An Evidence-Based Approach to Assessment and Treatment of Concussion and mild TBI #2931

INSTRUCTIONAL COURSE DETAIL

TUE, 26 OCT: 8:00 AM – 12:00 PM

PRESENTERS

Barry Willer PhD; Professor, University at Buffalo

Lohn Leddy MD; Clinical Professor, University at Buffalo, Director

Margaret Waskiewicz MS (OT); Adjunct Professor, NYU, Assistant Supervisor, Occupational Therapy, Rusk Institute

John-Ross Rizzo MD; Attending, Rusk Institute, NYU

Laura Balcer MD; Professor of Neurology and Vice Chair, NYU

Mara F. Sproul RN, MPA, CRRN, RN-BC; Program Manager, NYU Langone Concussion Center

Tara Denham PT; Outpatient Program Manager for Physical Therapy, NYU Langone Rusk Rehabilitation

Michael Ellis, MD; (Neurosurgery) Medical Director, Pan Am Concussion Program, Adjunct appointments in Surgery and Neurosurgery at the University of Manitoba

DIAGNOSIS

Brain Injury, Pediatric Rehabilitation

FOCUS

Clinical practice (assessment, diagnosis, treatment, knowledge translation/EBP)

Training/instruction in new knowledge/skills (attendees will develop new competencies that can be applied in practice or research)

BRIEF DESCRIPTION

Research has demonstrated that concussed individuals have significantly altered physiology. The presenters represent researchers/clinicians that have demonstrated dysautonomia, dysregulation of CBF, oculomotor and vestibular dysfunction. The primary focus will be translation of this research into practice. The presenters describe a physical examination process that represents evidence based as opposed to symptom-based evaluation. They will demonstrate the use of dynamic testing to reveal physiological, oculomotor, and vestibular dysfunction as part of accurate DIAGNOSIS. They will also describe a dynamic and evidence based approach to treatment. Presenters will describe the process and results of systematic return to sport and return to learn.

ABSTRACT BODY

There has been considerable new research on concussion and mTBI in the past decade.  Our presenters have been leaders in research on physiological aspects of concussion in humans.  We have demonstrated, for example, that cerebral blood flow (CBF) in concussed humans is not effectively regulated during exercise and that is one reason why patients have exercise intolerance.  Exercise intolerance has thus, become an important biomarker of concussion and concussion recovery.  We have also demonstrated alterations of autonomic nervous system (ANS) function that arise from concussion and that ANS dysfunction can be assessed through physical examination and dynamic testing. This workshop will be hands on and we will demonstrate how evidence based assessment can be completed.  We will also demonstrate how treatment of dysautonomia, exercise intolerance, oculomotor dysfunction, can lead to rapid improvement in the condition of patients.

We will also offer an overview of visual dysfunction following concussion, with a focus on oculomotor dysfunction. We will describe an interdisciplinary approach to vision therapy with special expertise from an occupational therapist.  We also offer instruction on how to assess cervicogenic issues and vestibular problems.  We will again describe an interdisciplinary approach to therapy with physical therapy, neuro-ophthalmology and physiatry.

Those at greatest risk for concussion and mTBI are adolescents.  Research has demonstrated that adolescents take considerably longer than children or adults to recover from concussion.  Female adolescents take the longest to recover.  For this reason we have made adolescents a specific focus of our research.  Our recent research has demonstrated that exercise testing of adolescents in the acute phase of concussion is not harmful to recovery.  We also found that the degree of exercise intolerance was, by far, the best predictor of time to recover.  The heart rate (HR) threshold for symptom exacerbation during initial testing was above 130 for all patients that recovered within three weeks; whereas all patients that took more than three weeks had a HR threshold below 130.We will describe the return to sport process we use for adolescents and compare that with the return to sport process we use with professional athletes.

In a recent publication we demonstrated a very high success rate in returning adolescents to sport without any further exacerbation of symptoms.  In this same publication we raised concern about the return to learn process that demonstrated at least one third of adolescent athletes reported problems in school.  We have since launched a study of how best to assist injured students in the return to learn process.  We will outline how we approach assisting young people in returning to the classroom effectively.

This preconference workshop involves presenters from three institutions that conduct research on the physiological issues associated with concussion and apply the research findings to practice.  Participants will find that assessment and treatment of concussion which is evidence based has great appeal.  All procedures and forms used in the three clinics will be described and made available to the participants with permission for use in their own clinics.

LEARNING OBJECTIVES

  1. Describe the evidence of physiological dysfunction characteristic of concussion and mTBI
  2. Explain how physiological dysfunction may be assessed using physical exam and dynamic testing
  3. Describe the treatment of physiological dysfunction including treatment for exercise intolerance, oculomotor dysfunction and vestibular dysfunction
  4. Explain how and why adolescents are at greatest risk for long term difficulties and recommendations for improving outcomes both in sport and school

INTENDED TARGET AUDIENCE

All therapists and researchers with an interest in concussion and mild TBI

BIO SKETCHES

Barry Willer has a PhD from York University in Toronto. He is a Professor in the Department of Psychiatry at the State University of New York at Buffalo. His research focus for the past thirty years has been brain injury. He directed the first Research and Training Center on Community Integration of those with TBI and authored the Community Integration Questionnaire (CIQ). He also authored the “Whatever it Takes Model” as an approach to management of those with severe TBI. In 1999 he authored the first return to play guidelines following concussion for the International Olympics Commission. More recently he provided much of the research base for the Return to Duty guidelines following concussion for the U.S. Department of Defense. Dr. Willer has published more than one hundred peer review articles and three books.

John J. Leddy MD is Professor of Clinical Orthopedics, Internal Medicine, and Rehabilitation Sciences at the University at Buffalo School of Medicine and Biomedical Sciences, a Fellow of the American College of Sports Medicine and of the American College of Physicians, and Director of Outcomes Research for the Department of Orthopaedics. He is a Division 1 team physician and Program Director for the Sports Medicine Fellowship at the University at Buffalo. He is the Medical Director of the University at Buffalo Concussion Clinic, which is the first center in the United States to use a standardized treadmill test to establish recovery from concussion and to use exercise in the rehabilitation of patients with prolonged concussion symptoms. He is published in the fields of orthopedics, sports medicine, physiology, nutrition, concussion and post-concussion syndrome. His primary research interest is the investigation of the basic mechanisms of the disturbance of whole body physiology in concussion and how to help to restore the physiology to normal to help patients recover to safely return to activity and sport.

John-Ross (JR) Rizzo, MD is a physician scientist at NYU Langone Medical Center’s Rusk Rehabilitation, where he is an Assistant Professor of Physical Medicine and Rehabilitation. He leads the newly formed Visuomotor Integration Laboratory (VMIL) where his team focuses on eye-hand coordination as it relates to acquired brain injury (ABI). He has recently completed an R03 through the National Institute of Aging (NIA) focusing his research goals on eye-hand coordination in stroke and the elderly stroke and now is completing a K12 through NICHD focusing on visuomotor integration in brain injury. He had numerous peer-reviewed publications and book chapters, in addition to domestic and international patents for his rehabilitation tools.

Dr. Michael Ellis completed his Honors Bachelor of Science (Psychology), Bachelor of Science(Medicine) and medical school training at the University of Manitoba. Afterwards he completed his neurosurgical residency training at the University of Toronto during which time he also completed a fellowship in Concussion Spectrum Disorders with neurosurgeon Dr. Charles Tator. Dr. Ellis is the Medical Director of the Pan Am Concussion Program and holds clinical appointments in the Department of Surgery and Pediatrics and Section of Neurosurgery at the University of Manitoba. He is also the co-Director of the Canada North Concussion Network and holds a scientist appointment in the Children’s Hospital Research Institute of Manitoba. Dr. Ellis’ research interests include the study of cerebrovascular responsiveness in patients with concussion and post-concussion syndrome using MRI Brain stress testing and the multi-disciplinary management of pediatric concussion.

Margaret A. Waskiewicz, MS, OTR/L is an occupational therapist at NYU Langone Medical Center’s Rusk Rehabilitation, where she is the Supervisor of the Adult Outpatient Occupational Therapy Unit. She is skilled with the assessment and treatment of patients with vision and cognitive/perceptual deficits and sensory processing. Most recently, she lectured at the American Occupational Therapy Association on sensory processing and brain injury and afterwards was asked to consult on the topic for a publication in Advance for occupational therapy practitioners. She is also an adjunct professor at New York University and Long Island University where she has taught both neurological based and occupational therapy classes and labs.

Mara F. Sproul, RN, MPA, CRRN, RN-BC, is a registered nurse with 20 years of experience in rehabilitation, pediatrics, geriatrics, cardiology, and nursing administration.  She is certified in geriatric and rehabilitation nursing and has a Master’s in Executive Public Administration from New York University, Robert F. Wagner Graduate School of Public Service. Mara has a Bachelor of Science from Molloy College of Nursing in New York. In her role as the Concussion Center Program Manager, she manages, coordinates and implements all aspects of patient care through the multidisciplinary center.  Mara is constantly striving to improve creative ways to foster a dynamic learning environment for patients and family members, and to promote the highest quality care and with the goal of continuous improvement. She is a member of the International Nursing Honor Society, Sigma Theta Tau, Association of Rehabilitation Nursing and the American Association of Neuroscience Nurses.

Tara Denham, PT, MA received her Masters of Physical Therapy degree from New York University in 1983. Tara is an American Physical Therapy Association (APTA) certified Vestibular clinician, in addition to being one of the course instructors for the annual APTA certification course. She founded the world renowned Vestibular Physical Therapy Center at Rusk Rehabilitation, New York University Langone Medical Center ( NYULMC) . Tara is the Outpatient Program Manager for Physical Therapy at NYU Langone Rusk Rehabilitation and as a vestibular clinician works with a diverse population of patients including patients who have sustained a concussion and traumatic brain injury.

Laura J. Balcer, MD, M.S.C.E., is a neurologist and epidemiologist at the NYU School of Medicine.   Dr. Balcer is Professor and Vice Chair of Neurology, Population Health and Ophthalmology. Dr. Balcer and her colleague, Dr. Steven Galetta, Philip K. Moskowitz Professor and Chair of Neurology, lead national collaborative clinical and research efforts in the neuro-ophthalmology of multiple sclerosis (MS) and sports-related concussion. Dr. Balcer received her medical degree in 1991 from the Johns Hopkins University School of Medicine. Following residency in neurology at the University of Pennsylvania, Dr. Balcer’s postgraduate training included a clinical fellowship in neuro-ophthalmology in 1996 and a Master’s Degree in Clinical Epidemiology (M.S.C.E.) at Penn in 2000. She is a member of the Ivy League Concussion Committee and co-director of a collaborative concussion research effort between the Ivy League and Big 10. Dr. Balcer is also a member of a new NCAA Concussion Task Force. During the past 15 years, Dr. Balcer’s clinical and research work has focused on the development of visual function tests and other outcomes for clinical trials in multiple sclerosis (MS). More recently Dr. Balcer’s expertise has been sought to examine new vision-based tests and other tools for concussion diagnosis and management and her research is looking at rapid number naming and its role in sideline testing.

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