Transcript Concussion in Sports in New York: A 2013 Update in Caring

Concussion in Sports in New York
Kristine Campagna, DO
Latham Medical Group
Assistant Team Physician, UAlbany
Faculty, AMC Primary Care Sports Med Fellowship
28 Years of Innovation Quality Compassion
Concussion in Sports in New York
• Objectives
– Case presentation to
highlight some common
issues
– Review of NYS legislation
– Discussion of best practice
models
– Insights from most recent
international consensus
statement
Concussion in Sports in New York
• Common issues
– Field side care, who do we send to the ER?
– 1st office follow-up, return to school decision?
• Limitations?
• Medications?
• Equipment?
– Deciding return to play
• Evaluation & testing
• Stepwise/graded protocol
Concussion in Sports in New York
• Case Presentation
– July 2012
– 16 y/o female soccer player sustained head-to-head contact
with opponent during tournament game on a Friday. Brief
headache/dizziness, but no LOC/amnesia. Continued to play.
– Sat. game, knocked over landing initially on buttocks, then
head hit ground. Symptoms recurred. No LOC. Got up and
continued.
– That night, nausea and fatigue.
– Sun. challenged for aerial ball and again knocked over, this
time head hits ground 1st. Immediate dizziness, photophobia.
Took time to get up, coach came onto field and took her off.
Concussion in Sports in New York
• After this 3rd impact, she had persisting headache and neck stiffness
symptoms.
• Despite that, was allowed to resume play after 10 minutes and
completed game without further incident.
• Tournament athletic trainer did evaluate and noted her balance was
abnormal.
• Presented to her PCP Mon AM, persisting headache and vomited x2
including episode while at PCP office. Referred to Emergency Dept. at
AMC.
• Past Medical History: extremity fracture(s), no previous head injury.
• Meds/Allergies: Ibuprofen prn, NKDA.
• Family/Social: High school soccer athlete, no neurological FH.
• ROS: Headache, neck stiff, N/V, dizziness, fatigue/sleeping a lot.
• Conclusions : Sport-related concussions can be difficult to diagnose.
Concussion produces an evolving constellation of somatic, cognitive
and neurobehavioral symptoms that are typically most severe
during the earliest acute post-injury period (i.e. within the first
24–48 h) and diminish over a matter of several days to weeks in the
majority of athletes. Athletes suspected of concussion should be
removed from play and evaluated thoroughly.
Sports Concussion Assessment Tool
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Sideline evaluation of cognitive
function is an essential component
in the assessment of this injury.
Brief neuropsychological test
batteries that assess attention and
memory function have been
shown to be practical and
effective.
Such tests include the SCAT3,
which incorporates the Maddocks’
questions and the Standardized
Assessment of Concussion (SAC).
Concussion in Sports in New York
• Physical Exam:
– BP 106/68, HR 68, RR 16, Temp 98.5, Weight 123lb.
– Generally looked well, alert & oriented x3, affect normal.
No bruising or discharge nose/ears.
– Cranial nerves: EOMI, no nystagmus/diplopia, visual fields
intact, fundi no papilledema, VII-XII symmetrical.
– UE: no ulnar drift, normal finger-nose, dysdiadochokinesis,
power/sensation/DTR’s symm. & normal.
– LE: power/sensation/DTR’s symm. & normal, Romberg
negative, struggled to walk heel-to-toe, unable to maintain
tandem stance with hands on hips and eyes closed.
– Neck: FROM, mild TTP right side paraspinal musculature.
• Serial
examination
best conducted
using same
format as initial
field side asst,
e.g. SCAT3
Concussion in Sports in New York
• Imaging
– CT Scan was done in
Emergency Dept.
• Assessment/Plan
– Concussion
– Discharged from ED,
for follow-up with PCP
or Sports Medicine
Concussion in Sports in New York
• Seen by Sports Medicine 4d later
– History and physical exam repeated; still reporting
headache, and balance still abnormal on exam
– Too symptomatic for computerized neuropsych
testing at this time
– Recommended rest from physical and cognitive
activity (was out of school on vacation, limited
computer/phone & TV)
– Suggested f/u in 1 week
CONCLUSIONS:
• current evidence evaluating the effect of rest and treatment following
a sport-related concussion is sparse
• initial period of rest may be of benefit
• long-term outcome of rest, and the optimal amount and type of rest?
• low-level exercise may be of benefit
• optimal timing post-injury currently unknown
• rehabilitative techniques in individuals with clinical findings suggesting
cervical spine or vestibular dysfunction may facilitate recovery
• need for high-level studies evaluating the effects of ;
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resting period
pharmacological interventions
rehabilitative techniques
exercise for individuals who are slow to recover
Concussion in Sports in New York
• Sports Med F/U 10d post-injury
– Persisting intermittent headaches, less intense, total Sx score 21
– Dizzy with sit-to-stand, BP 88/54
– Improved balance, able to heel-toe walk and could perform tandem
stance/hands on hips and eyes closed for 15 secs w/o mistake
– Computerized neuropsych test: (ACCURATE BUT VERY SLOW)
• memory composite verbal of 91 (66%ile)
• memory composite visual 85 (86%ile)
• visual motor speed composite of 24.67 (<1%ile)
• reaction time composite of 0.86 (1%ile)
• impulse control composite of 3
• cognitive efficiency index of 0.34
Computerized
NPT
(ImPACT,
CogSport, etc)
Concussion in Sports in New York
• 10d F/U Assessment:
– Still symptomatic from concussion which is typical for high
school athlete < 2 weeks from injury*
– Exam improved
– Initial NPT shows deficits with a slow processing speed and
reaction time
– Persisting neck pain needs assessed further
• Recommended:
– Continue to rest until asymptomatic
– X-ray C-spine, Physical Therapy
*
Conclusions:
• Cases of concussion in sport where clinical recovery falls
outside the expected window (i.e. 10 days) should be
managed in a multidisciplinary manner by healthcare
providers with experience in sports-related concussion.
• Important components of management, after the initial
period of physical and cognitive rest, include associated
therapies such as cognitive, vestibular, physical and
psychological therapy, assessment for other causes of
prolonged symptoms and consideration of a graded exercise
program at a level that does not exacerbate symptoms.
Concussion in Sports in New York
• Sports Med F/U 1 month after injury
– Headaches resolving, recur with light aerobic activity.
Some photophobia still. Sx score 13. Doing PT for
neck.
– Normal exam
– Computer NPT:
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memory verbal 90 (61%ile) same
memory visual 75 (54%ile) lower
visual motor speed 29.58 (2%ile) better but still low
reaction time 0.66 (11%ile) better but still slow
impulse control 3
cognitive efficiency index of 0.45
Concussion in Sports in New York
• 1 month Post-Injury Assessment:
– Patient is improving, but still symptomatic from
concussion with deficits persisting on NPT
• Recommendations:
– May continue aerobic activity if remains symptom
free only, may progress to more vigorous activity
(e.g. strength/conditioning or sprints), if tolerated
can advance to skills practices
– Must remain non-contact
Concussion in Sports in New York
• RTP protocol
– Advance each day
– 5-7 days to
complete
– Needs
supervision
Concussion in Sports in New York
• Treatment Plan:
– Contacted School
Physician & Athletic
Trainer a high school
soccer pre-season
about to begin
– Pharmacological
management of
headaches not
considered as was
improving (despite
relatively prolonged
course)
Concussion in Sports in New York
• Sports Med F/U 6 weeks post-injury
– Bumped head on car while getting out 4d prior,
relatively innocuous at time, but since then
symptoms have escalated.
– Attempted more vigorous activity under
supervision of school athletic trainer and felt a lot
worse.
– Exam remains normal, except unable to balance in
tandem stance >10 seconds (deterioration)
Concussion in Sports in New York
• 6 Weeks Post-Injury Assessment:
– Second head injury while still recovering from 1st
• Treatment Plan:
– Concern how will perform academically going into
senior year; initiated 504 plan and provided
recommendations to school regarding limitations
and accommodations.
– High school had an established return to school
protocol which was initiated, initially stayed at
home with tutoring x 2 weeks.
Concussion in Sports in New York
• Further treatment plan:
– No anticipated return to soccer fall season
– After normal EKG, started Amitriptyline to
decrease headache intensity
– Started Amantadine to help concentration
Concussion in Sports in New York
• Headache
prophylaxis
similar to
migraine
headache
management
Concussion in Sports in New York
• Sports Med F/U 9 Weeks Post-Injury
– Headache recurs after 1 hour of home tutoring, does
continue despite this to complete 2 hours/day.
Photophobia mild.
– Exam normal, including balance.
– NPT:
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memory verbal 81 (32%ile)
memory visual 72 (47%ile)
visual motor speed 31.5 (12%ile)
reaction time 0.69 (7%ile)
cognitive efficiency index 0.3
Concussion in Sports in New York
• 9 Week Assessment:
– Persisting postconcussive syndrome
with symptoms and
neuropsych deficits
• Recommendations:
– Increased Amitriptyline
up to 40mg QHS
– Projected return to
school by end of month
Concussion in Sports in New York
• Could we have
predicted this
prolonged
course?
Concussion in Sports in New York
• Sports Med F/U 3 Months Post-Injury
– Headaches and photophobia improved further
– Successful in return to school, now just about caught
up academically
– Still on meds, but dad feels she is ‘back to normal’
– NPT really unchanged:
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verbal memory81 (32%)
visual memory 72 (47%)
visual motor speed 31 (8%)
reaction time 0.65 (12%)
cognitive efficiency index of 0.26
Concussion in Sports in New York
• 3 Month Post-Injury Assessment:
– Concussion July 2013, now with persisting postconcussive syndrome 3 months later.
• Recommendations:
– Returned to school successful
– Instructed to consider return to activity under
guidance of school athletic trainer
– Continue meds
Concussion in Sports in New York
• Sports Med F/U 4 Months Post-Injury
– Symptom score still 15, but feels better.
– Exam normal
– NPT:
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verbal memory 76 (15%ile) same
visual memory 79 (66%ile) same
visual motor speed 39.05 (45%ile) much better
reaction time 0.55 (57%ile) much better
impulse control 6
cognitive efficiency index 0.28
Concussion in Sports in New York
• 4 month Assessment/Recommendations:
– Improved processing speed and reaction time,
ready for escalation in exercise intensity
Concussion in Sports in New York
• Sports Med F/U 6 Months Post-Injury
– Weaned off meds
– Tolerating 20-30 mins of aerobic activity daily
– Grades for this school year affected, difficulty
focusing and concentrating persisted.
– NPT:
Concussion in Sports in New York
• 6 Month Assessment &
Recommendations:
– Verbal memory deficit
remains, suggesting
permanency
– Reaction time and processing
speed approaching normal
– Referred for formal
neuropsychological
evaluation
Concussion in Sports in New York
• Brief computerized
cognitive evaluation
tools are the mainstay
of these assessments
worldwide, given the
logistical limitation in
accessing trained
neuropsychologists;
however, it should be
noted that these are
not substitutes for
formal
neuropsychological
assessment.
Concussion in Sports in New York
• Conclusions:
– Concussions are often difficult to diagnose
– Management initially still centers around rest
– There is no magic solution to getting kids better
– Individualized plan rather than set protocol
– It takes time to counsel and advise athletes and
parents, coaches and schools
– Communication is the principal management tool
– If in doubt, sit them out…
Concussion
Education
Written material is key
– http://archpedi.jamane
twork.com/article.aspx?
articleid=1148388
– http://www.cdc.gov/co
ncussion/sports/index.h
tml
– http://www.nysphsaa.o
rg/safetyresearch
Special thanks to Dr Hamish Kerr
Questions?