Conflicts. Objectives. You can t hide. Epidemiology 4/16/2018. I have no relevant financial relationships to disclose.

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Sydney Ferguson
5 years ago
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The Concussion Epidemic What the EM provider needs to

consultant for Weber-Shandwick Neha Raukar, MD MS, FACEP

Department of Emergency Medicine Director, Division of

University April 19, 2018 Objectives You can t hide

demographic groups Critically appraise different

biomechanics of concussion Review the definition of

counseling patients with a concussion Epidemiology 1.

1 The Concussion Epidemic What the EM provider needs to know Conflicts I have no relevant financial relationships to disclose. Certified ImPACT consultant NFL/KSI grant reviewer Paid consultant for Weber-Shandwick Neha Raukar, MD MS, FACEP CAQ Primary Care Sports Medicine Associate Professor, Department of Emergency Medicine Director, Division of Sports Medicine Warren Alpert School of Medicine Brown University April 19, 2018 Objectives You can t hide Evaluate the different rates of concussion among varying demographic groups Critically appraise different protection modalities by understanding of the biomechanics of concussion Review the definition of concussion and it s diagnosis Create a script for counseling patients with a concussion Epidemiology 1.7 million TBI annually in the US TBI accounts for 22% of all fatalities 46% of all fatal falls due to TBI raininjury/data/rates.html 1

2 Types of Traumatic Brain Injury Type of Injury GCS Concussion has a normal CT scan Traumatic Brain Classification 3-8 Severe Mild Mild Moderate 9-12 Minor LOC Amnesia Or disorientation Minimal No LOC No neurologic alteration Severe 3-8 Facts A concussion IS a traumatic brain injury 75% of all TBIs that occur are concussions Sports related concussions are grouped into this category RED FLAGS 2

Loss of consciousness Amnesia Seizure activity Persistent or worsening symptoms Symptoms/signs of other injuries Focal or

affecting the brain, induced by traumatic biomechanical forces.

defining the nature of a concussive head injury include: 1.

3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional

Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness.

that, in a small percentage of cases, post-concussive symptoms may be prolonged. 5.

Recognition of Concussion is Difficult Variety of signs and symptoms Signs can be subtle Reliance on self-report Somatic

3 Loss of consciousness Amnesia Seizure activity Persistent or worsening symptoms Symptoms/signs of other injuries Focal or lateralizing neurological symptoms The Official Definition Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic 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 either 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. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 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 a small percentage of cases, post-concussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies is seen in concussion. Recognition of Concussion is Difficult Variety of signs and symptoms Signs can be subtle Reliance on self-report Somatic Symptoms Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Vomiting Numbness/Tingling Balance disturbances Signs and Symptoms Emotional More emotional Sadness Nervousness Irritability Cognitive Symptoms Difficulty concentrating Difficulty remembering Foggines Feeling slowed down Sleep Disturbance Difficulty falling asleep Sleeping more/less than usual Drowsiness Fatigue Concussion is a functional injury with individual expression A concussion is the most complicated injury to the most complicated organ of the body 3

4 SCAT 5 to diagnose GCS Symptom scale Neuro exam 3 words, digits backwards, days backwards, 3 words, balance, finger to nose, (mbess), Biomechanical Mechanism Three components Contact Linear acceleration Rotational acceleration Cotton candy on a stick 4

5 What happens to your brain? Concussed Brain Normal Brain The metabolic mismatch results in symptoms Secondary insult The cytokines released lead to an upregulation of the inflammatory response This is where symptoms occur Concussive symptoms get worse 6-24 hours after the injury 5

Concussion is a process not an event Mechanisms of brain acceleration deceleration secondary to

(2013) The clinical spectrum of sport-related traumatic brain injury Nat. Rev. Neurol. doi:10.

33 Permission obtained from Innovative CEUs, LLC Head (not Helmet) Acceleration HMAS Courtesy: Virginia

insures consistent head/accelerometer contact Manoogian et al.

accelerometers real-time w/ alerts 64 players per base unit 1000 Hz All practices and games Head Impact

How do measures of HIE correlate with cases of diagnosed concussion is there an injury threshold? 3.

HIE: Impact Frequency Number of head impacts per practice, game and season ~10% of all college football

6 Concussion is a process not an event Mechanisms of brain acceleration deceleration secondary to biomechanical forces transmitted to the brain Linear Acceleration Rotational Acceleration Jordan, B. D. (2013) The clinical spectrum of sport-related traumatic brain injury Nat. Rev. Neurol. doi: /nrneurol Permission obtained from Innovative CEUs, LLC Head (not Helmet) Acceleration HMAS Courtesy: Virginia Tech HMAS (head-mounted accelerometer system) Design decouples accelerometers from helmet shell and insures consistent head/accelerometer contact Manoogian et al. Biomedical Sciences Instrumentation (2006) Head Impact Telemetry System (HIT System) 6 linear accelerometers real-time w/ alerts 64 players per base unit 1000 Hz All practices and games Head Impact Exposure (HIE) magnitude (accelerations) frequency (number) location (helmet) Head Impact Biomechanics in Sports What have we learned? 1. What is Head Impact Exposure (HIE) for different athlete populations 2. How do measures of HIE correlate with cases of diagnosed concussion is there an injury threshold? 3. Is there an association between HIE and signs and symptoms of concussion? HIE: Impact Frequency Number of head impacts per practice, game and season ~10% of all college football players sustain > 1000 impacts in a season 1 Individual football players with 2,000+ head impacts in a single season Football players sustain > 3x impacts in games than practices Significant difference in HIE among player positions Male college hockey players sustain 2x more head impacts than females 2 1 Crisco et al., J Athletic Training (2010) 2 Brainard et al., Med & Science in Sports and Exercise (2011) 6

HIE: Impact Severity Collegiate Football HIE: Severity and Frequency Collegiate Football 20g buddy head butt 300g +

0g and 1,187rad/s 2 Distribution of impact severity does not significantly change between games and practices (Crisco

, Journal of Applied Biomechanics (2011) Head Impact Biomechanics in Sports What have we learned? 1.

Diagnosed Concussion Events 120+ diagnosed concussions recorded with HIT System Number of impacts higher on

9] Occur most frequently to the Front Front (46%), Top (25%), Side (16%), Back (13%) Mean magnitude > top 0.

4%) impacts with higher magnitude NOT associated with injury what are we missing?

7 HIE: Impact Severity Collegiate Football HIE: Severity and Frequency Collegiate Football 20g buddy head butt 300g + recorded QB RB LB Impacts skewed toward lower severity Line 50% of all impacts < 20.0g and 1,187rad/s 2 Distribution of impact severity does not significantly change between games and practices (Crisco et al., 2011, 2012) Crisco et al., Journal of Applied Biomechanics (2011) Head Impact Biomechanics in Sports What have we learned? 1. What are there differences in Head Impact Exposure (HIE) for different athlete populations 2. How do measures of HIE correlate with cases of diagnosed concussion is there an injury threshold? 3. Is there an association between HIE and signs and symptoms of concussion? Diagnosed Concussion Events 120+ diagnosed concussions recorded with HIT System Number of impacts higher on concussion days Dx-Day: 21.0 [ ] Non Dx-Day: 13.8 [ ] Occur most frequently to the Front Front (46%), Top (25%), Side (16%), Back (13%) Mean magnitude > top 0.5% of all impacts sustained 103 ± 34 g > 8,000 (0.4%) impacts with higher magnitude NOT associated with injury what are we missing?? Head Impact Biomechanics in Sports What have we learned? 1. What are there differences in Head Impact Exposure (HIE) for different athlete populations 2. How do measures of HIE correlate with cases of diagnosed concussion is there an injury threshold? 3. Is there an association between HIE and cognitive measures in the absence of diagnosed concussion? Beckwith et al., FIC on Traumatic Brain Injury (2011) Beckwith et al., World Congress of Brain Injury (2012) Beckwith et al. Med Sci Sports Exerc (2013) 7

% of Athletes with Abnormal Cognitive Decline Compared to Baseline 4/16/2018 Un-Diagnosed Concussion?

significantly higher rate of concussion per head impact Athletes exposed to head contact but not diagnosed

and having head impacts Women s Ice Hockey: 1 mtbi every 1,883 impacts Football: 1 mtbi every 14,085

HIE and Concussion: Sex Differences Females experienced lower head impact exposure than males on days of

+/- 14 5313 +/- 15 W Hockey 43 +/- 11 4029 +/- 11 Bethany J. Wilcox Ph.D.et al.

8 % of Athletes with Abnormal Cognitive Decline Compared to Baseline 4/16/2018 Un-Diagnosed Concussion? Cognitive Testing Indicates Potential Under-reporting Concussion Rates by Sex Females experience a significantly higher rate of concussion per head impact Athletes exposed to head contact but not diagnosed w/ concussion 52% had abnormal cognitive decline at 72hr interval 50% at follow-up (7+ days) still playing and having head impacts Women s Ice Hockey: 1 mtbi every 1,883 impacts Football: 1 mtbi every 14,085 impacts Beckwith et al. World Congress of Brain Injury (2010).McAllister et al. Neurology (2012). HIE and Concussion: Sex Differences Females experienced lower head impact exposure than males on days of diagnosed concussions. Acceleration Linear Football 117 +/- 43 Rotational / M Hockey 71. +/ /- 15 W Hockey 43 +/ /- 11 Bethany J. Wilcox Ph.D.et al. Biomechanics of head impacts associated with diagnosed concussion in female collegiate ice hockey players. J Biomech Jul 16;48(10): INCIDENCE IS HIGHER IN WOMEN 8

Neck Musculature Susceptibility Reporting Why?

Reporting Physical Symptoms Headaches Visual Problems

emotional Sadness Nervousness Irritability Sleep

than usual Cognitive Symptoms Attention Problems Memory

Females More symptoms More severe symptoms Simple and

9 Neck Musculature Susceptibility Reporting Why? Neck Strength Let s be honest. Reporting Physical Symptoms Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Emotional More emotional Sadness Nervousness Irritability Sleep Disturbance Difficulty falling asleep Sleeping more/less than usual Cognitive Symptoms Attention Problems Memory Dysfunction Fogginess Fatigue Cognitive slowing Outcome Females More symptoms More severe symptoms Simple and complex reaction time compared to their own baselines Greater academic impact Cognitively impaired 1.7 times more often than males 9

RECOVERY IS LONGER IN WOMEN The problem Heading a soccer ball How bad could that be? Over 2.8 million AE in HS from 2005 2014 About 1000 concussions 68.

Limit heading from 11-13 Long term consequences 2005 UNC - Chapel Hill - data from more than 2,550 retired professional football players 61% had experienced at least one concussion during their

of the NFL 1,063 retired NFL players completed a survey Younger players (30 to 49 years) had a rate of 1.9% 19 times that of the national average of 0.1%. 6.

10 RECOVERY IS LONGER IN WOMEN The problem Heading a soccer ball How bad could that be? Over 2.8 million AE in HS from About 1000 concussions 68.8% (boys) and 51% (girls) due to head to head contact 30% (boys) and 25% (girls) due to heading The Solution Modify substitution rules to evaluate injured player No heading under the age of 10 Limit heading from Long term consequences 2005 UNC - Chapel Hill - data from more than 2,550 retired professional football players 61% had experienced at least one concussion during their career 24% had >= 3 Earlier onset of Alzheimer s disease among these men than the general male population Memory disorders University of Michigan s Institute for Social Research at the request of the NFL 1,063 retired NFL players completed a survey Younger players (30 to 49 years) had a rate of 1.9% 19 times that of the national average of 0.1%. 6.1% of players age 50 and older had been diagnosed with a dementia-related condition Five times the national average of 1.2% Sports Legacy Institute Developed in 2007 Is the CTE research center In 12 months, they had brains from 18 deceased contact athletes Ages had CTE 10

11 Chronic Traumatic Encephalopathy 11

The NFL response 39 rule changes in 5 years

Unaffiliated neurotrauma consultants Eye in

cognitive and physical rest TREATMENT AND

12 The NFL response 39 rule changes in 5 years Institution of Concussion protocols Unaffiliated neurotrauma consultants Eye in the sky (injury spotters) >$20,000,000 research grants annually Early Goals Protect brain vulnerability Basis for cognitive and physical rest TREATMENT AND RECOVERY Recovery Practically speaking. Activity Symptoms Impact Time 12

Balance medical needs and academic/work/life needs HOW LONG ARE THEY OUT?

take longer to heal Developing brain is more sensitive to the excitatory NT and the cascade

College athletes: 5-7 days HS athletes: 10-14 days Recovery confounders Concussion History

13 Balance medical needs and academic/work/life needs HOW LONG ARE THEY OUT? Recovery Confounders Not everyone recovers at the same rate Are there things that affect the rate of recovery? Age Concussion history Sex Comorbid conditions Recovery confounders Age Younger athletes take longer to heal Developing brain is more sensitive to the excitatory NT and the cascade that follows Age Average return to baseline testing Adults and pro athletes: 3-5 days College athletes: 5-7 days HS athletes: days Recovery confounders Concussion History History of 3 concussions More severe on field presentation Delayed recovery times Threefold increase for future concussion Long term neurological deficits/decline in cognitive performance 13

consciousness Coma 2.What is the appropriate management of concussion? Select all that apply a. Every concussed individual should see a physician b.

14 Question 1 Question 2 1. Which of the following is a sign or symptom of a concussion? Select all that apply. Headache Hemiparesis Dizziness Confusion Fixed dilated pupil Nausea and/or Vomiting Vertigo Amnesia Tinnitus Emotional or personality changes Papilledema Intention tremor Fatigue Temporary loss of consciousness Coma 2.What is the appropriate management of concussion? Select all that apply a. Every concussed individual should see a physician b. A concussed player can return to play in the same game or practice if examined by a physician c. A stepwise increase in exercise and activity can be started while symptomatic d. Physical rest is always recommended after a concussion e. Mental rest is always recommended after a concussion f. Signs and symptoms should be monitored for increasing severity g. Full neurological exam at initial assessment is recommended h. The standard mini mental status exam at initial assessment as an adequate cognitive test for concussion i. MRI of the brain is mandatory j. CT of the brain is mandatory Recovery Confounders Comorbid conditions Migraine headaches Attention deficit disorder Sleep disturbances Depression Anxiety Mood disorders The Future 14

IT S ALL IN YOUR HEAD!

IT S ALL IN YOUR HEAD! CARING FOR CONCUSSIONS IN YOUR COMMUNITY Stephen K Stacey, DO CPT, MC, USA OUTLINE Definition Epidemiology Diagnosis Evaluation Recovery Sequelae Prevention Resources for providers