Management of the Concussed Adolescent Tamara C. Valovich McLeod, PhD, ATC, FNATA John P. Wood, D.O., Endowed Chair for Sports Medicine Professor and Director, Athletic Training Program Director, Athletic Training Practice-Based Research Network Objectives 1. Increase awareness of current best practices for sport-related concussion. 2. Discuss best practices for the management of concussion in adolescents. 3. Describe return to physical activity and return to school progressions. 4. Demonstrate concussion assessment using a variety of validated clinical tools. Top 10 Things to Know 1. Definition 2. Epidemiology 3. Imaging 4. Symptoms 5. Assessment 6. Management 7. Treatment 8. Return to Activity 9. Effects 10. Prevention Tamara Valovich McLeod, 2013 1
1. What is a Concussion AMSSM (2012) A traumatically induced transient disturbance of brain function and is caused by a complex pathological process AAN (2013) A clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness Zurich (2013) A complex pathophysiological process affecting the brain, induced by biomechanical forces Features of Concussion 1. May be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head. 2. Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minute to hours 3. May result in neuropathological changes Acute clinical symptoms largely reflect a functional disturbance rather than a structural injury No abnormality is seen on standard structural neuroimaging studies 4. Results in a graded set of clinical symptoms that may or may not involve loss of consciousness Resolution of the clinical and cognitive symptoms typically follows a sequential course In some cases symptoms may be prolonged. McCrory et al, Br J Sport Med. 2013 Only 6.3%-8.9% of collegiate athletes demonstrated LOC following a concussion (Guskiewicz et al, 2000 & 2003; McCrea et al, 2003) LOC does not necessarily imply severity, nor predict recovery (McCrory et al, 2004) Tamara Valovich McLeod, 2013 2
What is a Concussion? A Mild Traumatic Brain Injury 2. Who Gets Concussed? Tamara Valovich McLeod, 2013 3
Epidemiology of Pediatric Sport-Related Concussion 1.6-3.8 million concussions annually (Langlois, 2006) 8.9% of all high school athletic injuries (Gessel, 2007) Nationwide estimates of sport-related mtbi hospital charges ~$6 million annually (Yang, 2007) Limited epidemiological data in patients under high school age ~144,000 pediatric (0-19y) patients report to ER (Meehan, 2010) Guskiewicz & Valovich McLeod, 2011 Tamara Valovich McLeod, 2013 4
3. How Useful is Imaging? Neuroimaging Primary use to rule out intracranial hemorrhage CT and MRI Often used but have little value in assessing less severe injuries CT should not be used to diagnose concussion No use in contributing to recovery or return to activity decisions Identified as one of the top 5 procedures that should not be ordered regularly Giza, 2013; McCrory, 2013; Schurr, 2014 The Future of Neuroimaging Functional MRI (Chen 2004, 2008; Jantzen, 2004; Lovell, 2007; Slobounov, 2010) Abnormal activation patterns consistently reported across studies during working memory tasks Diffusion tensor imaging (Zhang, 2010) Magnetic resonance spectroscopy (Vagnozzi, 2008; Henry, 2010) Tamara Valovich McLeod, 2013 5
fmri and Concussion Lovell et al, Neurosurg, 2007 4. What are the Symptoms? Sensitivity to light/noise Difficulty concentrating Feeling foggy Feeling slowed Difficulty remembering Vision problems Cognitive- Sensory Sleep- Arousal Fatigue Sleeping less than usual Trouble falling asleep Drowsiness Headache Nausea Vomiting Dizziness Balance problems Vestibular- Somatic Affective Sadness Feeling more emotional Nervousness Irritability Kontos et al, 2012 Tamara Valovich McLeod, 2013 6
Anxiety Dizziness Depression School Fatigue Emotional TBI Mood States Social PCS Fatigue Headache 5. How Should I Assess Concussion? Vestibular - Ocular Postural Control Symptoms Mental Status Clinical Exam Concussion Assessment Neurocognitive Acute Concussion: Evaluation Signs and symptoms Any ONE or more present to suspect concussion Clinical domains Cognitive symptoms Somatic symptoms Emotional symptoms Physical signs Behavioral changes Cognitive impairment Sleep disturbances Tamara Valovich McLeod, 2013 7
Concussion Assessment Broglio, 2014 Acute Concussion Evaluation (ACE) http://www.cdc.gov/ncipc /tbi/tbi.htm Background Parent questionnaire Prior concussion history Past medication and imaging history Comorbid factors Tamara Valovich McLeod, 2013 8
Cognitive and physical evaluation Standardized Assessment of Concussion Child version Balance assessment Modified BESS and/or tandem gait Neck Examination ROM, strength, tenderness Coordination Clinical Tests of Vestibular Function Interview / patient history Oculomotor screening Smooth pursuits Saccades Gaze stability SCC and otoliths Head shake/thrust Dynamic visual acuity Functional tests Gaze stability Balance Tamara Valovich McLeod, 2013 9
6. How Are Concussions Managed? REST Physical Rest Cognitive Rest Physical and Cognitive Rest 1 week of cognitive and physical rest decreased symptoms and increased ImPACT scores regardless of time between concussion and onset of rest (Moser, 2012) 1-7d, 8-30d, 31+ d Tamara Valovich McLeod, 2013 10
(Moser, 2012) Cognitive Rest No activity Full activity Asleep or comatose Goal: limit cognitive activity to a level that is tolerable and does not exacerbate symptoms Normal school Academic Decline Have you personally encountered a situation where a student athlete that you have treated experienced a decrease in school and academic performance as a direct result of a symptomatic concussion? Yes 79% (n=549) No 21% (n=142) ~44% of concussions resulted in some form of academic accommodations Mayfield, RM, In press Tamara Valovich McLeod, 2013 11
Temporary Academic Adjustments Excused absence Rest periods Deadline extensions Postpone/stagger tests Extend test time Light/noise accommodations Excuse from PE Monitor backpack weight, stair use Reader/recorded books Note taker Smaller, quiet exam room Preferential seating Tutor McGrath, J Athl Train, 2010 Communication Coach Primary Care Provider School Nurse Outside referral sources Athletic Trainer Counselor Parents Teachers Student Piebes et al, J School Nursing, 2009 ACE Return to School Tamara Valovich McLeod, 2013 12
Referral Neurologist Prolonged symptoms, sleep disturbances Neuropsychologist Cognitive deficits, school issues Vestibular therapist Dizziness and balance issues ED Management Rule out more serious injury With concussion we expect negative imaging Instructions for red flags Instructions for rest (physical and cognitive) Do not clear to RTP Follow-up with AT/PCP for continued evaluation and clearance Avoid giving RTP timelines 7. What Treatments are Effective? Tamara Valovich McLeod, 2013 13
Pharmacological No treatment has been shown to speed recovery Management of specific or prolonged symptoms Symptoms affecting QOL that benefit of treatment outweighs risks of medication Provider is experienced with sport-related concussion Concern with masking symptoms or side effects of medications increasing symptoms McCrory, 2013; Meehan, 2011; Petralgia, 2012 Activity During Recovery? No school or exercise activity School activity only School activity and light activity at home School and sports practice School and sports games Majerske, JAT, 2008 Active Rehabilitation Exercise has a positive effect on mental health Closely monitored rehabilitation in post-acute phase improved recovery time in adolescents who were slow to recover (Gagnon, Brain Inj, 2009) Controlled subsymptom threshold aerobic exercise improved recovery in athletes with PCS (Leddy, CJSM, 2010, 2011) Tamara Valovich McLeod, 2013 14
Vestibular Rehabilitation After Concussion Intervention Outcomes Gaze stabilization (X1) Standing balance Walking with balance challenges Canilith repositioning Dizziness rating Activities-specific balance confidence scale DHI Dynamic gait index Functional gait assessment TUG SOT (all conditions) Alsalaheen, JNPT, 2010 8. When Should a Patient Return to Activity? Return to Activity Progression that begins when asymptomatic Off medications No S&S at rest Full return to school Return to baseline on adjunct assessments Neurocognitive Balance Guskiewicz, J Athl Train. 2004 Tamara Valovich McLeod, 2013 15
Modifying Factors More Conservative Management McCrory, 2009 Prolonged Recovery Authors McCrea et al. 2003 Iverson et al. 2006 Collins Lovell, et al. 2006 Sample Size Population Tests Utilized 94 College Paper and Pencil 30 High School Computer ImPACT 134 High School Computer ImPACT Total Days Cognitive Resolution Total Days Symptom Resolution Individual Recovery Rates 3-5 Days 7 Days 91% recovered w/in 7 days 10 days 7 Days 50% recovered w/in 7 days NR NR 40% recovered w/in 7 days Slide Courtesy of Gerry Gioia, PhD ~24 hours between each stage McCrory et al, 2013 Tamara Valovich McLeod, 2013 16
http://www.biacolorado.org/resources/reap.pdf 9. What are the Short- and Long-Term Concerns? Concerns Short-term SIS Repeat Injury Long-term MCI Depression CTE Tamara Valovich McLeod, 2013 17
Giza & Hovda, J Athl Train, 2001. Pathophysiology of SIS Relatively minor second trauma Loss of autoregulation Increases intracranial pressure Herniation through the foramen magnum Brain stem failure Mortality rates near 50% and morbidity rates of 100% Tamara Valovich McLeod, 2013 18
Repeat Concussion 4-6 times risk for subsequent concussion (Gerberich et al, 1983; Wilberger, 1993; Zemper, 1994) 3 times more likely to sustain 2 nd in same season (Guskiewicz et al, 2000) Increased severity with subsequent concussion (Guskiewicz et al, 2000) S y m p to m S e v e rity 30 25 20 15 10 5 0 Baseline Control Concussion Injury 2 H rs Day 1 Day 2 Day 3 CRITICAL FIRST WEEK: Average of 7 days for full recovery 75% of repeat concussions within first 7 days 92% of repeat concussions within first 10 days Guskiewicz et al, JAMA 2003 Day 5 Assessment Point Day 7 Day 90 Courtesy of Kevin M. Guskiewicz, PhD, ATC 10. Can Concussion Be Prevented? Tamara Valovich McLeod, 2013 19
Protective Equipment Helmets Protect against head and facial injury in high velocity sports Do not reduce the risk of concussions Helmet Covers No protective benefit Concerns with adding weight to helmet (c-spine risk) Headbands Limited research, not encouraged or discouraged Mouthguards Reduces dental and orofacial injuries No evidence to support reduction in concussion risk Broglio, 2014; Benson, 2009; Halstead, 2001; ACSM, 2011; Hagel, 2005; Mueller, 2008; Sulheim, 2006 Education Concussion symptom video game improved identification in youth hockey players (Goodman, 2006) Concussion education increased reporting of concussion symptoms to coaches (Bramley, 2012) Every state concussion law requires education Proper Assessment Good pre-participation examination to identify concussion history Have you ever had an injury to your face, head, skull or brain that resulted in confusion, memory loss or headache from a hit to your head, having your "bell rung" or getting "dinged" while participating in sports or recreational activities? Thorough clinical examination Use of adjunct assessments Appropriate follow-up and RTP Tamara Valovich McLeod, 2013 20
Concussion Legislation May 2009 Jan 2014 AIA Policy Education Training coaches, athletes, parents Information sheet and consent AIA Policy Removal From Play Athlete, coach, AT, team physician, official, or parent can remove an athlete Return to Play No same day return Medically cleared by an appropriate health-care professional prior to resuming After medical clearance, RTP should follow a stepwise protocol Tamara Valovich McLeod, 2013 21
Bonus: What Resources Are Available? Arizona Resources Concussion Research Registry Concussion Consultation Tamara Valovich McLeod, 2013 22
NATA Special Topic 2013 June 27, 2013 OnePass Medical Providers Community Tamara Valovich McLeod, 2013 23
www.atsuconcussion.com tmcleod@atsu.edu 480-219-6035 www.atpbrn.org Tamara Valovich McLeod, 2013 24