Transcript Concussion Management: Primary Care Like the Pros David M. Smith, M.D., FAAFP March 17, 2014

Concussion Management:
Primary Care Like the Pros
David M. Smith, M.D., FAAFP
March 17, 2014
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Level the Playing Field
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NFL Concussion Protocol
• Sideline concussion
assessment
• Remove from play
• Evaluate in locker room
• Ipad modified SCAT3
• Compare to baseline
• Serial assessments
including ImPACT
• Initiate follow up plan
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Zurich 2012 Concensus Statement
• Concussion definition
– A brain injury with a
complex pathophysiological
process affecting the brain,
induced by biomechanical
forces
– Direct blow or any blow
elsewhere causing
“impulsive force” to head
Clin J Sport Med 2013;23:89-117
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Concussion
• Concussion typically results in a rapid onset of shortlived impairment of neurologic function that resolves
spontaneously
• In some cases, symptoms and signs may evolve over
a number of minutes or hours
• Acute clinical symptoms reflect a functional
disturbance rather than a structural injury
• May or may not involve loss of consciousness
• Symptoms may be prolonged
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Symptom Categories
Physical
Cognitive
Emotional
Sleep
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Symptom Categories
• Physical
–
–
–
–
Headache
Visual changes
Nausea
Light or noise sensitivity
• Cognitive
–
–
–
–
Fogginess
Memory dysfunction
Inattentiveness
Slowed mentation
• Emotional
–
–
–
–
Lability
Sadness
Irritability
Nervousness
• Sleep
– Insomnia
– Hypersomnia
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Loss of Consciousness
• 90% of concussions
involve no loss of
consciousness
• NOT predictive of the
severity of concussion
• Nature, burden, and
duration of clinical
postconcussive
symptoms determine
severity
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Concussion Symptoms:
How Long Do They Last?
• 85% of concussions fully recover in 3 – 4 weeks
• 10 – 15 % of concussions result in persistent
symptoms > 10 days
• Cases of concussion where clinical recovery falls
outside of expected window should be managed in a
multidisciplinary manner by providers experienced in
concussion management
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Concussion Management
• Acute
Best
Practice
Graded
Symptom
Checklist
Neuro
physical
balance
evaluation
– “Sideline” assessment
– Thorough evaluation
– R/O more serious
intracranial pathology
• Post injury
Neuro
cognitive
evaluation
– Serial assessmants
– Determine “return to play”
– Prevent “Second Impact
Syndrome”
– Prevent cumulative effects
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Neurological Exam
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Concussion Management:
Acute Evaluation
• Maddocks Score
– What venue are we at
today?
– Which half is it now?
– Who scored last in this
match?
– What team did you play
last week?
– Did your team win the
last game?
• SCAT 3 (Sports
Concussion Assessment
Tool, 3rd Edition)
– Adult and Child versions
http://links.lww.com/JSM/A30
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SCAT 3
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Acute Cognitive Testing
• Immediate recall
– Say 5 words and repeat
them back
Elbow
4–9–3
Apple
3–8–1–4
Carpet
6–2–9–7–1
Saddle
7-1-8-4-6-2
• Concentration
– Reverse string of digits
– Serial 7 substractions
• Delayed recall
– Recite 5 words from
previous
Bubble
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Neurophysical Balance Evaluation:
Vestibular and Visual
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Neurophysical Balance Evaluation:
Vestibular and Visual
• Saccades
• Optokinetic stimulation
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Neurophysical Balance Evaluation:
Visual
• Convergence
• Accommodation
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Neurophysical Balance Evaluation:
Visual
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Concussion Management:
Neurocognitive Evaluation
• ImPACT, AXON Sports,
HeadMinder, CNS Vital Signs
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Concussion Management:
Return to Activity Guidelines
Step 1: No
concentration,
light aerobic
exercise < 10 min
Step 2: Mild
concentration,
light aerobic
exercise < 20 min
Step 3: Moderate
concentration,
add light strength
training < 30 min
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Concussion Management:
Return to Activity Guidelines
Step 4: Sports
performance
training < 60 min,
full concentration
Step 5: Progress
to full activities
including contact
under observation
Full Return
to Play
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Case Example # 1
• Veteran NFL FB player with h/o 3 concussions hit
right side of head on turf when tackled, no LOC
• Stumbled and walked toward opposite sideline
• Appeared dazed and confused
• Walked w/o assist to locker room with Team MD
• IPAD SCAT3 completed
• Blurred vision, no HA, no dizziness or fogginess
• Neurologic, balance WNL
• Visual: convergence 12 cm, accommodation 15 cm
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Case Example # 1 (cont.)
• Post-injury day 1
– Visual symptoms resolved, no new symptoms reported
– ImPACT back to baseline
– Seen by neurosurgeon per protocol and cleared to begin
functional progression (advance from Phase 1)
• Post-injury day 2
– TM walking and light squats w/o symptoms
– HA developed several hours later
• Post-injury day 3
– Same exercise, same delayed HA response
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Case Example # 1 (cont.)
• Post-injury day 4
– Seen by Neurosurgeon at request of ATC and Team MD
– MRI with DTI (diffusion tensor imaging) negative
– Allowed to return to Phase 2 of functional progression
• Post-injury day 5
– Walked on TM, light strengthening and reported mild
dizziness attributed to watching TV while walking
– No delayed HA
– Decision to hold out of away game and advance functional
progression over next week with RTP 3 wks post-injury
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Teaching Points: Case # 1
• On field assessment significantly positive
• Serial assessments showed significant subjective
(delayed HA) but mild objective findings
• ImPACT post-injury day 1 returned to baseline but
player still symptomatic
• Imaging study done due to delayed symptoms
• Remote h/o multiple concussions may complicate
recovery but not shown to cause protracted recovery
• Establishing trust essential
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Case Example # 2
• High school FB player hit by opposing player’s helmet
left side of head
• Felt pain at point of impact but kept playing
• Does not recall much of 2nd quarter or half time
(post-traumatic amnesia)
• Father observed son kneeling and rubbing head
• Evaluated by Team MD and ATC in 4th quarter
• Marked dizziness, fogginess, and HA
• Required cart to get to car but told to go home
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Case Example # 2 (cont.)
• Parents took son to ER, required assistance
• ER MD evaluation and negative CT scan completed
• Parents insisted on admission for neurology
consultation
• Neurologist diagnosed “complex migraine” and
informed parents he did not think son had
concussion
• Discharged home with clearance to play FB in 5 days
– Rx for hydrocodone/acetaminophen and phenergan
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Case Example # 2 (cont.)
• Post-injury day 3
– Team MD, ATC, and PCP intervened and restricted
athlete to no physical activity and half day school
– Fogginess, dizziness, fatigue, light/noise
sensitivity, and mental slowness reported
– ImPACT done at school by ATC
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ImPACT: DOI 9/27/13
Baseline (8/16/13)
Post-injury #1 (9/30/13)
Delayed recovery
Memory (verbal)
82
Memory (verbal)
59
60.5
Memory (visual)
79
Memory (visual)
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44.5
Visual motor speed
30.42 Visual motor speed
17.02
22.5
Reaction time
0.63
Reaction time
1.07
0.86
Total symptom score
31
Total symptom score
75
Cognitive Efficiency Index 0.38
Cognitive Efficiency Index 0.14
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ImPACT: DOI 9/27/13
Baseline (8/16/13)
Post-injury #1 (9/30/13)
Post-injury #2 (10/23/13)
Memory (verbal) 82
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64
Memory (visual) 79
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38
Visual m. speed
30.42
17.02
23.43
Reaction time
0.63
1.07
0.69
Total sx score
31
75
35
0.14
0.21
Cog Efficiency Ind 0.38
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ImPACT: DOI 9/27/13
Baseline (8/16/13)
Post-injury #1
(9/30/13)
Post-injury #2
(10/23/13)
Post-injury #3
(11/19/13)
Memory (verbal) 82
59
64
70
(88)
Memory (visual) 79
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38
55
(78)
Visual m. speed 30.42
17.02
23.43
30.85 (40)
Reaction time
0.63
1.07
1.03
0.61 (0.55)
Total sx score
31
75
47
19
0.14
0.14
0.27
Cog Efficiency Ind 0.38
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Case Example # 2 (cont.)
• F/U evaluation (DOI: 9/27/13; DOE: 12/16/13)
– Achieved Return to Learn Step 4 with school
accommodating by allowing him to drop two classes and
catch up in remaining classes
– Achieved Return to Play step 3 under ATC guidance
– Asymptomatic except for residual intermittent left parietal
headache which resolves spontaneously
– F/U with MD scheduled in one month with possible
ImPACT test at that time
– PC 1/29/14 mother reports son doing well
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Teaching Points: Case # 2
• Learn the signs and symptoms which can predict
prolonged recovery (acute dizziness, subacute
fogginess)
• Establish good communication lines with those who
can assist in patient accommodations
• Neurocognitive tests are helpful tools
• Know when and where to refer for “outliers”
• Do not prescribe narcotics or any medications which
may mask symptoms of concussion
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Concussion Management:
Primary Care “Do’s and Don’ts”
Do’s
• Get educated and gain
experience
• Be available
• Know your patient and
establish trust
• Maximize lines of
communication
• Know when and where
to refer
Don’ts
• Rush the evaluation or
ignore serial assessments
• Hesitate to contact the
experts
• Allow pressure to cloud
judgement
• Disregard input from those
who know patient well
(parents, trainers, coaches,
teammates, teachers)
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Thank You
David M. Smith, M.D., FAAFP
Center for Sports Medicine
Clinical Assistant Professor
[email protected]
University of Kansas Hospital
Center for Concussion Management
[email protected]
913-945-8006
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