Concussion Melissa Novak, DO OHSU Sports Medicine What is a - PDF document

9/17/2015 Concussion Melissa Novak, DO OHSU Sports Medicine What is a Concussion? A Bell Ringer? 1

9/17/2015 A Ding? • Mild traumatic brain injury that interferes with normal function of the brain? 2

9/17/2015 Objectives • Identify concussion • Demonstrate familiarity and ability to use concussion evaluation tools • Explain how to manage the acute presentation of concussion • Describe the return to play protocol and return to learn NO!!!! • Grade I • Grade II • Grade III…. • A type of traumatic brain injury that is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull? – WebMD 3

9/17/2015 Zurich 2012 • Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces Zurich 2012 • 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… Zurich 2012 • Direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head. • 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 minutes to hours. 4

9/17/2015 Zurich 2012 • May have neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury • No abnormality is seen on standard structural neuroimaging studies. • Graded set of clinical symptoms • May or may not involve loss of consciousness. • Resolution of the clinical and cognitive symptoms typically follows a sequential course – However, some cases symptoms may be prolonged Sports Concussion Institute • A concussion is defined as a complex pathophysiological process that affects the brain, typically induced by trauma to the brain • It can be caused either by a direct blow to the head, or an indirect blow to the body, causing neurological impairments that may resolve spontaneously • Symptoms usually reflect a functional disturbance to the brain Sports Concussion Institute • May include these symptoms: – physical (e.g., headaches, nausea), – cognitive (e.g., difficulty with concentration or memory), – emotional • (e.g., irritability, sadness) – ‘maintenance’ • (e.g., sleep disturbances, changes in appetite or energy levels) 5

9/17/2015 Why Are We So Confused… • Turns out, there are greater than 100 published definitions of what a concussion is… • Carney et al., 2014, A recently published evidence- based systematic review of the concussion literature has helped to better define concussion Carney et al., 2014 • 1.) A change in brain function • 2.) Following a force to the head( a potentially concussive event) • 3.) May (or may not) be accompanied by temporary LOC • 4.) Identified in awake individuals • 5.) Includes measures of neurologic and cognitive dysfunction 6

9/17/2015 Consistent and Prevalent Diagnostic Indicators • Observed and documented disorientation or confusion immediately after the event • Impaired balance within 1 day after injury • Slower reaction time within 2 days after injury (and /or) • Impaired verbal learning and memory within 2 days after injury Carney et al., 2014 Concussion Symptom Frequency • Headache 75% • Dizziness 60% • Blurred vision 75% • Nausea 54% • Double vision 11% • Noise sensitivity 4% • Light sensitivity 4% • Carney et al., 2014 Sleep Disturbance • Sleep problems related to mTBI found a significantly high prevalence of TBI- related sleep-wake disturbances at 67% Kempf et al., 2010 7

9/17/2015 What actually happnes? Energy Crisis! What to Avoid! • 1. Do not hit your head again – A lot less biomechanical force is going to produce far more serious consequences • 2. Cells are starved for energy, we do not want to increase the demand for energy too quickly or too rapidly or too significantly • Mickey Collins, PHd So Now What? • We know what a concussion is… but how do we actually know an athlete or a patient has a concussion ??? 8

9/17/2015 Sideline Evaluation-what do we look for? • Appears dazed • Moves clumsily • Confused about play • Answers question slowly • Forgets plays prior to hit (retrograde amnesia) • Forgets plays after hit (anterograde amnesia) • Personality/behavior change • Loss of consciousness • Bottom line… we still have to rely on the athlete to supply some information for us… Sport Concussion Assessment Tool Sport Concussion Assessment Tool ( SCAT 3) • On the sidelines or after the game • Validated tools to assess the severity of the concussion • Can help to monitor progress • Cognitive, motor control and balance testing • Athletes aged from 13 years and older. • Ages 12 and under, use the Child SCAT3 9

9/17/2015 Symptom Scale • Completed by the athlete, at least 10 minutes post exercise • Maximum possible is 22 symptoms • Symptom severity score, add all scores in table – maximum possible is 22 x 6 = 132. SCAT3 • Neck Exam • Coordination • Modified BESS test (balance) 10

9/17/2015 Internet- Based Cognitive Testing Programs • Impact or Axon/Cogstate or others • Standardized, computerized, and validated – document subtle impairments in • Memory • Attention • Processing speed – The test can be worse at 48hrs – Usually recovers in 1-4 weeks. ImPACT • Immediate Post-Concussion Assessment and Cognitive Testing – Computerized Neurocognitive Testing • The results correlate 60-70% with symptoms • Found to be 94.6% sensitive and 97.3% specific for concussion (Schatz P. et al. 2012.). • Various protocols for post-concussive testing exist but many schools and organizations are currently using impact testing Unique Contribution of Neurocognitive Testing to Concussion Management This image cannot currently be displayed. Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion N=215, MANOVA p<.000000 (Lovell et al., 2004) 11

9/17/2015 ImPACT • Assesses 6 domains of brain function: – Attention span – Working memory – Sustained and selective attention time – Response variability – Non-verbal Problem Solving – Reaction time • Compare post-injury score on test battery to pre-injury baseline. www.impacttest.com • Not a perfect tool and not to be used in the absence of an experienced and knowledgeable physician. May incorrectly diagnose 10% of those tested. What to expect from Neurocognitive Testing • Can help to determine recovery from injury • Can help to manage concussion (return to academics, return to play etc.) • Can help to communicate status to coaches, parents, athletes • CAN NOT substitute for medical evaluation/treatment 12

9/17/2015 Balance Testing: BESS • Errors in 20 sec trial: – Hands off iliac crest – Open eyes – Step/stumble/fall – Moving hips > 30 o abd – Lifting forefoot/heel – Remaining out of test position > 5 sec • Max errors per condition = 10 • Normal total score = 12.03  7.34 www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf Balance Tests: BESS Currently the “gold standard” for concussion management Pros Cons • Quick • Performance differences based on sport • Inexpensive • ↑ in scores with exertion or • Easy to administer on fatigue (~20 min) sideline or in clinic • ↑ in scores if ankle instability • Minimal ceiling effect • Learning effect • Moderate to good reliability Bell DR et al; Sports Health 2011; Guskiewicz KM Clin Sports Med 2011 Neurologic Exam 13

9/17/2015 Neurologic exam • Cranial Nerves • Muscle strength • Reflexes • Sensation • Coordination • Balance • Eye movement – Nystagmus? The First 24-48 Hours… • remove from play, assess for danger signs that require medical attention: – Difficult to arouse or awaken( including a LOC) – unable to walk – ongoing nausea and vomiting( >3) – worsening headache – changes in vision – unequal pupils – severe confusion or disorientation – significant neurologic symptoms – signs including weakness, numbness or seizure. • If these danger signs on the field are absent, the athlete can be observed, the parent should be informed and the athlete should be referred to the appropriate medical professional for evaluation and clearance before returning to play 14