What to Tell Parents Justin M. Wright, MD Program Director, Sports - - PowerPoint PPT Presentation

Concussion Management and What to Tell Parents

Justin M. Wright, MD Program Director, Sports Medicine Fellowship Program Director, Family Medicine Residency Associate Professor, Department of Family and Community Medicine Paul L Foster School of Medicine

Objectives

• Define a concussion
• Define the pathophysiology of a concussion
• Describe the evaluation of a patient with a

suspected concussion

• Describe the treatment of a patient with a

concussion

• Describe the return-to-play protocol for a

concussion

What is a Concussion?

What about this?

What is a concussion?

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

2017 Berlin Guidelines

Why do we care?

11 ‘R’s of Concussion Management

• Recognize
• Remove
• Re-evaluate
• Rest
• Rehabilitation
• Refer
• Recover
• Return to Sport
• Reconsider
• Residual effects and

sequelae

• Risk Reduction

Recognize

Definition – Berlin 2017

• Direct blow to the head, face, neck or elsewhere on the

body with an ‘‘impulsive” force transmitted to the head.

• Rapid onset of short-lived impairment of neurological

function that resolves spontaneously.

• Functional disturbance rather than a structural injury
• Graded set of clinical symptoms that may or may not

involve loss of consciousness.

Pathophysiology

Impact force to head, neck, or body Disruption of neuronal cell membranes Widespread depolarization/Neurotransmitter release Large efflux of potassium Increased activation of Na+/K+ ATP- dependent pumps Hyperglycolysis/Depletion of energy stores Accumulation of lactic acid Calcium influx into mitochondria Impaired oxidative phosphorylation Decreased ATP production Initiation of apoptosis

Leddy, et al. Sports Health. Mar 2012;4(2):147-154.

Assessment

• Symptoms

– Somatic

• Headache
• Dizziness

– Cognitive

• “In a fog”

– Emotional

• Lability

Assessment

• Physical signs

– LOC – Amnesia

• Behavioral change

– Irritability

• Cognitive impairment

– Confusion – Slowed reaction time

• Sleep disturbance

– Insomnia – (Later finding)

Remove

Sideline Evaluation

• Evaluate for c-spine injury
• Remove player from participation

– Keep piece of equipment to prevent re-entry

• Use SCAT 5 or other sideline tool

– Maddock’s questions – Person/place/time unreliable

• Serial monitoring of athlete

– Appearance of signs/symptoms may be delayed several hours

• No same-day return to play

What venue are we at today? Which half is it now? Who scored last in this match? What team did you play last week / game? Did your team win the last game?

SCAT 5

Re-evaluate

Further Care

• Evaluation in ER or physician’s office
• (Natasha’s Law – H.B. 2038)

– Detailed neurologic exam

• Cranial nerves
• Cerebellar function

– Mental status

• Answers questions appropriately

Examination

• Cranial nerves

– Focal findings may indicate discrete lesion

• Pupils

– May be sluggish

• Cognitive function

– Serial 7s

• Balance

– Romberg – Tandem gait – Balance Error Scoring System (BESS)

BESS Test

• 3 different stances for 20

seconds each with eyes closed

• Watch for errors indicating loss
• f balance
• Errors

– Hands lifting off the iliac crests – Eyes opening – Stepping, stumbling, or falling – Moving the hip into more the 30 degrees of flexion or abduction – Lifting the forefoot or heel – Remaining out of the testing position for more than 5 seconds

Guskiewicz KM. Clin Sports Med. Jan 2011;30(1):89-102

Imaging?

• Typically normal in concussion

– Functional injury

• Indicated for:

– Focal neurologic deficits – Prolonged cognitive disturbance – Worsening symptoms

Neuropsychological Testing

The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and contributes significant information in concussion evaluation

• Berlin 2017 Guidelines

Rest

Management

• Rest

– Previous recommendations

• No activity until asymptomatic

– (yes, this also means school)

• Previously based on consensus opinion

What’s the Evidence?

• Griesbach, et al, 2004

– Rat Model – Sham vs. fluid percussion injury – Caged with or without access to a running wheel

• Either 0-6 days post-injury (acute) or

14-20 days post-injury (delayed)

– Measured brain-derived neurotrophic factor, proteins in synaptic function, and performance on Morris water maze – ***Immediate exercise after injury led to negative results on all testing

• Delayed exercise similar to sham

controls

• Neuroscience. 2004;125(1):129-139.

What’s the Evidence?

• Gibson, et al, 2013

– Chart review of 184 patients, 135 with complete records

• Recovery defined as symptom-free at rest and exertion, without medication;

computerized neurocognitive test scores at or above baseline or normative values; and balance at baseline

– Cognitive rest recommended to 85 patients – ***No association observed between the recommendation for cognitive rest and the duration of symptoms – Limitations

• Tertiary concussion center – cannot generalize
• Retrospective
• No documentation of compliance to rest
• More severe concussions more likely to be told to rest?

What’s the Evidence?

• Majerske, et al, 2008

– Chart review of 86 athletes – Outcome measure – Postconcussion symptom scores and neurocognitive scores (ImPACT) – Activity Intensity Scale

• 0 – no school or exercise activity
• 1 – school activity only
• 2 – school activity and light

activity at home

• 3 – school activity and sports

practice

• 4 – school activity and

participation in a sports game

– ***Moderate intensity activity performed better

J Athl Train. 2008;43(3):265-274.

What’s the Evidence?

• Moser, et al, 2012

– Chart review of 49 athletes evaluated for concussion

• Stratified based on time of

presentation (1-7d, 8-30d, 30+d)

• Prescribed at least one week of rest

(28 athletes required additional rest)

• Outcomes measured by ImPACT

testing and symptoms scores

– Significant effect of prescribed rest with no effect of time elapsed since concussion noted

• Improvement in cognitive function

and symptom score

– Retrospective, no control group

J Pediatr. 2012;161(5):922-926.

What’s the Evidence?

• Brown, et al, 2014

– Prospective cohort

• 335 patients evaluated within first 3

weeks of injury

– Patients completed cognitive activity scale at each visit

• Cognitive activity-days – average

cognitive activity level multiplied by days between visits

– Primary outcome – duration of post-concussion symptoms – ***Patients in highest quartile of cognitive activity-days took statistically longer to recover than those in first to third quartiles

What’s the Evidence?

• Thomas, et al, 2015

– Patients from pediatric ED within 24 hours of concussion – 88 patients randomized to 2 groups

• Usual care (1-2 days rest, then return to school and activity in stepwise fashion)
• 5 days strict rest (no school, work, or physical activity)

– Activity assessed by activity diaries – Outcome measures – symptom survey, neurocognitive assessment, and balance assessment – Results

• ***Strict rest group reported more daily postconcussive symptoms and slower symptom resolution

than usual care group

– No difference in balance or neurocognitive outcomes

– Limitations/Caveats

• No true control group
• Acute care setting
• Discharge instructions may influence perception of illness
• Use of diaries to quantify activity levels – recall bias

What’s the Evidence?

• Thomas, et al, 2015

– Results

• ***Strict rest group reported more daily postconcussive symptoms

and slower symptom resolution than usual care group

• No difference in balance or neurocognitive outcomes

– Limitations/Caveats

• No true control group
• Acute care setting
• Discharge instructions may influence perception of illness
• Use of diaries to quantify activity levels – recall bias

What’s the Evidence?

• Buckley, et al, 2015

– 50 consecutive collegiate athletes with concussion

• 25 before and 25 after protocol change

– Mandating 1 rest day from physical and cognitive activities – Same return to play protocol

– Evaluated on graded symptom score, SAC, BESS, ImPACT, and time to clinical recovery

• Clinical recovery – time until all tests were at baseline and athlete started RTP

protocol

– ***No-rest group achieved asymptomatic status 1.3 days faster than rest group (P=.047)

• No difference in return to baseline on SAC, BESS, ImPACT, or time to clinical

recovery between the two groups

New rest recommendations

• Typically 24-48 hours, then gradually increase

activity

– Symptom-limited

• Avoid vigorous exertion

Rehabilitation

Rehabilitation

• Concussion can result in diverse symptoms

and problems

– May have concurrent cervical spine and peripheral vestibular system involvement

• Cervical spine, vestibular, and psychological

interventions have all been shown to be effective

What about Exercise?

• Prolonged inactivity may be responsible for many post-injury

symptoms

– Deconditioning, depression, isolation

• Alteration in cerebral blood flow may also be culprit for prolonged

symptoms

– Autonomic dysfunction

• Growing body of evidence that controlled, subsymptom-threshold

exercise may be beneficial for prolonged concussion symptoms (>4 weeks)

• Exercise may be beneficial to improve cerebral blood flow and

reduce metabolism dysregulation

Exercise with Prolonged Symptoms

• Kurowski, et al, 2016

– 30 adolescents with 4-16 weeks of persistent concussion symptoms – Baseline – exercise test to determine time and intensity that symptoms arose – Randomized to subsymptom threshold exercise vs. full body stretching

• 5-6 days per week
• Exercise group – 80% of duration that

exacerbated symptoms

– Followed with post concussion symptom inventory

• ***Greater rate of improvement in

exercise group vs. stretching group

– Despite lower adherence to recommendations

J Head Trauma Rehabil. 2016.

Refer

Persistent Symptoms

• Failure beyond expected time
• f normal clinical recovery

– >10-14 days in adults – >4 weeks in children

• Treatment should target

specific medical, physical, and psychosocial factors

• Limited evidence for

pharmacotherapy

• Difficult cases should be

managed in multidisciplinary setting

Recovery

Recovery

• Return to normal activities

– School, work, sports

• Typical within one month from initial injury
• Predictors of slower recovery

– Severity of initial symptoms – Children and young adults with mental health problems or migraine headaches – ADHD or learning disorders

Return to Sport

Return to Sport

• Each step 24 hours apart
• If asymptomatic  progress to next step
• If symptoms develop

– Rest 24 hours – Repeat the last asymptomatic step

Reconsider

Special Populations

• Elite athletes

– Should be managed the same as non-elite

• Child and adolescent athlete

– Expected duration up to 4 weeks – Child SCAT5

• Parent and child symptom report

– Return to school

Return to School

• Coordinated effort

– Healthcare provider, the student, the parents, the teachers, and often the school nurse and guidance counselor

• Accommodations

– Excused absences from class – Rest periods during the day – Extension of assignments – Postponement of tests – Extended testing time – Accommodation for light and/or noise

• versensitivity

– Avoidance of physical exertion

Residual Effects and Sequelae

Long-term Sequelae

The potential for developing chronic traumatic encephalopathy (CTE) must be a consideration, as this condition appears to represent a distinct tauopathy with an unknown incidence in athletic populations. A cause- and-effect relationship has not yet been demonstrated between CTE and SRCs or exposure to contact sports. As such, the notion that repeated concussion or subconcussive impacts cause CTE remains unknown.

• 2017 Berlin Guidelines

Risk Reduction

Concussion Prevention?

• Impossible to eliminate all concussion in sport

– Strategies can reduce number and severity

• Helmets

– Great at preventing skull fractures

• Mouthguards

– Non-significant trend towards a protective effect – Better at protecting teeth

• Most consistent evidence is in rule changes

– Body checking rules in youth hockey

• More research needed

Search for the Holy Grail

Concussion Protocols

• In Texas – H.B 2038 (Natasha’s Law)
• If a concussion is suspected, the protocol is

enacted

– Even if concussion is not final diagnosis

• We (physicians) are not clearing to return to play,

we are clearing to start the RTP protocol

• Each school district has an individual protocol

– Specifics vary between districts

What do we tell parents?

• At the time of injury

– Rest – Monitor for signs of decompensation

• Not responding to commands
• Excessive drowsiness
• Focal neurological deficits

– DO NOT wake them up every hour – Avoid NSAIDs for the first 24- 48 hours

• Acetaminophen for pain
• At the office visit

– Explain that this is a brain injury

• A change in the way the brain

works as a result of a trauma

– Broken ankle analogy – If you’ve seen one concussion, you’ve seen one concussion

• Every one is different
• Must be managed individually

– Education and expectations are key

Summary

• Concussion is a functional injury
• No same-day return to sporting events
• Treatment must be individualized
• Proper treatment and gradual return to

activity may prevent immediate and long-term sequelae

Questions?

Sources

• McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held

in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699

• Scorza KA, Raleigh MF, O'Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician. 2012;85(2):123-132.
• Putukian M. The acute symptoms of sport-related concussion: diagnosis and on-field management. Clin Sports Med. 2011;30(1):49-61, viii.
• Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011;30(1):33-48, vii-iii.
• Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr.

2012;161(5):922-926.

• Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor

upregulation and recovery of function. Neuroscience. 2004;125(1):129-139.

• Lovell MR, Pardini JE, Welling J, et al. Functional brain abnormalities are related to clinical recovery and time to return-to-play in athletes.
• Neurosurgery. 2007;61(2):352-359; discussion 359-360.
• Gibson S, Nigrovic LE, O'Brien M, Meehan WP, 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj.

2013;27(7-8):839-842.

• Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train.

2008;43(3):265-274.

• Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP, 3rd. Effect of cognitive activity level on duration of post-concussion
• symptoms. Pediatrics. 2014;133(2):e299-304.
• Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957.
• McGrath N. Supporting the student-athlete's return to the classroom after a sport-related concussion. J Athl Train. 2010;45(5):492-498.
• Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial.
• Pediatrics. 2015 Feb;135(2):213-23
• Buckley TA, Munkasy B, Clouse, BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil.

2015;epub ahead of print