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Assessment of Concussion from the Sideline to Your Clinic

Assessment of Concussion from the Sideline to Your Clinic. Eugene Hwang, M.D., M.S. June 10, 2010 Family Medicine, Emory University School of Medicine, PGY-3 Sports Medicine, University of Nevada Las Vegas, PGY-4 Fellow. Ahhhh… memories… or lack there of…. Definition.

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Assessment of Concussion from the Sideline to Your Clinic

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  1. Assessment of Concussion from the Sideline to Your Clinic Eugene Hwang, M.D., M.S. June 10, 2010 Family Medicine, Emory University School of Medicine, PGY-3 Sports Medicine, University of Nevada Las Vegas, PGY-4 Fellow

  2. Ahhhh… memories… or lack there of…

  3. Definition • Mild traumatic brain injury (mTBI) • Abrupt acceleration/deceleration of the brain  transient loss of brain function  physical, cognitive, or emotional signs/symptoms • < 10 % concussions involve LOC • 300,000 concussions/year • 3% to 9% of high school and college football injuries involve concussions

  4. Pathophysiology • Linear/rotational forces of acceleration and deceleration on or within the brain • Microscopic level: • neuron depolarization • ion regulation • membrane channels • axon integrity • glucose metabolism • cell membrane stability • production of oxidative free radicals • Rare to see skull fractures, cerebral edema, intracranial bleeds, and epidural/subdural hematomas

  5. Cantu Classification Guidelines, 1986 Grade 1: No loss of consciousness, Post-traumatic amnesia for fewer than 30 minutes Grade 2: Loss of consciousness for fewer than 5 minutes ORPost-traumatic amnesia for more than 30 minutes Grade 3: Loss of consciousness for more than 5 minutes OR Post-traumatic amnesia for more than 24 hours

  6. Colorado Medical Society Guidelines, 1991 Grade 1: No loss of consciousness, No post-traumatic amnesia, Confusion Grade 2: No loss of consciousness, Post-traumatic amnesia, Confusion Grade 3: Loss of consciousness of any duration

  7. American Academy of Neurology Guidelines, 1997 Grade 1: No loss of consciousness, Concussion symptoms for fewer than 15 minutes Grade 2: No loss of consciousness, Concussion symptoms for more than 15 minutes Grade 3: Loss of consciousness of any duration

  8. Classification of Concussion According to the Zurich Conference in 2008: • Concussion grading scales should no longer be used • Terms “simple” and “complex”no longer used • Concussion now considered as a single entity that can be affected by various modifying factors

  9. Definition (Consensus Statement on Concussion in Sport: 3rd International Conference on Concussion in Sport, Zurich, November 2008) • Caused by direct blow to head, face, neck, or elsewhere on the body with an “impulsive” force to the head • Results in rapid onset of short-lived neurological impairment that resolves spontaneously • May result in neuropathological changes, but acute clinical symptoms reflect functional disturbance rather than structural injury • Results in graded set of symptoms that may or may not involve loss of consciousness. Resolution of symptoms typically follows sequential course • No abnormality is seen on standard neuroimaging

  10. Concussion Assessment • Assessment of acute concussion is multifactorial • Assess signs, symptoms, behavior, and abnormal brain function • Test memory • What team are we playing? • Who scored last? • Test cognitive functioning • Word recall (cat, pen) • Digit recall (say 4-2-5 backwards) • Months in order (recall months in backward order) • Neurological exam is paramount • Speech, eye motion, pupils, pronator drift, balance testing • Presence of one or more of these factors indicate high probability of concussion and should necessitate removal from field • Sport Concussion Assessment Tool (SCAT) • Quick standardized tool for concussion assessment

  11. Sideline evaluation • (1.) ABC’s • (2.) Exclude cervical spine injury • (3.) Evaluate concussion, use standardized tools (i.e. SCAT) if available • (4.) Do not leave the player alone • Serial monitoring for initial few hours following injury to observe for deterioration • (5.) Player not allowed to return to field on day of injury • Exception: certain elite adult athletes

  12. ED/Clinic Setting • Do a complete H+P • Do a comprehensive neurological exam • Monitor for worsening signs/symptoms • Obtain additional info from other sources (parents, coaches, trainers, etc.) • Emergent neuroimaging only if there is concern for severe brain injury or abnormality

  13. Neuroimaging • CT • Study of choice • Greater accessibility • Good for intracranial hemorrhage, contusion, or herniation • MRI • More sensitive and specific than CT in identifying small cerebral contusions, edema, and small non-hemorrhagic lesions • Prohibited by: cost, availability, claustrophobia, metal hardware in body • Other imaging studies • Functional MRI (f MRI) • Diffusion tensor imaging (DTI) • Positron Emission Tomography (PET) • Single Photon Emission Computerized Tomography (SPECT) • Near Infrared Spectroscopy (NIRS)

  14. Concussion Management • Patience is key! • Physical AND cognitive rest until symptoms resolve. • When symptomatic, restrict/prohibit physical activity and activities involving attention and concentration. • Emphasize delay in recovery if athlete resumes these activities too soon. • Do not overlook depression, anxiety, or mood disturbances. • Recovery should be based on the individual, NOT tables or guidelines. • Several factors will modify concussion management (Table 2).

  15. Concussion Modifiers TABLE 2. Concussion Modifiers Factors:Modifier: Symptoms Number Duration (>10 days) Severity Signs Prolonged LOC (>1 min), amnesia Sequelae Concussive convulsions Temporal Frequency - repeated concussions over time Timing - injuries close together in time ‘‘Recency’’ - recent concussion or TBI Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

  16. Concussion Modifiers (Table 2, Continued) Factors:Modifier: Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Age Child and adolescent (< 18 years old) Co- and Pre-morbidities Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Psychoactive drugs, anticoagulants Behaviour Dangerous style of play Sport High-risk activity, contact and collision sport, high sporting level

  17. Cantu Concussion Guidelines, Return to Play Management based on first concussion: Grade 1: Athlete may return to play if asymptomatic for one week (if athlete is totally asymptomatic, return to play on same day may be considered). Grade 2: Athlete may return to play if asymptomatic for one week. Grade 3: Athlete may not return to play for at least one month; athlete may then return to play if asymptomatic for one week.

  18. Colorado Medical Society Guidelines, Return to Play Management based on first concussion: Grade 1: Athlete may return to play if asymptomatic for 20 minutes. Grade 2: Athlete may return to play if asymptomatic for one week. Grade 3: Athlete should be transported to a hospital emergency department; athlete may return to play one month after injury if asymptomatic for two weeks.

  19. American Academy of Neurology Guidelines, Return to Play Management based on first concussion: Grade 1: Athlete may return to play if asymptomatic for 15 minutes. Grade 2: Athlete may return to play if asymptomatic for one week. Grade 3: Athlete should be transported to a hospital emergency department; if athlete had brief loss of consciousness (i.e., seconds), may return to play when asymptomatic for one week; if athlete had prolonged loss of consciousness (i.e., minutes), may return to play when asymptomatic for two weeks.

  20. Graduated Return to Play Protocol • Step-wise process • Each step = 24 hours • Progress to next stepif asymptomatic for at least 24 hoursat that current level • If symptomatic, rest for 24 hours, then drop athlete down to previous asymptomatic step and try to progress again

  21. Graduated Return to Play Protocol • TABLE 1. Graduated Return to Play Protocol • Rehabilitation StageFunctional Exercise at Each Stage of RehabilitationObjective of Each Stage • No activity Complete physical and cognitive rest Recovery • 2. Light aerobic exercise Walking, swimming or stationary cycling keeping Increase HR • intensity, <70% MPHR; no resistance training • 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; Add movement • no head impact activities • 4. Non-contact training drills Progression to more complex training drills, eg, Exercise, coordination, and cognitive passing drills in football and ice hockey; may load • start progressive resistance training • Full contact practice Following medical clearance, participate in normal Restore confidence and assess training activities functional skills by coaching staff • Return to play Normal game play

  22. Pharmacology • Helps to manage symptoms including anxiety, depression, insomnia, and headache • Acute anxiety  BZD’s • Depression  SSRI’s • Insomnia  BZD’s, TCA’s • Cognitive slowing/Fatigue  psychostimulants (i.e. Provigil), dopaminergic agents (i.e. Levodopa) • Mania/Psychosis  typical/atypical antipsychotics (i.e. Risperdal) • Prior to returning to play, athlete needs to be symptom-free and off these medications (except for antidepressants) • Initiation of these medications need close monitoring

  23. Neuropsychological Testing • Provides a way to assess information relating to neurological deficits suffered post-concussion when compared to baseline neurological function • Adjunct to clinical decision making process • Expense ($750-$4,000) and time factor (30 min to 3 hours) limits widespread use • Trained neuropsychologists are needed to assess findings • Examples: • Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) • Balance Error Scoring System (BESS) • Automated Neuropsychological Assessment Metrics (ANAM)

  24. Genetics • Current investigations ongoing to evaluate the association of genotypes, alleles, and genetic biomarkers to concussions • S100B • predicts long-term disability from a head injury • Apo E4 • risk factor for Alzheimer’s • G-219T polymorphism of ApoE promoter • increased risk for Alzheimer’s and unfavorable post-concussive outcomes • Tau mutation on Chromosome 17 • frontotemporal dementia

  25. Pediatric Athlete • Not a “little” adult! • Growth and development make concussion assessment and management very difficult • Less neck and shoulder musculature  less capable of transferring kinetic energy at the head throughout the body • Neurological development at risk • Ability to focus • Sustain attention • Memory recall • Rapid information processing

  26. Pediatric Athlete • No set timetable for recovery • Need to be conservative on return to play protocol • Consider extending out time of one or more steps • Emphasize cognitive rest and longer recovery period • Studies still limited in terms of the pediatric population

  27. Repeated Concussive Injury http://espn.go.com/video/clip?categoryid=3060647&id=5163151

  28. Repeated Concussive Injury • Concern for Second Impact Syndrome (SIS) • Athlete sustains head injury while still symptomatic from a previous head injury • Second head injury leads to metabolic disruption and loss of autoregulation of cerebral blood supply • Results in cerebral vascular engorgement, cerebral edema/swelling, increased intracranial pressure, cerebral/brainstem herniation, and ultimately, coma and death • Rare, but is of great concern in pediatric population due to immaturity of the brain • Contact sports (i.e. football, hockey) increase risk of SIS

  29. Ongoing research… • Pediatric population • Genetic/biomarker testing • Second Impact Syndrome • Male vs. female athlete • Protective equipment (i.e. helmets, mouthgards)

  30. Take Home Points • In terms of concussions, treat each athlete or patient as an individual • Be thorough in the initial evaluation and subsequent follow-up • Neuroimaging valid when suspicious for serious brain injury, otherwise no imaging needed • Be conservative on return to play • Be even more conservative with pediatric athletes

  31. The End

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