Closed Head Injury and Concussion

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1 Closed Head Injury and Concussion Stephen M. Simons, MD, FACSM Director, Sports Medicine Saint Joseph Regional Medical Center Co-Director, South Bend - Notre Dame Sports Medicine Fellowship 1

2 NFL Concussion November 2015 Video 2

3 Objectives Concussion principles. Presentation of concussion Presentation of more serious brain injury Sideline evaluation of the injured athlete 3

4 Disclosures Nothing to disclose. Assumption: Not currently head injured. 4

5 Focal Brain Injury Mentioned but not discussed in detail Subdural Hematoma Epidural Hematoma Intracerebral Hemorrhage Uncommon Catastrophic / Life Threatening The Physician MUST be alert to these possibilities. 5

6 6

7 7

8 Hype vs. Evidence More publications!!!! 1.Kutcher JS, Giza CC, Alessi AG. Continuum Lifelong Learning Neurol 2010;16(6):

9 2012-4th International Consensus Conference on Concussion 9

10 Concussion # s/ Incidence # s 1.6 to 3.8 million concussions related to sports. How many reported concussions? How is this data collected? How about subconcussive mtbi? Nondisclosure Issues Gender Difference F > M Is there a gender difference in concussion incidence and outcomes? Real or Reporting differences? Br J Sports Med 2009;43:i46-i50 10

11 Am J Sports Med 2011;39(5); Trends in Concussion Incidence in High School Sports? Figure 1. Concussion rates from to : overall and for boys and girls sports. 11

12 Concussion Rates Sports-Related Concussions in Youth: Improving the Science, Changing the Culture 2013 National Academies Press 12

13 North Carolina 797 surveyed 214 (26.9%) recalled Self Identified Sports Related Concussion (SISRC) Overall 33.2% Reported NOT disclosing Football 68.2% 13

14 Motivations for nondisclosure 14

15 Late 2013 Report Comprehensive Report from the National Research Council 15

16 Compared with previous generations, today s youth, due to an earlier average age of puberty (Biro et al 2010), may have a greater mismatch between the propensity to engage in risk taking (which arises with the onset of puberty) and behavioral inhibition (which is associated with development of the prefrontal cortex) 16

17 Concussion Definition Common Features Providing a known or presumed head trauma: Rapid onset of short lived impairment, resolves spontaneously Functional disturbance more than structural Graded set of clinical symptoms +/- L.O.C. Typically normal neuroimaging 17

metabolic crisis with potential loss for microstructure neuronal/ axonal integrity.

18 What occurs during Concussion? Neurometabolic cascade; ionic fluxes, hyperglycolysis Concussed brain in energy/ metabolic crisis with potential loss for microstructure neuronal/ axonal integrity. With more severe injury; shear injury & diffuse axonal injury (DAI) Recovery metabolically appears to lag behind symptom resolution 18

19 Biochemistry of brain injury Time Course and Recovery Giza and Howda. J Athletic Training 36:229,

20 Gender Differences Women have an increased incidence of concussion vs men in sports with same rules Reporting bias? Hormonal influence? Head size/ Neck strength? 20

21 Evaluation for Concussion Sideline Office Neuropsych Tests Imaging 21

Sideline Evaluations Historically previous generations

Therefore no need for detailed recognition of concussion.

concussion did not experience immediate or near

Responsibility to recognize signs / symptoms of a

22 Sideline Evaluations Historically previous generations of athletes were encouraged to shake it off. Therefore no need for detailed recognition of concussion. 50% of collegiate athletes eventually diagnosed with concussion did not experience immediate or near immediate onset of symptoms. Responsibility to recognize signs / symptoms of a concussion lies with all observers. The Athlete Teammates Coaches Officials Athletic Trainers Physicians Parents 22

23 Sideline Signs and Symptoms Education Since most athletic activity DOES NOT take place with skilled medical personnel present, the CDC developed the HEADS UP program. Designed to EDUCATE parents, coaches, athletes, offices. 23

Signs Observed Appears dazed or stunned (such as glassy eyes) Is confused about assignment or position Forgets an instruction or play Is unsure of score or opponent Moves clumsily or has poor

24 Signs Observed Appears dazed or stunned (such as glassy eyes) Is confused about assignment or position Forgets an instruction or play Is unsure of score or opponent Moves clumsily or has poor balance Answers questions slowly Loses consciousness (even briefly) Shows mood, behavior, or personality changes Can t recall events prior to hit or fall Can t recall events after hit or fall 24

Symptoms Reported by Athlete Headache or pressure in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light or noise

25 Symptoms Reported by Athlete Headache or pressure in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light or noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Feeling more emotional, nervous, or anxious Does not feel right or is feeling down 25

26 Relying on Symptoms?? Under-reported symptoms?? McCrea % did not want to leave the game 66% did not think injury was serious enough Dziemianowicz 2012; Anderson, Coyne, Kroshus Majority thought it was okay to play. McCrory 2013, Duhaime 2012 Delayed symptoms 26

27 Sideline Examination Tools 20 Different Symptom Checklists SAC - Standardized Assessment of Concussion SCAT3 or Child SCAT3 - Sport Concussion Assessment Tool MACE - Military Acute Concussion Evaluation Maddock s Questions 27

Challenges to Sideline Evaluation Gold-Standard for diagnosing a concussion is NOT objective it is an experienced clinician The evaluators

28 Challenges to Sideline Evaluation Gold-Standard for diagnosing a concussion is NOT objective it is an experienced clinician The evaluators familiarity with the athlete probably improves accuracy. Comparison to baseline testing is also helpful, but there are many confounding variables. 28

29 Sideline Evaluation ABC s Neurologic & Mental Status R/O c-spine, skull fx, bleed Spine board & Transport to appropriate facility if indicated Remove from play; close observation 29

30 Standardized Assesment of Concussion SAC 30

31 SAC in HS & College FB McCrea, JAT 01 Putukian - Zurich

32 SAC Summary The SAC is likely to identify the presence of concussion in the early stages postinjury. Sensitivity % Specificity % 32

33 Sideline Eval Immediate Memory and Orientation Maddock s Questions 33

34 Maddock s Questions Putukian - Zurich

35 SCAT Symptom Score 35

36 SCAT 3 - For Child 36

37 SCAT Symptoms Makdissi- Zurich 2012 Symptoms are not specific Symptoms at baseline Predominately studied in high school and collegiate athletes Average number = 2-3, Average Score = 5-10 Common symptoms: headache, fatigue, difficulty concentrating or remembering 37

Symptoms Checklist/ Scales Sensitivity - 64-89% Specificity - 91-100% Summary Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline

38 Symptoms Checklist/ Scales Sensitivity % Specificity % Summary Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology 2013 American Academy of Neurology Self-report of symptoms differs between athletes and their parents, with parent reports demonstrating greater diagnostic utility than youth self-report. (Gioia 2013) 38

39 Sideline Evaluation Balance Testing 39

40 Balance Testing Makdissi- Zurich 2012 Initial studies used sophisticated/ computerized test platforms- which are not practical for sideline assessment. Simple clinical tests - BESS - validated for concussion. Baseline Test-ReTest reliability is high. Consistent demonstration that balance is affected by concussion. Field Side - Modified BESS 40

41 Balance Assessment Putukian - Zurich

42 Sideline Tests Sensitivity/ Specificity Summary 42

43 Other Sideline Tools Catch a suspended vertical shaft Head Telemetry Voice Recognition Video Replay King Devick 43

Weighted Stick Test Clinical Reaction Time Test 80 cm rigid measuring stick coated in friction tape with a weighted rubber disk affixed to one end.

44 Weighted Stick Test Clinical Reaction Time Test 80 cm rigid measuring stick coated in friction tape with a weighted rubber disk affixed to one end. Athletes sit with dominant forearm resting on a table with hand positioned over the stick edge. Examiner releases the stick and the athlete catches as quick as possible. 44

45 Weighted Stick Test Clinical Reaction Time Test 45

46 Weighted Stick Test Clinical Reaction Time Test Authors conclusion: Any slowing of reaction time from baseline was significant. Sensitivity 75%; Specificity 68% - similar to other current tests. Simple to use. Low Cost 46

47 Head Telemetry 47

48 Voice Recognition An IPAD app for voice recognition Developed at Notre Dame Baseline tests. Athlete reads words as they appear on screen. Timing, quality of voice recorded. 48

49 Voice Recognition Post injury tests compared to baseline. Algorithms compare acoustic metrics for multiple voice samples. Validity in testing. 49

50 King-Devick Test Subjects read numbers on a card. Read from left to right, top to bottom. Timed for a total of three cards. 50

51 King-Devick Test Neurology 2011;76:

52 King-Devick Test Currently, there is not enough evidence to determine whether the test is effective in diagnosing or monitoring a concussion. Sports Related Concussions in Youth 52

53 ER/ Office Evaluation of Concussion Symptoms Examination Imaging Computer Neuropsych Tests Biomarkers 53

54 ER/ Office Evaluation of Concussion Initial Exam focused on need to determine life-threatening head injury. Same Symptom checklists as fieldside. Evaluate for focal neurologic deficits. Evaluate neck. 54

55 Monitor Symptom Checklists 55

56 ER/ Office Evaluation of Concussion Imaging CT - Used when concerned for intra-cranial bleeding, cerebral swelling, skull fractures. American Academy of Neurology recently recommended that CT NOT be used to evaluate sports-related concussion in the absence of signs and symptoms of more serious traumatic brain injury. (Concern for unnecessary radiation exposure) MRI - rarely helpful in acute setting. 56

57 Neuropsychological tests Tests Available ANAM - Automated Neuropyschological Assessment Metrics CNS Vitals Signs Cogstate Sport Headminder ImPACT 57

58 Neuropsychological tests Computer Neuropsych Tests Tests domains typically involved in athletic concussion Less expensive than paper / pencil Less time to administer Groups of athletes simultaneously Instant information to the provider More precise measures of reaction time 58

59 Neuropsych Tests Past history Previous concussions Other head injuries Educational background Previous testing Drug use Alcohol use Other factors Cognitive function Test setting/ distractions Motivation Fatigue Random variance/chance Psychological Factors Test Anxiety Depression/ other emotional states Test Performance Genetic factors Age Intelligence Sex Race Handedness Visual acuity Auditory acuity Methodological factors Testing situation Practice/ learning effects Administrator expertise Factors that impact the results of neuropsychological tests. McCrory

60 Neuropsychological tests USE FOR DIAGNOSIS? Mixed results of the DIAGNOSTIC utility of neuropsychological testing. General agreement that Neuropsychological tests should NOT be used in isolation for diagnosis. However, high scores on neuropsychological tests, indicating good cognitive function, are predictive of NOT having a concussion. 60

61 Neuropsychological tests Use for Tracking Recovery and Informing management? More sensitive than examination. Several studies document persistent postinjury scores even after symptoms resolve. Symptoms 3-4 days Abnormal Neuropsych Test 5-6 days 61

62 Neuropsychological tests Baseline Tests necessary? It is currently unclear if baseline testing vs comparison to normative standards provide clinically useful reduction of risk associated with concussive injury. Although baseline testing is a common practice, studies provide mixed (and limited) evidence concerning the utility and costeffectiveness of such testing. 62

2013 502 athletes ages 10-18 preseason baseline tested with ImPACT.

63 athletes ages preseason baseline tested with ImPACT. Separated into large groups or small groups Younger athletes= more invalid baseline tests Larger group testing = more invalid baselines 63

64 Investigations Neuroimaging (CT, MRI) Generally not needed. Consider when: Focal Neurological deficit Worsening symptoms Prolonged disturbance of conscious state Future imaging modalities fmri, DTI, MRS 64

65 Biomarkers S100β Neuron specific enolase (NSE) Glial fibrillary acidic protein (GFAP) Tau (cleaved tau, phospo tau, total tau) Neurofilament light protein (NFL) Microtubular associated protein 2 (MAP2) CPK-BB Spectrin breakdown products β amyloid protein (Aβ) Apoliprotein (Apoe) Myelin basic protein (MBP) Ubiquitin C-terminal hydrolase L1 (UCH-L1) 65

66 Biomarkers The PET scans revealed that the imaging patterns of the retired football players showed tau deposit patterns consistent with those that have been observed in autopsy studies of people with CTE. 66

67 Biomarkers Active Research Insufficient evidence for routine use. 67

68 Return to Play NO same day return to play Begin when symptom free Guidelines will be discussed in next lecture 68

69 Summary The clinical approach to concussion is evolving. Concussion incidence is probably greater than reported. There are many clinical advances to the assessment and management of the head injured athlete. Sideline evaluation Office evaluation Return to play decisions 69

70 Key References American Medical Society for Sports Medicine position statement: concussion in sport Kimberly G Harmon, et al. Endorsed by the National Trainers Athletic Association and the American College of Sports Medicine Br J Sports Med 2013;47: doi: /bjsports Sports-Related Concussions in Youth Improving the Science, Changing the Culture Committee on Sports-Related Concussions in Youth Board on Children, Youth, and Families Robert Graham, Frederick P. Rivara, Morgan A. Ford, and Carol Mason Spicer, Editors THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 McCrory P, et al. Br J Sports Med 2013;47: doi: /bjsports Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology Christopher C. Giza,, Jeffrey S. Kutcher, MD et al Neurology 80 June 11,

Sport-Related Concussion. Daniel Seidman DO 6 August 2016

Sport-Related Concussion. Daniel Seidman DO 6 August 2016 Sport-Related Concussion Daniel Seidman DO 6 August 2016 My Pertinent Qualifications - Current Fellow, PCSM - Henry Ford Hospital - Recent Graduate, FM - St. John Macomb-Oakland Hospital - Involved in