Concussion: A Treatable Injury MELISSA N. WOMBLE, PHD NEUROPSYCHOLOGIST, DIRECTOR INOVA SPORTS MEDICINE CONCUSSION PROGRAM

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1 Concussion: A Treatable Injury MELISSA N. WOMBLE, PHD NEUROPSYCHOLOGIST, DIRECTOR INOVA SPORTS MEDICINE CONCUSSION PROGRAM

2 THE CURRENT PROBLEM

3 1. WHAT IS A CONCUSSION? 2. ACUTE/SIDELINE EVALUATION 3. AT HOME MANAGEMENT 4. COMMON MYTHS 5. POST-INJURY CONCUSSION CARE 6. PREVENTION Objectives DISCUSSING CONCUSSION IN TERMS OF EVALUATION AND MANAGEMENT

4 Collins, et. al., KSST, 2013; Giza & Hovda, J Athl Train., 2001 Pathophysiology Disturbance of brain function is related to dysfunction of brain metabolism rather than a structural brain injury.

5 What Does that mean? There is an ENERGY CRISIS in the brain Brain is working less efficiently There is NOT bleeding, swelling or bruising as commonly thought Therefore, no imaging or special tests are going to definitively show concussion

6 CONCUSSION MYTH #1: M A CONCUSSION ONLY OCCURS AS A RESULT OF A DIRECT BLOW TO THE HEAD. Y T H

7 FACT F A A CONCUSSION MAY BE CAUSED BY A DIRECT BLOW TO THE HEAD, FACE, NECK OR AN INDIRECT HIT ELSEWHERE ON THE BODY IF THE FORCE OF THE IMPACT IS TRANSMITTED TO THE HEAD. C T

8 CONCUSSION MYTH #2: M A CONCUSSION OCCURS ONLY WHEN AN ATHLETE EXPERIENCES A LOSS OF CONSCIOUSNESS (LOC). Y T H

9 FACT F A C CONCUSSIONS CAN OCCUR WITH OR WITHOUT LOC. THE VAST MAJORITY OF CONCUSSIONS (ESTIMATED AT MORE THAN 90%) DO NOT RESULT IN LOC. THE SYMPTOM OF ON-FIELD DIZZINESS IS 7X MORE PREDICTIVE THAN ANY OTHER SYMPTOM IN TERMS OF PREDICTING LONGER RECOVERY FOLLOWING CONCUSSION. T

10 CONCUSSION MYTH #3: M IT IS SAFE FOR A PLAYER TO RETURN TO THE SAME GAME OR PRACTICE AFTER SUFFERING CONCUSSION-RELATED SYMPTOMS. Y T H

11 FACT F A C T THERE ARE UP TO 21 DIFFERENT SIGNS/SYMPTOMS OF CONCUSSION. ANY PLAYER WHO SUFFERS ANY SIGNS OR SYMPTOMS THAT ARE SPECIFIC TO CONCUSSION SHOULD NOT BE ALLOWED TO RETURN TO THE CURRENT GAME OR PRACTICE NO MATTER HOW QUICKLY SYMPTOMS MAY CLEAR. SYMPTOMS OF CONCUSSION DO NOT ALWAYS PRESENT IMMEDIATELY. INSTEAD, THEY OFTEN EVOLVE OVER TIME AND EVEN HOURS AFTER INJURY. WE ALSO KNOW THAT EVEN PLAYING UP TO 3 MINUTES AFTER AN INITIAL INJURY CAN RESULT IN AN 8.8X GREATER RISK FOR PROLONGED RECOVERY

12 Signs & Symptoms Physical Headache Nausea Vomiting Balance Problems Dizziness Visual problems Light/Noise Sensitivity Tinnitus CONCUSSION SYMPTOMS Emotional Irritability Sadness Feeling on-edge Nervousness Anxiety Rumination Depression Cognitive Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Amnesia Sleep Trouble falling asleep Sleeping more than normal Sleeping less than normal Fatigue/Drowsiness

13 Acute/sideline evaluation

14 Concussion Recognition

15 Sideline evaluation: Additional components IN ALL SUSPECTED CASES OF CONCUSSION, THE INDIVIDUAL SHOULD BE REMOVED FROM THE PLAYING FIELD AND ASSESSED BY A PHYSICIAN OR LICENSED HEALTH CARE PROVIDER. THERE IS NO PERFECT DIAGNOSTIC TEST OR MARKER FOR IMMEDIATE DIAGNOSIS IN THE SPORTING ENVIRONMENT RESEARCH WOULD SUGGEST THAT A SIDELINE EVALUATION SHOULD INCLUDE A COMBINATION OF: Cognitive Screening Balance Testing Neurological Examination Cranial Nerve Testing Evaluation of Motor-Sensory Function Vestibular/Ocular-Motor Assessment Exertion Testing (if assessment appears normal, but concussion is still suspected)

Neurological Screen 5. Delayed Recall 6.

16 Sideline evaluation: Additional Components AVAILABLE TOOLS: SCAT5/CHILD SCAT5 1. Immediate or on-field assessment 2. Symptom Evaluation 3. Cognitive Screening 4. Neurological Screen 5. Delayed Recall 6. Decision BESS OTHER TOOLS BEING STUDIED FOR SIDELINE USE: VOMS King Devick and MANY others.(remember: Review the Research Evidence and Be Comprehensive)

Obtained from the Center for Disease Control and Prevention Need for emergency care THE PURPOSE OF ACUTE CARE (I.E., EMERGENCY ROOM) FOLLOWING A CONCUSSION IS TO RULE OUT MORE SERIOUS INTRACRANIAL PATHOLOGY.

17 Obtained from the Center for Disease Control and Prevention Need for emergency care THE PURPOSE OF ACUTE CARE (I.E., EMERGENCY ROOM) FOLLOWING A CONCUSSION IS TO RULE OUT MORE SERIOUS INTRACRANIAL PATHOLOGY. IDENTIFYING WHEN ACUTE CARE IS NEEDED: HEADACHES THAT ARE SEVERE AND APPEAR TO BE WORSENING LOSS OF CONSCIOUSNESS SEIZURES VOMITING SLURRED SPEECH DISORIENTATION SIGNIFICANT BEHAVIORAL CHANGES WEAKNESS, NUMBNESS OR TINGLING IN THE EXTREMITIES CONCERNS REGARDING A CERVICAL INJURY ANY FOCAL NEUROLOGICAL SIGN

Post-Injury: First Follow-Up Follow-up Evaluations as

18 Timeline for medical care Prior to the Season: Baseline Testing Concussion Acute Care Visit (If Needed) 1-3 Days Post-Injury: First Follow-Up Follow-up Evaluations as Needed with the Physician. Ultimately Return to Play when Ready

19 At Home Management

20 CONCUSSION MYTH #4: M YOU MUST BE PLACED IN A DARK ROOM TO RECOVER FROM CONCUSSION. Y T H

21 Pendulum swinging on rest

Setting Guidelines Regulation Vs. Rest Adolescents randomly selected for a strict rest group vs. usual care reported more daily postconcussion symptoms and demonstrated a longer recovery.

22 Setting Guidelines Regulation Vs. Rest Adolescents randomly selected for a strict rest group vs. usual care reported more daily postconcussion symptoms and demonstrated a longer recovery. CONSIDERATIONS REGARDING FINDINGS: Emotional distress can be caused by missing work/school, falling behind, activity restrictions and missing social interactions. Situational depression may result in increased physical and emotional symptoms. Activity restrictions and lack of exercise may contribute to sleep abnormalities and adversely affect mood. Thomas, et. al., Pediatrics, 2015

23 FACT F STRICT REST HAS ACTUALLY BEEN SHOWN TO CAUSE INDIVIDUALS WITH CONCUSSION TO EXPERIENCE A GREATER SYMPTOMS AND EXPERIENCE PROLONGED RECOVERIES A C T

24 Management The general recommendation after concussion has been cognitive and physical rest; however, there is limited research to support the utility of STRICT rest. After the initial 24 hours: Limit naps to 30 minutes to prevent disruption of sleep at night. Limit all over-the-counter medications to 2-3 doses per week to avoid rebound headaches. Prolonging rest can lead to the development of additional symptoms. Individuals should begin to expose to normal activities, as tolerated, with breaks utilized for symptom management. There are several exceptions: Activities that could pose risk for head injury. Physical activities other than walking /stationary bike riding until evaluated. Close up visual-based activities other than normal school/work activities for extended periods (e.g., cell phone use). Collins & Womble, Pediatric Surgery, 2017; Heyer & Idris, Pediatric Neurology, 2014; Thomas, et. al., Pediatrics, 2015 Womble, et. al., AJO, 2016

25 1. DIET: Eat breakfast, lunch and dinner each day. 2. HYDRATION: Stay well hydrated. 3. SLEEP: Stick to a strict sleep schedule with a regular bedtime and wake-up time. It is generally recommend that individuals obtain 7-9 hours, with limited to no naps of no longer than 30 minutes. 4. PHYSICAL ACTIVITY: It is recommend that the individual take walks or ride a stationary bike following the injury. Once they are seen by a physician additional recommendations can be made. 5. STRESS: Try to reduce stress in the individual. Reduced focus on the injury can help to avoid nervousness and increased anxiety. Behavioral Management Strategies After the initial 24 hours following a concussion, the individual should MAINTAIN A REGULATED SCHEDULE.

26 Common Myths

27 CONCUSSION MYTH #5: M Y CONCUSSIONS DEFINITIVELY CAUSE LONG-TERM BRAIN DAMAGE AND CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE). T H

28 FACT F A C T POTENTIAL LONG-TERM EFFECTS FROM CONCUSSION COME PRIMARILY FROM POORLY MANAGED INJURIES OR ATHLETES PLAYING THROUGH SYMPTOMS. CONCUSSION IS A COMPLETELY TREATABLE CONDITION (IF MANAGED CORRECTLY). SCIENTIFIC STUDIES LINKING CONCUSSION AND LONG-TERM EFFECTS (I.E. CHRONIC TRAUMATIC ENCEPHALOPATHY OR CTE) ARE STILL IN PROGRESS AND NO DEFINITIVE CONCLUSIONS CAN BE MADE.

29 CONCUSSION MYTH #6: HAVING ONE CONCUSSION PLACES YOU AT INCREASED RISK FOR FUTURE CONCUSSIONS.

FACT F A C IF PROPER CLINICAL MANAGEMENT AND FULL RECOVERY OCCURS FROM AN INITIAL CONCUSSION, THE ATHLETE SHOULD NOT BE AT RISK FOR FUTURE CONCUSSIONS.

30 FACT F A C IF PROPER CLINICAL MANAGEMENT AND FULL RECOVERY OCCURS FROM AN INITIAL CONCUSSION, THE ATHLETE SHOULD NOT BE AT RISK FOR FUTURE CONCUSSIONS. PROPER CLINICAL MANAGEMENT IS THE BEST FORM OF PREVENTION. SOME PRE-EXISTING CONDITIONS (E.G. MIGRAINE, CAR SICKNESS, HISTORY OF LAZY EYE) PLACE THE ATHLETE AT HIGHER RISK OF INJURY. T

31 CONCUSSION MYTH #7: M ALL CONCUSSIONS, TREATMENTS AND RECOVERIES ARE ALIKE. Y T H

32 FACT F A C T NO TWO CONCUSSIONS ARE IDENTICAL. THROUGH RESEARCH, SIX DIFFERENT CLINICAL PROFILES FOR CONCUSSION HAVE BEEN IDENTIFIED. EACH PROFILE PRESENTS WITH DIFFERENT RISK FACTORS, SYMPTOMS, OUTCOMES AND SPECIFIC TREATMENT/REHABILITATIVE NEEDS.

33 Post-Injury Concussion Care

Inova sports medicine Comprehensive concussion program Local Youth

Care Centers Emergency Departments High School Athletic Trainers

Sending Patients to Our Program Inova Sports Medicine Comprehensive

2 Primary Care Sports Medicine Physicians and 3 Athletic Trainers

Optometry Psychiatry or Behavioral Health Vestibular Physical Therapy

34 Inova sports medicine Comprehensive concussion program Local Youth Sports Organizations Pediatricians & Primary Care Physicians Urgent Care Centers Emergency Departments High School Athletic Trainers Complicated Out of Region Referrals Internal/External Referral Sources Sending Patients to Our Program Inova Sports Medicine Comprehensive Concussion Program Physician-Based Team including: a Neuropsychologist, 2 Primary Care Sports Medicine Physicians and 3 Athletic Trainers External Treatment Options In House Treatment Options Behavioral Neuro- Optometry Psychiatry or Behavioral Health Vestibular Physical Therapy Exertion Therapy Sports Medicine, Orthopaedics & Trauma Physical Therapy Neurology/ Neurosurgery

35 Inova sports medicine concussion program Clinical Assessment Approach In-Office Evaluation Detailed Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing Goals Establish diagnosis and prognosis Establish clinical and treatment trajectories Establish treatment and rehabilitation plan Develop the Plan Vestibular Ocular- Motor Neurocognitive Concussion Symptoms Physical Exertion

36 TREATMENT OPTIONS REGULATION OF SCHEDULE AND USE OF BREAKS Concussion Treatments Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016

37 Return to Play: Hockey STAGE NON- CONTACT ACTIVITY CONTACT ACTIVITY ACTIVITY LIGHT ACTIVITY OBJECTIVES: ACTIVITY WITH LIMITED HEAD MOTION/ROTATION, INCREASED HEART RATE ABOVE RESTING MODERATE ACTIVITY OBJECTIVES: ELEVATED HEART RATE FOR A SUSTAINED LENGTH OF TIME, INCREASE HEAD MOTION/ROTATION, SPORT SPECIFIC FUNDAMENTAL SKILLS MAXIMAL ACTIVITY OBJECTIVES: MAXIMUM HEART RATE, FULL RANGE OF MOTION FOR HEAD/BODY LIGHT/INCIDENTAL CONTACT FULL CONTACT Skating on Ice FOCUS AREA Passing/ Shooting Puck Control Drills GAME PLAY Clearing Drills

38 prevention GEAR IS NOT MEANT TO PREVENT CONCUSSION EDUCATION BASELINE TESTING

39 THANK YOU! Inova Sports Medicine Concussion Program 8501 Arlington Boulevard Heathcote Boulevard Suite 200 Suite 210 Fairfax, VA Gainesville, VA Concussion Hotline: (703) Official Sports Medicine Partner of the Washington Nationals and Washington Redskins

MELISSA N. WOMBLE, PHD NEUROPSYCHOLOGIST/DIRECTOR INOVA SPORTS MEDICINE COMPREHENSIVE CONCUSSION PROGRAM

MELISSA N. WOMBLE, PHD NEUROPSYCHOLOGIST/DIRECTOR INOVA SPORTS MEDICINE COMPREHENSIVE CONCUSSION PROGRAM THE CURRENT PROBLEM 1. PATHOPHYSIOLOGY OF CONCUSSION 2. SIGNS AND SYMPTOMS OF CONCUSSION 3. TYPICAL