Sport-Related Concussion. Daniel Seidman DO 6 August 2016

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1 Sport-Related Concussion Daniel Seidman DO 6 August 2016

2 My Pertinent Qualifications - Current Fellow, PCSM - Henry Ford Hospital - Recent Graduate, FM - St. John Macomb-Oakland Hospital - Involved in Concussion Research

3 Disclosures I have no relevant financial or nonfinancial relationships to disclose.

5 Goals By the end of today s presentation, you will be able to: 1. Develop a better understanding of SRC 2. Diagnose and manage SRC 3. Successfully implement a RTP protocol 4. Educate patients and colleagues regarding the latest evidence and guidelines

6 Outline Define Concussion Discuss Epidemiology/Pathophysiology Review Zurich Guidelines Review AMSSM Consensus Statement Review AAN 2013 Guidelines Discuss Sideline Tools Case study Review Current Research

7 Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective

8 Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective

9 So...what is a concussion? AMSSM A concussion is defined as a traumatically induced transient disturbance of brain function and is caused by a complex pathophysiological process. AAN Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness.

10 So...what is a concussion? Zurich Consensus Statement Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. 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. Concussion typically results in the rapid onset of short- lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

12 So...what is a concussion? Practical Definition Concussion: a complex, traumatic, biomechanical brain injury which induces a transient neurometabolic cascade. It may or may not have the following characteristics: - Acute or delayed onset of neurological impairment - Head injury - Loss of consciousness - Physical exam findings If performed, neuroimaging will be negative*

13 Isn t that exciting?

14 Epidemiology - Many different numbers out there 38m children/adolescents play sports 170m adults play sports Approx. 1.7m sustain TBI CDC: m concussions annually $60 billion in healthcare costs There is evidence to indicate that there are greater risks for disabling brain injury or death from riding a bicycle, walking on the street, being in a car, or even swimming than contact football Daneshvar, et. al.

15 Pathophysiology - The Hit - Neurometabolic Cascade

16 Giza, et. al.

17 Giza, et. al.

18 Giza, et. al.

19 Giza, et. al.

20 Signs/Symptoms

21 Signs/Symptoms - AMSSM Domain 1: Physical - Headache, nausea, vomiting, balance, dizziness, photophobia, visual problems, fatigue, dazed, stunned Domain 2: Cognitive - Foggy, slowed down, difficulty concentrating or remembering, forgetful of recent events, repeats questions or answers questions slowly

22 Signs/Symptoms - AMSSM Domain 3: Emotional - Irritable, sadness, more emotional, nervousness Domain 4: Sleep - Drowsiness, sleeping more, sleeping less, difficulty sleeping

23 Signs/Symptoms - Zurich Clinical Domains 1. Symptoms - somatic, cognitive, emotional 2. Physical signs 3. Behavioral changes 4. Cognitive impairment 5. Sleep disturbance

24 Risk Factors - Previous concussion Number, severity, duration Sex Age Sport, position, style of play Genetics Mood disorders Migraines Learning disabilities and attention disorders

25 Diagnosis/Treatment/Management Preseason - Baseline testing (or Computerized NP tests) - Education

26 Diagnosis/Treatment/Management On the field - ABCs. Always. - Clear the c-spine - Neuro exam Next, - History - Physical - Sideline testing - Balance testing

27 Diagnosis/Treatment/Management In the emergency room/in office - H&P - Clinical status - Imaging

28 Diagnosis/Treatment/Management Additional notes - Frequent waking - Medications - Follow up

29 Diagnosis/Treatment/Management Neuropsychological testing - No universal recommendations - CNP is sensitive for deficits

32 Cheap, Clinical Tools - History Physical Exam SCAT3 King-Devick

33 SCAT3 - Sport Concussion Assessment Tool, 3rd e. - BESS, SAC, GCS, Maddock s Score - Coordination Exam - Physical Signs Score

36 SCAT3 - Can be used as a one-time tool on the sideline or in the clinic - Can be used to track, follow clinical condition in anticipation of RTP - For kids under 13, utilize Child SCAT3 - Instructions are on the test - Print online and keep in office - Diagnosis of concussion can still be made if SCAT3 is normal.

37 King-Devick - Originally an oculomotor test Assess rapid eye movement Rapid number-naming Reading a series of numbers

39 King-Devick - Validated as accurate and reliable - Cheap to use - Can be used to follow progression

40 Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective

41 5/27/15 PMHx: negative PSHx: T&A, tubes FHx: Noncontributory SocHx: Denies tobacco, etoh ROS: + Blurry vision, nausea, headaches

42 5/27/15 BP 121/60 mmhg Pulse 80 Temp(Src) 36.8 C (98.2 F) (Oral) Resp 16 Ht m (5') Wt kg (10 lb) BMI 1.95 kg/m2 SpO2 100% LMP 05/01/2016

43 5/27/15 PE: Negative

44 5/27/15 Assessment: Mild closed head injury Plan: - Motrin and Zofran - Lengthy discussion regarding imaging, no CT at this time. - No return until evaluated by PCP - Return should signs of ICH occur

45 Concussion Clinic 6/20/15 - Seen by AT - Seen by neuropsych - Seen by physician

46 6/20/15 - Struck head on ground, vision went black Coach saw her stumble Vision went dark again Headache, blurred vision, dizziness, nausea, confusion, and fatigue - Patchy memory

47 6/20/15 - Continued symptoms for 2 weeks Occurred on a weekend, went to school after Saw pediatrician Following a school trip, attending ½ days of school - Able to complete exams and assignments, but with worsening of symptoms

48 6/20/15 Modifiers - History of headaches - History of sleep difficulties - No ADHD - No mood disorders - Knee injury

49 6/20/15 SCAT3 Total # of Symptoms Symptom Score 5/27/ /20/

50 6/20/15 PE: Negative

51 6/20/15 Assessment: Concussion Plan: - Continue PRN headache meds - Cervical stretches, posture training - Symptom tracker - Follow up in 2 weeks

52 7/5/15 - Significant improvement - Continued headaches, dizziness - Been swimming without difficulty

53 7/5/15 SCAT3 Total # of Symptoms Symptom Score 5/27/ /20/ /5/

54 7/5/15 Plan: - Begin to ramp up cognitive activity - Consider specialist referral for previous history of headaches - Continue symptom tracker - Follow up in 2-3 weeks

55 7/25/15 - Daily headache, which was her baseline - Back to soccer-related drills

56 7/25/15 SCAT3 Total # of Symptoms Symptom Score 5/27/ /20/ /5/ /25/15 5 6

57 7/25/15 Plan: - ImPACT testing - RTP4 RTP5 - If all goes well, call to obtain clearance - Specialist referral for chronic headaches

59 Objective - Concussion can be difficult to diagnose Need for cheap, quick tools Validated in collegiate athletes Not studied well in HS athletes

60 Methods athletes at four local high schools Baseline testing If concussed, tested again Postseason testing

61 Results - 9 concussions All showed significant increase in read times Non-injured athletes scores were unchanged History of concussion

62 Conclusion - KD test is an accurate, easy to administer, sideline screening tool for concussion in adolescent football players - Further studies to address younger players

64 References McCrory, Paul, et al. "Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012." British journal of sports medicine 47.5 (2013): Giza, Christopher C., et al. "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." Neurology (2013): Harmon, Kimberly G., et al. "American Medical Society for Sports Medicine position statement: concussion in sport." British journal of sports medicine 47.1 (2013): Seidman, Daniel H., et al. "Evaluation of the King Devick test as a concussion screening tool in high school football players." Journal of the neurological sciences (2015): Giza, Christopher C., and David A. Hovda. "The neurometabolic cascade of concussion." Journal of athletic training 36.3 (2001): 228.

Carleton College Concussion Safety Protocol

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