Current Concepts in Concussion and Concussion Management
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Transcript Current Concepts in Concussion and Concussion Management
Current Concepts in
Concussion and
Concussion Management
Matt Leiszler, MD
Office-Based Sports Medicine Symposium
May 17, 2014
I have no relevant financial disclosures.
OUTLINE
Key Points
Background
Definitions
Presentation
Investigations/Studies
Management
Key Points
Key Points
These are the CURRENT concepts—very likely to evolve
80-90% of concussions resolve in 7-10 days
Majority of concussions do not involve loss of consciousness
No same day return to play
Sports Concussion Assessment Tool (SCAT-3)
New Imaging and Treatment options are on the horizon
State of the Art treatment currently: Rest
Background
Concussion
Background
CDC estimates 1.6 – 3.8 million
concussions occur annually in
sports/rec activities in the US each
year
33% of all concussions are sportsrelated (ages 5-19)
Background
Definition: Concussion (Zurich 2012)
“Concussion is a brain injury and is defined as a complex pathophysiological process
affecting the brain, induced by biomechanical forces. 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:
Concussion may be caused either by a direct blow to the head, face, neck or
elsewhere on the body with an ‘impulsive’ force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of
neurologic function that resolves spontaneously. However in some cases
symptoms and signs may evolve over a number of minutes to hours.
Concussion may result in neuropathological changes but the acute clinical
symptoms largely reflect a functional disturbance rather than a structural
injury and as such, no abnormality is seen on standard structural
neuroimaging studies.
Concussion results in a graded set of clinical symptoms that may or may not involve
loss of consciousness. Resolution of the clinical and cognitive symptoms
typically follows a sequential course. However it is important to note that in
some cases, post-concussive symptoms may be prolonged.”
Definition:
Concussion (AMSSM):
“A traumatically induced transient disturbance of
brain function and involves a complex
pathyphysiological process. Concussion is a
subset of mild traumatic brain injury which is
generally self-limited and at the less-severe end
of the brain injury spectrum”
Definitions
Concussion and Traumatic Brain Injury
Definitions
Post-Concussion Syndrome
AMSSM Position Statement 2013:
“Difficult to determine where concussion ends and
post-concussion syndrome begins”
“Symptoms and signs that persist for weeks to
months”
Zurich 2012: “Prolonged Symptoms”:
Symptoms > 10 days
10-20% of concussions
Definitions
Second Impact Syndrome
Numerous case reports, essentially
all under 22 years old
Rare, but devastating event
Unclear whether this has occurred
in an asymptomatic person
Head trauma on already injured
brain worsening metabolic
changes in the cells
Coherent for 15-60 seconds rapid
coma and respiratory failure
Concussion Legislation
Colorado’s
Senate Bill 40
“The Jake Snakenberg
Youth Concussion Act”
Signed March 29, 2011
Colorado Senate Bill 40
Senate Bill 40 Requirements
1. Training of coaches
2. Removal from play
3. Notification of a parent
4. Sign-off on return to play be medical
provider
Concussion Presentation
Multiple manifestations
No two concussions are exactly the same
Headache most common symptom; dizziness second
90% do not include loss of consciousness
Signs and Symptoms
Symptoms
Randolph, et al (2009):
12 Validated Symptoms: Concussion Symptom Inventory
• Headache
• Nausea
• Balance
problem/dizziness
• Fatigue
• Drowsiness
• “In a fog”
•
•
•
•
•
•
Difficulty concentrating
Difficulty remembering
Sensitivity to light
Sensitivity to noise
Blurred vision
Feeling slowed down
On-field/Sideline Evaluation
of Acute Concussion
Should occur if concussion even suspected
Player evaluated by physician or other licensed healthcare
provider
If no healthcare provider available remove from practice/play,
refer
ABC’s, Exclude cervical spine injury
After first aid issues addressed Sideline assessment tool
Do not leave player alone monitor over a few hours
A player with a diagnosed concussion should NOT be allowed
to return to play on the day of injury
When in doubt—sit them out!
Sport Concussion Assessment Tool
SCAT 3
Symptoms
SCAT 3
SCAT 3
SCAT 3
Referral to Emergency Department?
Worsening/Severe headache
Deteriorating mental status
Active vomiting
Focal neurologic findings
Numbness, tingling, weakness,
seizure, unequal pupils
Office or Emergency Department Evaluation
Full history, detailed neurological exam
Essentially perform a SCAT3
Determine clinical status—improving or
deteriorating?
Determine need for emergent neuroimaging in
order to exclude a more severe brain injury
involving a structural abnormality
Investigations/Studies
Investigations/Studies
Postural stability testing
Often returns to normal after 72 hours post-conc
Force plate technology
Balanced Error Scoring System
Investigations/Studies
Imaging of the Brain
CT, MRI—typically normal
If suspicion of intracerebral or structural lesion
exists Imaging
Prolonged disturbance of conscious state
Focal neurological deficits
Worsening symptoms
Investigations/Studies
Imaging of the Brain
Alternative imaging
Several methods being investigated
Exciting area of research
Investigations/Studies
Electrophysiological Recording Techniques
Electroencephalogram (EEG)
Evoked response potential (ERP)
Cortical magnetic stimulation
Reproducible abnormalities in postconcussive state
Not all studies differentiate concussed
athletes from controls
Investigations/Studies
Neuropsychological Assessment—Computer Testing
Evaluating cognitive recovery
Important component in overall assessment and
return to play
Baseline testing useful
Aids in clinical decision making—but not the sole
basis of management decisions
Investigations/Studies
Neuropsychological Assessment
Formal Neuropsych testing
Trained Neuropsychologist
Not required for all
May be beneficial in prolonged symptoms
Help identify other conditions
Investigations/Studies
Genetic testing and Biomarkers
Insufficient evidence for routine clinical use
Apo E4, ApoE promotor gene, Tau polymerase
IGF-1, IGF binding protein 2, Fibroblast
growth factor, Cu-Zn superoxide dismutase,
nerve growth factor, S-100
Serum and Cerebral Spinal Fluid biomarkers
being evaluated
Management
Cornerstone
REST
Management
Rest
Physical Rest
No training, playing, exercise, weight lifting
Exertion with ADLs
Cognitive rest
Minimize TV, extensive reading, video games
Limit to exacerbation of symptoms
Management
Return to school and social activities
Encouraged
School Accommodations
Extra time or delay tests and quizzes
until student is asymptomatic
Partial days
CDC: educational materials for
teachers/administrators
Management
Gradual resolution
80-90% of concussions resolve in a short
period (7-10 days)
Recovery may be longer in children and
adolescents
May require multiple office visits
Recovered?
Everyone says they “feel fine”
Ask:
1. “On a scale of 0–100%, how do you feel?”
2. “What makes you not 100%?”
3. Symptom Checklist—SCAT 3
Graduated Return to Play Protocol
Rehabilitation stage
1. No activity
2.Light aerobic
exercise
3.Sport-specific
exercise
4.Non-contact training
drills
5.Full contact practice
6.Return to play
Functional exercise at each stage of
rehabilitation
Objective of each stage
Symptom limited physical and cognitive Recovery
rest.
Walking, swimming or stationary
Increase HR
cycling keeping intensity < 70% MPHR
No resistance training.
Skating drills in ice hockey, running
drills in soccer. No head impact
activities.
Progression to more complex training
drills e.g. passing drills in football and
ice hockey.
May start progressive resistance
training
Following medical clearance participate
in normal training activities
Add movement
Exercise, coordination,
and cognitive load
Restore confidence and
assess functional skills by
coaching staff
Normal game play
24 Hours per step (so almost a week for full protocol)
If symptoms recur return to previous level
Evaluation by health care provider required for school age athletes
Difficult cases—persistent symptoms
Symptoms >10 days
Sports-related concussions less likely to
result in PCS
Consider other issues:Depression? Chronic
headaches? Learning disorders?
Multidisciplinary clinic
Children’s Hospital Complex Concussion Clinic
Sub-symptomatic exercise may be beneficial
Management
Pharmacotherapy
Useful for prolonged symptoms
Sleep disturbance
Anxiety
Anti-depressants
Upon return to play should not be on medications that
could mask symptoms
Avoid NSAIDs in first 48-72 hours
TCAs, Amantadine, Methylphenidate commonly reported as
being used for management
Antioxidants?
Other Treatment
Vestibular Therapy
Balance Therapy
Transcranial LED—Chronic TBI
Red and Near-Infrared LED
applied transcranially
Chronic Sequelae?
Chronic cognitive dysfunction
Chronic Traumatic Encephalopathy
Chronic Neurocognitive Impairment
CTE unknown incidence in athletic populations, cause/effect not
yet demonstrated between CTE and concussions or exposure to
contact sport
Acknowledge potential for long-term problems in all athletes
To Be Determined
Prevention
Protective equipment
Mouth guards
Prevent oral injuries
Head gear and helmets
Reduce impact forces, not concussions
Reduce head and facial injury
Cervical muscle strengthening?
Other Issues
Rule Changes
Checking
Limiting contact practices
Heading in soccer (50% of concussions are
due to arm to head contact)
Education of athletes, parents, coaches
Awareness of concussion symptoms and signs
Web-based resources, social media
Questions
How many concussions is “too many”?
Who will develop CTE? Number of hits? More “significant”
concussions?
Evolving role of advanced imaging?
What treatments may prove beneficial in concussion?
Validation of tools?
Prevention?
Key Points
These are the CURRENT concepts—very likely to evolve
80-90% of concussions resolve in 7-10 days
Majority of concussions do not involve loss of consciousness
No same day return to play
Sports Concussion Assessment Tool (SCAT-3)
Imaging and Treatment options are on the horizon
State of the Art treatment: Rest
References
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.
McCrory P, Johnston K, Meeuwisse Wet al. Summary and agreement statement of the 2nd International
Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196–204.
Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents
following sports-related concussion. Reddy CC, Collins M, Lovell M, Kontos AP. J Head Trauma Rehabil.
2013 Jul-Aug;28(4):260-5.
Management strategies and medication use for treating paediatric patients with concussions. Kinnaman
KA, Mannix RC, Comstock RD, Meehan WP 3rd. Acta Paediatr. 2013 Sep;102(9):e424-8.
Vestibular and balance treatment of the concussed athlete.Aligene K, Lin E. NeuroRehabilitation.
2013;32(3):543-53.
Should we treat concussion pharmacologically? The need for evidence based pharmacological
treatment for the concussed athlete. McCrory P. Br J Sports Med. 2002 Feb;36(1):3-5.
American Medical Society for Sports Medicine position statement: concussion in sport. Harmon KG,
Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A, Putukian M, Roberts W;
American Medical Society for Sports Medicine. Clin J Sport Med. 2013 Jan;23(1):1-18.
Thank You!