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

Transcription

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

2 THE CURRENT PROBLEM

3 1. PATHOPHYSIOLOGY OF CONCUSSION 2. SIGNS AND SYMPTOMS OF CONCUSSION 3. TYPICAL RECOVERY RATES FOR CONCUSSION 4. MANAGEMENT OF CONCUSSION 5. CLINICAL PROFILES OF CONCUSSION 6. RETURN-TO-PLAY Objectives DISCUSSING CONCUSSION IN TERMS OF EVALUATION AND MANAGEMENT

4 Collins, et. al., KSST, 2013; Giza & Hovda, Neurosurgery, 2014 Pathophysiology Disturbance of brain function is related to dysfunction of brain metabolism rather than a structural brain injury.

5 signs REMEMBER: A CONCUSSION MAY BE CAUSED BY AN INDIRECT BLOW TO THE HEAD, FACE, NECK OR ELSEWHERE ON THE BODY IF THE FORCE OF THE IMPACT IS TRANSMITTED TO THE HEAD. IDENTIFY WHAT HAPPENED DIRECT BLOW TO HEAD OR INDIRECT BLOW SECONDARY TO TRANSLATED FORCE TO HEAD (E.G., WHIP LASH ) HIGH RISK MECHANISMS: Double-Hit High velocity trauma Rotational trauma Unsuspected blow

6 signs SIGNS OF NEUROLOGIC DYSFUNCTION OR NEUROLOGIC SYMPTOMS AFTER A PLAUSIBLE MECHANISM = CONCUSSION REMEMBER: Most concussions are diagnosed based on symptoms, not signs. IF A PATIENT SHOWS CONCUSSION-LIKE SIGNS AND REPORTS SYMPTOMS AFTER A CONTACT TO THE HEAD, THE PATIENT HAS, AT THE VERY LEAST, SUSTAINED A MILD CONCUSSION. CONCUSSION SIGNS: Loss of Consciousness (LOC) Slow to Get Up Motor Incoordination/Balance Problems Blank/Vacant Look Disorientation Clutching Head Guskiewicz, et. al., J Athl Train, 2004

7 symptoms Concussion results in a constellation of physical, cognitive, emotional, and sleeprelated symptoms. SYMPTOM PERCENT # 1 Headache 75% # 2 Difficulty Concentrating 57% # 3 Fatigue 52% # 4 Drowsiness 51% # 5 Dizziness 49% # 6 Foggy 47% # 7 Feeling Slowed Down 46% # 8 Light Sensitivity 45% # 9 Balance Problems 39% # 10 Difficulty with Memory 38% Kontos, et. al., AJSM, 2012

8 Symptoms SYMPTOMS WILL VARY IN INTENSITY AND PRESENTATION BASED ON THE INDIVIDUAL AND THE SEVERITY OF THE CONCUSSION. PATIENTS MAY NOT LOOK OR EVEN ACT INJURED IMMEDIATELY AFTER THE INJURY. SYMPTOMS CAN WORSEN WITH COGNITIVE AND/OR PHYSICAL EXERTION. SYMPTOMS CAN WAX AND WANE THROUGHOUT THE DAY.

9 Recovery Rates It is generally thought that 80-90% of of patients recover from concussion within 7-14 days. NEW STUDY - Assessed recovery in 66 high school athletes across the first month following concussion. Focus of the study was on recovery in terms of symptom resolution, cognitive functioning and vestibular-oculomotor findings. Additionally, a comparison was made between boys and girls in terms of recovery length. Giza et al., Neurology, 2013; Henry L, et. al, Neurosurg, 2015; McCrory et al., Br J Sports Med, 2013

10 Recovery Rates Symptoms Recovery can last up to 4 weeks for Symptoms... *p<.05 N=66 Henry L, et. al, Neurosurg, 2015

11 Recovery Rates Neurocognitive Recovery can last up to 3-4 weeks for Memory... *p<.05 N=66 Henry L, et. al, Neurosurg, 2015

12 Recovery Rates Vestibular Recovery can last up to 3 weeks for Vestibular- Oculomotor Findings... Ocular *p<.05 N=66 Henry L, et. al, Neurosurg, 2015

13 Recovery Rates New research shows that average recovery varies from 1-4 Weeks LONGER RECOVERY WITH: 1) On-field dizziness 2) Migraine symptoms in 1 st week 3) Females RISK FACTORS AFFECT RECOVERY DEMOGRAPHIC FACTORS Sex Differences in Recovery 2.5x More Likely than Males to NOT be Recovered by Week 4 POST-INJURY FACTORS On-field Dizziness 6.3x Greater Risk for Protracted (>21 days) Recovery Post-Traumatic Migraine (PTM) 7.3x Greater Risk for Protracted (>21 days) Recovery Covassin, et. al., 2012; Eisenberg, et. al., 2014; Henry L, et. al, Neurosurg, 2015; Kontos, et. al., 2013; Lau, et. al., 2011; Mihalik, et. al., 2013

14 Management 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. Relander, et al., Br Med J, 1972; Thomas, et. al., Pediatrics, 2015

15 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 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

16 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. Choe & Blume, Journal of Child Neurology, 2016; Collins & Womble, Pediatric Surgery, 2017; Kacperski et al., Seminars in Pediatric Neurology, 2016; Womble, et. al., AJO, 2016

17 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 CLINICAL PROFILES RISK FACTORS Somatization CONCUSSION CONCUSSION CLINICAL PROFILES TREATMENT AND REHAB PATHWAYS Previous Concussions Vestibular Migraine Ocular LD/ADHD Female Gender Cognitive/ Fatigue Age Motion Sensitivity History of Lazy Eye? Sleep Problems Cervical Post- Traumatic Migraine Anxiety/ Mood

18 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Clinical profiles Vestibular Anxiety/ Mood Ocular Concussion Cervical Post- Traumatic Migraine Cognitive/ Fatigue

19 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Mucha, et. al., AJSM, 2014; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Vestibular THE VESTIBULAR SYSTEM & CONCUSSION SENSORY SYSTEM RESPONSIBLE FOR: Maintaining visual and spatial organization Managing balance function via pathways linking sensory organs of the ear with central processing areas in the brainstem, cerebellum, midbrain, and cerebral cortex SENSORY SYSTEM IMPORTANT FOR: 1. Vestibulo-Ocular Reflex - -> Maintenance of visual stability during movement 2. Vestibulo-Spinal Reflex - -> Postural control

20 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Pearce, et. al., AJSM, 2015; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Ocular THE OCULAR SYSTEM & CONCUSSION OCULAR MOTOR SYSTEM: The muscles around the eyes work together in an extremely sophisticated manner in order to accurately control eye movements. EYE MOVEMENTS ESSENTIAL FOR PROPER EYE FUNCTION: 1. Smooth Pursuits - -> The ability to stabilize gaze and follow a moving object with the eyes accurately 2. Saccades - -> The ability to jump your eye from one target to another accurately 3. Convergence - -> The ability of the eyes to move inward/outward in order to focus on an object as it moves near/far

21 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., AJSM, 2012; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Cognitive/ Fatigue COGNITIVE-FATIGUE & CONCUSSION COMMON COGNITIVE COMPLAINTS: Concentration (i.e., attention, distractibility) Memory (i.e., forgetfulness, repeating oneself) Processing Speed Mental Fogginess (i.e., one step behind) COMMON FATIGUE COMPLAINTS: Tiredness typically caused by cognitive or physical exertion, and/or illness Decreased endurance and/or energy levels

22 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., AJSM, 2013; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Post- Traumatic Migraine POST-TRAUMATIC MIGRAINE & CONCUSSION TYPICAL CHARACTERISTICS: Headache of less than 3 months in duration caused by traumatic injury to the head Headache developed within 7 days of injury Subtypes: tension-type, cluster-like, and migraine-like MIGRAINE AND CONCUSSION SIMILARITIES: Common molecular pathophysiology Increases in extracellular potassium and intracellular sodium, calcium, and chloride Excess release of excitatory amino acids and opioids (i.e., glutamate)

23 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Kontos, et. al., BJSM, 2016; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Anxiety/ Mood ANXIETY & CONCUSSION Anxiety refers to excessive and persistent worry and/or fear about everyday situations that is difficult to control. Oftentimes, patients will be unable to accurately identify or characterize their feelings of anxiety. Therefore, anxiety post-concussion may manifest in terms of: 1. Avoiding or running away from activitiess or situations that bring on anxious thoughts, feelings, and memories. 2. Continued symptoms despite normal neurocognitive data and non-provocative vestibular/ocular-motor examination. 3. Co-occurring sadness, hopelessness, or depression secondary to the significant changes in their day-to-day schedule and continued experience of post-concussive symptoms.

24 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Schneider, et. al., BJSM, 2013; Womble, et. al., AJO, 2016 Cervical CERVICAL INVOLVEMENT & CONCUSSION With the prevalence of whiplash injuries, the cervical spine can be injured when forces are transmitted to the head. Characterization of the headache in terms of location, onset, and daily course can be helpful in determining possible cervical involvement. Can be managed with: Soft tissue mobilization, posture re-education, range-ofmotion exercises, manual cervical/thoracic mobilization, biofeedback, pain-management techniques, and triggerpoint injections Use of muscle relaxants

25 CLINICAL PROFILES Ocular Cognitive/ Fatigue Post- Traumatic Migraine Anxiety/ Mood Frontal Headache Fatigue Heightened Distractibility Difficulties with Visually-Based Academics Pressure Behind the Eyes Focus Difficulties Fatigue General headache End of day symptoms Cognitive difficulties (e.g., sustained attention, word finding) after long durations of cognitive activity Possible sleep deficits Recurrent headache; intermittently severe Nausea Light/Noise Sensitivity Stress, anxiety, lack of exercise Deregulation of routine (i.e., sleep) May present with vestibular-migraine symptoms Ruminative thoughts Hypervigilant Fastidious Feelings of being overwhelmed Sleep Difficulties Sadness Hopelessness Cervical Headaches, neck pain, numbness/tingling, Symptoms with specific physical movements

26 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

27 Collins, et. al., KSST, 2014; Collins & Womble, Pediatric Surgery, 2017; Reynolds, et. al., Neurosurgery, 2014; Womble, et. al., AJO, 2016 Inova sports medicine Comprehensive concussion program Clinical Assessment Approach Neurocognitive Vestibular Physical Exertion Concussion Ocular- Motor Symptoms

28 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

29 RETURN-TO-PLAY C L E A R A N C E GENERAL GUIDELINES FOR A SAFE RETURN TO PLAY: SYMPTOM FREE AT REST SYMPTOM FREE WITH COGNITIVE ACTIVITIES SYMPTOM FREE WITH PHYSICAL ACTIVITY NORMAL NEUROCOGNITIVE DATA NORMAL OBJECTIVE EVALUATION

30 RETURN-TO-PLAY C L E A R A N C E STAGE STAGE #1 STAGE #2 STAGE #3 STAGE #4 STAGE #5 STAGE #6 STAGE #7 STAGE #8 ACTIVITY (EX. WITH FOOTBALL) NO PHYSICAL ACTIVITY LIGHT AEROBIC ACTIVITY WITH LIMITED HEAD MOTION MODERATE AEROBIC ACTIVITY NON-CONTACT PARTICIPATION IN PHYSICAL ACTIVITIES SPORT SPECIFIC FUNDAMENTAL SKILLS LIMITED CONTACT WITH BAGS LIMITED CONTACT WITH OTHERS FULL CONTACT DRILLS/ SCRIMMAGE GAME PLAY

31 Providing appropriate management techniques from the initial injury date can help in reducing symptoms and length of recovery. Certain risk factors can make an individual more vulnerable to concussion and longer recovery periods. Concussion results in patients experiencing specific symptoms that fall under different potential profiles. Assessment should include a detailed clinical interview and multiple tools with understanding of these tools. Assessment findings should set the stage for targeted management and treatment options based on the identified profile/profiles. It is not a one size fits all injury. Type, duration and intensity of treatment recommendations are dependent upon the clinical profile/profiles and severity of impairment.

32 THANK YOU! Inova Sports Medicine Comprehensive Concussion Program 8501 Arlington Blvd, Suite 200 Fairfax, VA (703) Concussion Hotline: (703) Official Sports Medicine Partner of the Washington Nationals and Washington Redskins