Disclosure Current Standards for Managing Sports Concussion - PDF document

1 2 Disclosure Current Standards for Managing Sports Concussion • Founder, RunSafe™ • Founder, SportZPeak Inc. A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco • Sanofi, Investigator initiated grant Primary Care Medicine: Update 2017 3 4 What is a Concussion? Objectives: • Type of mild traumatic brain injury 1. What is a concussion? • Blow to head, neck, body  force to head. 2. How do you manage a concussion initially? • Neurologic impairment within 48 hours of trauma. 3. When would an athlete return to • Symptoms usually resolve in 1-2 weeks activities? spontaneously but in some cases can be prolonged. 4. What are the long term consequences of • May or may not include loss of consciousness. concussion? 1

5 6 Concussion Symptoms Shear and Strain Physical Sleep Cognitive Emotional http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. 7 8 OLD SCHOOL - Grading Concussions (AAN) Pathophysiology - Neurometabolic Cascade Severity Signs/Symptoms Grade I (mild) Transient confusion, no LOC, resolves in <15 Need minutes Ion fluxes; Force to glucose but Energy vasocon- brain less blood striction crisis Grade 2 (moderate) Transient confusion, no flow LOC, resolves in > 15 minutes Grade 3 (severe) Any LOC: brief (sec) or prolonged (minutes) Giza CC and Hovda DA, J of Athletic Training, 2001. Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. 2

9 10 Concussion Severity? Case 1 • Concussion grading is retrospective 17 y/o high school lacrosse player presents to your office with a concussion. He is a senior and his last • Historically concussions were graded on the high school game is in 4 weeks. He has no history sideline based on amnesia and LOC at time of of concussion, depression, or anxiety. injury. – American Academy of Neurology, 1997; Cantu, 2001 • Studies have shown these factors not to be predictive of recovery. • Only when the athlete recovers can you tell how severe the concussion was 11 12 What is the likelihood that he will be Concussion Symptom Evaluation back to play in his last game? SYMPTOMS s/p 6d SYMPTOMS s/p 6d A. High: 90% of sports concussion patients are Headache 5 “ Don ’ t Feel Right ” 5 better within 3 weeks of injury. “ Pressure in Head ” 3 Difficulty Concentrating 3 Neck Pain 0 Difficulty Remembering 3 B. Moderate: 65% of sports concussion patients Nausea / Vomiting 0 Fatigue / Low Energy 2 are better within 3 weeks of injury. Dizziness 2 Confusion 0 C. Low: 25% of sports concussion patients are Blurred Vision 0 Drowsiness 2 better within 3 weeks of injury. Balance Problems 2 0 Trouble Falling Asleep Sensitivity to Light 2 More Emotional 0 D. Zero: sports concussion patients should rest Sensitivity to Noise 1 2 Irritability from contact for at least 4 weeks post injury. Feeling Slowed Down 3 Sadness 0 Feeling like “ in a Fog ” 0 0 Nervous / Anxious TOTAL 35 3

13 14 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 15 16 Concussion Evaluation: Red Flags Physical exam Transport to the nearest emergency department if patient • Normal neck exam experiences any of the following: • Increased headache or neck pain severity • Normal neurologic exam • Increased drowsiness, can’t be awakened • Increased confusion or disorientation • Unusual behavior change • Loss of consciousness or seizures • Weakness or numbness in arms or legs • Repeated vomiting • Fluid leaking from ears/nose • Slurred speech 4

17 18 Postural Stability Concussion Treatment • Cognitive rest • Physical rest • Medication • Tylenol • Ibuprofen after first 72 hours • No driving • No Etoh 19 20 Diagnostic Imaging NSAIDs for Headaches Neuroimaging (CT, MRI) • No studies show that NSAIDs harmful • Most patients do not require imaging • Anectodally, Naproxen > Ibuprofen > Tylenol • Use when suspicion of intracerebral structural lesion • OK to Medicate if symptomatic and it helps exists: •prolonged loss of consciousness • 70% adolescent patients treated in a headache •focal neurologic deficit clinic with chronic posttraumatic headaches met •worsening symptoms criteria for medication overuse headaches •Deterioration in conscious state • Be careful of overmedicating Halstead ME, Sports Health , 2016 5

21 22 Melatonin Unclear Evidence • May have utility in reducing post traumatic • Some use but no evidence in Pediatric headache after mTBI concussions – Kuczynski A et al. Dev Med Child Neurol. 2013. • Stimulants: Amantadine, Methylphenidate – Barlow KM et al. Trials. 2014. • IV hypertonic saline • Growing interest in sleep disorders that contribute to post concussion syndrome • IV therapies such as ketorolac, prochlorperazine, metoclopramide, or ondansetron • ?role for melatonin as treatment • Halstead ME, Sports Health , 2016 – Sullivan KA et al. Appl Neuropsychol Adult, 2016 23 24 What do you recommend he do with Case 2 respect to school? 16 y/o high school student presents to your office A. Continue school without adjustments. with concussion sustained 3 days ago during B. Continue school but no test-taking. football. He reports headache, fogginess, and C. Attend ½ days of school for a week, no test- dizziness that is mild to moderate intensity at taking. home but moderately severe at school. He is resting from sports. D. Rest from school until can tolerate 1-2 hours of work at home. E. Rest completely from school for a week. 6

25 26 UCSF Concussion Clinic School Return to Learn Progression Note Return to full day of school. Return to ½ day of school. 30 min schoolwork at a time until can do 1- 15 min 2 hours. cognitive activity at a No school. time. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. http://www.chop.edu/service/concussion-care-for-kids/returning-to- school.html 27 28 How Much Cognitive Rest Post Concussion? Symptom Resolution after Sport Concussion • 50% recovered and returned to play in 1 week; 90% in 3 88 patients (11-22 y/o) seen at pediatric ED randomized weeks (Collins et al. Neurosurgery, 2006.) • Strict rest x 5 days vs. “usual care” of 1-2 days rest, • 7-10 days avg. symptom resolution . then stepwise return to activity (3rd International Conference on Concussion in Sport (2008). Clin J Sport Med, 2009.) • Strict rest = no school, work, or physical activity • High schoolers take longer to recover based on –Neurocognitive and balance outcomes same neuropsychological testing compared to college athletes . – Strict rest group had more daily post concussive (Field et al, J Pediatr, 2003.) symptoms and slower symptom resolution Thomas DG et al. Pediatrics. 2015 Slide courtesy of Cindy Chang MD 7

29 30 Assuming she remains asymptomatic, Case 3 when would you clear her to return to full contact soccer games? 16 y/o high school student presents to your office A. Today (Monday) Monday morning with concussion sustained playing soccer 3 days ago (Friday). She initially B. Tomorrow (Tuesday) had headache, dizziness, and fogginess, but those C. In 2 days (Thursday) symptoms resolved yesterday. She is now D. 1 week post injury (Saturday) asymptomatic with a normal neurologic exam. She has no deficits on balance testing. She has no E. 2 weeks post injury deficits on memory testing. 31 32 Concussion Legislation Concussion legislation • 50 states have adopted youth concussion laws • California Assembly Bill 2127 (in effect 1/2015) • California: education code 49475 (effective 1/2012) •Adds to AB 25 1. Athletes and guardians sign a concussion –FB full-contact practice limits: information form yearly –No more than 2/week during preseason and season 2. Athlete suspected of having concussion removed –These practices cannot exceed 90 minutes at time of injury for the rest of the day –No full-contact in off-season 3. Athlete can return only after cleared by healthcare – Once clear must follow gradual return to play protocol professional trained in evaluation and of at least 7 days under supervision of licensed management of concussion provider 8