Concussion Management

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1 Concussion Management Jennifer Gray, DO Medical Co-Director, ThinkSMART! Concussion Management Program Department of Physical Medicine and Rehabilitation St. Charles Hospital Residency Program Director, Physical Medicine and Rehabilitation University Hospital at Stony Brook

2 Disclosures I have nothing to disclose

4 What is a Concussion? International Conference on Concussion in Sport a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces

5 weillcornellbrainandspine.org Diffuse Axonal Injury

7 Neurometabolic Cascade following 500 Brain Injury(Giza,Hovda 2001) % of normal K+ Blood Flow 200 glucose Cerebral blood flow Energy glutamate Minutes hours days

8 Problem Patient LOOKS normal Brain LOOKS normal

9 Symptoms Neuropsychiatric More Emotional Sadness Nervousness Irritability Cognitive Attention problems Memory dysfunction fogginess Fatigue Cognitive slowing Sleep Disturbance Difficulty falling asleep Sleeping less than usual Physical Headaches Visual Problems Dizziness Noise/Light sensitivity Nausea

10 Assessment

11 Assessment History HPI Etiology Amnesia LOC Initial management Any imaging done already

12 History Assessment Past medical/surgical Hx of concussion Hx of HA, mood disorder, neurologic disorder Medications Social Academic Other activities Kratomblast.com

13 Businessinsider.com Fcw.com

14 Assessment Physical exam Neurologic & exam Balance Cognitive Ocular Vestibulo-ocular function Binocular vision Cervical

16 Assessment Neurocognitive testing Pen and paper Computerized Best with a baseline!

17 Assessment Neuroimaging Conventional CT and MRI often normal in mtbi May show DAI

18 Diffusion Tensor Imaging Brigham and Women s Hospital, Psychiatry

19 Functional/Metabolic Imaging? MR Spectroscopy Functional MRI PET Scan Not for routine use

20 But isn t there a blood test??

21 Biomarkers After brain injury, proteins leak from the damaged neurons/brain cells Can they be measured to assess brain injury?? S-100β CTP

22 Treatment No way to fix the axon damage Rest Supportive Symptom based Neuroplasticity

25 Return to Learn and Cognitive Rest Academic accommodations Limit visual and cognitive exertion Home instruction Moderate evidence to support cognitive rest (Johnson etal, 2016) Evidence is not clear on how long

26 Treatment Omega 3 Fatty Acids DHA (docosahexanoic acid) Neuroprotective Shown to help with TBI recovery/prevention in rats (Mills, Bailes etal.) Recommended at 3000mg/day Caution: diabetes, bleeding disorders, psychiatric disorders, immunodeficiency

27 Exercise? Yes, Exercise! THIS DOES NOT MEAN BACK TO SPORTS!!!!! Gradually increasing aerobic activity as tolerated early in the course now recommended (walking, stationary bike) Grool, etal. (JAMA, 2016) those who returned to some activity vs. no activity within 7 days post injury had lower risk of persistent symptoms (problem = based on self report)

28 Exercise? Yes, Exercise! Concussion = reduced cerebral blood flow Autonomic nervous system dysfunction Higher rates of sympathetic output Exercise Reduces sympathetic activity/increases parasympathetic Increases CBF Treatment = EXERCISE gradual progression of aerobic activity John Leddy, MD; SUNY Buffalo

29 Treatment Headache management Vestibular therapy Vision therapy/prisms Treat cervical spine Cognitive therapy Supportive counseling Ken Mannie, coachad.com

30 Return to Sports and Physical Activity Asymptomatic at rest, normal physical exam, cognition at baseline Gradual return to play protocol Sometimes modified depending on the case (ie. non-athlete) Multiple prior concussions/course of current concussion may change plan

31 Post Concussion Syndrome vs Post Concussive Disorders Concussion symptoms lasting longer than expected Physiological PCS Vestibulocular PCD Cervicogenic PCD Mood Disorders Other medical issues Leddy, JJ, 2016; Ellis, M; Leddy, JJ, 2014

32 Prevention? Helmets and headgear Mouthguards Faceshields Education

33 Invisible Injury Bahrami, etal. (Radiology, 2017) 25 youth football players Changes in the white matter tracts on MRI after the season (compared to pre-season) Increased cumulative exposure to head impacts (measured with Head Impact Telemetry in the helmet) increased white matter change No concussion symptoms/diagnosis

34 Bahrami etal. 2016

Late Effects of Concussion CTE = Chronic Traumatic Encephalopathy NOT the accumulation of symptoms from previous injuries Progressive decline

35 Late Effects of Concussion CTE = Chronic Traumatic Encephalopathy NOT the accumulation of symptoms from previous injuries Progressive decline in function of neurons Short term memory, executive dysfunction, depression, emotional instability, suicidal behavior Movement disorders, ALS?

36 CTE Normal 65 year old NFL linebacker John Grimsley

37 Thank you!

Mild TBI (Concussion) Not Just Less Severe But Different

Mild TBI (Concussion) Not Just Less Severe But Different Disclosures Funded research: 1. NIH: RO1 Physiology of concussion 2016-2021, Co-PI, $2,000,000 2. American Medical Society of Sports Medicine: RCT