Craig Davidson, MD University Health Center Team Physician Department of Athletic Medicine University of Oregon

Craig Davidson, MD University Health Center Team Physician Department of Athletic Medicine University of Oregon

In the news Definition Pathophysiology Signs and symptoms

Review current clinical guidelines Return to play Academic accommodations Computerized neuropsychological testing Benefits Limitations Modifying factors in concussion management

Max Conradt

American Academy of Neurology Antegrade Amnesia Third Concussion Cantu

A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. The 4th International Conference on Concussion in Sport, Zurich, 2012

May be caused by either a direct blow to the head or a blow elsewhere on the body with force transmitted to the head Rapid onset with short-lived impairment of neurologic function that resolves spontaneously. Symptoms may evolve over minutes or hours The 4th International Conference on Concussion in Sport, Zurich, 2012

Acute symptoms reflect a functional disturbance rather than a structural injury Normal neuroimaging studies May or may not involve loss of consciousness Resolution of symptoms follow a sequential course Post-concussion symptoms may be prolonged The 4th International Conference on Concussion in Sport, Zurich, 2012

Rapid acceleration / deceleration of the brain Linear Rotational Combination

Abrupt neuronal depolarization Release of excitatory neurotransmitters Ionic shifts Changes in glucose metabolism Altered cerebral blood flow Impaired axonal function

From Giza & Hovda, JAT 2001

Signs Loss of consciousness Vacant stare Amnesia Symptoms Cognitive Somatic Emotional Sleep Disturbance

Cognitive Confusion Disorientation Feeling in a fog Inability to focus Excessive drowsiness

Somatic Headache Dizziness Nausea / vomiting Balance Problems Noise sensitivity Visual disturbance Light sensitivity Blurry or double vision

Emotional Irritable Sadness More emotional Nervousness

Sleep Disturbance Difficulty falling asleep Sleeping more / less than usual Frequent wakening Drowsiness

Exclude cervical spine injury Neurologic exam Should not be left alone following injury and serial monitoring for deterioration is essential over the initial few hours following injury

The appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode Concussion should be seen as an evolving injury in the acute stage The 4th International Conference on Concussion in Sport, Zurich, 2012

The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.

22 yo female presents with hx of nausea, headache, dizziness and confusion after a bike accident 10 days ago Bike vs Car (ran a stop sign) Struck by car and fell onto cement No helmet Taken to the ER and diagnosed with a concussion

Nausea and worsening headache the next day Land exercises with club sports swim team Pilates class 4 days later second ER visit with negative head CT Zofran Instructed to f/u at the University Health Center

Current Complaints Difficulty concentrating Has not been able to read for long periods of time Fatigue Ongoing nausea with occasional vomiting Headache 2/10 global Assessment: Concussion Plan-zofran, concussion awareness letter, physical and cognitive rest, f/u 1 week

3 weeks from DOI Drove to LA with club sports swim team 3 events Increased headache and nausea after meet Swam one workout since returning to campus and stopped early due to nausea Current complaints Low grade headache, 2/10 Difficulty focusing Trouble with writing in class

Assessment: Concussion Plan Disqualified until cleared Note to club sports office Recheck one week Improved over next month

Patient Information Home Instructions Concussion Awareness Letter

Excused absence from class No physical education classes Consider reduced make-up work Extension of assignment deadlines No testing until student is cleared

Extended time to complete assignments Extended testing time in quiet environment Provide written instructions for homework Provide class notes from teacher or peer

Preferential classroom seating Use of a note taker Temporary assistance of a tutor For timing issues of event close to testing allow time to relearn material the student studied/reviewed prior to the injury

This letter is to notify you that the abovenamed student is working with the Accessible Education Center for disability related services. The U of O is obligated under section 504 of the Vocational Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 to make reasonable accommodations for students with disabilities.

A player with diagnosed concussion should not be allowed to return to play on the day of the injury.

Mechanism of injury Concussion history Symptom score Duration of symptoms Neuropsychological testing Comorbid conditions Participation goals

Rehabilitation Stage Goal 1. No Activity Recovery 2. Light aerobic exercise Increase HR 3. Sport specific training Add movement 4. Non-contact drills Coordination 5. Full contact practice Confidence 6. Game play

Immediate measurement of performance and cognitive testing Test battery administered on computer Measures attention, memory, processing speed and reaction time Baseline scores compared to post concussion

Time, space, and money Language Comorbidities ADD/ADHD Invalid test goof off factor Poor baseline testing Learning curve Data does not make the diagnosis One tool in the toolbox

20 yo male fell backwards 2 weeks ago and hit head on stairs No LOC Dazed afterwards No nausea / vomiting Next day awoke with headache Noticed a few spots of blood on the pillow Local pain along back of head

Today 3/10 headache all over No occipital / neck pain Headache worse at end of day Complains that I m not myself Notes difficulty studying Not sleeping well frequent wakening Concerned about his academic performance

Additional History Roommate has commented about being moody Has had some fatigue Concerned about lack of motivation Notes left eye may be a bit blurry No prior history of concussion Business major - excellent student

PMHx Negative for anxiety, depression, ADD Paintball injury to right eye in 7 th grade with residual blurry vision Physical Exam Sluggish pupillary exam on right (post-op)

2 weeks of symptoms Continued to study and exercise weight training and cardio at rec center Emphasized cognitive and physical rest Head CT due to concern of blurry vision in good eye Concussion awareness letter for faculty Follow-up in 10 days

Feeling better Intermittent mild headache Dropped one class I do not think my brain is as sharp right now Concerned about a final next week Feels moody, denies depressive symptoms

About the same Fatigue Low grade headache Symptom Score 19 Impact Test

Continues to improve Intermittent headaches Poor sleep Not yet returned to regular exercise Thinking about taking the next term off Started on amitriptyline 10 mg 40 mg QHS

Impact score improved Clinically better Decision to stay in school Advised to advance physical activity slowly Recheck in one month

Stopped amitriptyline Played in a soccer game and had increased headache stopped and went home to rest Academically doing well Recommendation made to hold off on participation in sprinting sports and continue with activities as tolerated Follow-up PRN

Symptoms and signs of a concussion that persists for weeks to months after the incident ICD 10 three or more of the following HA, fatigue, dizziness, irritability, insomnia, concentration difficulty, memory difficulty DSM-IV Three or more symptoms + cognitive deficits in attention or memory

Concussion history Total number Time proximity Severity (duration of symptoms) Symptoms Total number Severity and duration Signs Prolonged LOC (>1 min)

Susceptibility Concussions occurring with lower impact force Concussions requiring longer recovery Age Youth and adolescent athletes may recovery more slowly Comorbid Conditions Migraine, depression, anxiety, ADD/ADHD, and learning disabilities

22 yo male from China presents for ER followup after MVA 8 days ago Restrained passenger in a sedan T-boned in intersection by a minivan, 20-30 mph Hit right side of head No LOC Given vicodin in ER and discharged to home

Today Feeling better Slight headache 3/10 (8/10 after MVA) Not sleeping well Occasional trouble focusing No nausea / vomiting Has not missed class

Assessment: Concussion s/p MVA Plan recheck one week

Today 3/10 headache right sided, worse in AM Dizziness Poor sleep Nonfocal exam Assessment: Closed head trauma s/p MVA with persistent focal headache Plan: Noncontrast head CT

Concussion History Concussion should be seen as an evolving injury in the acute stages Symptoms follow with sympt0m score Cognitive Somatic Emotional Sleep Disturbance

Cornerstone of concussion management is physical and cognitive rest Return to Play - individualized progression Modifiers for prolonged recovery Concussion hx Number of symptoms and the severity Susceptibility lower force, longer recovery Comorbid conditions

Academic accommodation General principles Utilize campus resources Management decisions are case by case

19 yo female freshman lacrosse athlete Struck in goggles with stick ( 8 am) Completed 4 drills Headache Nausea Rested the remainder of practice Trainer calls at 6:30 pm reporting persistent symptoms

Rested next day no practice Complains of mild nausea beginning of day 3 Symptom Score 2/6 for nausea, normal impact score Missed 10 days of school 1 yr. ago after a concussion

19 yo female hit a utility pole with her head while texting/walking four days ago Dazed initially Pain along small gash on forehead Fatigued the next day

Today 5/10 pain at site of trauma Still notes fatigue Complains of difficulty concentrating PMHx No prior hx of concussion ADHD treated with adderall

Assessment Concussion ADHD Plan Reviewed cognitive / physical rest Concussion handout Tylenol prn Recheck in one week (no showed)