Concussion Presentation, Management, and Prevention

1. ConcussionPresentation, Management, and Prevention Matt Bayes, MD Primary Care Sports Medicine The Sports Medicine Institute The Orthopedic Center of St. Louis

3. What is a concussion? • -A brain injury • -Caused by a bump or blow to the head or body, even if mild • -May result from a fall or from players colliding with each other or with obstacles • -Changes the way the brain normally works • -Causes a complex neurometabolic cascade that causes neuronal dysfunction • -No gross structural injury • -The brain comes to a sudden stop

5. What is a concussion? • Can’t see it • May be referred to as • “Ding” • “Bell rung” • Signs and symptoms • may be noticed • -Right after the injury • -Days or weeks later

6. What is a concussion? • -Can occur withoutloss of consciousness • -Can occur in any sport, during games or practices, or during unorganized activity

7. Statistics • -Up to 3.8 million sports- and recreation-related concussions per year • -1/10 of sports-related injuries require hospitalization • -20% of high school and 40% of college football players will sustain a head injury • -2 to 4 times greater risk of recurrence

8. High Risk Sports • Football/Rugby • Gymnastics • Hockey • Wrestling • Lacrosse • Equestrian Sports • Martial Arts/Boxing

10. -Appears dazed or stunned -Is confused about assignment or position -Forgets an instruction -Is unsure of game, score, opponent -Moves clumsily Signs of a Concussion

11. -Answers questions slowly -Loses consciousness -Shows behavior or personality changes -Can’t recall events prior to hit or fall -Can’t recall events after hit or fall Signs of a Concussion

12. -Headache or “pressure” in head -Nausea or vomiting -Balance problems or dizziness -Double or blurry vision -Sensitivity to light -Sensitivity to noise -Feeling sluggish, hazy, foggy, or groggy -Concentration or memory problems -Confusion -Does not “feel right” Symptoms Reported by Athlete

13. Symptom Explanations • “I’ve gone from HD to standard • definition” • “I feel like I’m underwater” • “I feel one step behind the rest of the • world”

14. What should you do when you suspect a concussion? • Keep the athlete out of play • -“When in doubt, take them out” • -Should never return while symptomatic • -Concussions take time to heal • -Returning too early increases the risk of a second concussion

15. What should you do when you suspect a concussion?Seek medical attention right away • Coaches and parents should not judge the severity of the injury themselves • A professional experienced in evaluating concussion should guide return to play

16. Important Informationfor the Physician • -Cause of injury and force of the hit or blow to the head • -Any loss of consciousness • -Any memory loss immediately following the injury • -Any seizures immediately following the injury • -Number of previous concussions

17. What should you do when you suspect a concussion? • Open lines of • Communication • -Athletes should tell parents and coaches • -OK to tattle on teammates • -Parents should be advised to have child seen by a physician • -Coaches should be told if a child has had a recent concussion in any sport

18. What should you do when you suspect a concussion? • Allow the athlete to return only with permission from a health care professional with experience in evaluating for concussion • Emergency room physicians cannot clear an athlete to return • Dire consequences with early return

19. Neuroimaging • -Typically normal • -Adds little to evaluation • -Use when suspicion of intracerebral • structural lesion

20. Who to scan? • -Worsening symptoms • -Prolonged LOC • -Focal neurologic findings

21. CT Scan • -More useful in the acute setting for significant injury • (Hematoma or hemorrhage ‘brain bleed’) • -Downside: significant radiation exposure

22. MRI • -Abnormal findings may not correlate with neuropsychiatric findings • -More expensive • -No radiation exposure • -Difficult to obtain in the acute setting (ER)

23. Consider MRI for: • -Prolonged post- concussive symptoms • -Marked or persistent neuropsychiatric problems

24. Future Directions • -fMRI shows promise • -Expensive and not widely available

25. Neuropsychologic Testing • -NP testing has given clinicians an additional tool to evaluate head injuries • -Excellent for documenting deficits • -Traditional paper and pencil testing is time-consuming and labor intensive • -Use as a diagnostic tool in sports medicine began in the mid-80’s and has grown steadily

26. Neuropsychologic Testing • -In most cases, cognitive recovery overlaps with the time course of symptom recovery • -Commonly follows symptom resolution • -Suggests that NP testing should be used in RTP protocols

27. Neuropsychologic Testing • -4 computer based models available: ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), CogState, Headminders, and ANAM (Automated Neuropsychological Assessment Metric) • -Available for adolescent through adult ages, ages 5-12 is in the final stages of development

28. Computerized Neuropsychologic Testing • -Take 20 minutes to perform on average • -Best utilization: comparison of post-injury scores to baseline scores to give objective date for cognitive deficits • -Alternative: In the absence of a baseline score there is extensive normative data that allow the comparison of an athlete post-injury to that of his/her peers

30. ImPACT’s technology assesses 8 key neurocognitive domains: • Impulse Control • Sustained Attention • Visuomotor Processing Speed • Visual and Verbal • Memory (immediate/delayed) • Working Memory • Selective Attention • Reaction Time • Response Variability

31. ImPACT • -Comprised of 7 test modules that assess multiple neurocognitive abilities • -Select module scores are combined to yield composite indices: reaction time, verbal memory, visual memory, processing speed, and impulse control • -Symptom self-report inventory is also included: 21 item scale requires the athlete to subjectively rank symptoms from 0 (not present) to 6 (severe symptoms) • -This can be compared to pre-injury symptoms, as well as followed during the recovery period

32. ImPACT • -The test results and subjective symptoms do not always correlate, and both should normalize as the athletes recover • -An athlete must be symptom free and cognitively intact both at rest and following exertional activity before return to play is allowed following a concussion

33. Limitations of ImPACT • -Use by untrained clinicians: not a yes/no • -Reliability has been debated • -Computerized tests have more test-to-test variability than traditional pen and paper test, making them more difficult to detect minor differences • -However, this variability protects against a practice effect

34. Limitations of ImPACT • -Contributing medical problems such as learning disability and ADD/ADHD can make test interpretation difficult, as can certain medications (some epilepsy meds can decrease reaction time as a side effect) • -Practice effect: Repeating a test over a short time interval may lead to artificial score inflation • -Interpretation of post-injury scores to normative data without a baseline can be error prone

35. Limitations of ImPACT • Using normative data without baseline: • -A ‘normal score’ in an individual who would score very high on baseline testing could lead to premature clearance • -Individuals who would score below average at baseline may be inappropriately denied clearance

36. ImPACT: How do I use it? • -Baseline testing is ideal: can be done in large groups in a computer lab or individually • -1st test post-concussion in the early symptomatic period (~48 hours). This is controversial: Does it change management? • -An early abnormal NP test gives objective data to the athlete and his/her parent, justifying their exclusion from school/play • -Low scores can prove a concussion to an athlete that may be minimizing symptoms • -Occasionally helps athletes in their interaction with overzealous coaches • -Repeat the NP test score after the athlete is asymptomatic, requiring ‘normal scores’ and symptom report before they are cleared to play

37. Neuropsychologic Testing: Summary • -Meant to enhance, not supersede, clinical judgment • -Should not be the sole basis for return to play decisions • -Just another tool in the toolbox of concussion management

38. Concussion Management • -Physical and cognitive rest until symptoms resolve • -Graded program of exertion prior to clearance and RTP • -Most concussions resolve within 3-5 days

39. Return to Play • -INDIVIDUALIZED!! • -Proceed to next level only if asymptomatic • -Each step should take 24 hours • -Start when asymptomatic at rest • -If symptoms recur, drop back to last asymptomatic level after a 24 hour period of rest

42. Medication Management • Management of specific prolonged symptoms with aim of shortening the duration • Headache • Concentration • Anxiety/Depression • Sleep disturbances • Athlete must be off medications prior to RTP

43. Pediatric and Adolescent Concussion • -Longer recovery • -May require modifications for cognitive rest • -Limit ALL activities that require concentration and attention • -More cautious RTP

44. Complications • Prolongation of symptoms • -A blow while still symptomatic • -The combined effects may make symptoms more severe and prolonged • -May be permanent and life-altering.

45. Complications • Postconcussive syndrome • Prolonged symptoms: Decreased memory and attention span Decreased mental processing Irritability Fatigue Sleep problems Headaches “Foggy” feeling

46. Complications • Decreased mental function • -Requires testing by neuropsychologist • -Repeated concussions may have a cumulative effect • -May lead to permanent problems

47. Complications • Second impact syndrome • -Brain swelling • -Likely to result in significant brain damage and death • -May be caused by a mild second injury in a symptomatic athlete

48. Follow up care • -Avoid contact activities • -Avoid sedating medications: Narcotics, antihistamines • -May note difficulty with reading, homework, and testing • -Ice, Tylenol, light diet

49. What to watch for after a head injury • -Should not be left alone • -Awaken every 2-3 hours? • -Normal signs in the first 2 days • Fatigue and desire for extra sleep • Headache • Nausea and vomiting • Problems with thinking, concentration, attention span

50. Seek immediate medical attention! • Marked change in personality • Confusion • Irritability • Worsening headache, especially with nausea and vomiting • Numbness, tingling, or weakness in arms or legs, changes in breathing patterns, or seizure • Eye and vision changes • Double vision • Blurred vision • Unequal-sized pupils