Transcript Slide 1
New Developments in the
Management of
Concussions
More like ankle sprains than you think
David Marshall, MD
Medical Director
Sports Medicine Program
Children’s Healthcare of Atlanta
Concussions in the News
11/1/10
June 7, 2009
“New Guidelines on Young Athletes’
Concussions Stir Controversy”
Introduction
Definition
Epidemiology of concussions
Pathophysiology
Background of grading
On field / in office assessment
Return to play decision making
Neurocognitive testing
What you can do as a school administrator
Definition of Concussion
A BRAIN INJURY involving rapid but
transient alteration in cognitive functioning
secondary to a blow to the head or a blow to
another part of the body resulting in
acceleration forces to the brain.
May or may not involve loss of consciousness
Recovery follows a sequential course
Standard imaging (CT, MRI) normal
A type of “minimal traumatic brain injury”
(MTBI)
Epidemiology
Nationwide Hospital –
Columbus, OH
“137,000 concussions in high school
athletes during 2007-08 school year
Football – 70,000
Girls soccer – 24,000
Boys soccer – 17,000
Girls basketball – 7000
Lacrosse, cheerleading, gymnastics, ice hockey
Epidemiology“Silent Epidemic”
CDC study estimates 300,000 sports and
recreation-related concussions per year
Study included only those with LOC
Other studies show concussions resulting in LOC
account for only 8% - 19% of injuries
Therefore 1.6 – 3.8 million concussions occur each
year
About one half of injuries are recognized and reported
Number may be doubled
Pathophysiology
Functional injury vs structural
Metabolic crisis
Ionic shifts involving glutamate, Na, K, Ca
Results in hyperglycolysis and increased
energy demand
Ca released from endothelial lining causing
cerebral vasoconstriction
This metabolic mismatch between energy
supply and demand is thought to propagate
neural cellular vulnerability
Pathophysiology
Functional injury vs structural
Metabolic crisis
Ionic shifts involving glutamate, Na, K
Results in hyperglycolysis and increased
energy demand
Ca released from endothelial lining causing
cerebral vasoconstriction
This metabolic mismatch between energy
supply and demand is thought to propagate
neural cellular vulnerability
Signs
Appears dazed
Vacant stare
Confused
Disorientation
Emotional lability
Clumsiness
Slow answering ?s
Behavior changes
Symptoms
Headache
Nausea/vomiting
Dizziness
double/blurred vision
Sensitive to light/noise
Foggy, “out of it”
Changes in sleep
Impaired concentration
Emotional, irritable, sadness
Signs
Appears dazed
Vacant stare
Confused
Disorientation
Emotional lability
Clumsiness
Slow answering ?s
Behavior changes
Symptoms
Headache
Nausea/vomiting
Dizziness
double/blurred vision
Sensitive to light/noise
Foggy, “out of it”
Changes in sleep
Impaired concentration
Emotional, irritable, sadness
Symptoms of Concussion
1. Headache
2. Feeling slow
3. Difficulty concentrating
4. Dizziness
5. Fogginess
6. Fatigue
7. Blurred/double vision
8. Light sensitivity
9. Memory dysfunction
10. Balance problems
71%
58%
57%
55%
53%
50%
49%
47%
43%
43%
Confusion
Memory
Multi-tasking
Irritability
Visual changes
Balance
Dizziness
Attention
Arousal/speech
Sleep/wake
Emotions
Fogginess
What grade is it?
When can he go back to play?
Background
Concussion management formerly
based on guidelines from expert opinion
Since 1973, 19 different grading
systems to grade concussion and guide
RTP decisions
International Symposium on Concussion
in Sport 2001, 2004, 2008
American Academy of
Neurology
Grade
One
Two
Criteria
Sx clear Sx > 15
< 15 min min
Any LOC
RTP
20 min
after sx
clear
2-4
weeks
after sx
clear
1-2
weeks
after sx
clear
Three
Multiple Concussions
2nd grade 1
out 2 weeks
2nd grade 2
out 1 month
2nd grade 3
out for season
3rd any grade
done for season
The Problem
These guidelines are not scientific or
evidence based, only expert opinions
Placed different emphasis on LOC, PTA,
length of symptoms
Return to play recommendations varied
for the same injury
The “bell ringer” - not so trivial
64 high school football players age 1317 who suffered grade 1 concussions
with all symptoms resolving within 15
minutes
Average time for full neurocognitive
recovery was 7 days
Lovell, Collins, Iverson et al: J Neurosurg 2003
2nd Study
Same group of high school kids with “grade
1” concussions showed significant decline in
memory function and an increase in symptom
reporting at 36 hours post-injury
Those who were asymptomatic by 5 min
returned to baseline on day 4
Lovell, Collins, Iverson, et al: Am J Sports Med
What does this mean?
These studies question the validity of
the grading system for management of
“mild” or grade 1 concussions
Findings also suggest that all high
school athletes diagnosed with
concussion be removed from play and
not return during that contest
Grading
It doesn’t matter!!!
Criteria for returning to play are the same for
all individuals regardless of their initial
symptoms or presentation
Asymptomatic after rest (physical and cognitive)
Asymptomatic after return to school and activity
“Normal” neurocognitive testing
Get away from minimizing terms like “bell
ringer” and “ding”
Similar to ankle sprain
Is this ankle ready to play?
Assessment
On the field / Office
Assessment
Symptoms of concussion vary widely
from individual to individual
May have only a single symptom or a
constellation of symptoms
Assessment
“If injured athlete shows any sign or
symptom of concussion, they are held out for
that game and given a more comprehensive
evaluation and cleared by a qualified medial
professional trained in the management of
concussions”
-International Symposia on Concussion in Sport,
Zurich 2008
Recommendations
NFL
NHL
MLB
NCAA
NFHS
GHSA
AAP, ACSM, AMSSM, AAN
Management of Concussion
3 Areas of Focus
Prevent Second Impact Syndrome
Prevent against cumulative effects of
injury
Neurocognitive and biomechanical
Prevent Post-Concussion Syndrome
Second Impact Syndrome
Management of Concussion
3 Areas of Focus
Prevent Second Impact Syndrome
Prevent against cumulative effects of
injury
Neurocognitive and behavioral
4x higher risk for 2nd concussion
Minor blow, symptoms last longer
Prevent Post-Concussion Syndrome
Later signs of Post-Concussion
Syndrome
Decreased processing speed
Short term memory impairment
Concentration deficit
Irritability/depression
Fatigue/sleep disturbance
General feeling of “fogginess”
Academic/occupational difficulties
September 30, 2009
“Dementia Risk Seen in
Players in NFL Study”
Management
Do not allow return to play till evaluated
fully
Cognitive rest
Remember the “metabolic crisis”
Physical rest
Neurocognitive testing
Cognitive Rest
Hold out from school till symptoms improve
Minimal TV
Minimal video games
texts/tweets/twits
Do not attend practice if symptomatic
When symptoms subside, may return to
school
½ day, core classes only, test modification,
etc
School suggestions
Have Concussion Management Plan
Teachers, school nurse, counselors, coaches,
administrators need to be aware
504 form
Watch for problems with:
Attention/concentration
Remembering or learning new information
Irritability, less tolerance of stressors
HA, fatigue when doing schoolwork
math /science
Identify the “Concussion
Recovery Team”
medical
Athlete
school
home
P.R.E.P.
Prepare
(look for this summer 2011)
Educate school personnel, coaches, parents, kids,
medical, etc.
Respond
What to do when an athlete is concussed
Enable the athlete to return to school,
Play
activities as the improve
Allow the athlete to return to sports
School options
No school
Return to school
Shortened day
Shortened classes with rest breaks
Extended time to complete HW, tests, etc
No tests
Void tests/coursework completed while
symptomatic
Probably need letter, 504 form
Physical Rest
No physical exertion while symptomatic
When symptoms subside, may begin 5 stage rehab
Stage
Stage
Stage
Stage
Stage
Stage
1-minimal exertion (30-40% max HR)
2-light exercise (40-50% max HR)
3-mod aggressive (60-80% max HR)
4-sport performance (80-90 max HR)
5-sports performance (full exertion with contact)
6-full return without restriction
Neurocognitive Testing
Sideline assessment tools
SAC, SCAT, ACE, Symptom checklists
Maddocks questions
Which field are we at?
Who are we playing?
What quarter (period) is it?
How far into the quarter is it?
Which side scored the last points?
Who did we play last week?
Did we win last week?
Neurocognitive Testing
CogSport
HeadMinder concussion resolution index
(CRI)
Reaction time index – white circle - spacebar
Cued RTI
Complex reaction time index (CTI)
Processing speed index
Animal decoding subtest
Symbol scanning subtest
Neurocognitive Testing
ImPACT – Immediate Post-Concussion
Assessment and Cognitive Testing
Concussion history, medical, psychological history
Symptom checklist
Subtests
Verbal memory composite
Visual memory composite
Visual motor speed composite
Reaction time composite
Impulse control composite
ImPACT subtests
Word memory
Design memory
Xs and Os
Symbol match
Color match
Three letter memory
Verbal memory
Visual memory
Reaction time
Visual motor
processing speed
Impulse control
When to ImPACT test?
concussion
baseline
Day 5-10
24-72 hrs
Weekly?
Return to Play
Asymptomatic at rest
Asymptomatic with max exertion
Cognitive and physical
“Normalization” of ImPACT test
Summary – Clinical Facts
Clinical symptoms linked to brain
related changes in physiology
Different biomechanics (genetics?) likely
lead to different symptom patterns
Physical and cognitive exertion play
strong role in recovery
Mild injuries become severe if not
managed properly
Summary – Clinical Facts
Lack of education and awareness of
injury is widespread
Neurocognitive testing and objective
evaluation is key in RTP
Individual management of injury
indicated…no 2 concussions are alike
What we still don’t know
Appropriate thresholds to define injury-when is the
brain truly concussed?
Why do some athletes have lower threshold for injury?
Is concussion cumulative or does proper management
mitigate effects?
Why do some athletes develop long-term difficulties
while many do not?
What are potential long-term effects of concussive
injury, if any?
Gender differences?
Where are we headed?
With CDC, continue to educate athletes,
parents, coaches, trainers, physicians on the
recognition and management of concussions
Know your “ABCs”
Continue research in kids regarding brain
related changes following injury
Need for continued study of identified and
unidentified risk factors
Develop a lifespan approach to understanding
injury
Where are we headed?
With CDC, continue to educate athletes,
parents, coaches, trainers, physicians on the
recognition and management of concussions
Know your “ABCs”
Continue research in kids regarding brain
related changes following injury
Need for continued study of identified and
unidentified risk factors
Develop a lifespan approach to understanding
injury
Thank You
Children’s Healthcare of Atlanta
Sports Concussion Clinic
404-785-1111