Concussions: the evidenced based office evaluation for primary care and beyond.

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1 Concussions: the evidenced based office evaluation for primary care and beyond. Presented By: Dr. Corey Dean MD, FAAP, FACP, and CAQSM Associate Program Director of Ambulatory Education St. Joseph Hospital Internal Medicine Residency Program Team Physician of Concordia University, Saline, Clinton and Ypsilanti- Lincoln High Schools Date: March 31, 2017

2 Goals and Objectives 1. Present a clinical care model for the management, treatment and in-office evaluation of concussion. 2. Present a case study on a student athlete with post concussive syndrome. 3. Discuss the role of the clinical interview, vestibular-ocular screening and office based tools for testing for concussion. 4. Present data correlating neurocognitive and vestibularocular outcomes following concussion. 5. Discuss tools for the athletic trainer, physical therapist and sports medicine physician to use for the office based physical examination of concussion. 2

3 Case: Recreational Basketball Player Henry is a 14 year old young man who was playing basketball and sustained a head injury in practice. Immediately he complained of symptoms of dizziness, headache and felt nauseous. He had no LOC. PMH: Migraines/ADHD Henry went to his family physician the next day and was diagnosed with a concussion. He was advised to return to school but kept out of practice and all sports until his symptoms resolved. A return to play protocol was instituted. 3

4 Case Presentation: Henry Week 1: Henry upon return to school started to have more headaches, his parents noted he was more irritable and had difficulty watching television or playing video games as my head hurts worse. He missed the next 4 days of school. He returned to his physician who referred Henry for neurologic evaluation. Week 2: The Neurologic evaluation showed vestibular-ocular dysfunction and neurocognitive testing was consistent with concussion. Return to Learn protocol was started and NO sporting activity allowed. Week 3-6: Henry slowly started to return to his school functional baseline with headaches and emotional lability resolving. After 6 weeks of rehab he was allowed back into a Return to play protocol with gym class first and then finally with basketball, able to play in his last game of the season. 4

Concussion Evaluation Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing Same day patient feedback Severity of Injury? Prognosis for Recovery? Neuroimaging indicated?

5 Concussion Evaluation Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing Same day patient feedback Severity of Injury? Prognosis for Recovery? Neuroimaging indicated? PMR/Vestibular/Optometry referral? Level/type of Physical Exertion Allowed? Level of Cognitive Exertion Allowed? Academic Accommodations? Return to Learn? Return to Play? Communication to ATC, School nurse, Physical Therapist, Team Physician, Referring Physician, etc. 5

6 In office Evaluation Clinical Interview Vestibular-Ocular Screening Neurocognitive Testing Return to School/Play/Work 6

7 Factors affecting Concussion Outcomes 7

8 Typical symptoms of Concussion Physical Sleep Cognitive Emotional Headache Sleeping more/less Difficulty thinking More emotional Nausea Drowsiness/fatigue Difficulty concentrating Irritable Vomiting Trouble falling asleep Confusion Sad Balance Mentally foggy Nervous Slowed Reaction Feeling slowed Depressed Dizziness Sensitivity to light Sensitivity to sound Fuzzy/Blurry vision 8

9 Timing of Concussion symptoms Among patients presenting to a pediatric ED after a concussion. - Physical symptoms such as headache predominate immediately after the injury - Emotional symptoms tend to develop later in the recovery period - Cognitive symptoms may be present throughout. Eisenberg, M, et al, Duration and Course of Post-Concussive Symptoms, Pediatrics, June

10 Risk factors for a more complicated recovery of Concussion Age Younger > Older -Field, Lovell, Collins et al. J of Pediatrics, Pellman, Lovell et al. Neurosurgery, 2006 Learning Disability ADHD, Pervasive Developmental Disorders, etc. -Collins, Lovell et al, JAMA, Elbinet al., Data under review Repetitive Concussion -Collins, Lovell et al, Neurosurgery, Iverson et al, CJSM, Moser et al, JCEN, 2011 Gender Girls > Boys -Colvin, Lovell, Pardini, Mullin, Collins, AJSM, Covassinet al, CJSM, 2009 Migraine History & Symptoms Mood disorders Depression, Anxiety, PTSD, etc. Substance Abuse -Mihalik, Collins,Lovellet al, J Neurosurgery, Lau, Collins, Lovell et al. AJSM

11 Predicting Protracted Recovery On Field --Outcomes are highly variable --Vestibular-related symptoms of onfield dizziness and sub-acute fogginess best predict more protracted recoveries Lau, Kontos, Collins, and Lovell, Americian Journal of Sports Medicine, Days Post Injury --Migraine-type symptoms (and potentially preexisting history of migraine)may place individuals at increased risk of injury and longer recovery --Fogginess --Difficulty Concentrating --Vomiting --Dizziness --Nausea --Headache --Balance Lau, Lovell, Collins, et al, Canadian Journal of Sports Medicine,

12 Examination Algorithm of Concussion Matuszak, JM, et al, A Practical Concussion Physical examination Toolbox: Evidenced-Based Physical Examination for Concussion. Sports Health, March

13 In Office Physical Exam of Concussion Physical Exam How to Perform Findings Dysmetria Nystagmus Smooth pursuits Saccades Gaze stability Convergence Balance Finger to nose with examiners finger moving horizontally. Examiners finger moving horizontally progressively more rapidly, stopping centrally. Examiners finger moving in a H pattern with the patient following with their eyes only. Examiners fingers held at shoulder-width at eye level and patient focuses between finger movement and examiners nose. Patient fixes gaze on thumb while nodding & shaking head Patient takes a pen with letters holding at arms length and brings to their nose until blurry/double Tandem heel-toe gait forward and backward with eyes open/closed Slow reaction time, past pointing. Unable to track, beats of nystagmus at center of visual field. Unable to visually track & provokes symptoms (HA). Unable to perform as symptoms provoked or > 2 eye movements to locate finger to nose. Unable to perform or only a few reps before symptoms provoked. Letters blurry/double at > 6 cm from tip of nose. Raises arms for stability or widens gait with sway. JM Matuszak, et al, A Practical Concussion Physical Examination Toolbox: Evidence- Based Physical Examination for Concussion, Sports Health,

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Subjective Complaints Related to Vestibular- Ocular Dysfunction: Looking Beyond Balance -Dizziness, Fogginess, Feeling detached -Motion discomfort, Nausea -Difficulty in busy

22 Subjective Complaints Related to Vestibular- Ocular Dysfunction: Looking Beyond Balance -Dizziness, Fogginess, Feeling detached -Motion discomfort, Nausea -Difficulty in busy visual environments -Anxiety, Increased emotionality, Intolerance to busy places -Fatigue, Difficulty focusing, Blurred vision, Difficulty with Math/Reading -Impaired balance 22

23 Evidenced Based In Office Physical Exam of Concussion Examination Sensitivity Specificity Vital Signs-orthostatics Neurologic exam Cranial Nerve assessment Manual muscle testing/reflexes Balance testing Vestibular-Ocular exam History+Balance+Vestibular testing JM Matuszak, et al, A Practical Concussion Physical Examination Toolbox: Evidence-Based Physical Examination for Concussion, Sports Health, Resch JE, et al. The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one, BMJ Open Sport Exerc Med,

24 Strength of Recommendation Taxonomy (SORT) Level A Consistent, good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening 24

25 SORT for Exam of Concussion Examination Domain Neurological Musculoskeletal Balance/ coordination Vestibulo-ocular/ ophthalmologic Mental status Recommended Elements (SORT) CNs (C) MMT (C) DTRs (C) Head and neck for trauma or tenderness (B) ROM (B) Spurling test (B) Static and/or dynamic balance Assessment-BESS testing (B) Screening ocular examination consisting of: Evaluation of the eyes Nystagmus Saccades Smooth pursuits Near point of convergence/ Accommodation (A) Mental status Orientation, immediate and delayed recall, concentration, mood, affect, insight, judgment (B) Additional Elements (SORT) UMN testing (C) Neck isometrics (B) Cervical proprioception (B) Jaw and TMJ (C) Thoracic spine (C) Coordination tests (B) Fundoscopic evaluation (C) Pupillary reactivity (C) Visual acuity (C) If dizziness or imbalance present, consider: Orthostatic vital signs (B) via supine to stand stress test (B) Otoscopic evaluation, Dix-Hallpike maneuver, and assessment of dynamic visual acuity (B) Preinjury psychiatric difficulties (A) Screening for depression and anxiety (B) Substance use disorders (C) JM Matuszak, et al, A Practical Concussion Physical Examination Toolbox: Evidence- Based Physical Examination for Concussion, Sports Health,

26 SORT for Exam of Concussion Category A recommendations Category B recommendations - Comprehensive vestibular-ocular exam - Assess for pre-injury psychiatric difficulties (Depression, Anxiety, ADHD, etc.) - Performing a complete neurologic exam -- orthostatic vital signs -- mental status evaluation -- the head and neck exam -- static and dynamic balance testing (Balance Error Scoring System) 26

27 Neurocognitive Testing Pros More objective measure of testing Baseline data before concussion Recovery and Return to Play can be decided more objectively Cons Gaming the system Cost Time Training need specialized training to perform reliably 27

28 Sensitivity and Specificity of Computerized Neurocognitive Testing The current results demonstrate that computerized neurocognitive testing is a useful, valid tool as part of a comprehensive post-concussion evaluation. Regardless of whether athletes are candid regarding the presence of post-concussion symptoms, performance on neurocognitive testing can identify neurocognitive deficits with 91-95% sensitivity. Schatz P, Sandel N. Sensitivity and Specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine,

29 Return to Learn Sign/Symptom Headache Dizziness Visual symptoms Noise sensitivity Difficulty concentrating Sleep Disturbances Potential Adjustments in School Frequent breaks, Identify aggravators and reduce exposure and Planned rest and quiet time in school (nurses office) Allow student to place head down Allow student to avoid crowded hallways Reduce exposure to computers, videos, smart boards and Reduce brightness of screens Audiotapes of books Lunch in a quiet area No band, choir, or shop classes, No noisy gyms, and Earplugs Extra time to complete tests Oral test taking or reduce number of written tests to 1 per day Allow for late start and/or shortened day Allow rest breaks Halstead, M, et al, Return to Learning Following Concussion, Pediatrics, October

30 Return to Play Stage Activity Objective 1. No activity Complete physical rest-no symptoms at rest before advance RTP 2. Light aerobic exercise Walking, swimming, aerobic exercise up to 70% max predicted HR, no resistance training 3. Sport-specific exercise Sport-specific exercise such as skating and running drills, no head impacts 4. Noncontact training drills Progress to complex drills; add resistance training 5. Full contact practice Normal practice after cleared by medical personnel Recovery Increase Heart Rate Add movement Exercise coordination, add cognitive load Restore confidence and timing, allow assessment of functional skills Return to play Normal game play Full return to play Halstead, M, et al, Return to Learning Following Concussion, Pediatrics, October

31 Prescription for Cognitive Rest Modified homework if it causes symptoms Modified computer work No texting No video games Modified reading No television Increased fluid intake Increased rest (get 9-10 hours of sleep minimum) 31

32 Acute concussion evaluation tools Sideline evaluation SCAT 3 SAC ACE Sideline version BESS testing In Office Evaluation Comprehensive Neurologic exam Acute Concussion Evaluation (ACE) checklist Physician/Clinician Office Version and Care plan G. Gioia & M. Collins, 2006; This form is part of the Heads Up: Brain Injury in Your Practice tool kit developed by the Centers for Disease Control and Prevention (CDC). 32

33 Tools and Applications for Concussion 33

34 Acute Concussion Evaluation - Acute Concussion Evaluation (ACE) Physician/Clinician Office Version - Acute Concussion Evaluation (ACE) Care plan 34

35 After the hit: the bio-psycho-social aspects of a concussion Suffering from a concussion can be frustrating, especially when athletes are temporarily removed from their social environments (i.e. sports and school). But it s important to remember you are not in this alone. Take time to recognize your support systems, be it parents, siblings, physicians, coaches, trainers, teammates, or friends. Stay connected. The collective goal is to get you better and back to sport (and everyday life!) symptom-free. 35

36 Take Home Points 1. Vestibular-related symptoms of on-field dizziness and sub-acute fogginess best predict more protracted recoveries. Past medical histories of ADHD, Mood disorders, learning disorders, migraines, younger age and female gender all raise the risk of a prolonged concussive history. 2. The category A recommendations for the evidenced based exam are to perform a comprehensive vestibular-ocular neurologic exam and to assess for pre-injury psychiatric difficulties. 3. The category B recommendations revolve around performing a complete neurologic exam that includes orthostatic vital signs, mental status evaluation, screening for depression and anxiety, the head and neck exam, and static and dynamic balance testing. 4. Before one can consider returning to play, one has to acclimate to return to learn. The collective goal is to get you better and back to sport (and everyday life!) symptom-free. 36

37 Thank you Questions????? 37

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