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

M ELISSA N. W OMBLE , P H D N EUROPSYCHOLOGIST /D IRECTOR I NOVA S PORTS M EDICINE C OMPREHENSIVE C ONCUSSION P ROGRAM

THE CURRE CURRENT P PROB OBLEM

P ATHOPHYSIOLOGY OF C ONCUSSION 1. S IGNS AND S YMPTOMS OF C ONCUSSION 2. T YPICAL R ECOVERY R ATES FOR C ONCUSSION 3. M ANAGEMENT OF C ONCUSSION 4. C LINICAL P ROFILES OF C ONCUSSION 5. R ETURN -T O -P LAY 6. Object ectives es DISCUSSING CONCUSSION IN TERMS OF EVALUATION AND MANAGEMENT

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  I DENTIFY WHAT HAPPENED REMEMBER:  D IRECT BLOW TO HEAD OR A CONCUSSION INDIRECT BLOW SECONDARY MAY BE CAUSED BY TO TRANSLATED FORCE TO AN INDIRECT HEAD ( E . G ., ‘ WHIP LASH ’) BLOW TO THE HEAD , FACE , NECK  H IGH R ISK M ECHANISMS : OR ELSEWHERE ON THE BODY IF THE  ‘Double-Hit’  High velocity trauma FORCE OF THE  Rotational trauma IMPACT IS  Unsuspected blow TRANSMITTED TO THE HEAD .

sig igns ns  S IGNS OF NEUROLOGIC DYSFUNCTION OR NEUROLOGIC SYMPTOMS AFTER A PLAUSIBLE MECHANISM = C ONCUSSION REMEMBER:  “I F A PATIENT SHOWS CONCUSSION - LIKE SIGNS AND REPORTS Most SYMPTOMS AFTER A CONTACT TO THE HEAD , THE PATIENT concussions HAS , AT THE VERY LEAST , SUSTAINED A MILD CONCUSSION .” are diagnosed based on  C ONCUSSION S IGNS : symptoms, not  Loss of Consciousness (LOC) signs.  Slow to Get Up  Motor Incoordination/Balance Problems  Blank/Vacant Look  Disorientation  Clutching Head Guskiewicz, et. al., J Athl Train , 2004

symptoms ms SYMPTOM PERCENT # 1 Headache 75% Concussion # 2 Difficulty Concentrating 57% results in a # 3 Fatigue 52% constellation # 4 Drowsiness 51% of physical, cognitive, # 5 Dizziness 49% emotional, # 6 Foggy 47% and sleep- # 7 Feeling Slowed Down 46% related symptoms. # 8 Light Sensitivity 45% # 9 Balance Problems 39% # 10 Difficulty with Memory 38% Kontos, et. al., AJSM , 2012

Symptoms ms  S YMPTOMS WILL VARY IN INTENSITY AND PRESENTATION BASED ON THE INDIVIDUAL AND THE SEVERITY OF THE CONCUSSION .  P ATIENTS MAY NOT LOOK OR EVEN ACT INJURED IMMEDIATELY AFTER THE INJURY .  S YMPTOMS CAN WORSEN WITH COGNITIVE AND/OR PHYSICAL EXERTION .  S YMPTOMS CAN WAX AND WANE THROUGHOUT THE DAY .

Re Recover y Ra Rate tes  It is generally thought that 80-90% of of patients recover from concussion within 7-14 days.  N EW S TUDY - 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 Symptoms Recovery can last up to 4 weeks for Symptoms... * p <.05 N =66 Henry L, et. al, Neurosurg , 2015

Re Recover y Ra Rate tes Neuro- cognitive Recovery can last up to 3-4 weeks for Memory... * p <.05 N =66 Henry L, et. al, Neurosurg , 2015

Re Recover y Ra Rate tes Vestibular Recovery can last up to 3 weeks for Vestibular- Oculomotor Findings... Ocular * p <.05 N =66 Henry L, et. al, Neurosurg , 2015

Re Recover y Ra Rate tes  R ISK F ACTORS A FFECT R ECOVERY New research shows that  D EMOGRAPHIC F ACTORS average  Sex Differences in Recovery recovery  2.5x More Likely than Males to NOT be “Recovered” by varies from Week 4 1-4 Weeks  P OST - INJURY F ACTORS LONGER  On-field Dizziness RECOVERY  6.3x Greater Risk for Protracted (>21 days) Recovery WITH:  Post-Traumatic Migraine (PTM) 1) On-field dizziness 2) Migraine symptoms  7.3x Greater Risk for Protracted (>21 days) Recovery in 1 st week 3) Females 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- C ONSIDERATIONS R EGARDING F INDINGS : concussion Emotional distress can be caused by missing work/school, falling  symptoms and behind, activity restrictions and missing social interactions. demonstrated a  Situational depression may result in increased physical and emotional symptoms. longer recovery. 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 After the initial 24 hours:  The general  Limit naps to 30 minutes to prevent disruption of sleep at night. recommendation  Limit all over-the-counter medications to 2-3 doses per week to avoid rebound headaches. after concussion Prolonging rest can lead to the development of additional has been  symptoms. cognitive and physical rest; Individuals should begin to expose to normal activities, as  tolerated, with breaks utilized for symptom management. There however, there is are several exceptions: limited research  Activities that could pose risk for head injury. to support the  Physical activities other than walking /stationary bike riding until utility of STRICT evaluated. rest.  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

1. D IET : Eat breakfast, lunch and dinner each day. 2. H YDRATION : Stay well hydrated. 3. S LEEP : 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. P HYSICAL A CTIVITY : It is recommend that the individual take walks or ride a stationary bike following the injury. Once they are seen by a physician additional recommendations can be made. 5. S TRESS : Try to reduce stress in the individual. Reduced focus on the injury can help to avoid nervousness and increased anxiety. Beh ehavi vioral Man l Managem emen ent S Strateg egies After the initial 24 hours following a concussion, the individual should MAINTAIN A REGULATED SCHEDULE. 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

CLINICA CAL P L PROFILES LES C ONCUSSION T REATMENT AND R ISK F ACTORS C ONCUSSION C LINICAL R EHAB P ATHWAYS P ROFILES Somatization Previous Concussions Vestibular Migraine Ocular LD/ADHD Cognitive/ Female Gender Fatigue Post- Age Traumatic Migraine Motion Sensitivity Cervical History of Lazy Eye? Anxiety/ Sleep Problems Mood 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 Anxiety/ Ocular Mood Concussion Cognitive/ Cervical Fatigue Post- Traumatic Migraine Collins, et. al., KSST , 2014; Collins & Womble, Pediatric Surgery , 2017; Reynolds, et. al., Neurosurgery , 2014; Womble, et. al., AJO , 2016

Vestibular THE V VEST STIBULAR SYST SYSTEM & & CONCUSSI SSION ON  S ENSORY 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  S ENSORY SYSTEM IMPORTANT FOR : 1. Vestibulo-Ocular Reflex - -> Maintenance of visual stability during movement 2. Vestibulo-Spinal Reflex - -> Postural control 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

Ocular THE O OCU CULAR SYST SYSTEM & & CONCUSSI SSION ON  O CULAR M OTOR S YSTEM :  The muscles around the eyes work together in an extremely sophisticated manner in order to accurately control eye movements.  E YE M OVEMENTS E SSENTIAL FOR P ROPER E YE F UNCTION : 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 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