New Vision for Concussion: Updates in the Evidence …. Balcer -- New Vision...New Vision for Concussion: Updates in the Evidence Laura J ... \ഠYet as neuro-ophthalmologists we agree
23
New Vision for Concussion: Updates in the Evidence Laura J. Balcer, MD, MSCE Professor of Neurology, Population Health and Ophthalmology Vice Chair, Neurology Co-Director, NYU Concussion Center
New Vision for Concussion: Updates in the Evidence
Laura J. Balcer, MD, MSCE Professor of Neurology, Population Health and Ophthalmology Vice Chair, Neurology Co-Director, NYU Concussion Center
Presenter
Presentation Notes
On behalf of the team, thank you for the opportunity to present an update on the new NYU Langone Concussion Center.
The speaker and her research team have no financial interest in any of the tests or devices discussed in this presentation Dr. Balcer has received consulting fees from Biogen for work related to multiple sclerosis visual outcome measures
We Need Vision! Actually, the value of vision has
long been recognized…
Presenter
Presentation Notes
So, this picture of the legendary coach John Madden and Roger Goodell shows why we need better sideline tests for concussion. Yet as neuro-ophthalmologists we agree that a vision-based test is key to add to the current sideline protocols of balance and memory testing that you see performed at many of the professional and collegiate athletic events.
Sideline Testing: What is the Evidence?
• Simple definition of concussion, but need better tools!
• SCAT3 put together by consensus, lacks a vision test (definite gap)
• New concussion consensus statements may not include vision
• This is likely not due to a lack of data!
Sideline Testing
Symptom Checklist
Standardized Assessment of
Concussion (SAC)
Presenter
Presentation Notes
Data were analyzed from each of four measures: The Post-Concussion Scale, known in the SCAT3 as the symptom checklist. The Standardized Assessment of Concussion, or SAC---a brief cognitive test of memory and concentration.
Sideline Testing Balance Error Scoring
System (BESS) or Timed Tandem Gait
King-Devick (K-D) Test of Rapid Number Naming or
MULES (Rapid Picture Naming)
Presenter
Presentation Notes
… the modified Balance Error Scoring System, a test where the athlete is judged as to whether he or she makes errors or mis-steps during balance tasks. The King-Devick test of rapid number naming was analyzed as a potential vision based performance measure to complement these tests.
We Need Vision! • Vision captures >50% of the brain’s pathways
• Abnormal eye movements are a proven indicator of suboptimal brain function
• Can detect dysfunction not detected by cognitive tests
• Requires sensory and cognitive integration
Presenter
Presentation Notes
Including a vision-based test in concussion is essential, since evidence suggests cognition and balance tests do not capture all concussions. Vision takes up >50% of the brain’s pathways, most of which are vulnerable in concussion. A performance measure that requires eye movements may be particularly helpful, since impaired eye movements are a proven indicator of suboptimal brain function. But how could a soccer mom or dad measure something as complicated as eye movements?
Vestibulo-Ocular Motor Screening
• Asks the patient if they have symptom provocation after various eye movements
• Neuro-ophth expertise is required, thus not possible for most teams and levels of play
• Takes 5 to 7 minutes to do • Mostly a subjective test - symptoms
provoked in 33 to 61% (VOR best) • Misses motility problems that could be
detected by objective exam • Not validated on sidelines Am J Sports Med 2014
Rapid Number Naming (K-D)
• Sideline test, takes less than a minute (tests over 100 saccades)
• Parent can administer!
• Based on saccadic eye movements, requires attention, concentration, language (DLPFC, FEF, parietal lobe)
• Lets the visual system do the work rather than the examiner
Presenter
Presentation Notes
There is great geopgraphic heterogeneity of the disorder suggesting that genetic and other factors are likely to playing a role in this condition. This condition must be considered in the context of your geography
Rapid Number Naming (K-D)
Time to read all 3 cards = baseline score • Objective, takes <1 minute, anyone can do! • Delay in time has been seen in concussed
boxers, collegiate athletes and rugby players
Test Card 1 Test Card 2 Test Card 3
Presenter
Presentation Notes
So 4 years ago , having spent our careers testing vision test for multiple sclerosis, Steve and I were asked to study a new vision-based rapid number naming test called King-Devick. Designed originally as a reading test for kids, this test is easy, takes less than a minute, and anyone, including soccer moms and dads, can do it! The athlete is asked to read three test cards with numbers as quickly as possible, and total time is the baseline or pre-season score. Since > ½ of the brain’s pathways go into vision and reading, we anticipated that athletes with concussion would take longer to read the cards compared to a pre-season or pre-competition baseline.
So, the King-Devick (K-D) Test Has Been Extensively Studied
K-D
sco
re (s
ec)
Identified concussed athletes in boxers and MMA fighters, collegiate cohorts, New Zealand Rugby League
And we found that in our first study of the K-D test that involved boxers and MMA fighters, that those athletes with overt head trauma here in the red had significantly worse time scores compared to their pre-fight baseline, demonstrating that this test can distinguish the most obvious cases of head trauma. Numerous subsequent studies have shown that the K-D test identifies athletes with concussion, in cohorts ranging from collegiate to youth to New Zealand rugby players. The test is feasibly administered by sports parents. And competition alone does not worsen, or increase, K-D time scores as shown in multiple cohorts of non-concussed control athletes.
K-D Meta-Analysis • N=1,419 athletes from 15 published studies
• De-identified participant-specific data for pooled analyses; meta-analyses using fixed-effects model techniques
• Pooled sensitivity 86% (96/112 concussed had worsening), specificity 90% (181/202 controls had no worsening of K-D)
• Relative risk of concussion if any worsening of K-D score from baseline = 4.92 (5x risk!)
KM Galetta, et al., Concussion 2015
Presenter
Presentation Notes
And we found that among 217 athletes, 30 were diagnosed with concussion using the clinical definition. Using a Wilcoxon sign-rank test for paired data, significant worsening of K-D scores was noted from baseline to post-injury among concussed athletes. Using the published criterion of a 2-point of greater worsening out of a maximum 30 for the SAC, greater than half of the concussed athletes had a worsening, and the difference had less statistical significance.
K-D Meta-Analysis (15 Studies): Weighted Average Pre-Season Baselines
KM Galetta, et al., Concussion 2015
Presenter
Presentation Notes
Interesting thought for which data are beginning to emerge: can we use structural changes in the eye, such as deposits of retinal thinning, in a similar manner to MS, to predict development of CTE in living athletes? This will be important when clinical trials of treatment emerge. In fact, at the other end of the age spectrum, we have all heard reports about a condition in retired athletes that is pathologically similar yet very different from Alzheimer’s disease, called CTE. This has been seen among retired boxers and NFL players, and we have just formed a collaboration with the leading neurology researcher in this area at Boston University. Our question that we’re addressing as part of these collaborative studies is can we use imaging of the eye to predict potential signs of clinical CTE in living athletes.
K-D Meta-Analysis (15 Studies): Relative Risk of Concussion if Worse KD
KM Galetta, et al., Concussion 2015
Presenter
Presentation Notes
Interesting thought for which data are beginning to emerge: can we use structural changes in the eye, such as deposits of retinal thinning, in a similar manner to MS, to predict development of CTE in living athletes? This will be important when clinical trials of treatment emerge. In fact, at the other end of the age spectrum, we have all heard reports about a condition in retired athletes that is pathologically similar yet very different from Alzheimer’s disease, called CTE. This has been seen among retired boxers and NFL players, and we have just formed a collaboration with the leading neurology researcher in this area at Boston University. Our question that we’re addressing as part of these collaborative studies is can we use imaging of the eye to predict potential signs of clinical CTE in living athletes.
Rapid Number Naming in Concussion …Digitized! Slower times in patients compared to controls….
...and increased inter-saccadic intervals in patients with concussion
The purpose of these analyses of the AFFIRM data was to determine the capacity for low-contrast letter acuity and high-contrast visual acuity, used as exploratory outcomes in this trial, to detect visual improvement. Analogous to previous AFFIRM analyses that showed lower probabilities of sustained visual loss in patients receiving natalizumab, we determined whether low-contrast acuity could also show greater probabilities of clinically-significant visual improvement in the active treatment group.
Rapid Number Naming in Concussion …Digitized!
Similar saccade amplitudes but increased inter-saccadic intervals in patients with concussion
The purpose of these analyses of the AFFIRM data was to determine the capacity for low-contrast letter acuity and high-contrast visual acuity, used as exploratory outcomes in this trial, to detect visual improvement. Analogous to previous AFFIRM analyses that showed lower probabilities of sustained visual loss in patients receiving natalizumab, we determined whether low-contrast acuity could also show greater probabilities of clinically-significant visual improvement in the active treatment group.
Rapid Number Naming in Concussion …Digitized!
Longer (worse) K-D test times are associated with prolonged inter-saccadic intervals
The purpose of these analyses of the AFFIRM data was to determine the capacity for low-contrast letter acuity and high-contrast visual acuity, used as exploratory outcomes in this trial, to detect visual improvement. Analogous to previous AFFIRM analyses that showed lower probabilities of sustained visual loss in patients receiving natalizumab, we determined whether low-contrast acuity could also show greater probabilities of clinically-significant visual improvement in the active treatment group.
MULES Test of Rapid Picture
Naming
Disease-free controls: 38.6 ± 7.3 seconds
(range 29.4 – 53.4 sec)
Cobbs et al. J Neurol Sci 2017.
MULES and the K-D Test
Cobbs et al. J Neurol Sci 2017.
Presenter
Presentation Notes
The purpose of these analyses of the AFFIRM data was to determine the capacity for low-contrast letter acuity and high-contrast visual acuity, used as exploratory outcomes in this trial, to detect visual improvement. Analogous to previous AFFIRM analyses that showed lower probabilities of sustained visual loss in patients receiving natalizumab, we determined whether low-contrast acuity could also show greater probabilities of clinically-significant visual improvement in the active treatment group.
The purpose of these analyses of the AFFIRM data was to determine the capacity for low-contrast letter acuity and high-contrast visual acuity, used as exploratory outcomes in this trial, to detect visual improvement. Analogous to previous AFFIRM analyses that showed lower probabilities of sustained visual loss in patients receiving natalizumab, we determined whether low-contrast acuity could also show greater probabilities of clinically-significant visual improvement in the active treatment group.
At the Other End of the Age Spectrum: Vision in Chronic Traumatic
Encephalopathy (CTE) • Afferent vision is an incredibly useful tool for MS • Can we use OCT to predict CTE? (NIH U01)
Presenter
Presentation Notes
Interesting thought for which data are beginning to emerge: can we use structural changes in the eye, such as deposits of retinal thinning, in a similar manner to MS, to predict development of CTE in living athletes? This will be important when clinical trials of treatment emerge. In fact, at the other end of the age spectrum, we have all heard reports about a condition in retired athletes that is pathologically similar yet very different from Alzheimer’s disease, called CTE. This has been seen among retired boxers and NFL players, and we have just formed a collaboration with the leading neurology researcher in this area at Boston University. Our question that we’re addressing as part of these collaborative studies is can we use imaging of the eye to predict potential signs of clinical CTE in living athletes.
Stay Tuned!! • OCT measures of
retinal nerve fiber and ganglion cell layer thickness reduced in contact sport athletes
• Similar patterns for low-contrast acuity and quality of life!
Leong et al. To be presented at NANOS 2017.
Presenter
Presentation Notes
Interesting thought for which data are beginning to emerge: can we use structural changes in the eye, such as deposits of retinal thinning, in a similar manner to MS, to predict development of CTE in living athletes? This will be important when clinical trials of treatment emerge. In fact, at the other end of the age spectrum, we have all heard reports about a condition in retired athletes that is pathologically similar yet very different from Alzheimer’s disease, called CTE. This has been seen among retired boxers and NFL players, and we have just formed a collaboration with the leading neurology researcher in this area at Boston University. Our question that we’re addressing as part of these collaborative studies is can we use imaging of the eye to predict potential signs of clinical CTE in living athletes.
Vision in Concussion • Seven years of data show that rapid number
naming is sensitive, additive to SCAT3 tests
• Vision is a vulnerable system in concussion, encompasses >50% of the brain’s pathways
• Simple performance measures continue to have great value and sensitivity in medicine
• Goal: establish accessible vision-based testing for sideline and clinical applications
