Transcript Concussion: Evidenced-Based BluePrint for Success

Concussion:
Evidence-Based Blueprint for Success
Aaron Vaughan, MD
MAHEC Sports Medicine Director
MAHEC/Mission Primary Care Sports Medicine Fellowship Director
Pediatric Grand Rounds
16 July 2014
Objectives
• Local, Regional, National Pulse/Resources
• Diagnosis of Concussion/PCS
• In-Office Framework/Algorithm
▫ Vestibular-Ocular Motor System (VOMS)
• Evidence-based
• Pertinent, Practical
Teaching Points
• Know your guidelines
▫ NC: Gfeller Waller Concussion Act
• Know what you don’t know (and where/who to look
for info)
▫ CDC, BIANC, Local Providers/Referral Sources
• Know your bonus prizes/red flags
▫ Cerebral bleeds, Orbital Floor
• Know your exam
▫ Vestibular-Ocular***
• Know your Options
▫ School is Key: Accommodate
Local, Regional, National
“Preliminary Approval in NFL
Concussion Lawsuit”
• Original settlement
▫ $675 M for players with neurologic
symptoms
▫ $75 M for baseline testing
▫ $10 M for medical research
▫ $112 M lawyers fees
• No cap
Local/Regional: WNC
• >60,000 seen in ER/yr (2007)
• Sport-Related: 607/yr (1996-99)
• Football: 33/100k athlete exposures
National
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
ED Visits Hosp
420.6 82.7
433.9 85.6
423.3 94.6
486.3 97.6
505.0 92.8
478.9
98.7
457.5
91.7
616.4
95.5
677.4
98.0
715.7
91.7
Deaths
18.5
18.3
18.2
18.1
18.6
18.2
18.2
17.7
17.2
17.1
Total
521.0
537.2
535.4
601.3
615.7
595.1
566.7
728.9
791.9
823.7
CDC Rates of TBI-related Emergency Department Visits,
Hospitalizations, and Deaths — United States, 2001–2010
Per 100,000
National Hospital Ambulatory Medical Care Survey — United
States, 2001–2010 (Emergency Department Visits)
Rates of TBI-related Emergency Department Visits,
Hospitalizations, and Deaths----US, 2001-2010
National
Hospital
Ambulatory
Medical Care
Survey —
United States,
2001–2010
(Emergency
Department
Visits)
National
Hospital
Discharge
Survey —
United States,
2001–2010
(Hospitalizatio
ns)
National
Vital Statistics
System
Mortality Data
— United
States, 2001–
2010 (Deaths)
National
Rates of TBI-related Emergency Department
Visits by Age Group — United States, 2001–2010
National Hospital Ambulatory Medical Care Survey — United
States, 2001–2010 (Emergency Department Visits)
Case
• JA is a 16 year old women’s soccer player who
goes up for a header and instead knocks heads
with an opposing player. She has initial dizziness
and a headache as well as a left occipital
contusion. These symptoms last for 1 hour and
by the time she presents to the ER her symptoms
have totally resolved. Her parents push for a CT
for “clearance” which is normal. She presents to
your clinic the next day because her athletic
trainer her told her to. She remains subjectively
symptom free.
Case (cont)
• Was this a concussion
▫ Yes
▫ No
Concussion = Clinical Diagnosis
Mechanism + Symptoms
Algorithm: In-Office
• Concussion Algorithm: In-Office
Case (cont)
What is a Concussion?
▫ A complex vascular and neurochemical process
affecting the brain, caused by direct or indirect
traumatic forces to the head
Keys:
• Not a Structural,
but a Functional
Problem
• Loss of
consciousness
only occurs in
only 10% of
concussions.
Case (cont)
Signs/Symptoms of a Concussion
• Physical
• Emotional
• Cognitive
• Sleep
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Headache
Nausea
Dizziness
Impaired Balance
Phonophobia/Photophobia
Tinnitus
Cervicalgia
Confusion
Mental “fogginess”
Feeling slowed down
Concentration difficulties
Memory Impairment
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Irritability
Sadness
Anger
Nervousness/Anxiety
Mood lability
Drowsiness
Sleeping more than usual
Restless sleep
Increased sleep
latency/Trouble falling
asleep
Case (cont)
• Concussion Types
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Executive
Psychogenic
Cervicogenic
Vestibular
Ocular
Migrainous
Case (cont)
• Objective #1: Rule out ‘Badness’
▫ ie: When to send to ER or Need for
Imaging
Keys:
 Signs of increasing pressure on brain
• Do not interrupt
sleep to check for
symptoms
Loss of consciousness > 30 seconds
Convulsions / seizures
Deteriorating level of consciousness or behavior
Headache that is rapidly worsening or becoming
severe
 Late onset of or persistent vomiting
 Late onset of or worsening amnesia / memory loss
 Focal neurological signs (motor function, vision,
speech)
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Case (cont)
• An appropriate evaluation in your office would include which of the
following?
▫ A review of her symptoms; a neurologic exam and send her for a stat
MRI
▫ A review of her symptoms; a neurologic exam and a concussion
assessment tool
▫ A review of her symptoms; a few memory questions and a balance
test
▫ A review of her symptoms; order a stat MRI and blood sample
checking for elevated levels of S100 calcium binding protein B
(S100B)
Algorithm: In-Office
• Concussion Algorithm: In-Office
Exam
• Symptom Evaluation
▫ SCAT3/Child SCAT3
• Exam
▫ Physical
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Orbits
Dental
Cervical
Other distracting injuries
▫ Neurologic
 CN II-XII
 Gross Motor/Sensory
Exam (cont)
• Vestibular-Ocular
▫ VOMS
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Smooth Pursuits
Saccades: Horizontal
Saccades: Vertical
Convergence (near point)
VOR: Horizontal
VOR: Vertical
Visual Motor Sensitivity Test
VOMS
• VOMS
▫ Vestibular-Ocular injury: Rotational/Occipital
blow
 Symptoms:
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Migraine presentation
On-field ‘dizziness’
Vision complaints (blurred, focus issues)
Balance problems
Motion sickness
Anxiety in busy environments
Problems with math/screen time/reading
Exam (cont)
• Neurocognitive
Exam (cont)
• Neurocognitive: ImPACT
▫ What is It?
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One piece of the overall concussion evaluation and management process.
A sophisticated test of cognitive abilities.
A tool to help health care professionals track recovery of cognitive function
A tool that helps health care professionals and educators make decisions about
academic needs following concussion
▫ What isn’t It?
 A cure-all for concussion. Concussions still happen.
 A substitute for medical evaluation and treatment.
 Not a tool to “Diagnose”
 The only tool out there
Case (cont)
• Which of the following recommendations do you
have for her care?
▫ Have her go into “cocoon therapy” and go to complete
bed rest avoiding all electronic devices
▫ She can warm up tonight at 50 % effort and if that goes
well, she can compete without any restrictions
▫ Avoid any physical activities that raise her heart rate
and limit cognitive activities that “tire” her brain
▫ Allow her to briskly walk the dog and do basic
tumbling moves and limit her Facebook time to less
than 1 hour a day
Algorithm: In-Office
• Concussion Algorithm: In-Office
Rest
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Gfeller Waller Accommodations
Physical Rest
Avoid activities that elevate heart rate
Applies to all activities: practice, competition, physical education, dance,
non-school based activities, household chores
Avoid further trauma / injury to the brain
Sleep is essential
Hydration/nutrition
20-30 mins/light aerobic activity
Cognitive Rest
Limit concentration effort
▫ Homework, school work, job-related work
▫ Texting, computer, video games or television use
▫ May require changes to a normal academic day
Bottom Line: Don’t do anything that makes symptoms worse!
Use symptom score
Case (cont)
• Once she is asymptomatic, has a normal exam and
passes a concussion assessment tool, what level of
exercise are you going to allow her first day back?
▫ Allow her to briskly walk the dog and do basic
tumbling moves
▫ Light aerobic exercise (e.g. stationary cycle or walking
laps for 30 minutes)
▫ Sport-specific exercises at moderate effort for less than
1 hour (e.g. moderate jog, moderate footwork drills,
shooting drills)
▫ Start out light for about ½ hour and if she tolerates
that, allow her to progress to a full workout that first
day
Algorithm: In-Office
• Concussion Algorithm: In-Office
PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION
Keith H. May, David L. Marshall, Thomas G. Burns, David M. Popoli, John A. Polikandriotis
Int J Sports Phys Ther. 2014 April; 9(2): 242–255.
Return to Play
Case (cont)
•
What are you going to do for her if her
symptoms plateau at 3-4 weeks?
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Arrange a referral to a concussion specialty clinic
Arrange for a brain MRI and if it is normal she never really had a
concussion anyway
Arrange for more extensive testing such as an ImPACT test or
CogState test
Have her initiate a return to play protocol to see if it aggravates her
symptoms; if not, allow her to return to full activities once completing
the protocol
How do you evaluate someone for Post
Concussive Syndrome?
• Be suspicious when:
▫ A concussion seems to be stalling out after one week
▫ Concussion symptoms continue after three weeks
▫ Concussion symptoms come back shortly after increasing activities
• Is it still a concussion or is it something else (Bonus Prize)?
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Inner ear problems
Cervical spine trigger points or facet problems
Migraine cluster
Post traumatic stress disorder
Something more serious?
 Seizure disorder
 New presentation of brain mass/tumor
 Subdural hematoma
Algorithm: In-Office
• Concussion Algorithm: In-Office
Review
• Be suspicious of a concussion/PCS. “If in doubt hold them out”
• Be familiar with your algorithm; Know your exam (VOMS)
• Signs/symptoms change. Evaluate the athlete looking at:
Cervicogenic, Psychogenic, Vestibular, Ocular, Migrainous, Executive
dysfunction
• There are many tools to help you on the sidelines and in the office.
The law recommends that you use one.
• Initial treatment is based on both physical and cognitive rest until the
symptoms resolve.
• Returning to activities is gradual process once asymptomatic. RTP
Protocols vary
• Work closely with all of the health care providers involved (athletic
trainers, school nurses, consulting neurologist or neuropsychologists)
to provide the best care for this complex problem.
Resources
• Other web based Resources:
▫ CDC Heads Up: Brain Injury in Your Practice
 http://www.cdc.gov/concussion/headsup/physicians_t
ool_kit.html
▫ North Carolina High School Concussion Paperwork
 http://www.nchsaa.org/health-and-safety
▫ North Carolina Concussion Clearance Form
 http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwla
w.html
▫ Brain Injury Association of North Carolina
 http://bianc.net/
▫ Zurich Concussion in Sport
Aaron Vaughan, MD
MAHEC/Mission Sports Medicine
[email protected]
http://mahec.net/patient-information/family-health/sports-medicine
330-904-9273
@DrAJVaughan