M ELISSA N. W OMBLE , P H D N EUROPSYCHOLOGIST /D IRECTOR I NOVA S - - PowerPoint PPT Presentation

MELISSA N. WOMBLE, PHD

NEUROPSYCHOLOGIST/DIRECTOR INOVA SPORTS MEDICINE COMPREHENSIVE CONCUSSION PROGRAM

THE CURRE CURRENT P PROB OBLEM

Object ectives es

DISCUSSING CONCUSSION IN TERMS OF EVALUATION AND MANAGEMENT

1.

PATHOPHYSIOLOGY OF CONCUSSION

2.

SIGNS AND SYMPTOMS OF CONCUSSION

3.

TYPICAL RECOVERY RATES FOR CONCUSSION

4.

MANAGEMENT OF CONCUSSION

5.

CLINICAL PROFILES OF CONCUSSION

6.

RETURN-TO-PLAY

Patho thophy hysiology

Disturbance of brain function is related to dysfunction of brain metabolism rather than a structural brain injury.

Collins, et. al., KSST, 2013; Giza & Hovda, Neurosurgery, 2014

sig igns ns

REMEMBER:

A CONCUSSION

MAY BE CAUSED BY AN INDIRECT BLOW TO THE HEAD, FACE, NECK OR ELSEWHERE ON THE BODY IF THE FORCE OF THE IMPACT IS TRANSMITTED TO THE HEAD.

 IDENTIFY WHAT HAPPENED  DIRECT BLOW TO HEAD OR

INDIRECT BLOW SECONDARY TO TRANSLATED FORCE TO HEAD (E.G., ‘WHIP LASH’)

 HIGH RISK MECHANISMS:

 ‘Double-Hit’  High velocity trauma  Rotational trauma  Unsuspected blow

sig igns ns

REMEMBER: Most concussions are diagnosed based on symptoms, not signs.

 SIGNS OF NEUROLOGIC DYSFUNCTION OR NEUROLOGIC

SYMPTOMS AFTER A PLAUSIBLE MECHANISM = CONCUSSION

 “IF A PATIENT SHOWS CONCUSSION-LIKE SIGNS AND REPORTS

SYMPTOMS AFTER A CONTACT TO THE HEAD, THE PATIENT HAS, AT THE VERY LEAST, SUSTAINED A MILD CONCUSSION.”

 CONCUSSION SIGNS:

 Loss of Consciousness (LOC)  Slow to Get Up  Motor Incoordination/Balance Problems  Blank/Vacant Look  Disorientation  Clutching Head

Guskiewicz, et. al., J Athl Train, 2004

symptoms ms

Concussion results in a constellation

• f physical,

cognitive, emotional, and sleep- related symptoms.

SYMPTOM PERCENT # 1 Headache 75% # 2 Difficulty Concentrating 57% # 3 Fatigue 52% # 4 Drowsiness 51% # 5 Dizziness 49% # 6 Foggy 47% # 7 Feeling Slowed Down 46% # 8 Light Sensitivity 45% # 9 Balance Problems 39% # 10 Difficulty with Memory 38%

Kontos, et. al., AJSM, 2012

Symptoms ms

 SYMPTOMS WILL VARY IN INTENSITY AND

PRESENTATION BASED ON THE INDIVIDUAL AND THE SEVERITY OF THE CONCUSSION.

 PATIENTS MAY NOT LOOK OR EVEN ACT INJURED

IMMEDIATELY AFTER THE INJURY.

 SYMPTOMS CAN WORSEN WITH COGNITIVE

AND/OR PHYSICAL EXERTION.

 SYMPTOMS CAN WAX AND WANE THROUGHOUT

THE DAY.

Re Recover y Ra Rate tes

 It is generally thought that 80-90% of

• f patients recover from concussion

within 7-14 days.

 NEW STUDY - Assessed recovery in 66

high school athletes across the first month following concussion.

 Focus of the study was on recovery in terms of

symptom resolution, cognitive functioning and vestibular-oculomotor findings.

 Additionally, a comparison was made between

boys and girls in terms of recovery length.

Giza et al., Neurology, 2013; Henry L, et. al, Neurosurg, 2015; McCrory et al., Br J Sports Med, 2013

Re Recover y Ra Rate tes

Recovery can last up to 4 weeks for Symptoms...

*p<.05 N=66

Henry L, et. al, Neurosurg, 2015

Symptoms

Re Recover y Ra Rate tes

Recovery can last up to 3-4 weeks for Memory...

Henry L, et. al, Neurosurg, 2015

*p<.05 N=66

Neuro- cognitive

Re Recover y Ra Rate tes

Recovery can last up to 3 weeks for Vestibular- Oculomotor Findings...

Henry L, et. al, Neurosurg, 2015

*p<.05 N=66

Vestibular Ocular

Re Recover y Ra Rate tes

New research shows that average recovery varies from 1-4 Weeks LONGER RECOVERY WITH:

1) On-field dizziness 2) Migraine symptoms in 1st week 3) Females

 RISK FACTORS AFFECT RECOVERY

 DEMOGRAPHIC FACTORS

 Sex Differences in Recovery

 2.5x More Likely than Males to NOT be “Recovered” by

Week 4

 POST-INJURY FACTORS

 On-field Dizziness

 6.3x Greater Risk for Protracted (>21 days) Recovery

 Post-Traumatic Migraine (PTM)

 7.3x Greater Risk for Protracted (>21 days) Recovery

Covassin, et. al., 2012; Eisenberg, et. al., 2014; Henry L, et. al, Neurosurg, 2015; Kontos, et. al., 2013; Lau, et. al., 2011; Mihalik, et. al., 2013

Man anagement

Adolescents randomly selected for a strict rest group

• vs. usual care

reported more daily post- concussion symptoms and demonstrated a longer recovery.

CONSIDERATIONS REGARDING FINDINGS:



Emotional distress can be caused by missing work/school, falling behind, activity restrictions and missing social interactions.

 Situational depression may result in increased physical and emotional

symptoms.



Activity restrictions and lack of exercise may contribute to sleep abnormalities and adversely affect mood.

Relander, et al., Br Med J, 1972; Thomas, et. al., Pediatrics, 2015

Man anagement

The general recommendation after concussion has been cognitive and physical rest; however, there is limited research to support the utility of STRICT rest.



After the initial 24 hours:

 Limit naps to 30 minutes to prevent disruption of sleep at night.  Limit all over-the-counter medications to 2-3 doses per week to

avoid rebound headaches.



Prolonging rest can lead to the development of additional symptoms.



Individuals should begin to expose to normal activities, as tolerated, with breaks utilized for symptom management. There are several exceptions:

 Activities that could pose risk for head injury.  Physical activities other than walking /stationary bike riding until

evaluated.

 Close up visual-based activities other than normal school

activities for extended periods (e.g., cell phone use).

Collins & Womble, Pediatric Surgery, 2017; Heyer & Idris, Pediatric Neurology, 2014; Thomas, et. al., Pediatrics, 2015 Womble, et. al., AJO, 2016

After the initial 24 hours following a concussion, the individual should MAINTAIN A REGULATED SCHEDULE.

Beh ehavi vioral Man l Managem emen ent S Strateg egies

• 1. DIET: Eat breakfast, lunch and dinner each day.
• 2. HYDRATION: Stay well hydrated.
• 3. SLEEP: Stick to a strict sleep schedule with a regular bedtime and

wake-up time. It is generally recommend that individuals obtain 7-9 hours, with limited to no naps of no longer than 30 minutes.

• 4. PHYSICAL ACTIVITY: It is recommend that the individual take walks
• r ride a stationary bike following the injury. Once they are seen by

a physician additional recommendations can be made.

• 5. STRESS: Try to reduce stress in the individual. Reduced focus on the

injury can help to avoid nervousness and increased anxiety.

Choe & Blume, Journal of Child Neurology, 2016; Collins & Womble, Pediatric Surgery, 2017; Kacperski et al., Seminars in Pediatric Neurology, 2016; Womble, et. al., AJO, 2016

Previous Concussions Female Gender

TREATMENT AND REHAB PATHWAYS CONCUSSION CLINICAL PROFILES RISK FACTORS

Migraine LD/ADHD

CONCUSSION

Age Motion Sensitivity

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

CLINICA CAL P L PROFILES LES

Vestibular Ocular Cognitive/ Fatigue Cervical Anxiety/ Mood

Post- Traumatic Migraine

History of Lazy Eye? Sleep Problems Somatization

Clinica cal p l profiles les

Vestibular Ocular Concussion Anxiety/ Mood Cervical

Post- Traumatic Migraine

Cognitive/ Fatigue

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

THE V VEST STIBULAR SYST SYSTEM & & CONCUSSI SSION ON

 SENSORY SYSTEM RESPONSIBLE FOR:

 Maintaining visual and spatial organization  Managing balance function via pathways linking sensory organs of the ear with central processing areas in the brainstem, cerebellum, midbrain, and cerebral cortex

 SENSORY SYSTEM IMPORTANT FOR:

1. Vestibulo-Ocular Reflex - -> Maintenance of visual stability during movement 2. Vestibulo-Spinal Reflex - -> Postural control

Vestibular

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Mucha, et. al., AJSM, 2014; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

THE O OCU CULAR SYST SYSTEM & & CONCUSSI SSION ON

 OCULAR MOTOR SYSTEM:

 The muscles around the eyes work together in an extremely sophisticated manner in order to accurately control eye movements.

 EYE MOVEMENTS ESSENTIAL FOR PROPER EYE FUNCTION:

1. Smooth Pursuits - -> The ability to stabilize gaze and follow a moving object with the eyes accurately 2. Saccades - -> The ability to jump your eye from one target to another accurately 3. Convergence - -> The ability of the eyes to move inward/outward in order to focus on an object as it moves near/far

Ocular

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Pearce, et. al., AJSM, 2015; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

COGNI NITI TIVE-FATIGUE UE & & CONCUSSI SSION ON

 COMMON COGNITIVE COMPLAINTS:

 Concentration (i.e., attention, distractibility)  Memory (i.e., forgetfulness, repeating oneself)  Processing Speed  Mental Fogginess (i.e., one step behind)

 COMMON FATIGUE COMPLAINTS:

 Tiredness typically caused by cognitive or physical exertion, and/or illness  Decreased endurance and/or energy levels

Cognitive/ Fatigue

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., AJSM, 2012; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

POST ST-TR TRAUMA UMATI TIC MIG IGRA RAIN INE & & CONCUSSI SSION ON

TYPICAL CHARACTERISTICS:

 Headache of less than 3 months in duration caused by traumatic injury to the head  Headache developed within 7 days of injury  Subtypes: tension-type, cluster-like, and migraine-like

MIGRAINE AND CONCUSSION SIMILARITIES:

 Common molecular pathophysiology  Increases in extracellular potassium and intracellular sodium, calcium, and chloride  Excess release of excitatory amino acids and opioids (i.e., glutamate)

Post- Traumatic Migraine

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., AJSM, 2013; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

ANXIETY & Y & CONCU CUSSI SION ON

 Anxiety refers to excessive and persistent worry and/or fear about everyday situations that is difficult to control.  Oftentimes, patients will be unable to accurately identify

• r characterize their feelings of anxiety. Therefore,

anxiety post-concussion may manifest in terms of:

1. Avoiding or running away from activitiess or situations that bring on anxious thoughts, feelings, and memories. 2. Continued symptoms despite normal neurocognitive data and non-provocative vestibular/ocular-motor examination. 3. Co-occurring sadness, hopelessness, or depression secondary to the significant changes in their day-to-day schedule and continued experience of post-concussive symptoms.

Anxiety/ Mood

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., BJSM, 2016; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

CER VI VICA CAL I L INVOLVE VEMEN ENT & C CONCUSSI SSION ON

 With the prevalence of whiplash injuries, the cervical spine can be injured when forces are transmitted to the head.  Characterization of the headache in terms of location,

• nset, and daily course can be helpful in determining

possible cervical involvement.  Can be managed with:

 Soft tissue mobilization, posture re-education, range-of- motion exercises, manual cervical/thoracic mobilization, biofeedback, pain-management techniques, and trigger- point injections  Use of muscle relaxants

Cervical

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Schneider, et. al., BJSM, 2013; Womble, et. al., AJO, 2016

Ocular

Frontal Headache Fatigue Heightened Distractibility Difficulties with Visually-Based Academics Pressure Behind the Eyes “Focus” Difficulties

Cognitive/ Fatigue

Fatigue General headache “End of day” symptoms Cognitive difficulties (e.g., sustained attention, word finding) after long durations of cognitive activity Possible sleep deficits

Post- Traumatic Migraine

Recurrent headache; intermittently severe Nausea Light/Noise Sensitivity Stress, anxiety, lack

• f exercise

Deregulation of routine (i.e., sleep) May present with vestibular-migraine symptoms

Anxiety/ Mood

Ruminative thoughts Hypervigilant Fastidious Feelings of being

• verwhelmed

Sleep Difficulties Sadness Hopelessness

CLINICA CAL P L PROFILES LES

Cervical Headaches, neck pain, numbness/tingling, Symptoms with specific physical movements

Behavioral Neuro- Optometry

Inova sp spor ts m medici cine Compr preh ehensive ve concussi ssion

• n p

progr gram

Urgent Care Centers Pediatricians & Primary Care Physicians

Local Youth Sports Organizations

High School Athletic Trainers Complicated – Out of Region Referrals

Psychiatry

• r

Behavioral Health Vestibular Physical Therapy Sports Medicine, Orthopaedics & Trauma Physical Therapy Neurology/ Neurosurgery

Emergency Departments

In House Treatment Options External Treatment Options

Exertion Therapy

Internal/External Referral Sources Sending Patients to Our Program

Inova Sports Medicine Comprehensive Concussion Program

Physician-Based Team including: a Neuropsychologist, 2 Primary Care Sports Medicine Physicians and 3 Athletic Trainers

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Concussion

Neuro- cognitive Physical Exertion Symptoms Ocular- Motor Vestibular

Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

Behavioral Neuro- Optometry

Inova sp spor ts m medici cine Compr preh ehensive ve concussi ssion

• n p

progr gram

Urgent Care Centers Pediatricians & Primary Care Physicians

Local Youth Sports Organizations

High School Athletic Trainers Complicated – Out of Region Referrals

Psychiatry

• r

Behavioral Health Vestibular Physical Therapy Sports Medicine, Orthopaedics & Trauma Physical Therapy Neurology/ Neurosurgery

Emergency Departments

In House Treatment Options External Treatment Options

Exertion Therapy

Internal/External Referral Sources Sending Patients to Our Program

Inova Sports Medicine Comprehensive Concussion Program

Physician-Based Team including: a Neuropsychologist, 2 Primary Care Sports Medicine Physicians and 3 Athletic Trainers

GENERAL GUIDELINES FOR A SAFE RETURN TO PLAY:

SYMPTOM FREE AT REST SYMPTOM FREE WITH COGNITIVE ACTIVITIES SYMPTOM FREE WITH PHYSICAL ACTIVITY NORMAL NEUROCOGNITIVE DATA NORMAL OBJECTIVE EVALUATION

C L E A R A N C E

RETURN RN-TO TO-PLAY AY

RETURN RN-TO TO-PLAY AY

STAGE ACTIVITY (EX. WITH FOOTBALL) STAGE #1

NO PHYSICAL ACTIVITY

STAGE #2

LIGHT AEROBIC ACTIVITY WITH LIMITED HEAD MOTION

STAGE #3

MODERATE AEROBIC ACTIVITY

STAGE #4

NON-CONTACT PARTICIPATION IN PHYSICAL ACTIVITIES SPORT SPECIFIC FUNDAMENTAL SKILLS

STAGE #5

LIMITED CONTACT WITH BAGS

STAGE #6

LIMITED CONTACT WITH OTHERS

STAGE #7

FULL CONTACT DRILLS/ SCRIMMAGE

STAGE #8

GAME PLAY

C L E A R A N C E

 Providing appropriate management techniques from the initial injury date can help in reducing symptoms and length of recovery.  Certain risk factors can make an individual more vulnerable to concussion and longer recovery periods.  Concussion results in patients experiencing specific symptoms that fall under different potential profiles.  Assessment should include a detailed clinical interview and multiple tools with understanding of these tools.  Assessment findings should set the stage for targeted management and treatment options based on the identified profile/profiles. It is not a “one size fits” all injury.  Type, duration and intensity of treatment recommendations are dependent upon the clinical profile/profiles and severity

• f impairment.

Inova Sports Medicine Comprehensive Concussion Program 8501 Arlington Blvd, Suite 200 Fairfax, VA 22031 (703) 970-6464 Concussion Hotline: (703) 970-6427

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