“The Tassel is worth the Hassel”
Hello all! For my classmates and I, I believe this cake sums up what we’ve been working towards for the past 3 years. Thanks for visiting my Wiki Site. Huge props to the UNC team (Kmac in particular). This is a great mode of delivering projects. I actually had fun playing with the site in creating my project!
Now, shall we get down to business. I’ve always been interested in concussions. Maybe that’s because I suffered 2-3 in high school (I don’t remember exactly how many HaHa). Since learning more about brain injuries in PT school, it baffles me more and more how we still rely on symptom based diagnoses for concussions. Society is starting to wake up to just how serious these injuries can be, especially for young athletes who are susceptible to the famed “second impact” scenario.
My Capstone required a new research table that focused on new neuroimaging techniques that can diagnosis mild traumatic brain injuries (aka concussions). The two imaging techniques that I focused on were functional Magnetic Resonance Imaging (fMRI) and diffuse tensor imaging (DTI). Since diagnosis of concussions in today’s sports medicine continues to be symptom based, many researchers are hopeful that these imaging techniques will bridge the gap to a more consistent diagnostic process. There are case reports already available in the literature that show examples of the use of DTI imaging in diagnosing mTBI and post concussive syndrome. Since concussions and head injuries in sports have become much more high profile (Tim Tebow, Sydney Crosby, etc) researchers have started focusing on the development of mTBI diagnostics. Isn’t it sad that it took high profile athletes to bring about change?
The two different types of neuroimaging techniques featured are not quite yet readily available to the general public across the country. Not to mention, like many other imaging techniques, they can be extremely expensive; therefore adequate evidence supporting their diagnostic abilities needs to be available before their wide-spread use is warranted. The link below outlines the different research articles I used in preparation for this project. There are several review articles that discuss the physics behind the new imaging technologies, and how they are able to detect the presence of either, vascular changes, or diffuse axonal injuries within the brain. The remaining articles are either cohort studies or RCT’s that use participants whom have been diagnosed with a concussion, then scanned either by fMRI, DTI, or both. Admittedly, the evidence at the moment is far from conclusive, however the “experts” all agree that neuroimaging is headed in the right direction to aid health care professionals in diagnosing this serious injury.
The PowerPoint attached will be presented to a group of PT, PTA, ATC, and PT aides at my final clinical rotation, “Cincinnati Sports Medicine”. The presentation focuses on mechanism of injury for many sports-related concussions, pathophysiology of these injuries, and discussing the two new imaging techniques. I chose this route because Cincinnati Sports Medicine routinely has health personnel at high school and collegiate sporting events. The use of pictures and videos, as well as written text is present in an effort to attack all different learning types in my audience. Below are two video examples:
DTI
*Please view slide 21 in the powerpoint for the notes as this video does not have sound.
fMRI
There is also an evaluation form for the attendants of the presentation to complete with an opportunity to provide feedback on my presenting style, effectiveness, and knowledge of the material. Please, if you have the chance, review my PowerPoint presentation. Feel free to complete the evaluation form and email it to me. Feedback is important to me and it will ultimately make my presentation in a few months all that much better! My email is jdunigan@med.unc.edu
Please don’t hesitate with any questions/comments/concerns.
References
- www.youtube.com/watch?v=ovoTWaHnVnA
- www.youtube.com/watch?v=uVht8AMknfc
- www.cdc.gov/Concussion
- Slobounov SM, Gay M, et al. Alteration of brain functional network at rest and in response to YMCA physical stress test in concussed athletes: RsFMRI study. NeuroImage. 2011; 55: 1716-1727
- Bazarian JJ, Zhu T, et al. Subject-specific changes in brain white matter on diffusion tensor imaging after sports-related concussion. Magnetic Resonance Imaging. 2012; 30: 171-180.
- Slobounov SM, Zhang K, et al. Functional abnormalities in normally appearing athletes following mild traumatic brain injury: a functional MRI study. Exp Brain Res. 2010; 202: 341-354.
- Pulsipher DT, Campbell RA, et al. A Critical Review of Neuroimaging Applications in Sports Concussion. Head and Neurologic Conditions. 2011; 10(1): 14-20.
- McCullough BJ, Jarvik JG. Diagnosis of Concussion: The Role of Imaging Now and in the Future. Phys Med Rehabil Clin N Am. 2011; 22: 635-652.
- Gonzalez PG, Walker MT. Imaging Modalities in Mild Traumatic Brain Injury and Sports Concussion. Am Acad Phys Med and Rehabil. 2011; 3: 413-424.
- Cubon VA, Putukian M, et al. A Diffusion Tensor Imaging Study on the White Matter Skeleton in Individuals with Sports Related Concussion. Journal of Neurotrauma; 28: 189-201.
- Henry LC, Tremblay J, et al. Acute and Chronic Changes in Diffusivity Measures after Sports Concussion. Journal of Neurotrauma. 2011; 28: 2049-2059.
- Zhang K, Johnson B, et al. Are functional deficits in concussed individuals consistent with white matter structural alterations: combined FMRI & DTI Study. Exp Brain Res. 2010; 204: 57-70.
- Hendee WR, Scherzinger AL. Basic Principles of Magnetic Resonance Imaging–An Update. West J Med. 1985; 143(6): 782-792.
6 Responses to “Neuroimaging and Mild Traumatic Brain Injury”
jdunigan
Thank you all for the recommendations. I will take each of your suggestions and apply them to the PowerPoint prior to the presentation in June. I really liked the suggestions regarding the use of too many words on my slides. This has always been something I’ve struggled with throughout my scholastic adventures. I will try hard to take some of those words, move them to the notes section, and add more visually stimulating material. Thanks for the suggestions. Particularly thanks to Kmac for the great suggestions, as well as Pam Elske-Leonetti for the great support. T minus 102 days until graduation!
Susan Russell
Josh,
I love the topic, especially since your site came up when I have so many return-to-play athletes from a concussion at my high school. Slide 11 has protocol for concussions; is this only in the ED? How could this affect the clinician that is seeing them after the ED visit? You do not mention what is the standard practice of today; the Heads Up information from the CDC is great except that it says you may want to see a physician which is incorrect for NC (where you MUST see a physician).
Slobounov’s study makes me think wow we have come so far in dealing with concussions over the past five years but where is this going to go next? There is already so much resistance from athletes and parents when you pull their child for weeks at a time for a concussion that they do not feel the symptoms after a couple of days/a week in the future; will a concussion pull you out longer and how will all of this affect patients reporting signs and symptoms? A slide of possible concussion treatment in the future would be nice and any ideas on how to combat the high cost if we imaged EVERYONE with a concussion?
Also, for Slide 12: is there a better resolution picture for the physician guideline? Once in slide show mode I cannot read everything due to it being blurry.
Great project! I cannot wait to see how concussion management changes over the next five years!!
lhack
Josh,
Thank you for your project. I am really fascinated by concussions even though I am primarily a general outpatient orthopedic therapist. My life outside of work puts me around many youth, college, and adult athletes and I think this is a very hot topic right now.
I am not sure if you made the corrects that Kmac suggested yet…but, I would also like to see some summary slides. Maybe one that summaries DTI v. fMRI and again the “on the horizon slide.” It was a lot of information to take in as someone who does not specialize in concussions and I think summary slides are a great way to tie it all together. I suspect in Cincinnati there will be a handful of clinicians that will appreciate that as well.
In addition, the more charts, graphs, art you can add and the less words you can use (but use during your presentation) the better. These are pretty busy slides, but I understand for the purpose of the capstone project (show us what you know) they need to be.
Great work again! Thanks for exposing me to more information on concussions!!! Love it!
Lindsey Hack, PT
Derrick
Josh,
I really like the topic you researched. I liked the fact that you included current practices for diagnosis of concussion and the benefits/downside to each. I was unaware of the cumulative effect of sub-concussive blows and how they can add up to a mild TBI. Good info to know to pass onto any athletes I might see as well as to be on the lookout for any symptoms of TBI. Great work Josh!
Mandy
Hey Josh,
First let me say excellent job on the PowerPoint. A presentation like this one is more along the lines of what I wanted to see at CSM this year; new information about concussions and how to diagnoses them. I feel like you did a good job presenting the mechanism of injury and pathophysiology of concussions. I think it was smart to include information about the techniques being currently used to diagnoses concussions and I especially like the pros/cons slides which summarized the information nicely. I think the information on the new techniques was well presented and I liked that I also learned new information about concussions in this section as well; that many sub-concussive blows may accumulate to a mTBI. I also thought it was interesting that athletes that are non-symptomatic and have been cleared for return to sport still have brain dysfunction with physical activity. Overall I thought that the presentation was very attractive; the slides were not too busy, there text focused on the important information, and there was a good use of visuals and multi-media to highlight your key points.
Since you are looking for more direct feedback on your PowerPoint, in order to prepare for your presentation, I made some notes about observations or questions I had while going through it. You can take or leave any of these comments but I hope they may help you!
Slide 9- Will you be providing commentary for this slide. It is a busy picture that I found myself just skipping over without additional information.
Slide 10- Although I believe your audience may know the symptoms of PCS it may be helpful to throw them out there as a review.
Slide 19- I liked how you presented both sides and acknowledged the differences in results. You present ‘normal’ values for FA on a later slide, are there such values for MD? You discuss increases/decreases but from what number?
Slide 22- I was first struck by the very small sample size but you can’t do anything about that. I found myself wondering whether there were significant differences between the sub-concussive blow athletes and the mTBI athlete. Can the imaging actually find differences between participating/non-symptomatic athletes and those with mTBI?
Slide 23- I think in the commentary you meant to say could instead of good!
Slide 24- Does that mean the experts believe that any change in values denotes mTBI since results have been inconsistent?
Slide 32- Seems like the fMRI research has used many different methods (visual reality and YMCA bike stress test) to investigation blood flow changes after mTBI; is this good for comparison of results?
Lastly I would have liked a slide describing why you thought this information was important to physical therapists or how we could integrate this information into our practice.
Mandy
Karen McCulloch
Hi Josh,
Your site looks great. I looked back through the powerpoint – you’ve made some nice improvements there. My main question that is remaining relates to the CDC guidance that is included in one of your slides now (which is a great addition). You may be planning to talk about this, but I think a summary slide that summarizes current best practice and then perhaps “practices on the horizon” might make sense. The DTI stuff is interesting and may end up being common practice at some point, but for now, its too early to expect that – I’m not sure that message comes through very well after your lit review of the imaging stuff at the end. Once you get to your clinical site, you’ll want to get a sense of their standard of care with imaging and compare that to what you have in your presentation so you’re sensitive to rationale they use for their practice.
kmac