Overview of History Epidemiology Concussions Recognition - - PDF document

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Overview of Concussions

David Wang MD, MS

Elite Sports Medicine Director of Sports Medicine Quinnipiac University CSMS April 28th 2014

Concussion Overview

Overview History Epidemiology Recognition Cumulative Injuries Imaging/Biomarkers Treatment/Rehabilitation Prevention

The thoughts about concussions have really changed in the past 20 years

The management of

concussions has been understood for a long time before it was in vogue to talk about them.

It is now much easier as a

practitioner to care for them with the help of the media and legislation.

The Old Way Currently

We certainly are recognizing and caring for

concussions much better.

Although there has been much progress we

still see examples of mismanagement every day.

Now with concussions we are also dealing with:

Overanalyzing Confusion on concussions Liability Chronic traumatic encephalopathy School accommodations Return to sports/retirement

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Let’s briefly look at where we were 2500 years ago Concussion History

Hippocrates made

numerous comments on brain injury.

“In cerebral concussion

whatever the cause, the patient becomes speechless, ...falls down immediately, loses their speech, cannot see or hear”

Concussion History

Not until the first century AD

did Rhazes describe concussion and differentiate it from a more severe head injury.

He described concussion as

an abnormal physiological state without gross traumatic lesions of the brain.

Sports Concussion History

The main sports of the time

were combative sports. Galen of Pergamon documented numerous gladiator injuries.

Described several post

accident symptoms such as dizziness.

History of Concussion

In the middle ages sports were

not well organized but revolved around jousts, duels, and fighting.

Physicians further documented:

the faltering of speech, impairment of memory, dullness of understanding, and short lived symptoms of tinnitus and photophobia.

Fairly close to where we are today

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Definition

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 Rapid onset of short lived neurologic symptoms. No structural injury. Resolution of the clinical and cognitive symptoms

typically follows a sequential course.

Epidemiology

The CDC estimates there are

3.5 million sport related concussions per year.

Concussions represent 10%

• f all sports injuries

sustained by high school athletes.

Signs of Concussion

Vacant stare Delayed responses Inattention Disorientation Slurred/Incoherent speech Perseveration

Signs of Concussion

Incoordination Nausea/vomiting Inappropriate

emotionality

Memory problems Loss of consciousness

Top 10 Symptoms of Concussion

Headache Feeling slowed down Difficulty concentrating Dizziness Fogginess Fatigue Blurry or double vision Sensitivity to light Memory problems Balance problems

Headaches Pearl

A key point when evaluating these patient’s is that there is

more than one cause of headache in an athlete who has been struck on the head.

Concussion Inter-cranial bleed Extra-cranial injury Cervical injury Previous headache issues

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Odd Symptoms after Concussion

Voice changing Sweating Right to left handed Heart rate and blood pressure

changes

Pseudo-seizure Increased urination Better math skills

Concussion Symptoms

Another way at looking at

concussion symptoms is to simplify them into 4 categories: Cognitive, Physical, Emotional, and Sleep.

Vestibular Symptoms

The vestibular system is a

critical system that is responsible for balance as well as vision.

Concussion and Vision

67% of the neural connections

within the brain are involved with some aspect of vision. Such as visual input, visual perception, and visual integration.

Hence why visual changes are

so common after concussion.

Pursuit Pathway

Visual Issues from Concussion

Accommodative Insufficiency Blurry Vision Convergence Insufficiency Double Vision Light Sensitivity Ocular-Motor Dysfunction Reduced Visual Processing Speed

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Visual Symptoms

Ocular focusing and tracking are common

concussion problems that affect school participation.

Reading Writing Note taking Walking hallways

Balance and Concussion

Balance deficits are

commonly seen after concussion.

In some cases these can be

severe requiring assistance with ambulation.

Balance Measurements Dysautonomia

Seen fairly commonly in the pediatric

concussion population

Tachycardia Orthostatic hypotension Hypertension Just recently “red hot ears”

Toledo, Neurosci Biobehav Rev. 2012

Injury Locations and Symptoms

Post-Concussive Syndrome

Underlying psychological issues “Bad” concussion vs. mTBI “Microscopic Macroscopic” head injury Genetics? Female Gender (neck, hormonal, other) Injury type (i.e. Overlapping Concussion Syndrome) A missed diagnosis (vestibular, cervical, etc)

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Cumulative Injuries

Chronic Traumatic Encephalopathy (formerly

Dementia Pugilistica)

Overlapping Concussion Syndrome Second Impact Syndrome

Chronic Traumatic Encephalopathy

Stage 1 - Headache and loss of attention Stage 2 - Depression, anger outbursts, and

short-term memory loss

Stage 3 - Executive dysfunction and cognitive

impairment

Stage 4 - Dementia, aggression, and word

finding difficulties

CTE Pathology

Tau protein deposition

around vessels (3R, 4R) .

Occurs in the deep portions

• f the sulcus.

Appears to start in the

frontal lobes.

CTE Contributors

Genetics -Apoprotein E Prion?

Tauopathies (Just a few)

• Alzheimer’s disease
• Pick’s disease
• Down Syndrome
• Creutzfeldt-Jakob disease
• Tuberous Sclerosis
• Prion protein cerebral amyloid angiopathy
• Down Syndrome
• Frontaltemporal dementia and parkinsonism linked to chromosome 17

Overlapping Concussion Syndrome

Charts from 615 patients were reviewed and

419 met criteria for analysis.

400 “normal” concussions and 19 OCS

patients identified.

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Results

Overlapping Concussion Syndrome

Symptomatic patients in recovery but not

resolved who suffer another blow to the head have a prolonged recovery course. In our concussion clinic 4.5% of the patients seen had OCS.

Yet another reason to keep athletes who

remain symptomatic from concussion out of harms way, even if they are improving.

Other Insults

There are other insults to a concussed patient that can

worsen or prolong the concussion symptoms.

Any types of physical or emotional stress can worsen

symptoms.

Things like elective surgery (even dental) or changes in

family dynamics (divorce) can worsen symptoms.

Stress from missing school work.

Second Impact Syndrome

Well documented yet rare event often

resulting in death.

Injury occurs after a second blow is received

while still symptomatic from a previous head injury.

Loss of vasoregulation is felt to be cause of

cerebral swelling and brain herniation.

Imaging

CT scans do not show changes MRI increased sensitivity for cerebral edema,

hemosiderin deposition, and cerebral contusion.

Imaging

fMRI measures brain function via blood flow

and oxygenation. Has demonstrated lower frontal cortex activity following concussion.

Resting State Networks Arterial Spin Labeling MRI can measure

cerebral perfusion

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Imaging

MR Spectroscopy (N-Acetylaspartate levels

associated with energy impairment)

MR Elastography (measures brain tissue

stiffness)

DTI is used to measure white matter integrity

Bioenzyme Markers

S-100 Neuron-specific enolase (NSE) Myelin basic protein (MBP) GFAP

Biomarkers

SNTF (Brain enriched protein calpain-cleaved

alpha II-spectin N-terminal fragment)

High levels of SNTF after brain injury

corresponds to persistent symptoms after injury (axonal injury)

Tested 1 hour to 144 hours after the injury

(Simon, J Neurotrauma 2014)

Biomarkers

Tau proteins are also currently being

investigated as a biomarker in concussion.

Tau -C levels higher in post concussion

• samples. Tau-A levels correlated with

duration of post concussive symptoms. (Shahim, J Neurotrauma 2015)

Treatment of Concussion

On the field first aid for head injuries

If concussion suspected remove from the game/practice.

Do not allow to return even if athlete appears normal. Suggest evaluation by medical provider before return to

• sports. If athletes condition appears worrisome or is

worsening then immediate medical treatment is indicated.

If unconscious first evaluate for breathing and cardiac

• activity. If not breathing or pulseless then CPR/AED.

Protect the neck of the unconscious athlete. Immediate medical treatment is indicated.

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Treatment

The mainstay of treatment remain cognitive

and physical rest.

How much rest and the type of the rest can

vary from person to person depending on many factors.

Return to Learn

Return to learn (school) followed by return to

play is the overall game plan.

There can be some subtle variations of this in

practice, such as return to activity, but in principle it should be followed. Research is now demonstrating benefits to recovery with exercise especially after 2 weeks from the injury.

Treatment/Rehabilitation

Physical therapy can be important in concussion

management.

Cervical injuries often accompany concussions

and often lead to headaches (AM, band-like).

Vestibular issues can be treated with

specialized vestibular PT.

Exercise can also be a part of rehabilitation.

Treatment

Initial rest 24-72 hours usually indicated Medications Exercise Rehabilitation Vestibular Rehabilitation Other Supplements Cervical Physical Therapy

Medications

Sleep is a critical component to rest and recovery from concussion and sometimes

requires medications.

Pain from headaches can require medications. Although less common nausea and vomiting may require medication. Attention Deficit symptoms can require medications. Cognitive “fogginess” may respond to medications. Memory may respond to alternative treatments. Some symptoms may respond to specific supplements if genetic mutations are noted.

Exercise Rehabilitation

Buffalo Protocol (Leddy MD) As some of the symptoms of concussion are

felt to be autonomic this treatment was created to identify physiologic recovery. If there is not physiologic recovery then a plan to help facilitate autonomic recovery.

4/26/15 ¡ 10 ¡ Establish the Diagnosis of a Symptom Limited Threshold

Greater than 85% age predicted max HR for 20 minutes

without symptoms is physiologic recovery.

If not recovered then start a training program. Program (running/biking) starts at 80-90% of achieved

maximum HR before symptoms for 20 minutes 6-7 days per week.

Target HR is increased 5-10 each week. Leddy has reported resolution of symptoms in several cases.

Vestibular Rehabilitation Supplements

In the animal model omega-3 fatty acids/DHA

supplements for 30 days decreased brain injury signs compared to those without the supplement.

These fatty acids are felt to decrease neural

inflammation.

It has also been thought that these can be taken

preventively.

Novel Supplements

Supplying 3 branched chain amino acids (leucine,

isoleucine, and valine) to brain injured animals helped restore normal function.

These BCAA’s are needed to produce the

neurotransmitters glutamate and gamma amino- butyric acid (GABA).

Glutamate stimulates neurons while GABA

inhibits them.

Novel Ideas

Glutamate levels are elevated

after head injury and are felt to initiate a chain reaction of cellular degradation and impairment.

Cannabinoids are felt to be

neuroprotective by neutralizing the glutamate activity and the cascade of neural damage that can follow.

Cervical PT

Neck pain leading to

cervical headaches is very common.

Neck pain leading to

dizziness and visual changes can also occur.

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Genetics Genetics

Apolipoprotein (ApoE) (3 polymorphisms) Produced by astrocytes to transport cholesterol to

neurons.

May help in the breakdown of amyloid (Alzheimer’s) ApoE 4 Found in 14 % population Impairment of above

Genetics

Apoprotein E promotor COMT DRD2 Others

Prevention Prevention

Equipment Conditioning Rules Hydration Scheduling of the pediatric

athlete

Supplements

NECK STRENGTH

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Helmets

Protective Equipment Challenges

Elusive Concussion Threshold

• Less than 0.5% of impacts exceeding 80 g cause concussion
• Impacts exceeding theoretical thresholds did not result in

deficits on clinical measures

• Concussions ranged from about 60 – 170 g, no relationship

between severity of head impact and acute clinical outcomes

Common Questions

Is there a concussion proof helmet? Is there evidence that mouthguard can protect

from concussion?

Do after market force reduction materials

help protect from concussion?

Do head impact indicators help?

Summary

Concussions can be obvious or more insidious to diagnose. Concussions can present with a multitude of symptoms. The initial management of concussions consists of relative rest

(cognitive and physical).

The vast majority (85%) of concussions resolve following an

uncomplicated course.

Those with more prolonged or complicated symptoms may

require interventions such as therapy and/or medications as well as scholastic accommodations.

Common Questions

Any evidence that an uncomplicated

concussion can lead to long-lasting or permanent impairments?

Is there a proven proper way to manage a

sports related concussion?

Concussion Recovery

Several prospective studies of neurocognitive

recovery following concussion have yet to identify impairments past 7 days. (Bellanger, 2007)

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Concussion Mangement

There is no proven method for concussion management.

Most agree on the a few basic points.

Removal from risk/activity Evaluation Initial rest if needed Graded return to school/activities No return to sport if still symptomatic

Common Questions

Is there a vulnerable window after concussion

resolution?

Do concussions in Football lead to

neurodegenerative disease/CTE?

Vulnerable Window

There is evidence that brain chemistry is altered for

nearly a month after a uncomplicated concussion.

In a study of NCAA FB players with concussion

6.5% had a repeat injury the same season. (Guskiewicz 2003)

9/12 within the first 7 days 11/12 within 10 days

Long Term Issues in Football

Not Clear 3439 NFL Players with 5+ years from

1959-1988. All causes mortality 56% expected when compared to controls. Suicide rates 41% expected. Conclusion that due to decreased midlife deaths more likely to die of late life diseases such as

• neurodegenerative. (Baron 2012)

Long Term Issues in Football

438 HS football players from 1946-1956

compared to classmates. No increase in the rate of any neurodegenerative disease. (Salvica 2012)

Survey data 513 retired NFL players

completing a cognitive test (AD8). 35% may have cognitive problems. No controls. (Randolph 2013)

How many concussions before it’s time to retire?

There is no answer to this question. Consider Forces Recovery time Cognitive/Personality changes Risk of activity

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Understand

The benefits of sports in a child’s life Self esteem Socialization Friends Work ethic/education

Understand

Imagine this child Prior to the sport they were shy without many friends.

A bit clumsy and didn’t fit in socially.

With the sport came great success National accolades/Olympic possibilities Friends/Popularity Self Esteem

Understand

Everybody knew this kid as a successful athlete with a bright future. Every note in his yearbook had something to do with his sports not

his grade point average.

Then take it all away Loss of self esteem Depression Any injury would feel better than this feeling Any risk would be worth it to escaping the sadness

Understand

Thats what this means to many when we start

throwing out the retirement card.

The kid did survive but it wasn't without a lot

• f pain.

Please understand that pain

Managing Concussions is not…

Closing Thoughts

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Concussions are not ... Concussions are not... Concussions are..... Concussions

As much as we want to categorize them... As much as people want to follow an algorithm... As much as we want a specific return to learn

program...

As much as we want to follow a specific return to

play program...

We can’t.

Concussions Happen to Individuals

These are unique people with unique lives that

have their own goals and plans for life.

I believe we have to learn these facts to better care

for the individuals who suffer from a concussion.

Knowing these facts can better help us with return

to learn as well as return to play and in a more global sense “Return to Life.”

Thank You