Concussion 101 Natalie Stork, MD Assistant Professor University of Missouri-Kansas City School of Medicine, Department of Orthopaedic Surgery and Department of Pediatrics Children s Mercy Kansas City, Division of Orthopaedics and Section of Sports Medicine The Children s Mercy Hospital, 2015
Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation 2
Practice Gap New knowledge and management tools have been published regarding the diagnosis and management of acute concussion 3
Objectives Epidemiology Pathophysiology Diagnosis Treatment Return to play Dispel Common Myths 4
Definition Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiologic process. Harmon KG. et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport 5
Epidemiology ~ 3.8 million concussions per year Risk Factors Prior history Number, severity, duration of symptoms* Certain sports/positions Females* Age 6
Pathophysiology Acceleration, Deceleration, Rotational forces Increased: Na+K activity Lactate Calcium Glutamate K+ Efflux Energy Crisis Depolarization; Neuronal suppression Decreased: Glucose ATP Cerebral blood flow 7
Diagnosis Clinical No one test History Physical exam Cognition Focused neurologic exam Balance/Coordination Absence of structural injury 8
Diagnosis Red flags Repetitive emesis Mental status changes Focal neurological deficit Seizure Weakness/Numbness in extremities Worsening symptoms 9
Diagnosis Mechanism of injury Loss of consciousness? Sideline Assessment Primary assessment SCAT3, King Devick test Office Assessment Imaging Rule out structural injury 10
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Diagnosis - Office Evaluation General Mental Status Cranial Nerves Vestibulo-Ocular Balance/Coordination Smooth Pursuits, Saccades, Convergence Musculoskeletal Cervical spine Upper/Lower extremity strength 13
Myth or Truth? Myth: If there is no Loss of Consciousness, the diagnosis of concussion is much less likely Truth: The majority of concussions have no associated loss of consciousness 14
Myth or Truth? Myth: It is important to grade the concussion upon initial diagnosis as this can have prognostic value for the patient s recovery.. Truth: Grading systems for concussions are not currently recommended because: Classification is arbitrary Not found to be helpful in prognosis or management 15
Neuropsychological Testing Objective measure* One of many tools Should not be used in isolation Not used to diagnose concussion Timing, frequency, type?? Interpretation 16
Myth or Truth? It is important to counsel the patient s family on the frequency of monitoring upon discharge from the ED/Clinic. Myth: The patient should be woken from sleep ever 1-2 hours overnight to assure normal exam Truth: The patient should be appropriately observed in the Emergency Department or Clinic prior to discharge Truth: If concern regarding neurologic status remains, patient should not be discharged home 17
Treatment Any athlete suspected of having a concussion should be evaluated immediately Diagnosis of concussion should not be returned to play on same day* Risks of premature return to play Second Impact Syndrome Increased risk of more severe injury/prolonged recovery 18
Treatment Acute Concussion Rest Cognitive/Mental Relative Physical Complete* Medications Generally not used in the acute treatment Over the counter medications* Other therapies Vestibulo-ocular Physical therapy 19
Returning to Learning Multiple potential barriers Goal Prevent symptom provoking exertion Timely return Consideration for predominant symptoms Headache Dizziness Light/Noise sensitivity Memory/Concentration difficulties 20
Returning to Learning Encourage family to meet with school administration Discuss potential accommodations Parents/Athlete generally are the decision makers as to when the child should return 21
Return to Play Goals Back to full mental and cognitive activities* Asymptomatic for 24-48 hours Off any over the counter medication used for concussion symptoms 22
Return to Play (RTP) Step 1: Light aerobic activity Step 2: Sport specific exercise Step 3: Non contact sport specific drills/resistance training Step 4: Sport specific contact practice Step 5: Full activity/game/competition Asymptomatic for 24-48 hours between steps If patient develops symptoms during RTP: Stop activity Wait to become asymptomatic for 24-48 hours May begin RTP, starting again with step 1 23
Myth or Truth? Myth: An athlete should be medically retired after sustaining 3 concussions. Truth: There is no evidence to help guide us in determining how many concussions is too many in the context of long term sequela. Truth: More concussions is generally not ideal 24
Return to play What is known regarding multiple concussions History of concussion associated with higher risk of re-injury May report more symptoms at baseline Prolonged recovery predictors Greater number Duration of symptoms 25
Return to Play What is not known Prior history associated with prolonged recovery Evidence based guidelines for retiring an athlete Many questions remain regarding chronic traumatic encephalopathy 26
Treatment Post Concussive Syndrome Post Concussive Syndrome Symptoms persisting beyond normal recovery period (>6 weeks) Etiology unknown Often requires multidisciplinary approach 27
Prevention Rule modification May provide prevention of some injuries Helmets/Headbands Prevent direct impact injuries Have not been shown to prevent concussions 28
Practice Change The learner with feel comfortable in the diagnosis, basic management of acute sports related concussion 29
Resources CDC http://www.cdc.gov/headsup/ AAP Council on Sports Medicine/Fitness https://www.aap.org/en-us/about-the-aap/committees-councils- Sections/Council-on-sports-medicine-and-fitness/ SCAT 3 http://bjsm.bmj.com/content/47/5/259.full.pdf AMSSM http://www.sportsmedtoday.com/head-ct-17.htm 30
References 1. Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26. doi:10.1136/bjsports-2012-091941. 2. Halstead ME, Walter KD, Fitness TC on SM and. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2010;126(3):597-615. doi:10.1542/peds.2010-2005. 3. Matuszak JM, McVige J, McPherson J, Willer B, Leddy J. A Practical Concussion Physical Examination Toolbox Evidence-Based Physical Examination for Concussion. Sports Health Multidiscip Approach. 2016;8(3):260-269. doi:10.1177/1941738116641394. 4. Halstead ME, McAvoy K, Devore CD, et al. Returning to Learning Following a Concussion. Pediatrics. October 2013:peds.2013-2867. doi:10.1542/peds.2013-2867. 5. Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025. doi:10.1001/jama.2016.1203. 31