Concussion Update and Case Presentations

Transcription

1 Concussion Update and Case Presentations Cayce Onks, DO, MS, ATC Associate Professor Primary Care Sports Medicine Penn State Concussion Program Departments of Family Medicine and Orthopaedics

2 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do (or) do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. I will disclose that I will in every attempt try to communicate the current evidence for Concussion. If I have an opinion I attempt to let you know I do need to disclose that I have a history of concussions

3 Learning Objectives Identify, evaluate, and diagnose concussions Explain and discuss current controversies with parents regarding concussion

4 Case 1 A 12 y/o male presents with his mother for headaches. This started about a month ago when he began playing middle school football for the first time. It became worse 10 days ago when he was making a tackle on a player. Following this he had dizziness, photophobia. He admits to having neck pain consistently since the start of football as well. He has already been seen for this and was felt to potentially have migraines and a sinus infection. He has been prescribed a triptan and butalbital/ acetaminophin/caffeine for the headaches and Amoxicillin/Clavulanic Acid. The triptan did not work and they haven t started the other 2 meds. Mom just wants to know if he has a concussion or not?

5 Sport Related Concussion Defined Direct blow to the head or indirect force that is transmitted to the head Rapid onset and often short lived impaired neurologic function that resolves spontaneously, but occasionally can evolve over minutes to hours Largely reflect a functional disturbance rather than a structural change (standard neuroimaging is normal) Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. In some cases may be prolonged. The symptoms must not be explained by other mechanisms (Diagnosis of exclusion)

6 Diagnosis Meets the definition criteria Symptoms include headaches, feeling in a fog, or emotional symptoms Physical Signs: LOC, Amnesia, neurologic deficit Balance impairment Behavioral Changes Irritability Cognitive Impairment-Slowed reaction times Sleep/Wake Disturbance Consider the SCAT 5

7 SCAT /04/26/bjsports SCAT5.full.pdf /04/26/bjsports childscat5.full.pdf

8 Do I need to Image? Concussion is a functional not structural phenomenon so standard imaging is normal YES if concern for structural intracranial etiology Prediction rule for children aged 2 and above normal mental status no loss of consciousness no vomiting non-severe injury mechanism no signs of basilar skull fracture no severe headache Negative predictive value 99.95%, Sensitivity 96.8%

9 What about for prolonged sub-acute symptoms? 3338 children reviewed with concussion and 427 had MRI s 2 had changes compatible with trauma Both has a history of a significantly larger number of head injuries than the cohort 61 had abnormal findings not related to trauma Of these there were 2 that had surgical findings, but both patients had clear neurologic impairments that were nonresolving

10 Future Diagnostics Blood Saliva EEG Functional MRI Diffusion Tensor Imaging Cerebral blood flow Transcranial magnetic stimulation

11 Started 2014 Enrolled 23,533 athletes and cadets Already captured 1174 concussions in 2017 Collecting genetics, biomarkers, cognitive testing, oculomotor, MRI

12 Case 1 A 12 y/o male presents with his mother for headaches. This started about a month ago when he began playing middle school football for the first time. It became worse 10 days ago when he was making a tackle on a player. Following this he had dizziness, photophobia. He admits to having neck pain consistently since the start of football as well. He has already been seen for this and was felt to potentially have migraines and a sinus infection. He has been prescribed a triptan and butalbital/ acetaminophin/caffeine for the headaches and Amoxicillin/Clavulanic Acid. The triptan did not work and they haven t started the other 2 meds. Mom just wants to know if he has a concussion or not? The child had a direct hit to the head and had immediate symptoms consistent with a concussion Confusing because children often have neck pain and tension headaches with helmets when they first start wearing them He also has fall allergies that are starting that were causing congestion Mom then asks should he be exercising? and do I need to change his helmet so this doesn t happen again?

13 Should he be exercising? Review of the current evidence for exercise in concussion Appears that it is not harmful A prescription for an individualized subthreshold dose of aerobic exercise appears to safely improve symptoms, speed return to activity, and restore function

14 Do I need to change his helmet so this doesn t happen again Helmets are effective at reducing the incidence of skull fracture and superficial head injuries In terms of concussion prevention, football helmet improvements may be reaching a point of diminishing returns and are not likely to be the solution to the concussion issue we face today.

15 Case 1 A 12 y/o male presents with his mother for headaches. This started about a month ago when he began playing middle school football for the first time. It became worse 10 days ago when he was making a tackle on a player. Following this he had dizziness, photophobia. He admits to having neck pain consistently since the start of football as well. He has already been seen for this and was felt to potentially have migraines and a sinus infection. He has been prescribed a triptan and butalbital/ acetaminophin/caffeine for the headaches and Amoxicillin/Clavulanic Acid. The triptan did not work and they haven t started the other 2 meds. Mom then asks should he be exercising? It appears that it does not harm to exercise at subthreshold symptoms and do I need to change his helmet so this doesn t happen again? Make sure that helmet is fitted properly and that it is approved by the National Operating Committee on Standards for Athletic equipment. Otherwise no need to change helmet.

16 Case 2 16 y/o male football player who sustained his 1 st lifetime concussion during a Friday night football game. He has complete resolution of his symptoms at 10 days and has moved through your return to play protocol. You are ready to return to full play. Dad has a couple of questions: Would getting them out of play earlier have helped? They did some sort of test at school. Can we use that to help with return?

17 Early Removal from play? First publication from the CARE consortium 506 Sport related concussions Classified as either immediate removal from activity (I-RFA) vs delayed removal from activity I-RFA group Significantly less time missed from sport Shorter symptom duration Significantly less severe symptoms

18 Use of Computerized Neurocognitive Tests?

19 Use of Computerized Neurocognitive Tests? Validity questioned currently Different age groups Testing environment? Reliability of baseline testing better for some products than others Reliability of products ability to show post test declines is in question

20 Case 2 16 y/o male football player who sustained his 1 st lifetime concussion during a Friday night football game. He has complete resolution of his symptoms at 10 days and has moved through your return to play protocol. You are ready to return to full play. Dad has a couple of questions: Would getting them out of play earlier have helped? YES They did some sort of test at school. Can we use that to help with return? Computerized Neurocognitive tests currently not required for diagnosis or return to play (Berlin Consensus). CDC guidelines suggest it may sometimes be used for diagnosis but not required.

21 Case 2 Walking out the door dad asks: By the way, do we have to worry about CTE? OH Boy. When is my next patient?

22 Chronic Traumatic Encepholapathy (CTE) Case Series of 202 deceased football players whose brains had been donated for research Neuropathological Evaluations Retrospective informant clinical assessments Online questionnaires regarding athletic and military history

23 CTE neuropathologically identified 177/202 Grouped into mild CTE pathology (27) and severe CTE pathology (84) Behavioral and mood symptoms: 96 and 89% Cognitive symptoms: 85 and 95% Signs of dementia: 33 and 85%

24 First available scientific data that objectively defined a pathological entity which supported concerns regarding the long term effects of repetitive brain trauma Highly publicized and created significant concern from the public Has been scrutinized heavily by the scientific community

25 Criteria for defining the clinical syndrome of CTE is absent Absence of in vivo biomarkers Attribution of candidate symptoms in retired players complicated by premorbid and comorbid factors that influence normal or expected cognitive functioning No appropriately defined reference group to compare Available data limited and complicated by selection bias defines a pathological entity that appears more prevalent in repetitive brain trauma

26 Highlights that this entity has been recognized in the past as dementia pugilistica. Debated 1 st half of 1900 s with no consensus that this increased risk of neurological issues Data does not rise to the level of a verifiable disease. Currently at the level of a case report Protein deposits are poor predictors of behavioral symptoms NFL players are physically and mentally healthier than men of their demographic background Mortality rates 50% of the expected and suicide rates 40% of expected Explanation may be that p-tau may be more present but is inert and has no toxic or self-propagating effects

27 Cross sectional survey 107 orthopedic surgery 74 neurosurgery Collegiate contact sports: OS-44.7% NS-21.7% 31-fold higher for OS and 15.1-fold higher for NS than their college peers Rate of Concussion: OS-42.6% NS-42.4% Significantly higher than the general population Highlights the need to explore the potential benefits of sport as well as the risks

28 Case 2 Walking out the door dad asks: By the way, do we have to worry about CTE? There is no question we should be concerned and take every head injury seriously. There are many unknowns regarding the potential association of CTE and repetitive head trauma. For that reason we need to be conservative in our management of concussion considering risks, but also consider the benefits. OH Boy. When is my next patient?

29 Highlights for Clinical Practice Concussions are a well defined entity Brain imaging is not required to diagnose Structured light aerobic exercise at subthreshold symptoms does not cause harm and may help in treatment Helmets do not prevent concussion Early removal from play for concern of concussion is protective The use of computerized neurological testing is not currently required CTE is a pathologic diagnosis with no current method for clinical diagnosis. Appropriate concern for such an entity should be recognized, but also an understanding of the limitations in science currently. A discussion with families regarding the risks and benefit of sport can be very helpful.

30 CDC Guidelines Resources Great return to school resources! Return to Play protocol

31 Closing Thoughts/Questions?