What to Tell Parents Justin M. Wright, MD Program Director, Sports - PowerPoint PPT Presentation

Concussion Management and What to Tell Parents Justin M. Wright, MD Program Director, Sports Medicine Fellowship Program Director, Family Medicine Residency Associate Professor, Department of Family and Community Medicine Paul L Foster School of Medicine

Objectives • Define a concussion • Define the pathophysiology of a concussion • Describe the evaluation of a patient with a suspected concussion • Describe the treatment of a patient with a concussion • Describe the return-to-play protocol for a concussion

What is a Concussion?

What about this?

What is a concussion? Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. 2017 Berlin Guidelines

Why do we care?

11 ‘R’s of Concussion Management • Recognize • Recover • Remove • Return to Sport • Re-evaluate • Reconsider • Rest • Residual effects and sequelae • Rehabilitation • Risk Reduction • Refer

Recognize

Definition – Berlin 2017 • Direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive” force transmitted to the head. • Rapid onset of short-lived impairment of neurological function that resolves spontaneously. • Functional disturbance rather than a structural injury • Graded set of clinical symptoms that may or may not involve loss of consciousness.

Pathophysiology Impact force to head, neck, or body Hyperglycolysis/Depletion of energy stores Disruption of neuronal cell membranes Accumulation of lactic acid Widespread depolarization/Neurotransmitter release Calcium influx into mitochondria Large efflux of potassium Impaired oxidative phosphorylation Increased activation of Na + /K + ATP- dependent pumps Decreased ATP production Initiation of apoptosis

Leddy , et al . Sports Health. Mar 2012;4(2):147-154.

Assessment • Symptoms – Somatic • Headache • Dizziness – Cognitive • “In a fog” – Emotional • Lability

Assessment • Physical signs – LOC – Amnesia • Behavioral change – Irritability • Cognitive impairment – Confusion – Slowed reaction time • Sleep disturbance – Insomnia – (Later finding)

Remove

Sideline Evaluation • Evaluate for c-spine injury What venue are we at today? • Remove player from participation – Keep piece of equipment to Which half is it now? prevent re-entry Who scored last in this match? • Use SCAT 5 or other sideline tool What team did you play last – Maddock’s questions – Person/place/time unreliable week / game? • Serial monitoring of athlete Did your team win the last – Appearance of signs/symptoms game? may be delayed several hours • No same-day return to play

SCAT 5

Re-evaluate

Further Care • Evaluation in ER or physician’s office • (Natasha’s Law – H.B. 2038) – Detailed neurologic exam • Cranial nerves • Cerebellar function – Mental status • Answers questions appropriately

Examination • Cranial nerves – Focal findings may indicate discrete lesion • Pupils – May be sluggish • Cognitive function – Serial 7s • Balance – Romberg – Tandem gait – Balance Error Scoring System (BESS)

BESS Test • 3 different stances for 20 seconds each with eyes closed • Watch for errors indicating loss of balance • Errors – Hands lifting off the iliac crests – Eyes opening – Stepping, stumbling, or falling – Moving the hip into more the 30 degrees of flexion or Guskiewicz KM. Clin Sports Med. Jan 2011;30(1):89-102 abduction – Lifting the forefoot or heel – Remaining out of the testing position for more than 5 seconds

Imaging? • Typically normal in concussion – Functional injury • Indicated for: – Focal neurologic deficits – Prolonged cognitive disturbance – Worsening symptoms

Neuropsychological Testing The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and contributes significant information in concussion evaluation -Berlin 2017 Guidelines

Rest

Management • Rest – Previous recommendations • No activity until asymptomatic – (yes, this also means school) • Previously based on consensus opinion

What’s the Evidence? • Griesbach, et al , 2004 – Rat Model – Sham vs. fluid percussion injury – Caged with or without access to a running wheel • Either 0-6 days post-injury (acute) or 14-20 days post-injury (delayed) – Measured brain-derived neurotrophic factor, proteins in synaptic function, and performance on Morris water maze – ***Immediate exercise after injury led to negative results on all testing • Delayed exercise similar to sham controls Neuroscience. 2004;125(1):129-139 .

What’s the Evidence? • Gibson, et al, 2013 – Chart review of 184 patients, 135 with complete records • Recovery defined as symptom-free at rest and exertion, without medication; computerized neurocognitive test scores at or above baseline or normative values; and balance at baseline – Cognitive rest recommended to 85 patients – ***No association observed between the recommendation for cognitive rest and the duration of symptoms – Limitations • Tertiary concussion center – cannot generalize • Retrospective • No documentation of compliance to rest • More severe concussions more likely to be told to rest?

What’s the Evidence? • Majerske, et al , 2008 – Chart review of 86 athletes – Outcome measure – Postconcussion symptom scores and neurocognitive scores (ImPACT) – Activity Intensity Scale • 0 – no school or exercise activity • 1 – school activity only • 2 – school activity and light activity at home • 3 – school activity and sports practice • 4 – school activity and J Athl Train. 2008;43(3):265-274. participation in a sports game – ***Moderate intensity activity performed better

What’s the Evidence? • Moser, et al , 2012 – Chart review of 49 athletes evaluated for concussion • Stratified based on time of presentation (1-7d, 8-30d, 30+d) • Prescribed at least one week of rest (28 athletes required additional rest) • Outcomes measured by ImPACT testing and symptoms scores – Significant effect of prescribed rest with no effect of time elapsed since concussion noted • Improvement in cognitive function and symptom score – Retrospective, no control group J Pediatr. 2012;161(5):922-926.

What’s the Evidence? • Brown, et al , 2014 – Prospective cohort • 335 patients evaluated within first 3 weeks of injury – Patients completed cognitive activity scale at each visit • Cognitive activity-days – average cognitive activity level multiplied by days between visits – Primary outcome – duration of post-concussion symptoms – ***Patients in highest quartile of cognitive activity-days took statistically longer to recover than those in first to third quartiles

What’s the Evidence? • Thomas, et al, 2015 – Patients from pediatric ED within 24 hours of concussion – 88 patients randomized to 2 groups • Usual care (1-2 days rest, then return to school and activity in stepwise fashion) • 5 days strict rest (no school, work, or physical activity) – Activity assessed by activity diaries – Outcome measures – symptom survey, neurocognitive assessment, and balance assessment – Results • ***Strict rest group reported more daily postconcussive symptoms and slower symptom resolution than usual care group – No difference in balance or neurocognitive outcomes – Limitations/Caveats • No true control group • Acute care setting • Discharge instructions may influence perception of illness • Use of diaries to quantify activity levels – recall bias

What’s the Evidence ? • Thomas, et al, 2015 – Results • ***Strict rest group reported more daily postconcussive symptoms and slower symptom resolution than usual care group • No difference in balance or neurocognitive outcomes – Limitations/Caveats • No true control group • Acute care setting • Discharge instructions may influence perception of illness • Use of diaries to quantify activity levels – recall bias

What’s the Evidence? • Buckley, et al, 2015 – 50 consecutive collegiate athletes with concussion • 25 before and 25 after protocol change – Mandating 1 rest day from physical and cognitive activities – Same return to play protocol – Evaluated on graded symptom score, SAC, BESS, ImPACT, and time to clinical recovery • Clinical recovery – time until all tests were at baseline and athlete started RTP protocol – ***No-rest group achieved asymptomatic status 1.3 days faster than rest group (P=.047) • No difference in return to baseline on SAC, BESS, ImPACT, or time to clinical recovery between the two groups

New rest recommendations • Typically 24-48 hours, then gradually increase activity – Symptom-limited • Avoid vigorous exertion

Rehabilitation

Rehabilitation • Concussion can result in diverse symptoms and problems – May have concurrent cervical spine and peripheral vestibular system involvement • Cervical spine, vestibular, and psychological interventions have all been shown to be effective