8/10/2016 � Disclosures ESSENTIALS OF PRIMARY CARE: A Core Curriculum for Ambulatory Practice August 7-12, 2016 I have nothing to disclose Concussion in the Athlete: Current Status and Future Directions Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine Case Objective An 18 year old female soccer goalie comes into your office � today for follow up of a wrist injury and also mentions that… Develop strategies to care for common office � A soccer ball hit her in the head during high school practice problems including sport-related concussions � yesterday. She initially felt dizzy and foggy, but that cleared after 5 minutes, so she continued running drills. She felt unusually tired and took a nap after practice. When she awoke, she had a headache, which worsened as � she tried to study that evening. In three days, she is playing against their high school rival. � She denies having a headache today and school was “fine.” Her HS soccer coach wants a letter for her wrist saying she � is cleared to play. Her coach doesn’t know about her headache. 1 �
8/10/2016 � Which of the following is an Sometimes it’s not easy… accurate statement? A. Since she is 18 and an adult, she � Concussion is defined as a doesn’t need a clearance letter traumatically induced transient B. She currently doesn’t have symptoms so disturbance of brain function and can play in the upcoming game involves a complex pathophysiological C. She needs to undergo a mandatory RTP 65% protocol of no < 7 d from today process. D. She needs to undergo a 5 day RTP � Concussion is a subset of mild protocol starting from yesterday traumatic brain injury (MTBI) which is 29% E. I am confused! (even if you are, don’t generally self-limited and at the less- pick E!) severe end of the brain injury 2% 2% 1% spectrum. . . . . . . u . . . . a . . . y d h a a a f t o o i n ’ n n g g a r r e s e e v d e e n o d d n n ( a d ! u u d 8 y l o o e 1 t s n t t s s s u i e d d f e r n r e e o h u e e s c c n n e e m e e c h h h a n S i S S I S What is a concussion? What is a concussion? Three Conditions Three Conditions 1. Biomechanical 2. Rapid Acceleration Force and Deceleration � Caused by a bump, causing brain to blow, or jolt to the move violently head inside of skull � The head does not have to be directly hit for the brain to injured � Whiplash � Blast injuries 2 �
8/10/2016 � Visualizing a Concussion Visualizing a Concussion • AND/OR a � The brain is the concussion can be consistency of caused by custard or Jell-O rotational forces, � A concussion can which twist the occur due to linear brain forces where the brain slams into • Most concussions the rough interior are caused by a of the skull combination of both forces What is a concussion? Three Conditions 3. Causes a temporary disruption of normal neurological functioning � Disruption in functioning = physical and cognitive symptoms 3 �
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8/10/2016 � Just because you don’t have “Window of Vulnerability” these, doesn’t mean you are ok • The period between the concussion and recovery • Return-to-play during this time could cause more severe or even catastrophic brain injury • May be unsafe to return to competition until brain activity has returned to normal • In rats, that time period averages ~10 days � Giza and Hovda, JAT 2001 Concussion Symptoms Brain Changes = Signs and Symptoms Physical • Headache • Fuzzy or blurry vision • Nausea or vomiting Sleep (early on) • Sleeping more than • Dizziness usual • Sensitivity to noise or light • Trouble falling • Balance problems asleep • Feeling tired, having no • Sleep less than energy usual 5 �
8/10/2016 � Just because you don’t have symptoms Brain Changes = Signs and Symptoms right away, doesn’t mean you are ok Cognitive • Evolving injury • Difficulty thinking clearly/Foggy • Some sx present immediately • Dazed or feeling “out of it” • Some sx are delayed • Feeling slowed down • Some pts will not display any signs or • Difficulty concentrating symptoms initially, but sx may appear • Difficulty remembering new information within minutes or hours • Serial assessments are key Emotional/Mood • Don’t underestimate adrenaline or an • Irritability athlete’s ability to rationalize symptoms as • Nervousness or anxiety something else, like a cold or sinus HA • Sadness • More emotional • Even athletes who said they had ‘recovered’ within minutes of a concussion still showed abnormalities on cognitive tests 36 hours later • Evidence that no youth athlete “recovers” on the same day of injury � AJSM 2004 � Collins et. al., Neurosurgery 2006 6 �
8/10/2016 � California State Laws � AB 25, Concussion Law 2012 Remember: � 3 parts (education, remove from play, written medical note to return) � AB 1451, Coaches Concussion Training Law 2013 Return to Learn � Mandatory education every 2 years (or work) � AB 2127, Concussion Safety Law 2015 � Limit FB full-contact practices BEFORE � Mandatory RTP protocol of no less than 7 days Return to Play from the diagnosed date of concussion � RTP under the supervision of LHCP Return to Learn What about strict rest after an acute concussion? � The Hidden Injury � Teacher doubt, anger at extra work � 88 patients (11-22 yoa) seen at pediatric � Coach doubt, anger at lack of toughness ED randomized � Balance being at school vs. home � Strict rest x 5 days vs. “usual care” of 1-2 days � Socialization component of recovery rest, then stepwise return to activity � Increasing anxiety at falling behind in school � Neurocognitive and balance outcomes � Loss of identity as an athlete same � Cognitive rest � Strict rest group had more daily post � Benefit vs. harm re: prolongation of symptoms or concussive symptoms and slower ultimate outcome symptoms resolution � Will restrictions create more emotional stress? � Halstead et al, Pediatrics 2013 � Thomas et al, Pediatrics 2015 7 �
8/10/2016 � What can improve recovery in our patients with concussion? � If the child is evaluated within one week of injury by a concussion specialist • 16d vs. 36d (p < 0.001) � Let’s educate and build a larger network of trained knowledgeable providers � If the child reported a headache on the field at time of injury • 23d vs. 33d (p < 0.001) � Let’s educate more of our children—and their teammates and coaches-- about the various signs and symptoms of concussions � Bock et al Childs Nerv Syst 2015 Goals of Concussion Care in Primary Care Evaluation Primary Care Setting Diagnostic Interview 8 �
8/10/2016 � Acute Management Acute Management � Once symptoms are manageable, allow for � Brain is in acute slow introduction of mental, physical, and energy/metabolic social activities crisis � Generally 3-7 days post injury � 2-5 Day Window of “Aggressive � Asymptomatic status is NOT necessary to Rest” begin gradual return to activities � Cocoon therapy not necessary and likely harmful Acute Management Acute Management Return to Learn – “Concussion Care Plan” � After initial rest period, important to slowly increase physical activity � Start with low exertion activities (e.g. walking) � Slowly increase exertion as symptoms start to subside 9 �
8/10/2016 � Acute Management Acute Management Return to Play – “Concussion Care Plan” � Return to Play – “Concussion Care Plan” Asymptomatic at rest and exertion 1. Normal physical/neurological 2. Game examination play Normal cognitive function 3. Sport Light specific aerobic Medically cleared for a graduated return activity activity to play Which is not a risk factor Acute Management associated with a delayed recovery? Return to Play – “Concussion Care Plan” A. Having ADHD B. Female sex 54% C. Hx of migraine HA D. Hx of sleep disorders E. Retrograde amnesia 27% 9% 5% 5% x D A s a e r H s H e s i D e d e e r n A a l n o m g m a i s n i a e r d i F g e v i p a m d H e a e r f g o s l o x f r H o t x e R H 10 �
8/10/2016 � Chronic/Slow to Recover Chronic/Slow to Recover Management Management • Post Injury Psychological Factors � Evaluate Risk Factors Associated With • Depression, anxiety and neuroticism better Delayed Recovery predictors of postconcussive symptoms than cognitive impairments • Concussion may be precipitating event leading to anxiety disorder (diathesis) • Increasing awareness of somatic non-concussion symptoms are misattributed (hypersensitivity) • History of psychiatric diagnosis is risk factor for prolonged recovery Chronic/Slow to Recover Post Concussion Management Management When to consider referral � Suboptimal Effort � Learned helplessness. Not even going to try due to perceived difficulty of task � Secondary Gain � Concussion symptoms are very non-specific and therefore is a socially acceptable way of manifesting psych-related symptoms � Malingering � Outright fraud for monetary or material benefit 11 �
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