Disclaimer. Objectives 4/7/2013

Transcription

1 Post-Concussion Management in the Clinic Steve Lauer PhD MD Department of Pediatrics Center for Concussion Management University of Kansas Medical Center April 19, 2013 Disclaimer I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Objectives Review Concussion Physiology Update on Concussion Guideline Statements Discuss Key Components of Concussion Assessment in the Clinic Setting Review Treatment Modalities for Concussion Symptoms Introduce Return-to-Learn 1

2 Kansas State Bill 33 effective 5/25/11 Concussion education must be distributed from the state educators to each school district for coaches, school athletes and parents/guardians A signed release form must be signed by parent/guardian each year Immediately remove athlete from play if concussion is suspected in practice/competition A health care provider (MD or DO) must provide a written clearance to return to play or practice when the athlete is medically cleared Case 15 year old, generally healthy female, no significant PMH, lives with father, onset of menses at 11, no medications or allergies. 9 th grade, likes school, active, social. Shopping at local store and shelving fell on her, hitting her head. No LOC, did not go to ED. Headache, phonophobia and generally irritability (per dad) have persisted for 2 weeks Unable to attend school; causes headache and it s just too loud. 2

3 Zurich th International Conference on Concussion in Sport Concussion is a functional disturbance of brain function, not a structural disturbance Concussion results in a graded set of clinical symptoms Loss of consciousness is NOT a requisite finding Classification of concussions is not supported The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve Return to activity follows a stepwise process AAN Guidelines 3

4 Risk Factors for extended recovery Previous concussion Prolonged loss of consciousness (>1 minute) Amnesia Post-concussive seizures Comorbidities: ADHD, learning disabilities, psychiatric diagnoses, migraine, motion sickness Post-Concussion Symptoms 4

5 Assessment Tools Patient symptom score Physical Exam Neuropsychological Testing ImPact Patient Symptom Checklist Balance and Coordination 5

6 Vision Abnormalities 1. Vertical and Horizontal Gaze Stability 2. Convergence (<6 cm) ImPACT Immediate Post-Concussion Assessment and Cognitive Testing 20 minutes; Computerized; Developed at University of Pittsburgh Baseline testing being done in school athletic programs, some private clubs Normative data down to 11 years of age, available in 19 languages Measures memory, speed and accuracy Impact report 6

7 Patient PSC score was 48 Couldn t do one-leg stand and 5 errors on tandem Convergence at 14 cm Could barely complete ImPact, all scores <1% without a baseline Basics of Management Cognitive rest Symptom management Cognitive rest Symptom-specific therapy in extended cases What does Cognitive Rest Mean? Being VERY BORED!!! No texting No video games No music No TV No Screen time of any kind 7

8 Case Scenario Returned to clinic 1 week later and had not done any component of cognitive rest. No improvement. Returned 1 week later with considerable improvement but still not at baseline Referred to vestibular therapy Pharmaceutical Management Amantadine Concerta Strattera Ritalin Ibuprofen Amitryptyline Propanolol Magnesium Lexapro Zoloft Cymbalta Melatonin Trazodone 8

9 Concussion Recovery ImPACT back to baseline Normal Exam (cognition/balance) Symptom Free Begin Return to Play Protocol Return to Practice Guidelines Light aerobic exercise (walk/bike) (10 min) Light aerobic exercise (running) (30 min) Light resistance or weight training (non-contact/full equip) (30-60 min) Full practice (full contact) Supervised by trainer/coach Return to play Return to Learning Pathway Home Total rest No driving, computer, texting, video games, homework Home light mental activity No driving, up to 30 min homework School part time, max assistance Breaks, lunch in quiet place, early passing periods, no testing, extra time for assignments School part time, mod assistance Similar to above, but increase amount of work, no testing School full time, min assistance May require some accommodations 9

10 Return to Learning To Return to Play, the concussed patient should first proceed through the return to learning pathway To Return to play, the concussed patient must proceed asymptomatically through the return to practice steps Only after review of these documented steps by a medical provider should a concussed patient be returned to competitive sports Subspecialty Referrals Neuropsychology Speech therapy Vestibular therapy Physical therapy Vision therapy Ophtho/ENT Mental health Sleep clinic Case scenario After 3 visits with vestibular therapy, much improved and returned to clinic. PSC at 4 Tandem gait without error, 2 errors on single leg. ImPact with most scores in the 30-50% range. At educational baseline Released from concussion clinic 10

11 References Neuron (2010) 76: The Neuropathology and Neurobiology of Traumatic Brain Injury Journal of Athletic Trainers (2001) 3: The Neurometabolic Cascade of Concussion Br J Sports Med (2013) 47: Zurich Statement AAN Concussion Guidelines, published online Clinical Report--Sport-Related Concussion in Children and Adolescents Neurosurgery (2006) 58: Examining Concussion Rates and Return to Play in High School Football Players Wearing Newer Helmet Technology: A Three-Year Prospective Cohort Study 11