Sport-Related Concussion Daniel Seidman DO 6 August 2016
My Pertinent Qualifications - Current Fellow, PCSM - Henry Ford Hospital - Recent Graduate, FM - St. John Macomb-Oakland Hospital - Involved in Concussion Research
Disclosures I have no relevant financial or nonfinancial relationships to disclose.
Goals By the end of today s presentation, you will be able to: 1. Develop a better understanding of SRC 2. Diagnose and manage SRC 3. Successfully implement a RTP protocol 4. Educate patients and colleagues regarding the latest evidence and guidelines
Outline 1. 2. 3. 4. 5. 6. 7. 8. Define Concussion Discuss Epidemiology/Pathophysiology Review Zurich Guidelines Review AMSSM Consensus Statement Review AAN 2013 Guidelines Discuss Sideline Tools Case study Review Current Research
Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective
Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective
So...what is a concussion? AMSSM A concussion is defined as a traumatically induced transient disturbance of brain function and is caused by a complex pathophysiological process. AAN Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness.
So...what is a concussion? Zurich Consensus Statement Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head. 2. Concussion typically results in the rapid onset of short- lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion 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. However, it is important to note that in some cases symptoms may be prolonged.
So...what is a concussion? Practical Definition Concussion: a complex, traumatic, biomechanical brain injury which induces a transient neurometabolic cascade. It may or may not have the following characteristics: - Acute or delayed onset of neurological impairment - Head injury - Loss of consciousness - Physical exam findings If performed, neuroimaging will be negative*
Isn t that exciting?
Epidemiology - Many different numbers out there 38m children/adolescents play sports 170m adults play sports Approx. 1.7m sustain TBI CDC: 1.6-3.8m concussions annually $60 billion in healthcare costs There is evidence to indicate that there are greater risks for disabling brain injury or death from riding a bicycle, walking on the street, being in a car, or even swimming than contact football Daneshvar, et. al.
Pathophysiology - The Hit - Neurometabolic Cascade
Giza, et. al.
Giza, et. al.
Giza, et. al.
Giza, et. al.
Signs/Symptoms
Signs/Symptoms - AMSSM Domain 1: Physical - Headache, nausea, vomiting, balance, dizziness, photophobia, visual problems, fatigue, dazed, stunned Domain 2: Cognitive - Foggy, slowed down, difficulty concentrating or remembering, forgetful of recent events, repeats questions or answers questions slowly
Signs/Symptoms - AMSSM Domain 3: Emotional - Irritable, sadness, more emotional, nervousness Domain 4: Sleep - Drowsiness, sleeping more, sleeping less, difficulty sleeping
Signs/Symptoms - Zurich Clinical Domains 1. Symptoms - somatic, cognitive, emotional 2. Physical signs 3. Behavioral changes 4. Cognitive impairment 5. Sleep disturbance
Risk Factors - Previous concussion Number, severity, duration Sex Age Sport, position, style of play Genetics Mood disorders Migraines Learning disabilities and attention disorders
Diagnosis/Treatment/Management Preseason - Baseline testing (or Computerized NP tests) - Education
Diagnosis/Treatment/Management On the field - ABCs. Always. - Clear the c-spine - Neuro exam Next, - History - Physical - Sideline testing - Balance testing
Diagnosis/Treatment/Management In the emergency room/in office - H&P - Clinical status - Imaging
Diagnosis/Treatment/Management Additional notes - Frequent waking - Medications - Follow up
Diagnosis/Treatment/Management Neuropsychological testing - No universal recommendations - CNP is sensitive for deficits
http://www.sycva.com/page/show/2128999-return-to-player-guidelines
Cheap, Clinical Tools - History Physical Exam SCAT3 King-Devick
SCAT3 - Sport Concussion Assessment Tool, 3rd e. - BESS, SAC, GCS, Maddock s Score - Coordination Exam - Physical Signs Score
SCAT3 - Can be used as a one-time tool on the sideline or in the clinic - Can be used to track, follow clinical condition in anticipation of RTP - For kids under 13, utilize Child SCAT3 - Instructions are on the test - Print online and keep in office - Diagnosis of concussion can still be made if SCAT3 is normal.
King-Devick - Originally an oculomotor test Assess rapid eye movement Rapid number-naming Reading a series of numbers
King-Devick - Validated as accurate and reliable - Cheap to use - Can be used to follow progression
Case Study 5/27/15 JQ, a 13 yo F presents to ER at 9:30pm. - Collided and hit her head on the ground - Throbbing and stabbing pain - Blurry vision - Balance issues - No LOC - Took ½ norco and ice - ineffective
5/27/15 PMHx: negative PSHx: T&A, tubes FHx: Noncontributory SocHx: Denies tobacco, etoh ROS: + Blurry vision, nausea, headaches
5/27/15 BP 121/60 mmhg Pulse 80 Temp(Src) 36.8 C (98.2 F) (Oral) Resp 16 Ht 1.524 m (5') Wt 4.536 kg (10 lb) BMI 1.95 kg/m2 SpO2 100% LMP 05/01/2016
5/27/15 PE: Negative
5/27/15 Assessment: Mild closed head injury Plan: - Motrin and Zofran - Lengthy discussion regarding imaging, no CT at this time. - No return until evaluated by PCP - Return should signs of ICH occur
Concussion Clinic 6/20/15 - Seen by AT - Seen by neuropsych - Seen by physician
6/20/15 - Struck head on ground, vision went black Coach saw her stumble Vision went dark again Headache, blurred vision, dizziness, nausea, confusion, and fatigue - Patchy memory
6/20/15 - Continued symptoms for 2 weeks Occurred on a weekend, went to school after Saw pediatrician Following a school trip, attending ½ days of school - Able to complete exams and assignments, but with worsening of symptoms
6/20/15 Modifiers - History of headaches - History of sleep difficulties - No ADHD - No mood disorders - Knee injury
6/20/15 SCAT3 Total # of Symptoms Symptom Score 5/27/15 20 92 6/20/15 17 44
6/20/15 PE: Negative
6/20/15 Assessment: Concussion Plan: - Continue PRN headache meds - Cervical stretches, posture training - Symptom tracker - Follow up in 2 weeks
7/5/15 - Significant improvement - Continued headaches, dizziness - Been swimming without difficulty
7/5/15 SCAT3 Total # of Symptoms Symptom Score 5/27/15 20 92 6/20/15 17 44 7/5/15 13 29
7/5/15 Plan: - Begin to ramp up cognitive activity - Consider specialist referral for previous history of headaches - Continue symptom tracker - Follow up in 2-3 weeks
7/25/15 - Daily headache, which was her baseline - Back to soccer-related drills
7/25/15 SCAT3 Total # of Symptoms Symptom Score 5/27/15 20 92 6/20/15 17 44 7/5/15 13 29 7/25/15 5 6
7/25/15 Plan: - ImPACT testing - RTP4 RTP5 - If all goes well, call to obtain clearance - Specialist referral for chronic headaches
Objective - Concussion can be difficult to diagnose Need for cheap, quick tools Validated in collegiate athletes Not studied well in HS athletes
Methods - 343 athletes at four local high schools Baseline testing If concussed, tested again Postseason testing
Results - 9 concussions All showed significant increase in read times Non-injured athletes scores were unchanged History of concussion
Conclusion - KD test is an accurate, easy to administer, sideline screening tool for concussion in adolescent football players - Further studies to address younger players
References 1. 2. 3. 4. 5. McCrory, Paul, et al. "Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012." British journal of sports medicine 47.5 (2013): 250-258. Giza, Christopher C., et al. "Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology." Neurology 80.24 (2013): 2250-2257. Harmon, Kimberly G., et al. "American Medical Society for Sports Medicine position statement: concussion in sport." British journal of sports medicine 47.1 (2013): 15-26. Seidman, Daniel H., et al. "Evaluation of the King Devick test as a concussion screening tool in high school football players." Journal of the neurological sciences 356.1 (2015): 97-101. Giza, Christopher C., and David A. Hovda. "The neurometabolic cascade of concussion." Journal of athletic training 36.3 (2001): 228.