Concussion Care in College Health Expanding Knowledge and New Perspectives Peter C. Doyle MD
Concussion-what is it? • A mild traumatic brain injury with no significant findings on currently available neuroimaging devices (CT, MRI). Sudden impacts with rotational acceleration of the head are a common cause. • An injury of neuronal tracts and mitochondria that disrupts the normal sodium-potassium- calcium channels responsible for transmission of nerve impulses. • This damage is on an axonal level and takes ATP energy to repair.
What is happening at the level of the axon? Worst case:
What happens most often.
Axonal repair. • A healthy brain uses 25% of our energy output on a daily basis. • The injured brain requires many more calories to effect repairs • This increased energy need is thought to account for a large part of the profound fatigue often felt after concussion.
Diagnosis of Concussion • Usually by history of the injury or by direct observation of the event. • Easy dx with high energy impacts ( high speed collision in contact sports, fall from bicycle, hit by boom on the sailing team etc.) • Harder diagnosis with minor injuries ( I stood up fast bumped my head on a shelf, a tennis ball hit me on the head etc.)
Disposition of the concussion Patient if you are the initial evaluator! • When in doubt, send them out! Beware of: • High energy injury – MVA, bike etc. • Shoulders, clavicles, wrists, knees may mean concussion too! • Any Loss of Consciousness • Any neuro deficits • A History or suspicion of intoxication • Worsening symptoms
Disposition of the concussion patient sent to you from the ED or another clinician. • Exactly the same as above! • Re-evaluate! • Trust yourself! • Be most cautious during the first three days!
Why I like the CDC’s “Mild TBI Pocket Guide” • It reminds me to look out for intoxication! • Ask about medications - especially anticoagulants • Look for physical evidence of trauma above the clavicle • Don’t forget age! • A dangerous mechanism is defined as ejection from a motor vehicle, a pedestrian struck, and a fall from a height > 3 feet or 5 steps
Remember the Red Flags! • Neck pain or tenderness • Double vision • Weakness or tingling/burning in arms or legs • Severe or increasing headache • Seizure or convulsion • Loss of consciousness • Deteriorating conscious state • Vomiting • Increasingly restless, agitated or combative
The Good News • Symptoms will get better • Most minor concussions require no special care – 70-80% will resolve on their own. • Treatment is available for the bad ones. • Research is continually producing useful hints about prognosis and therapy.
The Bad News. • There is tremendous fear and anxiety associated with this illness. • No real consensus on management. • Wide variability in terms of symptoms. • Wide variability in terms of recovery times. • Little correlation between level of initial injury and development of post concussive syndrome! • Outcomes can be substantially affected by various pre-existing conditions.
Pre-existing conditions to be aware of: • Motion sickness • Migraine headaches • ADD ADHD Learning disabilities • Depression • Anxiety • Insomnia • Convergence Insufficiency
Evaluation and Management of Concussion • Once severe injury is ruled out, think in terms of identifying major symptoms. • Objective symptoms - ocular, vestibular and cervical. • More subjective symptoms – cognitive, fatigue, anxiety/mood, post traumatic headache.
Look at the whole patient. • Think of the 6 common symptom pattern model: - Vestibular - Ocular - Cognitive/Fatigue - Anxiety/Mood - Post Traumatic Migraine - Cervical/Neck Pain • Most concussions will exhibit more than one pattern Possible 7 th pattern - neuroendocrine -
Cervicalgia – neck pain • Assess for gross defects (limited ROM, acute vertebral tenderness to palpation, acute muscle spasms). • Treat with nsaids, initial ice for 10 minutes TID and after 2 – 3 days, alternating heat and ice. • Gentle stretching as tolerated. • Refer to Chiropractic, Ortho or PT if the student is willing to go.
Vestibular and Oculomotor deficits are highly prevalent following concussion. Convergence insufficiency identifies athletes at Risk of prolonged recovery from Sports related concussion. Am J Sports Med. 2017 Aug;45(10):2388-2393. doi: 10.1177/0363546517705640. Epub 2017 May 16
Prevalence of Ocular Deficits - Overview • In the Normal Population • Convergence Insufficiency – 5% • Accommodation Insufficiency– 6% • Abnormal Eye Movements – age-related • After Concussion/mTBI • Convergence Insufficiency – 30%-45% • Accommodation Insufficiency – 20%-50% • Abnormal Eye Movements – 20%-40%
Ask about pre-existing Ocular conditions • Convergence insufficiency • Phorias/Lazy Eye • History of poor depth perception • History of poor eye-hand coordination • Prior eye surgery or therapy • Abnormalities of binocular vision
Management of Ocular deficits • If new CI, AI, loss of binocular vision, blurry vision or severe intolerance to light are present, consider prompt referral to a Optometrist familiar with post concussion ocular therapy • Ocular deficits can be highly disconcerting and will drive other symptoms such as headache and dizziness very quickly.
Ocular evaluation - VOMs
Visual Motion Sensitivity test. • The test that most commonly provokes symptoms in my experience. • The vestibular ocular reflex is also commonly provocative • Use the VOMs to identify injury, practicing all provocative tests for a few minutes once or twice a day can become effective therapy. • Look for laterality of injury. • Refer slow responders to OT promptly.
Ocular therapy and management of symptoms • If gross ocular deficits are detected, why wait to begin treatment? • For C.I. pencil push-ups or a Brock String. • Practice suppressing VMS, OKN and VOR – start slow and increase speed as patient improves. • Practice accommodation for A. I. • Practice saccades, smooth pursuits, mazes are great! • Consider sunglasses, tints for screens, cut outs to focus on one paragraph at a time.
Does vision therapy work? • Vision Therapy/ Rehabilitation was recommended for 82.5% of patients • Convergence Insufficiency • Successful outcome: 83% • Improved: 15% • Accommodative Insufficiency • Successful outcome: 33% • Improved: 67% • Saccadic Dysfunction • Successful outcome: 71% • Improved: 2% Scheimann et al. CHOP 2018
Vestibular Evaluation and Management
• Tandem gait testing and Single leg stance are most often positive. Look for laterality. • Testing with eyes open and closed – watch for falls with tandem gait! Dual task is more sensitive. • Finger to nose test is rarely useful for me. • Once again, use deficits to guide therapy. Consider practicing one legged stance on firm floor and progress to foam pad etc. Practice bad side 3x more often than good side. • Simple exercises are available on YouTube – See Leslie Montgomery Concussion
Practical Experience Time! • VOMs • Balance • These exercises will improve symptoms. • They will give patients a sense of control. • They will provide a metric of improvement. • They can give us a sense of when to send for specialty care.
Documenting oculomotor and vestibular tests Formal BESS and VOMS testing takes time. I use a 3 level scale. 1. Feels normal 2. Doesn’t feel right 3. Feels way wrong/ I’m going to barf! Trust what your patients are telling you. They will know what doesn’t feel right!
Cognitive Evaluation and Management of Cognitive Complaints • Symptoms are almost always very alarming in our population!
• Currently a very subjective evaluation -most people can do serial 7’s etc. • Symptoms are worse with screen time, busy environments, background noise and motion. • Best treated with stimulus control, sleep, and early exercise. Avoid alcohol!!! • Restart cognitive effort after 1-2 days. Try 10-30 minutes once or twice a day to start. If unable to study in the morning try again in the afternoon. Advance as you would exercise. • It is ok to pretreat with acetaminophen or ibuprofen to control headache pain.
Main drivers of cognitive symptoms? • Initially in 1-3 days - ? Spreading mitochondrial dysfunction and energy deficit due to calcium influx etc. • Short term – energy deficit plus ocular/vestibular injury patterns • Pain and headache. • Mid to longer term – ocular injury plus insomnia, circadian rhythm disruptions.
Medications for cognitive therapy. • Manage environments first – meds alone are a bad idea. • Amantadine 100mg PO BID ? • Sleep aids if necessary. • Supplements – more on this later. • Stimulants verrry rarely. • Generally left to concussion clinics and used for patients with post concussion symptoms.
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