Concussion Management

Transcription

1 Concussion Management Significant changes towards more individualized, specific management. Increased knowledge has lead to State and Local legislation. Jeff Anthony DO, FAAFP, FAOASM San Diego Sports Medicine Center Olympic Training Center; SDSU; SDCC

2 No Disclosures

3 Concussion Management The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. No play day of injury No Play if any symptoms 85-90% resolve by 10 days Consensus Statement on Concussion in Sport the 4th International Conference on Concussion in Sport. Held in Zurich, November 2012

4 Post Concussion Management Timeframe Concussions are: Evolving, multifactorial, and individual. No longer graded Acute: 1-7 days Rest; start easy re-introduction Sub acute: 5 14 days Gradually increase activity Protection Chronic: days and longer Consider other therapies: scrutinize circumstances, Rx; Physical / Ocular / Counseling therapy.

5 No activity Light Aerobic Sport Specific Concussion Management RTP overview, stages: Non contact drills Full contact practice Return to play -Protection -Increased HR -Add movement -Coordination/Cognitive -Assess fcnal /Confidence Consensus Statement, Zurich, 2012

6 Concussion Management Risk factors that influence recovery: Severity Previous concussions / timing H/o Headaches / Migraines LD / ADHD Depression / Anxiety disorders Age: younger may take longer Sex: Female may take longer H/o Motion sensitivity/vertigo Ocular issues (amblyopia)

7 Management is directed by Evaluation History MOI Physical exam R/o ICB Evaluate for concussion CN Cerebellar / Balance Vestibular - Ocular eval Neurocognitive

8 Multi-System Approach targeted at manifestations Musculoskeletal injuries Headache Cervical strain Neurocognitive issues Memory, mentation, calculations Vestibular Dysfunction Balance Dizziness Vertigo Light headedness Visual/ocular disturbance Exertional component

9 Post concussive Headache Very common (70%) 30% do not Ms Tension HA whiplash Management: Ergonomics, BM HEP OMT, PT, Acupuncture Biofeedback, visualization techniques

10 Migraine: Rx Brain injury: Post Concussion HA Other Causes Related to concussion Tx: unloading brain Rebound: Chronic NSAIDS, Tylenol Dehydration/metabolic: Tx: correct disturbance Neuro impingement: Occipital N.; injection

11 Neurocognitive NC used for evaluation and monitoring Neuropsych testing: cornerstone of concussion management* *Consenses statement, Zurich, 2012 Memory, mentation, calculations Face-face, paper/pencil Computerized: ImPact, Concussion VS, C3 logic Return to learning (RTL): Gradually increase mentation and academics

12 ImPact

13 Vestibular: Balance / Coordination Concussions can affect the afferent (proprioception) or integration (brain stem) signals, reducing balance Balance testing is valuable for Dx and management. Program: balance exercises, both with eyes open and closed (utilizing somatosensory and vestibular inputs) Progressive difficulty Single leg, unstable surface, surfing, jump/twist/catch, etc.

14 Vestibular: Dizziness Diagnosis malady, then treat specifically Light headed or Vertigo? Light headedness Cervical muscle tightness Metabolic, hypoglycemia, etc. Anxiety Vertigo Room is spinning Uneasy or queasy feeling, like on a boat Treated differently

15 Vestibular-Ocular Reflex (VOR) Activation of the vestibular system causes compensatory eye movements The ability for the eyes to maintain vision on an object with head movement Eg., running down street while reading a sign. VOR keeps image on Fovea of eye

16 Symptoms Vestibular issues Dizziness, fogginess, nausea, anxiety, overwhelmed, can t multi-task, off balance. Dx with VOMS (Vestibular Oculomotor Screen) Sensitive for dx and monitoring concussion Pursuit, Saccades, Convergence, VOR (Vestibulo- Ocular reflex) Goal is to restore brain s ability to sense and respond to motion; (Reduce dizziness, help balance)

17 Canalith repositioning BPPV Can occur with concussions. Positional vertigo Dx: Dix-Hallpike maneuver Tx: Epley maneuver

18 Concussion and Vision 46% concussed pts have visual problems (Carl Hillier, OD FCOVD) (Vision Dx, Clinical Pediatrics, 2015; The neuro-opth of head trauma, Lancet Neuro 2014) Photophobia: dysfunctional pupillary response Blurred vision: dysfunctional accommodation Diplopia: dysfunctional binocularity Loss of place while reading: dysfcn. ocular motility

19 Ocular motor Coordinate eyes for vision during head motions Testing: Saccadic movements, smooth pursuits, convergence deficits, or symptoms during exam Rehab Performing similar motions, allowing brain to rebuild these mechanisms, allowing accurate vision with motion. May use prisms, lenses, etc. Dynamic exertion training: Patient focuses on one object while running

20 Neuro-Optometric Rehab Vision Rehab. goals: (Carl Hillier, OD FCOVD) Recapture accommodative (CN 3) and binocular (CN 3, 4, 6) skill and endurance Recapture saccadic skill and endurance Recapture pupillary response (CN 3) to reduce photophobia. Using specific procedures and instrumentation (stereo-scopes, plus and minus lenses, prisms)

21 Concussion Management -other- Sleep disturbance, common Causal factors: Brain trauma, anxiety, depression, lack of exercise Tx: progressive relaxation; visualization Rx: melatonin, benedryl, Trazodone Anxiety / Depression Assess for pre-injury issues Psychotherapy (inform. / formal) SSRIs: Zoloft, Lexapro

22 Somatic: Rx Treatment HA: NSAIDs, muscle relaxers; removal of Rx! Amitriptyline, Magnesium (500mg), B2 (400mg), Topamax Emotional: Psychotherapy, SSRIs (Lexapro, Zoloft, Prozac) Sleep disturbance: Behavioral, Melatonin, Trazodone 50mg, Amitriptyline 30mg Cognitive: Amantadine Stimulants: Adderall, Ritalin, Stratera

23 Musculoskeletal Neurocognitive Concussion management Vestibular Dysfunction Visual/ocular disturbance / other Exertion and Sport specific training As pt improves, test the brain by exertion and sport specific activity (coordination, proprioception, etc.) Treatment needs to be specific; prioritize malady Team approach

24 California State Law Re: Concussion, HS AB (Assembly Bill) 2127 (1/15) License Health care provider (LHCP) Head injury, not just concussion Requires graduated return to activity > 7 days Encourages CIF to develop protocols (CA Interscholastic Federation) CIF protocols (3/15) Physician (MD/DO), rather than LHCP Concussion specifically RTP, RTL protocols

25 Return to Play protocol

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27 Essentials for RTP (CIF) No physical activity for at least 2 days after athlete seen by Dr. Dr. must clear athlete before RTP protocol starts Return to sport cannot be sooner than 7 days AFTER seen by Dr If the concussion injury does not resolve in 7-10 days, treatment should also consider: Further Reduction of aggravating factors, mental and physical Consider Rehab for balance, oculomotor, CT strain, etc. Consider medications as appropriate

28 Keys to RTP Athlete needs to see a Physician (MD/DO) asap after injury to start the clock for recovery The athlete must do a supervised, graduated RTP protocol to return to sport The athlete needs written notification: to begin protocol, and for release to full sport (stage 3) by a licensed physician (MD/DO). If concussion is not improving, recommend seeing a physician experienced in the field to facilitate safe recovery Baseline testing is recommended

29 Clinical case Athlete injured on Friday night with a mild concussion (Day 0). Seen Monday by physician (Day 3). If Now asymptomatic, Begin Stage I: no activity for at least 2 full symptom-free days

30 Case Begin Stage II-A : light aerobic activity. Must be performed under direct supervision by designated individual (Day 5). Begin Stage II-B : moderate activity (Day 6). Begin Stage II-C : strenuous activity (Day 7). Begin Stage II-D : non-contact training (Day 8) Must have written physician clearance for return to play prior to Stage III.

31 Case Stage III : Limited contact practice (Day 9). Stage III(second level): Full contact (Day 10). Must complete at least one contact practice before return to competition. Highly recommended divided into 2 contact practices. Stage IV: Return to play(competition) (Day 11). (If Asx on day of concussion AND seen by Dr., Day 9)

32 CIF Return to Learn Protocol

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34 CIF Return to Learn Protocol Brain rest- usually 2-5 days after injury, can progress to next stage when begins to improve Return to School Partial Day usually ends 5-21 days after injury. If no sx s, can attend full days of school

35 CIF Return to Learn Protocol Return to School Full Day- no more than 1 test or quiz per day, extra time for homework/tests, light physical activity Full Recovery- normal home, social and school activities. May begin and must complete CIF RTP Protocol before strenuous physical activity or contact sports

36 Concussion Management Summary Significant change in management of concussions: from grading/cookie cutter approach to: individual care with focus on manifestations. Relative rest for brain and body; allow healing without re-incident; gradual progression as tolerates. Prioritize treatment to specific manifestations Utilize Rx; Vestibular/Ocular/Physical/and Psychological therapy as needed Guidelines per state / organizations; RTP and RTL protocols

37 Thank You San Diego Sports Medicine Center

38 References California Interscholastic Federation (CIF) CIF.org AB 2127; Assembly Bill 2127, interscholastic sports Consensus statement on concussion in sport: 4 th international, Zurich, 2012 The neuro-opth of head trauma, Lancet Neuro 2014 ImPact, Clinical Trajectories