Update of Concussion Management 2013 SC School Nurses Meeting

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1 Update of Concussion Management 2013 SC School Nurses Meeting Craig M Burnworth, M.D. Primary Care Sports Medicine Moore Orthopaedics Sports Concussion Center

2 Disclosures I, Craig Burnworth, MD, or family members have no relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

3 Overview Concussion definition Concussion symptoms Concussion diagnosis Concussion management Post concussive syndrome Return to play Future of concussion Cases

4 Concussion Definitions The term concussion is often used in the medical literature as a synonym for mild traumatic brain injury (mtbi), but it probably describes a subset of milder brain injury. The Quality Standards Subcommittee of the American Academy of Neurology defines concussion as a traumainduced alteration in mental status that may or may not involve loss of consciousness [1] (1997)

5 Concussion Definitions 4th International Conference on Concussion in Sport Held in Zurich, Nov 2012 "Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces... Several common features include the following: Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an 'impulsive' force transmitted to the head.(2,15)

6 Concussion Definition Zurich continued Concussion typically results in the rapid onset of shortlived impairment of neurologic function that resolves spontaneously. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.(2,15)

7 Concussion Definition Zurich continued Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. Concussion is typically associated with grossly normal structural neuroimaging studies.(2)

8 Concussion 80-90% of concussion symptoms are short lived lasting 7-10 days 5-10% have prolonged symptoms >4-6 weeks, may progress to post concussive syndrome Recovery time may be longer in children and adolescents (2,15)

9 Epidemiology American football - 10% of college and 20% of high school players suffer from a concussion each year.(3) Males >females ratio of males : 1 females (4) 9% of all injuries in high school (8) High school football players experience approximately 3000 hits per season, with some hits generating forces in excess of 100 G s (12)

10 Pathophysiology Trauma causes deregulation of the normal ion flow. Efflux of Potassium out of the cell Influx of Calcium Increased Na-K pump activity depletes ATP Occurs in a setting of decreased perfusion to the brain, limits glucose delivery. Abrupt release of neurotransmitters

11 Pathophysiology continued Mismatch of metabolism and energy requirements. Brain enters period of decreased metabolic activity Calcium levels in the cell can remain high for days and may effect mitochondrial metabolism

% of normal Neurometabolic Cascade Following Traumatic Brain Injury (Giza & Hovda, 2001) 500 400 Calcium 300 K+ 200 Glucose Glutamate 100 50 0 2 6

12 % of normal Neurometabolic Cascade Following Traumatic Brain Injury (Giza & Hovda, 2001) Calcium 300 K+ 200 Glucose Glutamate minutes hours days Cerebral Blood Flow Giza et al, The Neurometabolic Cascade of Concussion. J Athl Train Jul Sep; 36(3):

13 Signs and Symptoms

14 Concussion Symptoms and Signs Symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and or emotional symptoms (e.g. lability) Physical signs (e.g. loss of consciousness, amnesia) Behavioral changes (e.g. irritability) Cognitive impairment (e.g. slowed reaction times) Sleep disturbance (e.g. drowsiness) (2,15)

15 Acute Sideline Concussion Evaluation Standard emergency management principles. Exclude cervical injury Remove from play immediately Sideline evaluation (SCAT2, SCAT3 or similar tool) Do not leave patient alone monitor over time Do not return to play the same day Determine need for emergent neuroimaging (2,15)

16 Sideline Education

17 Second Impact Syndrome A controversial term first described by Saunders and Harbaugh in 1984 (16). Second Impact Syndrome (SIS) consists of two events. Typically, it involves an athlete suffering post-concussive symptoms following a head injury (17). The athlete then returns to play and sustains a second head injury, diffuse cerebral swelling, brain herniation, and death can occur. The timing of the second event is variable. From 1980 to 1993 the National Center for Catastrophic Sports Injury Research in Chapel Hill, NC, identified 35 probable cases among American football players.(17)

18 Concussion evaluation History and Physical Imaging? SCAT2/SCAT3 form Neuropsychological testing Balance testing Other

19 History?

20 SCAT 2/SCAT 3 assessment form Useful tool supplement to the 3 rd International Conference on Concussion Consensus Statement Can be use on sidelines by Athletic trainers Can be use in the office as well Useful tool to follow symptoms of concussion Includes information for patient, parents and coaches on what to watch for and return to play guidelines Free to use, distribute. Not to replace physician evaluation.

21 SCAT 2 design 4 page document Demographic info- Self reported symptom evaluation Glascow coma score, Maddocks Score, Cognitive assessment Balance examination, coordination examination, Cognitive assessment, Score sheet Warnings, Return to play guidelines, Score and Clearance information

23 Symptoms - Utilizing the SCAT 2 Headache Pressure in the head Neck pain Nausea or vomiting Dizziness Blurred vision Balance problems Sensitivity to light Sensitivity to Noise Feeling slowed down Feeling like in a fog Don t feel right Difficulty concentrating Difficulty remembering Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional Irritability Sadness Nervous or Anxious

24 SCAT 2 Baselines? Average High School: score 89 SD-6, average balance % of HS students can do months backwards, 90% of college. 55% of H.S.football 41 percent can do 5 digits backwards, 32% of football

25 SCAT 3 Age 13 and older Initial GCS and observations. Wait 15 minutes prior to testing balance and neurocognition to avoid misdiagnosis from exertion or fatigue(15) Mild variations, the forms are laid out differently with symptoms evals on same page as other testing questions. Poor design in my opinion.

26 Child SCAT 3 Age 12 and under (15) Child SCAT 3 incorporates simplified child and parent interviews with different scoring. A little less user friendly since formatted differently than the SCAT 2 but can still be useful.

27 My neurological exam Alertness and orientation Ability to give a history, including amnesia (retro/anterograde from event) CN 2-12 H-test, convergence, Saccadic eye movements (horizontal and vertical) 20 secs, vestibular ocular reflex 20 secs. Finger to nose, rapid alternating movements, heel to shin, Rhomberg, balance testing

28 Imaging

29 When to image? Prolonged disturbance of conscious state Focal neurologic deficit Worsening symptoms (2) Otorrhea, rhinorrhea, postauricular or periorbital hematomas, concern for skull fracture (9) Failure to improve (at some future time point)

30 Neuropsychological testing Multiple products available. Have been validated in large populations Best if personal baseline available for comparison Normative data available if no baseline May be abnormal in asymptomatic individuals due to incomplete resolution or attempted hiding of symptoms (7) Does not replace neuropsychologist

31 Neuropsychological testing Verbal memory Visual memory Visual motor speed Reaction time Internal validity with impulse control

32 Neuropsychological testing If outside of 2 standard deviations for 3 of the categories should be held out of school. If profound symptoms initially it has some predictive ability for who may progress to post concussive syndrome. Single test may be difficult to use in special populations. ADD, ADHD, LD, auditory processing disorder, Dyslexia, color blindness, Malingerers Is available in multiple languages

33 NP testing Computer based test require preceptor and controlled environment to ensure validity Require minutes depending on user Baseline testing can be done in a computer lab at high schools or in your office with trained staff and internet access. Reaction time may be effected by the mouse or other external factors such as distractions Athletes may try to game the baseline

34 Balance testing Balance Error Scoring System (BESS) Force plate systems

35 BESS Easy to use, inexpensive Best if you have an individuals baseline Injury may alter results and specificity Balance with feet together, Standing on non-dominant foot and tandem stance on floor and foam pad Count loss of balance events and produces score

36 Force Plate systems More expensive, require additional equipment. May normalized before symptoms fully resolve Should not be used as stand alone tool.

37 Concussion management Remove from play the day of injury No driving! No practices or gym class, restrict physical activity. Limit screen time, computers, TV, texting, gaming Limit excessive stimulus Consider homeschool or shortened school day School accommodations (Communication is key)

38 Concussion management Determine frequency of follow up. ATC available? Do not send home alone, should be monitored closely over first few hours and someone should stay with the patient overnight.

39 School Accommodations Symptom limited activity. Hold Gym, Orchestra, Chorus No Driver s Ed. No use of power tools, ladders, heights Us traditional materials whenever possible. Anticipate problems Provide notes, written instructions

40 School Accommodations cont. Limit make-up work Visit school nurse as needed for rest breaks or Tylenol Delay standardized testing. Open book tests. Alternate or simplified assignments. Limit the use of computers.

41 Homebound? Should be considered if child is intolerant to mainstream school or has severe symptoms. May be considered if poor neurocognitive testing.

42 Graduated return to play protocol 1. rest until asymptomatic (physical and mental rest) 2. light aerobic exercise (e.g. stationary cycle) 3. sport-specific exercise 4. non-contact training drills (start light resistance training) 5. full contact training after medical clearance 6. return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to stage 1 if symptoms recur. Resistance training should only be added in the later stages. Medical clearance should be given before return to play.

43 Post Concussive Syndrome World Health Organization defines PCS as persistence of 3 or more of the following after head injury: headache, dizziness, fatigue, insomnia, concentration difficulty, or memory difficulty (14) DSM-IV and ICD-10 definitions vary on timeline (14)

44 Post Concussive syndrome Consider referral to brain injury specialist, neuropsychologist, specialized physical therapy for vestibular therapy, exertional therapy Research emerging for subsymptom threshold exercise training. May benefit from day 14-21, but be detrimental sooner (13) May need to initiate pharmacotherapy (amantadine, antidepressant, etc.) Has been shown to shorten the duration of symptoms in PCS May need prolonged accommodations from school.

45 Repeated Concussions If suffer a concussion 3x more likely to suffer second concussion during the same season compared to nonconcussed teammates (10). If sustained LOC found to be 6x more likely to suffer a concussion than those who have never lost consciousness (11) This may be due to intrinsic factors (low threshold, genetic factors, incomplete recovery), or extrinsic (style of play, equipment, adherence to rules)

46 Retirement from contact sports Substantial Symptom Burden- interferes with work, school or family productivity to a substantial degree. Subjective Decreasing force required to cause injury- should be strongly considered to be remove from sport if each event seems to occur with less force even after cleared with best practices. Changes from baseline cognition or personality (9) X# of concussions?

47 Future of concussion Genetic testing for at risk individuals (APO E4 allele, ApoE promoter gene, Tau polymerase, among others) fmri shows areas of function deficits in concussed individuals. Also shows changes in subclinical cases after head trauma. Rule changes Safety equipment on the field has not been shown to decrease concussions, just skull fractures and facial injuries.

48 Marketing Concussion

49 Case 1 16 y.o. male football player identified as having a concussion during Friday s football game. No LOC,1 st concussion. Gradual improvement over weekend. You see them on Monday, No symptoms. Normal examination. Normal neurocognitive testing.

50 Case 1 management Plan progressive exertion as described in SCAT 2 form with athletic trainer if available. Symptoms return with running on day 2. You wait until symptom free for 24 hours again then proceed with progressive exertion. Start back at Day 1 of progression, misses the next game but returns for the following week.

51 Case 2 15 y.o. female soccer goalie, had 1st concussion in preseason resolved in 7 days following standard protocol. Concussed in practice head to ground contact 6 weeks later. No LOC. You see 3 days after injury. Mild symptoms. Normal physical exam except mild balance problems and abnormal saccadic eye movements. Neurocognitive testing abnormal for symptoms and reaction time

52 Case 2 management Plan to follow up in 1 week. When she returns exam is normal including neurocognitive testing. Due to this being second concussion in the same season, she is held out for the remainder of the season. Still let her follow progressive exertion short of contact. May condition and limited practice.

53 Case 3 Your soccer goalie returns the next summer. She had a 3 rd concussion with player to player contact 3 days ago. Season was going well with no symptoms. She had brief LOC, went to ER had normal imaging. Still significantly symptomatic, severe headache, dizziness, light and noise sensitivity. Mild nausea waxes and wanes. Poor balance on testing, poor vestibular ocular reflexes, h- test, saccadic eye movement all off. Neurocognitive testing significantly low for visual and verbal memory, reaction time and symptoms.

54 Case 3 management Week 1- Held out of school, issued note to school for accommodations. No driving, limit stimulus and screen time. Recheck week 2, only mild improvement on clinical exam and neurocognitive testing. Continue to hold out for another week. Plan- See weekly until symptoms resolve. School accommodations made.

55 Case 3 management continued At week 4 symptoms still mild, difficulties with concentration and assignments. Symptoms mildly improved. Testing only mildly improved. Discuss referral to Peds Neurology or PM & R specialist to consider further testing and medications. At 2 months symptoms have resolved. Testing back to baseline. On meds for symptoms (amantadine). Able to begin exercising. Recommendations?

56 Case 3 continued After 3 concussions with progressive worsening, strong consideration for no more contact sports. Need to wean of meds with help of specialist. Patient disheartened, but seeks out alternative sports. Obtain new baseline once completely cleared.

57 Craig Burnworth, MD David Scott, MD Moore Orthopaedic Clinic, Sports Medicine, Concussion Center Columbia and Lexington, SC

58 References 1) Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 1997; 48:581. 2) Consensus statement on concussion in sport- The 3 rd International Conference on concussion in sport, held in Zurich, Nov J Clin Neuroscience 16 (2009) 3) Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes. JAMA 1999; 282:958. 4) Kraus JF, McArthur DL. Epidemiologic aspects of brain injury. Neurol Clin 1996; 14:435. 5) Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80 100

59 References 6) Schwarz A. Silence on concussions raises risks of injury. New York Times 15 September ml?hp (accessed 19 Oct 2007) 7) Broglio S, et al J Ath Tr 42: ) Gessel B, Fields S, Collins C, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4): ) Kutcher J. Management of the complicated sports concussion patient Sports Health J;2(3): ) Guskiewicz K, Weaver N, Padua D, Garret W Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5);

60 References 11) Delaney J, Lacroix V, Laclerc S, et al. Concussions during the 1997 Canadian Football League season. Clin J Sports Med 2000;10(1): ) NPR. NFL; Dodging the concussion discussion? Published Aug 26, ) Leddy J, Kozlowski K, Donnelly J, et al. A preliminary study of subsymptom threshold exercise training for refractory postconcussive syndrome. Clin J Sports Med 2010;20(1): ) BoakeC, McCauley SR, Levin HS, et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2005;17:

61 References 15) Consensus statement on concussion in sport- The 4th International Conference on concussion in sport, held in Zurich, Nov Br J Sports Med 2013; 47: p ) Saunders R, Harbaugh R. The second impact in catastrophic contact-sports head trauma. JAMA. 1984;252: ) Cantu RC. Second impact syndrome. Clin Sports Med. 1998;17:37 44.

Pre and Post Concussion Management

Pre and Post Concussion Management Timothy A. Tolbert, Ph.D., ATC Clinical Coordinator Marshall University Athletic Training Program 1 Concussion A complex pathophysiological process affecting the brain,