Disclosures 7/22/2015 MANAGEMENT OF SPORTS RELATED CONCUSSION. Brad Herskowitz MD Neurologist Baptist Hospital

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1 MANAGEMENT OF SPORTS RELATED CONCUSSION Brad Herskowitz MD Neurologist Baptist Hospital Disclosures I have no relevant financial conflicts of interest. I will not discuss off label or unapproved usage. 1

2 Objectives Understand the basic pathophysiology of concussions Recognize concussion signs and symptoms Be competent in primary care setting in evaluating and treating athletes with sports related concussions Be able to know when it is safe for an athlete to RTP or when to refer to a concussion specialist Why do we care so much about CONCUSSION? Major public health issue Frequent occurrence in sport Potential catastrophic or long term sequelae NFL We have the ability to change culture of sport Lystedt Law 2

3 Epidemiology million SRC occur annually (underestimate) McCrea et al 2004 studied 1,532 varsity HS football players in Wisconsin 29.9% reported previous concussion 15.3% suffered a concussion during current season but only 47.3% reported their injury Reasons: did not think injury serious or did not know it was a concussion, did not want to be held out of play Risk of repeat concussions greatest in first 7-10 days after RTP Epidemiology Increased rates last decade 9% high school injuries, 6% college Males: football, rugby, ice hockey and wrestling Females: soccer and basketball In comparable sports with same rules, Females 2x more concussions 3

4 Concussion Guidelines 1 st International Conference on Concussion in Sport, Vienna 2001 Consensus statement created 2 nd Prague 2004 Did away with concussion grading Simple vs complex 3 rd Zurich 2008 All classifications removed 4 th Zurich 2012 New tools, SCAT 3 Timing of treatments Sports Societies American Academy of Neurology (AAN) American Medical Society for Sports Medicine (AMSSM) National Athletic Trainers Association (NATA) Concussion in Sport Group (CISG)- 4 th International Consensus Conference of Concussion in Sport (Zurich, 2012) Definition (Zurich 2012) complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces that may be caused by a direct blow to the head, face, neck or other part of body with an impulsive force transmitted to the head. McCrory et al Rapid onset of short lived impairment of neuro fxn resolving spontaneously May have neuropath changes, but acute clinical symptoms reflect functional disturbance, not structural Graded set of neurological syndromes, with or w/o LOC Grossly normal neuroimaging studies 4

5 7/22/2015 Mechanism of Injury Rapid linear acceleration and deceleration Rotational or angular acceleration Midbrain/diencephal RAS Pathophysiology -Complex metabolic cascade: impaired neurotransmitter function abnormal concentration of ions depolarization decreased blood flow -Brain has increased vulnerability in post concussion state ENERGY CRISISIncreased need for energy coupled with decreased blood flow- BRAIN HAS TO WORK HARDER TO MEET SAME DEMANDS! Acute Assessment On Field ABC s Cervical spine injury- if concerned immobilize Assess for more serious brain injuryed for brain imaging Suspicion- REMOVE FROM PLAY Sideline HISTORY/ PHYSICAL/COGNITIVE/BALANCE TESTING SCAT 3 5

6 Signs and Symptoms Signs and Symptoms HEADACHE- 70% DIZZINESS- LOC- 10% Amnesia- rga, pta Symptoms typically present immediately but can be delayed 80-90% of athletes will have symptom resolution by 7-10 days miserable minority last longer Detailed Assessment- SCAT 3 6

7 Sideline Assessment If no evidence for concussion RTP Serial evaluations If diagnosed with a concussion Should not return to play same day of concussion SCAT 3 or other sideline assessment Player should not be left alone following injury, requires serial monitoring for several hours Arrange for appointment with HCP NEUROIMAGING Adds little benefit to concussion workup Use when suspicion of intracerebral or structural process exists: Focal abnormality Worsening symptoms Prolonged disturbance of conscious state Other imaging not recommended yet i.e. fmri, PET Patient Instructions No frequent awakenings, SLEEP is beneficial to athlete If level of consciousness is a concern, send to ER for imaging Avoid aspirin or NSAIDS Physical and mental rest No driving 7

8 OFFICE EVALUATION History Event Mechanism Symptoms History of concussion or risk factors Speak to trainer or parents Concerning symptoms for Imaging Worsening symptoms Pronounced amnesia Office Evaluation Physical Exam Neuro exam-look for focal deficits SCAT 3 Balance testing- BESS Office Evaluation- TOOLS SCAT 3 Objective Serial monitoring Computerized Neuropsychological Testing Provides objective assessment of cognitive function Usually follows symptom resolution Performed when clinically asymptomatic Determine academic restrictions 8

9 28 minutes Baseline before season Can be abnormal even with symptom resolution McGrath et al- Post exertion NP test failure 27%-normal IMPACT, abnormal Post exertion IMPACT Neuroimaging Typically normal in concussion Head CT Skull fracture, hemorrhage MRI brain May obtain if prolonged symptoms Others fmri, SPECT, DTI, PET- mainly research tools Concussion Management Physical Rest-not strict Cognitive Rest No TV, extensive reading, video games, etc. May need school accomodations Sleep- no naps Regular diet and hydration Gradual RTP 9

10 Concussion Management Medications Headaches- NSAIDS, acetominophen Insomnia- melatonin, trazodone, zolpidem, tricyclics Neurobehavioral- Amantidine, methylphenidate Depression- SSRI s Vestibular Therapy Management Gradual resolution within 7-10 days Gradual return to school and social activities that does not result in exacerbation of symptoms Step wise RTP strategy 10

11 Graduated RTP Protocol 24 hours per step If symptoms return to previous asymptomatic level Return To Play No symptoms Normal Physical exam Normal NP testing Off all medications Modifying Factors effecting RTP 11

12 Post Concussion Syndrome 15% with history of concussion >3 months Symptoms Headache- tension, migraine Irritability Dizziness Insomnia Depression/anxiety Cognitive/ memory Psychological factors When to Hang it Up? No clear criteria 3 concussions in a season- sit out season Retirement consideration Lower threshold for concussion Longer duration of symptoms and more severe Neurocognitive impairment SECOND IMPACT SYNDROME Does it exist? an athlete who has sustained an initial head injury, most of a concussion, sustains a second head injury before symptoms from the first concussion have cleared. This second injury is believed to result in catastrophic cerebral swelling which can be fatal Hypothesis- disordered cerebral autoregulation causing congestion and malignant cerebral edema with increased ICP and herniation LACK OF EVIDENCE THAT IT EXISTS 12

13 Second Impact Syndrome Single blow enough to cause cerebral swelling McCrory, cases in world literature, only 5 with repeated injury 14 autopsy- 11 with structural brain injury (SDH) Only described in North America, not Europe or Australia (rugby) Boxers at risk- why not more in boxers with repetitive head injury? BOTTOM LINE: increased risk for more severe injury if brain not healed Prevention Daneshvar et al 2011 Mouthguardshave benefit in prevention oral injury, but no evidence of concussion reduction Head gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence Helmetsreduce head and facial injury in skiing and snowboarding and other sports Chronic Traumatic Encephalopathy First described dementia pugulistica, CTE 1996 Progressive neurodegenerative disorder caused by multiple concussions or subconcussive blows to the head Other causes? Steroid abuse, drug and alcohol abuse, Genetic predispositions, Depression/Stress Over 30 NFL players diagnosed with CTE, hockey, wrestling Signs and Symptoms Dementia/ memory loss, Aggression, Depression/ suicide, behavioral change 13

14 Chronic Traumatic Encephalopathy First described dementia pugulistica, CTE 1996 Progressive neurodegenerative disorder caused by multiple concussions or subconcussive blows to the head Other causes? Steroid abuse, drug and alcohol abuse, Genetic predispositions, Depression/Stress Over 30 NFL players diagnosed with CTE, hockey, wrestling Signs and Symptoms Dementia/ memory loss, Aggression, Depression/ suicide, behavioral change CTE Pathology-tau deposition in cerebral sulci distinct from AD, FTD APOE may be RF? Post mortem diagnosis Florida Concussion Bill A bill to be entitled 2 An act relating to youth and student athletes; 3 amending s , F.S.; requiring independent 4 sanctioning authorities to adopt policies to inform 5 certain officials, coaches, and youth athletes and 6 their parents of the nature and risk of certain head 7 injuries; requiring that a signed consent form be 8 obtained before the youth participates in athletic 9 practices or competitions; requiring that a youth 10 athlete be immediately removed from an athletic 11 activity following a suspected head injury; requiring 12 written clearance from a medical professional before 13 the youth resumes athletic activities; authorizing a 14 physician to delegate the performance of medical care 15 to a licensed or certified health care practitioner 16 and consult with or use testing and the evaluation of 17 cognitive functions performed by a licensed 18 neuropsychologist; amending s , F.S.; 19 requiring the Florida High School Athletic Association 20 to adopt policies to inform certain officials, 21 coaches, and student athletes and their parents of the 22 nature and risk of certain head injuries; requiring 23 that a signed consent form be obtained before a 24 student athlete participates in athletic practices or 25 competitions; requiring that a student athlete be 26 immediately removed from an athletic activity 27 following a suspected head injury; requiring written 28 clearance from a medical professional before the 29 student resumes athletic activities; authorizing a 30 physician to delegate the performance of medical care 31 to a licensed or certified health care practitioner 32 and consult with or use testing and the evaluation of 33 cognitive functions performed by a licensed 34 neuropsychologist; providing an effective date

15 7/22/2015 Conclusion Heterogenous/complex disorder Institution of safety guidelines and laws to protect the athletes Algorithms in place to assist LHCP and get athletes back on the field safely and timely Tremendous research/ Neuroimaging Bottom line is to make it safer for athletes and prevent long term sequelae THANK YOU!! Baptist Hospital Homestead Hospital West Kendall Baptist Hospital Baptist Children s Hospital Mariners Hospital Baptist Outpatient Services Doctors Hospital Miami Cardiac & Vascular Institute South Miami Hospital 45 15