10/12/18 Outline 1. Epidemiology 2. Evaluation 3. Treatment Sports Concussion 2018: • How much rest? • Return to learn / work What the Clinician Needs to Know • Return to sports Carlin Senter, MD 4. How many concussions is too many? Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco UCSF Primary Care Medicine: Principles and Practice October 12, 2018 Disclosures UCSF Sports Concussion Program UCSF Orthopaedic Institute § None 1500 Owens Street San Francisco, CA 94158 Phone: (415) 353-1915 Fax: (415) 514-6075 Concussion@ucsf.edu 10/12/18 1
10/12/18 § 2.8 million traumatic brain injuries (TBI)s / year in US • These are only those seeking care in ED – likely major underestimate • Majority are mild TBI § Mechanism of injury https://www.brainline.org/slideshow/infographic-leading-causes-traumatic-brain-injury. Accessed October 7, 2018. 2
10/12/18 https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html Master CL, Mayer AR, Quinn D, Grady MF. Concussion. Ann Intern Med. 2018 Jul 3;169(1):ITC1-ITC16. Accessed 9/10/18. Concussion definition Concussion symptoms § mTBI: mild traumatic brain injury § Blow to head, neck, body à neurological symptoms within Physical 48 hours § CT and MRI normal § May or may not include loss of consciousness Sleep Cognitive § Cannot be explained by drug, alcohol, medication use, or other injuries or comorbidities Emotional http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017. 3
10/12/18 Concussion pathophysiology Concussion recovery § Concussion severity is determined retrospectively § Grading scales no longer used § Typical time to resolve Force to Ion fluxes; Need glucose brain, Energy vasocon- but less • Adults: 10-14 days axonal crisis striction blood flow stretching • Kids: Up to 4 weeks § Counsel patients and families that most patients with concussion do not have significant difficulties that last more than 1-3 months post injury. Giza CC and Hovda DA, J of Athletic Training, 2001. https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. Accessed 9/10/18. http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017. Case #1 § 27 y/o software engineer presenting with concussion. § 5 days ago fell while skiing, helmeted. No LOC but immediate headache. § Friends took her to local ED, no head CT needed. Advised to rest and to follow up the following week in primary care. § Has not returned to work or exercise. § Mild-moderate headache is worse with bright light and with using computer / screens. Also feels foggy and tired. § Medications: none § PMHx: none (incl no h/o concussion, HA, ADHD, psych) § SHx: work is understanding of her injury. No drug use. 1-2 alcoholic beverages/week. 4
10/12/18 Each of the following factors has been Concussion evaluation associated with longer recovery from concussion except for which? 1. Rule out 1. Intracranial hemorrhage A. Loss of consciousness at time of injury 2. Cervical injury B. Higher initial symptom burden 2. Determine C. History of neurological disorder 1. Symptoms D. History of psychiatric disorder 2. Severity of symptoms E. Learning difficulties 3. Risk factors for longer recovery F. Family and social stressors 4. Post injury memory, balance, reaction time https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html Accessed 9/10/18. http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017. 1. Self-reported symptom assessment Symptom severity score = 46 Clusters: headache, emotional https://www.seata.org/resources/Pictures/Sport%20concussion%20assessment%20 tool%20-%205th%20edition%20(1).pdf. Accessed June 26, 2017. 5
10/12/18 2. Neurological exam with balance When to order head CT - pediatrics Balance Error Scoring System: BESS § Pediatric Emergency Care Applied Research Network (PECARN) Head Injury / Trauma Algorithm • https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma- algorithm § Plug risk factors for intracranial injury into calculator to rule out need for head CT. • Age < 2 y/o • Amnesia • Vomiting • Non-frontal scalp • LOC hematoma • Severe MOI • GCS < 15 • Severe or worsening headache • Concern for skull fx http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg When to order head CT - adults Utility of brain MRI in concussion § 3T MRI more sensitive to micro hemorrhage than CT § In research setting, mTBI patients with normal head CT but abnormal acute brain MRI had poorer 3-month outcomes compared to those with normal imaging. § Despite this data, further investigation needed prior to recommending brain MRI for routine clinical care. § Routine brain MRI not recommended by American Academy of neurology nor the American Medical Society for Sports Medicine Giza CC et al. Neurology. 2013;80:2250-7. Harmon KG et al. Clin J Sport Med. 2013;23:1-18. Yuh EL et al. Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury. Ann Neurol. 2013;73:224-35. https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule. Accessed 9/10/18. 6
10/12/18 Blood tests for concussion Returning to case #1 § Biomarkers for acute concussion 27 y/o woman 5 days s/p fall while skiing with concussion. Software engineer. Has been off work since injury. § Genetic testing for alleles that can predispose to concussion § Symptom severity score high (46) § Used primarily in research settings § “Health care providers should not use biomarkers outside of a § Clustering in headache, light sensitivity, mood research setting for the diagnosis of children with mTBI.” § Neck exam normal § Neurological exam non-focal • BESS score of 15 (10-24 th percentile for her age Master CL, Mayer AR, Quinn D, Grady MF. Concussion. Ann Intern Med. 2018 Jul group) 3;169(1):ITC1-ITC16. https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html Accessed 9/10/18. How would you treat this patient? Concussion treatment § Reassurance A. Order urgent head CT to rule out subtle post traumatic bleed, return to clinic after CT. § Cognitive rest B. Gradually return to work now as tolerated, rest § Physical rest from physical activity, f/u 1 week. § Medication: acetaminophen or NSAIDs* prn headache C. Rest from work and from physical activity until symptom free, f/u 1 week. § Sleep D. Return to work and physical activity now. § Nutrition § Mood *Avoid NSAIDs acutely due to theoretical risk of intracranial hemorrhage. 7
10/12/18 How much rest after a concussion? How much rest after concussion? Thomas DG et al. Benefits of strict rest after acute concussion: a 1-2 days randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23. § 88 patients (11-22 y/o) seen at pediatric ED randomized § Strict rest x 5 days vs. “usual care” of 1-2 days rest, then stepwise return to activity § Neurocognitive and balance outcomes same at 3 and 10d post injury § Strict rest group had more daily post concussive symptoms and slower symptom resolution over the 10d study period http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Slide courtesy of Cindy Chang, MD Accessed June 26, 2017. Return to learn / work progression q Concussion Information Sheet Return to full day of school. q Acute Concussion Notification Form Return to ½ day of school. q Graded Concussion Symptom Checklist 30 min schoolwork at a 15 min q Physician Letter to School After Concussion Visit time until can cognitive do 1-2 hours. No school / activity at a q Concussion Return to Learn (RTL) Protocol work. time. OK to do light reading, little bit q Physician Recommended School Accommodations TV, drawing, Following Concussion cooking as long as doesn’t worsen q Concussion Return to Play (RTP) Protocol symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html http://www.cifstate.org/sports-medicine/concussions/index Accessed June 26, 2017. 8
10/12/18 Diet or supplements to expedite recovery? Case #2 § 15 y/o high school girls soccer player § Diet: literature is sparse § Concussion f/u in clinic § No strong evidence for use of supplements in § Injured 1 week ago concussion management at this time. § Rested at home x 2 days then gradually returned to school with RTL protocol • Promising results in animal studies and a few human studies on traumatic brain injury in § Tolerating school 100% recovery or prevention of concussion: § Has not done any physical activity • Creatine § No concussion symptoms • Omega-3 fatty acids • S. baicalensis • Curcumin § Soccer championship game in 2 days. She requests your • Vitamins C, D, E • Resveratrol clearance to play. • Melatonin § What do you recommend? Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9. What do you recommend? A. Clear her for game play in 2 days. B. Clear her to practice today and if no symptoms, clear for game in 2 days. C. Clear her for practice today and to follow a Follow gradual RTP gradual return to play protocol of 7 days. progression D. Recommend 1 more week of rest from physical activity then f/u in office. E. Recommend 1 month out of soccer post injury then f/u in office. 9
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