Concussion Melissa Novak, DO OHSU Sports Medicine What is a - - PDF document

9/17/2015 1

Concussion

Melissa Novak, DO OHSU Sports Medicine

What is a Concussion?

A Bell Ringer?

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A Ding?

• Mild traumatic brain injury that interferes

with normal function of the brain?

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Objectives

• Identify concussion
• Demonstrate familiarity and ability to use

concussion evaluation tools

• Explain how to manage the acute

presentation of concussion

• Describe the return to play protocol and

return to learn

NO!!!!

• Grade I
• Grade II
• Grade III….
• A type of traumatic brain injury that is

caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull?

– WebMD

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Zurich 2012

• Concussion is a brain injury and is defined

as a complex pathophysiological process affecting the brain, induced by biomechanical forces

Zurich 2012

• Several common features that incorporate

clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…

Zurich 2012

• Direct blow to the head, face, neck or

elsewhere on the body with an ‘‘impulsive’ force transmitted to the head.

• Typically results in the rapid onset of

short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

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Zurich 2012

• May have neuropathological changes, but the

acute clinical symptoms largely reflect a functional disturbance rather than a structural injury

• No abnormality is seen on standard structural

neuroimaging studies.

• Graded set of clinical symptoms
• May or may not involve loss of consciousness.
• Resolution of the clinical and cognitive symptoms

typically follows a sequential course

– However, some cases symptoms may be prolonged

Sports Concussion Institute

• A concussion is defined as a complex

pathophysiological process that affects the brain, typically induced by trauma to the brain

• It can be caused either by a direct blow to

the head, or an indirect blow to the body, causing neurological impairments that may resolve spontaneously

• Symptoms usually reflect a functional

disturbance to the brain

Sports Concussion Institute

• May include these symptoms:

– physical (e.g., headaches, nausea), – cognitive (e.g., difficulty with concentration or memory), – emotional

• (e.g., irritability, sadness)

– ‘maintenance’

• (e.g., sleep disturbances, changes in appetite or

energy levels)

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Why Are We So Confused…

• Turns out, there are greater than 100

published definitions of what a concussion is…

• Carney et al., 2014, A recently published

evidence- based systematic review of the concussion literature has helped to better define concussion

Carney et al., 2014

• 1.) A change in brain function
• 2.) Following a force to the head( a

potentially concussive event)

• 3.) May (or may not) be accompanied by

temporary LOC

• 4.) Identified in awake individuals
• 5.) Includes measures of neurologic and

cognitive dysfunction

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Consistent and Prevalent Diagnostic Indicators

• Observed and documented disorientation or

confusion immediately after the event

• Impaired balance within 1 day after injury
• Slower reaction time within 2 days after injury

(and /or)

• Impaired verbal learning and memory within 2

days after injury

Carney et al., 2014

Concussion Symptom Frequency

• Headache

75%

• Dizziness

60%

• Blurred vision

75%

• Nausea

54%

• Double vision

11%

• Noise sensitivity

4%

• Light sensitivity

4%

• Carney et al., 2014

Sleep Disturbance

• Sleep problems related to mTBI found a

significantly high prevalence of TBI- related sleep-wake disturbances at 67%

Kempf et al., 2010

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What actually happnes? Energy Crisis! What to Avoid!

• 1. Do not hit your head again

– A lot less biomechanical force is going to produce far more serious consequences

• 2. Cells are starved for energy, we do not

want to increase the demand for energy too quickly or too rapidly or too significantly

• Mickey Collins, PHd

So Now What?

• We know what a concussion is… but how

do we actually know an athlete or a patient has a concussion ???

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Sideline Evaluation-what do we look for?

• Appears dazed
• Moves clumsily
• Confused about play
• Answers question slowly
• Forgets plays prior to hit (retrograde amnesia)
• Forgets plays after hit (anterograde amnesia)
• Personality/behavior change
• Loss of consciousness
• Bottom line… we still have to rely on the

athlete to supply some information for us…

Sport Concussion Assessment Tool Sport Concussion Assessment Tool ( SCAT 3)

• On the sidelines or after the game
• Validated tools to assess the severity of

the concussion

• Can help to monitor progress
• Cognitive, motor control and balance

testing

• Athletes aged from 13 years and older.
• Ages 12 and under, use the Child SCAT3

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Symptom Scale

• Completed by the athlete, at least 10

minutes post exercise

• Maximum possible is 22 symptoms
• Symptom severity score, add all scores in

table

– maximum possible is 22 x 6 = 132.

SCAT3

• Neck Exam
• Coordination
• Modified BESS test (balance)

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Internet- Based Cognitive Testing Programs

• Impact or Axon/Cogstate or others
• Standardized, computerized, and validated

– document subtle impairments in

• Memory
• Attention
• Processing speed

– The test can be worse at 48hrs – Usually recovers in 1-4 weeks.

ImPACT

• Immediate Post-Concussion Assessment and

Cognitive Testing

– Computerized Neurocognitive Testing

• The results correlate 60-70% with symptoms
• Found to be 94.6% sensitive and 97.3%

specific for concussion (Schatz P. et al. 2012.).

• Various protocols for post-concussive testing

exist but many schools and organizations are currently using impact testing

N=215, MANOVA p<.000000 (Lovell et al., 2004)

Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion

Unique Contribution of Neurocognitive Testing to Concussion Management

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ImPACT

• Assesses 6 domains of brain function:

– Attention span – Working memory – Sustained and selective attention time – Response variability – Non-verbal Problem Solving – Reaction time

• Compare post-injury score on test battery to pre-injury
• baseline. www.impacttest.com
• Not a perfect tool and not to be used in the absence of

an experienced and knowledgeable physician. May incorrectly diagnose 10% of those tested.

What to expect from Neurocognitive Testing

• Can help to determine recovery from injury
• Can help to manage concussion (return to

academics, return to play etc.)

• Can help to communicate status to

coaches, parents, athletes

• CAN NOT substitute for medical

evaluation/treatment

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Balance Testing: BESS

• Errors in 20 sec trial:

– Hands off iliac crest – Open eyes – Step/stumble/fall – Moving hips > 30o abd – Lifting forefoot/heel – Remaining out of test position > 5 sec

• Max errors per condition = 10
• Normal total score = 12.03  7.34

www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

Balance Tests: BESS

Pros

• Quick
• Inexpensive
• Easy to administer on

sideline or in clinic

• Minimal ceiling effect

Cons

• Performance differences

based on sport

• ↑ in scores with exertion or

fatigue (~20 min)

• ↑ in scores if ankle instability
• Learning effect
• Moderate to good reliability

Currently the “gold standard” for concussion management

Bell DR et al; Sports Health 2011; Guskiewicz KM Clin Sports Med 2011

Neurologic Exam

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Neurologic exam

• Cranial Nerves
• Muscle strength
• Reflexes
• Sensation
• Coordination
• Balance
• Eye movement

– Nystagmus?

The First 24-48 Hours…

• remove from play, assess for danger signs

that require medical attention:

– Difficult to arouse or awaken( including a LOC) – unable to walk – ongoing nausea and vomiting( >3) – worsening headache – changes in vision – unequal pupils – severe confusion or disorientation – significant neurologic symptoms – signs including weakness, numbness or seizure.

• If these danger signs on the field are

absent, the athlete can be observed, the parent should be informed and the athlete should be referred to the appropriate medical professional for evaluation and clearance before returning to play

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Initial recommendations

• 2-5 days of relative rest from

– school and work activities – computer/ video screens ( esp. interactive games) and highly stimulating environments

• Transition back as soon as tolerated!!

Most Concussions Resolve Spontaneously

• Watchful waiting usually sufficient

– 2 more hours of sleep – “Brain breaks” – Introduce exercise when symptoms begin to resolve or as soon as tolerate in the first 1-2 weeks – Exercise has been shown to be one of the best treatments to help concussions resolve even in complicated cases (Leddy et al.,2013)

Concussions: Return to Play

A Step-Wise Symptom Limited Program

• 1. Rest until asymptomatic ( Recovery: mental and physical

rest for 2-5 days or longer if needed for severe symptoms)

• 2. Light aerobic exercise ( HR: 70% max, jog, exercise bike)
• 3. Sport- specific exercise( Add movement: No head

impact)

• 4. Non-contact training drills (Exercise intensity,

Coordination and cognitive load: add wt lifting, passing, plays )

• 5. Full contact training (After medical clearance: Restore

confidence and assess functional skills by coach/ ATC)

• 6. Return to competition( game play- only after return to

academics)

Each stage is about 24 hrs or longer and return to stage one if symptoms reoccur

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Return to play

• Goal: minimize recovery time/prevent

further injury

– Premature return to play = ↑ complications

Guskiewicz KM et al; Med Sci Sports Exerc 2007 Guskiewicz KM et al; JAMA 2003

– Studies indicate that cognitive or physical stress can delay recovery

Griesbach GS et al; Neuroscience 2004 Leddy JJ et al; NeuroRehabilitation 2007

– Increasing concern over long term effects

Acute Concussion Evaluation ACE

• Gerard Gioia, PhD1 & Micky Collins,

PhD2 1Children’s National Medical Center 2University of Pittsburgh Medical Center

• http://www.cdc.gov/headsup/providers/

Return to School

    

50 60

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OSAA Concussion Return to Play Form

OSAA Return to Play

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Concussion recovery: How long does it take?

n = 134 male football athletes

Collins et al; Neurosurgery 2006

Rehabilitation

• 10-20% of concussed athletes may have

prolonged recovery past 28 days

• Individualized rehab program can be useful

(Vidal P. et al. 2012)

• The overall goals of therapy are

– Adaptation: visual-vestibular interaction exercises; – Substitution: promote balance and reduce falls by re-weighting sensory stimuli; – Habituation: repeated exposure to provoking stimuli

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Pittsburg model

OHSU Model

Adapted from Collins MW et al; Knee Surg Sports Traumatol Arthosc 2014

Concussion Anxiety/ Mood Ocular Cognitive Migraine Cervical Vestibular Auditory Autonomic

Multidisciplinary Approach

• Speech -language pathologist:

– cognitive and executive function

• memory, speed of processing, attention, planning,

problem solving, organization, social cognition, and school interventions

• Physical therapy-

– vestibular/ balance therapy, gaze stabilization, neck problems, and exercise prescription

• Occupational Therapy-

– visual and functional therapy

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Multidisciplinary Approach

• Neuro-Psychology-

– Cognitive testing to determine brain function, can also help to determine contributions due to anxiety/depression etc.

• Psychology

– cognitive behavioral therapy, cognitive restructuring, biofeedback, and strategies to address emotional and psychological effects to improve coping skills, resiliency and function

When to Refer

• Rehab program initiated at around one

month

• Recommend referral to specialty centers

for comprehensive concussion care when a concussion takes longer than 21-28 days to heal

Concussion Medication Management

• Fish oil and tylenol early, NSAID after 72 hrs
• Amitriptyline 10 mg pills. Take10-50mg ( 1-5 pills) at

night at bedtime as directed for Headache/nerve pain and to help with sleep.

• Amantadine 100 mg BID is used for concussion

symptoms.Please take one pill in Am then after one week consider adding one more at noon. Continue for about 2-4 weeks to see if this helps with your concussion- related symptoms.

• Topimax: 50 mg BID start 25 HS, increase q3-7
• Antidpressants, aleve, anti-seizure meds, Bblocker,triptan

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Summary

• Early identification & Diagnosis
• Clinical assessment and tracking

– SCAT3, ImPACT, BESS, ACE

• Active Treatment Plan

– Days NOT Weeks of rest – Early exercise and sleep promotion – School adjustments and accommodations

• When to refer

– 21-28 days prolonged recovery

OHSU Concussion Management

503-494-4000

• Pre-season Impact baseline testing

– Can do whole team or individuals

• Post –concussion evaluations
• Concussion Rehabilitation Team

– PT, Vestibular/ENT, SLP/cognitive,OT/vision

• Pediatric Neuropsychology testing if

chronic

• Sport Concussion Support Group

(student/family)

Melissa Novak, DO novakm@ohsu.edu www.ohsusportsmedicine.com Questions?

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References

• J. Chesnutt . New Insights in Concussion Diagnosis, Evaluation and Rehabilitation. OHSU Sports

Medicine, Department of Orthopedics & Rehabilitation and Family Medicine, Oregon Health & Science University, Portland, OR, USA.

• Carney N. Ghajar J, et al. Concussion Guidelines Step 1: Systematic Review of Prevalent Indicators.

Neurosurgery 75:S3–S15, 2014.

• McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on

Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258.

• Stiell I. et al. The Canadian CT Head Rule for patients with minor head injury. Lancet
• SCAT3, Br J Sports Med 2013 47:259
• OSAA: www.osaa.org
• G. Gioia & M. Collins. “Heads UP: Brain Injury in Your Practice” tool kit. CDC.
• Balance Error Scoring System (BESS). University of North Carolina's Sports Medicine Research

Laboratory, Chapel Hill, NC.

• imPact Testing, https://www.impacttest.com
• Brogli S. Cantu R. Gioia G. et al. National Athletic Trainer’s Association Position Statement:

Management of Sports Concussion. J Athletic Training . 2014;49(2):245-265.

• Giza C. Kutcher J. et al. Summary of evidence-based guideline update: Evaluation and

management of concussion in sports : Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80;2250-2257.

References

• www.ohsusportsmedicine.com
• CDC “Heads Up”: www.cdc.gov/concussion/
• Oregon Concussion Awareness and Management

Program: www.ocamp.org

• Center on Brain Injury Research and Training:

www.cbirt.org

• Brain 101: http://brain101.orcasinc.com
• Neuro-Optometric Rehabilitation Association (NORA):

www.nora.cc

• Brain Injury Association of Oregon: www.biaoregon.org/
• Brain Injury Association of Washington:

www.braininjurywa.org/