Concussion Evaluation and Treatment in the Office. J. Scott Delaney MDCM, FRCPC, FACEP McGill University

Transcription

1 Concussion Evaluation and Treatment in the Office J. Scott Delaney MDCM, FRCPC, FACEP McGill University

2 FACULTY DISCLOSURE Dr. Delaney has no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.

3 Goals and Objectives Definition Office Diagnosis - Symptoms - Physical Examination - Neuropsychological (Cognitive) testing Treatment

4 Mister D. Inged 19 year old hockey player attending the finest university in Canada Hit 3 days ago, no memory of event or game, now headaches, unable to concentrate, poor sleep, feels worse at school Comes with video

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6 Mister D. Inged How do you make a diagnosis of concussion? What type of activities can he do and when? Any medications or treatments? Can he still go to the Pub Crawl on this weekend?

7 Concussion- Definition Vienna Concussion in Sport (CIS) Group Any alteration in cerebral function caused by a direct or indirect (rotation) force transmitted to the head resulting in one or more of the following acute signs or symptoms: - LOC - light sensitivity/photophobia - confusion/disorientation - nausea/vomiting - headache - abnormal vision - dizziness/vertigo - hearing problems - memory difficulties - etc. Delayed signs and symptoms: - sleep irregularities - fatigue - personality change - depression - lethargy

8 Don t be Fooled Delaney JS et al, Mechanisms of injury for concussions in university football, ice hockey, and soccer. Clin J Sport Med Some athletes were not hit in the head Chest contact in hockey Also: BLAST INJURY in Military Vast majority had No LOC

9 Office Evaluation General medical history Past concussion history Mechanism of injury - How much force?? Pillars: - Assessment of symptoms - Physical examination - Neuropsychological (Cognitive) testing

10 Symptom Score Scales - 22 items scored 0-6 (Max score= 132) - Non-concussed baseline: 1134 Baseline Males HS : mean=16.9 (SD 5.3) 214 Baseline Females HS : mean=19.7 (SD 3.3)

11 SCAT-5 Symptoms Headache Neck Pain Dizziness Balance problems Sensitivity to noise Feeling like in a fog Difficulty concentrating Fatigue or low energy Drowsiness More emotional Sadness Pressure in head Nausea or vomiting Blurred vision Sensitivity to light Feeling slowed down Don t feel right Difficulty remembering Confusion Trouble falling asleep Irritability Nervous or Anxious

12 Asking About Symptoms How do you ask: survey/questionnaire Vs interview? Self Reported Symptoms Total Number of symptoms Total Symptom Score Interviews Total Number of symptoms Total Symptom Score Who conducts interviews? Male interviewer Total Number of symptoms Total Symptom Score Female interviewer Total Number of symptoms Total Symptom Score

13 Concussion Examination- Physical Exam Examine the EYES Examine the NECK Neuro exam usually normal but.. - Best bet: Balance Error Scoring System (BESS) - Done on firm +/- foam : 3 separate sections Double leg stance Single leg stance Tandem leg stance

14 Visual Assessments Nearly 30% of concussed patients report some level of visual problem following concussion - (Lovell et al., 2006) Coordination of eye movements is off : subtle not visual acuity Students/workers who must move their eyes over a page or screen to read Increases symptoms

15 Neck Related Symptoms Can have many similar symptoms to a pure brain concussion headache, dizziness, poor memory, and vertigo - Whiplash - Cranio-cervical shake syndrome (CCSS) Leslie and Craton- CJSM Sept 2013 Neil - Cervicogenic/vestibular post-concussion disorder (CGV) Buffalo group

16 Neck Exam Headaches - Many are neck related - Tenderness over occipital nerves Neck headaches - Present in the morning - Get better with medication - Get better with exercise - Good for PT/AT/Osteo

17 Balance Error Scoring System (BESS) Score= firm: a/10 + b/10 + c/10 = x/30 foam: d/10 + e/10 + f/10 = y/30

18 BESS Regular VS Modified Modifed BESS (out of 30): - ONLY FIRM surface used - firm: a/10 + b/10 + c/10 = x/30

19 BESS- Concussed VS Baseline Regular BESS: - Guskiewicz KM et al, Postural stability and neuropsychological deficits after concussion in collegiate athletes. J Athl Train. 2001; Population Control (baseline) 9 ± 4 Concussed 15 ± 8 # Errors - More abnormal on day 1 - Most return to normal by day 5

20 Affects on BESS Post exertion - Normalize after 20 minutes Sports - Gymnastics better than Basketball (Bressel et al 2007) Braced or taped - do slightly worse than barefoot (Broglio et al, 2009) Age - young and older ( >40 y.o.) do worse

21 BESS If no baseline: - helpful if very abnormal or very good

22 Neuropsychological Testing Assess cognitive status of individual Can test: - Cognitive processing speed, working memory, verbal and visual memory, attention, concentration, new learning, executive functions, reaction times, etc. NP recovery can overlap with symptoms recovery, precede or follow symptom resolution Not an IQ test: only one part of concussion evaluation - Not used solely to make diagnosis

23 Neuropsychological Testing Can be affected by many factors, including: - Age, education, cultural background - Sex (also OCP use in females) - Fatigue, exercise/exhausted - Distraction - Sleep - Depression, anxiety - Intoxication - Learning disabilities, Attention problems

24 Neuropsychological Testing Abbreviated - Pencil and paper: McGill, SCAT5 - Computerized: ImPACT, CogState/Axon minutes Formal - Neuropsychologist - Best at detecting other conditions (anxiety, learning difficulties, depression) hours

25 Standardized Assessment of Concussion (SAC) 4 main sections - Orientation - Immediate memory 5 objects immediately up to 6 numbers in reverse - Concentration recite months of year in reverse - Delayed recall delayed recall of 5 objects

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28 Treatment- Feedback Use concussion symptoms as feedback A concussion does not like to be irritated. Use the onset or exacerbation of concussion symptoms as useful feedback. - When the concussion symptoms occur or when they are worsened, the patient should ask themselves What am I doing to cause this? - The patient should then try to stop the activity or behavior that is irritating the concussion.

29 Aggravating Factors Loud or constant noise Bright lights Exercise and Physical Exertion Cognitive Stress (job or school work) Crowds Computer screens or smart boards Television

30 Aggravating Factors Driving Sexual Activity Travel Vacation Activities Stressful/emotional situations Etc.

31 Cognitive Rehab Rest - Sooner is better but?? How long Start with short periods of concentration and then breaks Increase concentration time over day or days Students - May initially only attend some classes and listen - More time for exams and assignments - Reintegrate to full course load: Gym is last

32 School Cognitive rest: this may involve avoidance of class, assignments, computer screen exposure, texting, television and other mentally stimulating activities. This step may last several days or longer Class attendance: this may involve only attending selective classes without taking notes. It may be helpful to provide the student with course notes from the teacher or another classmate so that the concussed student can listen to the lectures, without having to worry about taking notes.

33 School Class participation and homework: the student may begin to take notes and participate in class discussions. If this goes well, the student can begin doing small assignments for limited periods of time. As symptoms improve, student can gradually increase amount of time spent studying in class and at home. Full class participation and homework: When the student is able to fully participate in all classes, assignments and exams, may begin a gradual return to sports under the guidance of a healt professional.

34 Exercise in Concussions Aerobic Resistance Contact - New CISG recommendations post Prague - Some light (sub symptom) aerobic exercise early may be beneficial

35 Sub-symptom Exercise Not return to play exercise Sub-symptom threshold exercise training (SSTET) - Goal is to exercise below level of exertion / exercise that causes the onset or aggravation of concussion symptoms Must determine the level of exertion or exercise which causes either: - ONSET of symptoms in those patients who have no symptoms at rest - WORSENING of symptoms in those patients who already have symptoms at rest

36 Sleep Sleep pattern is often disturbed in all concussion patients - Poor sleep can exacerbate symptoms of concussions Brief course of medications may be given to re-regulate sleep patterns - Some evidence melatonin may aid in concussion recovery due to sleep regulation Good sleep hygiene (habits) are advised

37 Diet Some research that omega-3 fatty acids may help reduce brain injury in animals exposed to head injury. Not sure if there is a similar effect in humans - No harm - Humans cannot produce omega-3 fatty acids - Omega-3 fatty acids can be found in fish such as salmon, herring, anchovy, tuna, trout, Flaxseeds, walnuts, canola and soybean oils. - 2 grams of omega-3 fatty acids daily in soft gel supplements

38 Medications Headaches - No good research on concussion headaches - Acetaminophen NSAIDS,+/- narcotics, migraine meds Beware of rebound headaches from prolonged/overuse of medications - Headaches very difficult to treat - diagnostic tool - If respond: may be tension related - Chronic headaches: Amitriptyline (Elavil) used by neurologists for many years

39 Medications Headaches - Many are neck related - Occipital nerve blocks Injections at base of skull If local pain over occipital nerves

40 Medications Sleep abnormalities - Short trial of medication (zopiclone) - Some evidence melatonin (3mg -10mg/day X 28 days) may help recovery Vertigo - Anti-vertigo meds - Also: therapy with desensitization exercises - Research showing a benefit

41 Medications Avoid alcohol - May not feel well - May have headache (? Hangover or concussion) - Disrupts regular sleep patterns - My fall or get into physical altercation

42 Rehabilitative Therapy (PT, AT, Osteo) Dizziness and balance problems - Vestibular rehabilitation has proven effective in several studies (more later) Headaches - Cervical spine May benefit from targeted therapy Often a component of headaches post TBI

43 Rehabilitative Therapy Visual retraining - To coordinate the ocular movements

44 Prolonged Recovery Children and Adolescents Multiple Concussions Sleep abnormalities Amnesia - Retrograde or anterograde Possibly: - Learning disabilities - Attention disorders - Migraine headaches

45 Healing Curve 6 Weeks 3 Months % Healing 2 Weeks Time

46 Return to Life- Regular Folks Rest until no symptoms at rest or no more improvement Start sub symptom exercise Start cognitive exercises (concussion rehab) at home - Winword, crosswords, Sudoku - Before going back to work or school, need to know they can do some of the tasks required for a certain period of time

47 Return to Life- Regular Folks Reintroduce work/school gradually if possible May need extra time for assignments/exams Usually restart physical exercise when work/school is back to 100% NO SPORTS UNTIL BACK TO SCHOOL or WORK at 100%

48 Summary Symptoms are valid tool in diagnosis Examine the eyes and neck Do BESS - May scare them Rest sooner rather than later Gradual increase in cognitive activity Trial of certain medications - More neck injections/occipital nerve block Earlier sub-symptom exercise

49 Questions?