Well, that's one thing. But after you have a concussion when you have a migraine every day and you do this, it's not good.

And so that's really all I have to say about that. Cocoon therapy is not good. We have a lot of referrals that come to us from all over the country. And they've been living in that dark room for weeks, months, and longer. And it just creates a whole host of other problems. So how long does it take to recover from a concussion? Everyone wants to know that. Every mom that walks in my office wants to know how long their child's going to be out.

So if you look at the literature, if you start doing a literature review on this, you're going to see most concussions resolve in seven to 14 days. You can see here most people, everyone agreed, that there's varying lengths of recovery. But the general consensus is 7 to 14 days. So we don't see that in our clinic. Maybe the kids that recover in seven to 14 days don't come to our clinic. But we certainly don't see this. So a recent study that we did, we looked at 66 high school athletes. We called them triage because we saw them within the first 24 to 48 hours of injury.

And we wanted to track them over the first month and see exactly how long they took. They were a diverse group in terms of sports that they played and mechanism of injury. And what we did that was a little bit different is we took inventory of their symptoms, their neurocognitive test scores, and their vestibular and ocular motor screens. Most of the literature out there is only looking at symptoms. So if someone has symptoms, they're not recovered. And once they say they're symptom-free, they're considered recovered. We also looked at the difference between male and female.

And what we saw was that recovery for symptoms can last up to four weeks. So at the three week mark, we have nearly half of them. We had 45.5%, I think, recovered. But you can see that's drastically different, even looking at symptoms alone than that 80% to 90% recovering in seven to 14 days. So this is considerably more conservative overall.

We can see three to four weeks for memory scores. So these, you have verbal and visual memory scores right now. When we look at cognitive functioning, we're separating verbal and visual memory. We're also looking at processing speed and reaction time. And the interesting thing that we found with our cognitive scores here is visual memory, processing speed, and reaction time is a nice linear progression. And verbal memory, you really didn't get any significant improvement until week three.

So this is further proof that you really need a multi-domain cognitive assessment when you're determining return to play. And then when we looked at their vestibular and ocular motor recovery, which was measured through vestibular to their motor screening that we do, you can see a nice linear progression there. Females-- like with the symptoms. So females are more likely to report more symptoms. And they're more likely to have vestibular ocular motor deficits than males. But you can see a nice linear curve there.

So so we're seeing that really recovery, on average, is more of a three to four week. We always consider protracted recovery greater than three weeks. So that's our goal but what we see we see recoveries taking much longer. Recovery from concussion is influenced by modifying factors, the severity of injury, and the type and timing of treatment that is applied. So I'm going to break that down a little bit, getting into the modifying factors. So there's some demographic factors.

When we talk about sex, females are more likely to sustain a concussion and they're more likely to have more complicated recovery. And the same with the younger children. So the younger in age, the longer your recovery typically takes. The elementary age kids are going to take longer than middle school, who's going to take longer than high school. That's why you see your professional athletes back in two days. It really does seem to play out that way.

And then there's the post-injury factors. And I'm going to talk about these individually as we get to the next slides. So looking very quickly at the demographic factors, when I go back to that study I just presented, in this case males were 2 and 1/2 times more likely than females to be recovered by week four. So in terms of the post-injury factors, this study, I believe, 2011 was published. What we found here is that the number one predictor of protracted recoveries at greater than a three week period immediately following injury is on field or immediate post injury dizziness.

When I'm doing my clinical assessment in the office, that's one of the questions I always ask, did you feel dizzy right after you got hit? If so, that's a red flag for me. Interestingly, so we went through all of the signs and symptoms in this study, and loss of conscious and vomiting, which if you're ever at a high school event and you see someone unconscious on the field or someone vomiting, it creates a lot of concern and it's very dramatic. Those two factors did not at all predict protracted recovery.

We actually see those who lose consciousness sometimes have a much faster recovery period. And we're still not sure why. So on-field dizziness is greater than six times greater risk for protracted recovery. And then there's this idea of post-traumatic migraine. So 75% of concussions are going to say they have a headache. Once you know they have a headache, you have to pull apart, is it a headache or is it a migraine headache? So is it a chronic persistent headache with sensitivity to light or noise and nausea? Or is it just a headache?

If it's a post-traumatic migraine versus a group that doesn't have any headache, you have a seven times greater chance that they're going to have a protracted recovery. If it's post-traumatic migraine versus just a regular headache, it's almost a three times greater chance. So there's something about that post-traumatic migraine profile. All right, concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery trajectories.

We had a lot riding on this statement of agreement. So we developed the statements of agreement and presented them to the group. And we had a lot riding on this because this statement right here is based on a model that we developed in Pittsburgh. We first published this in 2014. What we were seeing, this is based on what we were seeing in our clinic. You know, concussion for many years was kind of this ambiguous, homogeneous injury that was hard to get a good feel for, handle on. What we developed is that you can start to pull apart these clinical pathways.

There are patterns that you can see in terms of their symptoms. So we identified six clinical profiles. There's the vestibular profile. So these folks are going to be more of the motion sick, dizzy, off balance folks. The ocular subtype, so people who have a convergence insufficiency or are having difficulty with binocular eye movement. There's the cognitive fatigue group, so the folks that we see with very low test scores. The ones who are having a hard time going through the workday or the school day. Post-traumatic migraine group. The cervical group. And anxiety mood group.

So there's somewhat of an anxiety mood component in most cases. But this is a more pervasive anxiety mood component. So the trick here is once you can identify the clinical profiles, you can start pulling apart, well, what are you going to do with this patient? It's very rare that you have someone walk into your office that fits one of these profiles. It happens, but usually they're layered. So my job is to determine, what's your primary profile? What's your secondary? What's your tertiary? And that allows me to develop a treatment plan based on their overall profile.

And there's growing empirical support for these. So this started as a very anecdotal model. And as we started combing the literature and talking to other folks in the field, we've realized that this is a more universal way of looking at it. And so this is exciting for us. A thorough multi-domain assessment is warranted to properly evaluate the clinical profiles of concussion. This is our assessment model here at UPMC. At this point, I've been all over this country talking to clinics that are trying to get up and running. So everyone wants to know how to do this.

How do I have a concussion clinic? It's a very hot issue right now. And I think the one reason that we're so successful here in Pittsburgh and that some clinics struggle is because we do a very comprehensive assessment model and we use a multi-disciplinary approach, which I'll get to in a second. If you leave any of these areas out, you're missing a big piece of the puzzle. So it's not just about assessing their symptoms, you have to look at their neurocognitive test scores. You have to look at their vestibular system, their ocular motor system, and get them moving, even if it's just having them walk up and down the hallway, see how they're doing.

We try to get our patients in the gym. So down in the south side we have a Sports Medicine Center, which is a really nice place to see patients because we can take them right down stairs and put them on a treadmill, put them on a stationary bike, see how they do. A multi-disciplinary treatment team offers the most comprehensive approach to treating the clinical profiles associated with concussion. So that's the second half to that.

I can't do my job in isolation. I would not be successful if I didn't have the team around me, and that includes the folks that send me patients and the folks that I then send my patients to. So at UPMC, that center circle is neuropsychology. The key here is you have to have someone that is the point guard. You have to have someone who's going to be the point person for these patients. You could have, really, any discipline in there. But we find that neuropsychology works really well.

So we get our referrals from EDs, PCPs, athletic trainers, pediatricians. We get some from out of the region. The patients come to me, my colleagues. We do a clinical interview. We do their neurocognitive test scores. We do their vestibular ocular motor screen. And then we develop a treatment plan. And that treatment plan is going to include, where am I sending you next? And so we have neurovestibular and exertion therapies. We have neurooptometry we can use. PMNR, we have primary care sports medicine with our group, neuroimaging if we need.

And then the patients come back to me. I gather all that information. They come back and we revise their treatment plan. It is truly a multi-disciplinary approach, though. And like I said, I just I wouldn't be able to do it without that team. So this is a big one. Concussion is treatable. Looks like we had one or two people that were a little bit on the fence with that but concussion is a treatable injury. When you get the cases that don't seem treatable, there's something else going on. The nature of the injury, the metabolic injury that is concussion, is treatable.

This is not going to show it's not a structural injury. It's not going to show up on any imaging. Concussion is treatable. And so the idea here is we have to get that message out and we also have to understand, if it seems like it's not treatable, there is something else going on. That may be an underlying mood component or an anxiety that's driving the symptoms up. But this is a treatable injury. Going back to that Harris poll, we asked what the treatments are. What do you think is a good treatment for concussion?

And the only perceived treatments we got were rest, hydration, and over-the-counter medications. Active treatment strategies may be initiated early in recovery. I have a lot of colleagues across the country who will not give someone a neurocognitive test if they're symptomatic. And to me, that doesn't make any sense because this is a brain injury and we have to have data. Early intervention does not mean we're going to start physical therapy day two or we're going to have you start running the day of a concussion. But that means, I want to see-- I see kids in my office the same day they've had a concussion.

I like them to go get medical clearance first and then come see me. But early intervention can be getting them on a consistent sleep schedule, making sure they're hydrated, they're eating regular meals, they're taking a walk every day. The earlier we see the patients in our office the better outcomes. We've tracked that year after year. Matching targeted and active treatments to clinical profiles may improve recovery trajectories following concussion. So this is the entire basis of my practice. This is a graphic of my job. When I have a patient come in my office, I need to determine what their preexisting risk factors are.

Anyone who has a personal or family history of migraine headaches, anyone who has a history of learning disability or ADHD, females, younger kids, anyone with motion sensitivity, ocular motor dysfunction, so like an uncle with a lazy eye, that plays into this. Anyone who's had a lot of concussions, especially if they've gone untreated, these are all risk factors. If I hear any of those things, number one, I'm thinking about what clinical trajectories that might drive. But number two, I'm concerned that this is someone who might be at risk for a more protracted recovery.

We get details on their injury, consider post-injury modifying factors, develop their clinical trajectory model, and then we can do an individualized treatment plan based on all of that information. So every single patient that comes into my office is different. Everyone's going to have a different-- I could have four field hockey players that all got injured in the same game walk in the door and they're all going to look very different once we get them in the office.

All right, so I know this is a lot of information. I apologize it went so fast. But the conclusions, concussion is heterogeneous. We know this. There's emerging clinical profiles. We're going to keep working on this. We've identified six. I'm sure there's more than that. This is a work in progress and folks across the country are starting to jump on this research, which is really exciting for us too. We know that prescribed rest is not the only intervention. And we need to move the discussion on concussion toward more active and targeted treatments. This is our messaging.

We want to get that cocoon therapy out of the lexicon and really get people thinking about not being afraid to get folks active. We really need to conduct multi-site studies to characterize concussions. So we've started doing that. There's the NCAA DoD care study, which is huge. So every summer we baseline test every single athlete at the University of Pittsburgh. It's a huge endeavor. It takes weeks. And it takes a lot of manpower.

But that's being done across the country. And so we're trying to collect baseline data, and this doesn't just include neurocognitive test data, This includes vestibular screenings and ocular screenings, balance assessments. We're gathering a lot of information. And we're going to use those databases to start to really quantify clinical profiles. It's going to take a while to do so, but we're working on it. And we really need to conduct randomized controlled trials to determine the treatment effectiveness.

As I mentioned, this is hard to do with concussion. So that that first study I mentioned, that removal from play injury, we're working on that right now. So that study told us, those who stayed in play had a more protracted recovery. But what we need to know is what is the dosing of that? How long can you stay in play? What happens after you have your symptoms? So we're working on that.

We also need to identify biomarkers to quantify the injury. This has been discussed for years. There's folks all over the country working on this and there's nothing we can use yet. But imagine if I could give my patients a blood test to tell them that their concussion is recovered. That would be great. That would also eliminate some of these chronic, what we now call post concussion syndrome cases that maybe are just dealing with a mood component or a vestibular injury. So that's something that could be on the horizon.

And we also need to address the role of these sub-concussive hits that everyone's talking about. So CTE is in the media a lot, you know, these long term effects. And part of the problem with that conversation is there are some findings. And as I'm sure you all know, science moves very slowly. But as science is moving slowly, the media has grabbed this information and it has skyrocketed. So now there's all this fear about long term effects of this injury and we don't know. We don't have the data to really talk about this in a informed way.

So we need that research. And that research is being done. But again, that's going to take a long time. And so we need these well-controlled in vivo studies. But we also need to let our kids have a life, so we want to back off a little.