Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Psychosocial and Mental Health Influences in Sports-Related Concussion Stephen A. Russo, Ph.D. Clinical Psychologist / Concussion Management Specialist Clinical Director and Founder, Philadelphia Concussion Specialists Rothman Orthopedics Concussion Network Provider . Phone: (484) 818-2225 E-mail: srusso@philaconcussion.com 1 Disclosure Statement Stephen A. Russo, Ph.D. Dr. Russo has no relevant financial relationships to disclose. Dr. Russo was Director of Sport Psychology at the University of Pittsburgh Medical Center (UPMC) from 1999-2003 and is married to a former ImPACT Applications employee and a current employee of Sway Balance Systems. . 2 Psychosocial and Mental Health Influences in Sport-Related Concussion 1
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Presentations Goals Highlight Potential Emotional and Mental Health Outcomes that Can Provide Attendees Influence Compliance Practices as with an Understanding well as Recovery from SRC of the Evolution of Sports-Related Conceptualize Concussion as a Concussion (SRC) Heterogeneous Injury with Various Clinical Trajectories and Outline Management Differences Between an Unresolved Concussion and Post-Concussion Syndrome Demonstrate How Explain How a Health Psychology Social, Biological, and Paradigm; an Inter-Disciplinary Psychological Factors Approach to Clinical Management; and Influence Concussion Consultation with a Concussion Recovery and Suicide. “Specialist” Can Promote Improved . Clinical Outcomes 3 The Current Definition of Cerebral Concussion McCrory et. al. (2005). Clinical Journal of Sports Medicine, 15 (2), 48-55. A Complex Pathophysiological Process Affecting the Brain, Induced by Traumatic Biomechanical Forces to the Head, Face, Neck or Elsewhere on the Body … Rapid Onset of Short-Lived Neurological Impairment that Resolves Spontaneously Clinical Symptoms Reflect a Functional Disturbance Rather than Structural Injury Typically Associated with Grossly Normal Structural Neuro-imaging. . 4 Psychosocial and Mental Health Influences in Sport-Related Concussion 2
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Cognitive Behavioral Conceptualizations of Injury Adapted from Brewer (2012), New York: John Wiley & Sons, Inc; Engel, GL (1980), Am J Psychiatry; Murphy et al. (2014), Washington DC: U.S. Department of Veterans Affairs; Santi & Pietrantni (2013) Journal of Human Sport & Exercise. Biopsychosocial Model Views Injury, Pain, and Chronic Health Conditions as a Multidimensional Integration of Physical, Psychological, and Social Factors Where Relationships Among Factors Influences Ones Clinical Presentation and Rehabilitation Outcomes Patient 1 Patient 2 Patient 3 Social Bio Psych Social Bio Psych Psych . Social Bio 5 Cognitive Behavioral Conceptualizations of Injury Adapted from Brewer (2012), New York: John Wiley & Sons, Inc; Engel, GL (1980), Am J Psychiatry; Murphy et al. (2014), Washington DC: U.S. Department of Veterans Affairs; Santi & Pietrantni (2013) Journal of Human Sport & Exercise. Biopsychosocial Model Views Injury, Pain, and Chronic Health Conditions as a Multidimensional Integration of Physical, Psychological, and Social Factors Where Relationships Among Factors Influences Ones Clinical Presentation and Rehabilitation Outcomes Patient 1 Patient 2 Patient 3 Social Bio Psych Social Bio Psych . Psych Social Bio 6 Psychosocial and Mental Health Influences in Sport-Related Concussion 3
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Neurometabolic Cascade Following Cerebral Concussion Giza & Hovda (2001). Journal of Athletic Training, 36 (3), 228-235. 500 Calcium 400 300 K+ % of normal 200 Glucose 100 Glutamate 0 2 6 12 20 30 6 24 3 6 10 minutes hours days . Cerebral Blood Flow UCLA Brain Injury Research Center 7 Characteristics of Post-Traumatic Cerebral Metabolism & Blood Flow Giza & Hovda (2001). Journal of Athletic Training, 36 (3), 228-235. Cerebral Glucose Metabolism Cerebral Blood Flow 100% Above Normal 50% of Normal, No Ischemia THE MISMATCH BETWEEN THE ENERGY DEMANDS OF THE BRAIN AND THE METABOLIC FUNCTIONS THAT SUPPLY CEREBRAL GLUCOSE PRODUCE AN “ENERGY CRISIS” . UCLA Brain Injury Research Center 8 Psychosocial and Mental Health Influences in Sport-Related Concussion 4
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Most Commonly Reported Concussion Symptoms: High School and College Athletes Lovell et al. (2004); N = 215 71 % Headache 50 % Fatigue 58 % Feeling Slowed Down 49% Blurry or Double Vision 57% Difficulty Concentrating 47% Light Sensitivity 55 % Dizziness 43% Memory Dysfunction 53% Fogginess 43% Balance Problems . 9 Concussion Management: Return to Play Protocol PRE-SEASON 1-3 DAYS FOLLOW- FIRST BASELINE UP FOLLOW- TESTING TESTING, UP AS NEEDED CONCUSSION AT SCHOOL REMOVE EVALUATION RETURN TO PLAY OR CLINIC FROM PLAY Because Concussed Athletes Were Notorious for Hiding Symptoms and Vary Tremendously in How They Perform on Formal Testing, The . Concepts of Baseline and Post-injury Testing Were Developed 10 Psychosocial and Mental Health Influences in Sport-Related Concussion 5
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Using Trajectories to Inform Treatment Collins et al. (2014). Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 22(2), 235-246. Clinical Interview Constitutional Risk Factors Functional or Acquired Risk Factors VESTIBULAR Computerized Neurocognitive Testing ANXIETY / MOOD Match / Exceed Baseline Performance? Examine Composite and Subtest Cognitive Profiles for Trajectories MIGRAINE Postural Stability/Balance Assessment Fatigue / Examination Findings Findings Help Determine Level / Type of Activity COGNITIVE / FATIGUE Vestibular-Ocular Screening (VOMS) Provocation Events? Vestibular Tasks OCULAR Ocular Tasks Clinical Management CERVICAL SPINE Behavioral Management (Rest, Exert, Refer) . Therapy and/or Medication Considerations Academic and Vocational Considerations 11 The Cranial Nerves . 12 Psychosocial and Mental Health Influences in Sport-Related Concussion 6
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Visual System Structures and Function Visual System one of the Most Complex Structures of the Human Brain! Eyes and Cerebral Pathways of the Visual System are Responsible for Much More than Just Eyesight. Color and Movement Recognition as Well as Visual Acuity Begins in the Eye Eye has Some Camera-Like Features: The Cornea and Lens Focus Light Light Refracts ( BENDS ) as it Passes Through the Cornea on its Way to Retina Ciliary Muscles within the Eye Adjust Focus . by Changing Shape of Lens ( ACCOMMODATION ) . 13 Visual System Structures and Function Capo´-Aponte et. al. Military Medicine, 2012 The Ability to Coordinate Sensory Input % as well as Derive Meaning and Direct Action % mTBI Type of Visual Impairment: Controls p n = 20 n = 20 from what We See is Related to the Basic Functioning of the Eyes. Convergence Insufficiency 55% 5% 0.0012* However, Brain does NOT Function like a Camera! Sensory Information Must be Decoded and Saccadic Impairment 30% 0% 0.0202* Processed by Brain, Which Requires Energy and Accurate Information! <0.0001 Pursuit impairment 60% 0% * Vision Requires Sensory and Cognitive Integration and Assessing Vision Allows Ocular Misalignments 55% 5% 0.0012* (Vertical Phoria) Us to Detect Dysfunction Not Picked Up Using Cognitive Testing Alone Ocular Misalignment 45% 5% 0.0084* (Horizontal Phoria) Vision is Also Dependent on Eye Movement . Which is Controlled By Extraocular Muscles Accommodative that Function Along Cranial Nerves 65% 15% 0.0031* Dysfunction 14 Psychosocial and Mental Health Influences in Sport-Related Concussion 7
Bucks County Intermediate Unit's 4th Annual January 29th, 2020 School Concussion Conference Persistent Sxs May Be Due to Vestibular Dysfunction An Understanding of the Visual and Vestibular Systems and the Assessment of these Systems is Necessary to Treat Concussive Injuries Effectively “Active” Intervention May Be Needed to Ensure Resolution of Vestibular and Visual Problems . 15 Vestibular System Structures and Function Nerve Fibers from Vestibular Receptors Synapse in the Vestibular Nuclei in the Brainstem Hair Cells Embedded in Columns (Cupulae) Emerge from Receptors and Transduce Movement into Electrical Signals Some Fibers Go Directly to the Cerebellum. Head Tilt and Acceleration / Deceleration is Signaled by Slippage of Otolith-Laden Gel across the Hair Cells of the Saccule / Utricle The Vestibulo-Ocular Reflex ( VOR ): Allows You To Gaze at a Fixed Point while Your Head Moves. Motion Sickness: The Feeling of Nausea Caused by Passive Movements Sensory Conflict Theory: Motion Sickness Can Be . Due to Conflict in Visual and Vestibular Information 16 Psychosocial and Mental Health Influences in Sport-Related Concussion 8
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