Evaluation and Management of Concussion

1. Evaluation and Management of Concussion C. S. Nasin, MD Team Physician University of Rhode Island

2. Evaluation

5. “Its just a ding….right?” •43 High School football players with grade I AAN concussions •All cleared within 15 minutes • Is it safe to return to the competition? Lovell MR et al. American Journal of Sports Medicine, Vol. 32, 2004.

6. “It’s just a ding…right?”

8. Physical Exam…in the office History: particular attention to Risk Factors (Prior concussions, ADD, migraines, learning disabilities, and co-morbid mental illness)

9. Office Physical Examination HEENT: pupils, fundoscopic exam Neck: C-spine tenderness Neurologic: Cranial nerves, Motor, DTRs, Rhomberg *Mental Status exam: 3 word recall, Serial 7’s, “WORLD” backwards

10. Physical Examination, continued Dysfunction of Visual Accommodation/Convergence •Visual Accommodation: changes optical power to maintain a clear image (focus) NPA (Near point of accommodation) “Push up test” use relatively small letters (0.4M or 0.5M) to help better control accommodation. Slowly move these letters closer to the eye until they become blurry. Measure the distance the letters became blurry. This is the near point of accommodation. Increased with dysfunction and age. Children have NPA of approximately 7cm from the bridge of the nose. •NPC (Near point of convergence)- as above. Note when patients lose ability maintain binocular vision. Up to 10cm.

11. Physical Examination, continued… • Posturography • Although the somatosensory aspects of balance remain intact, the integration between the visual and vestibular components show dysfuntion after mTBI. • Balance Error Scoring System (BESS) testing • Neurocom Sensory Organization test (SOT)

12. “To CT or not to CT…That is the question…” Certainly indicated if: • Focal neurological exam • Progressive symptoms

13. CT Head Algorithms Sensitivity 100% Specificity 51% Sensitivity 100% Specificity 13%

14. Neuropsychological Testing Used to provide a sensitive index of higher brain functioning by measuring: • Memory • Attention • Executive function • Speed and flexibility of cognitive processing

15. Neuropsychiatric Testing

16. Computer Based Neurocognitive Testing • Offers some advantages to traditional paper and pencil testing • Allows for evaluation of large numbers with minimal manpower • Data is easily stored • More accurate measurement of certain cognitive processes (reaction time/processing speed) • Randomization of test stimuli reduces “practice effects” • Provides a concise clinical report

17. Computer Based Neuropsychiatric Testing…Disadvantages • Has never been validated for use with concussed athletes • Is a SCREENING tool, does not replace formal neuropsychiatric testing and evaluation • Normal score≠ No concussion • Normal score ≠ Return to play • Does not replace clinical evaluation • Simply a “piece of the puzzle”

18. Treatment

19. REST!!

20. Physical Rest • Not only limited to contact sport activity • •No heavy exertion • •No resistance training

21. Cognitive Rest A major challenge in a college setting! •Education of the college community •Communication with Disability Services and the Dean’s office.

22. Pharmacologic Treatment

23. Medical Treatment Neuropsychiatric •Emotional • Depressed • Nervous/Irritable Cognitive •Inattention • Memory deficits • Fatigue •“Fogginess” Physical •Headache • Visual • Dizziness • Noise/Light Sensitivity • Nausea Sleep Disturbance Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010

24. Medical Treatment Neuropsychiatric SSRIs, Therapy Physical Migraine Prophylaxis -TCAs, β-blockers, CCB, SSRIs Vestibular Therapy Cognitive Stimulants -Ritalin*, Strattera* -Amantadine* Sleep Disturbance Melantonin, Trazadone * Off label use Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010

25. Medical Treatment Neuropsychiatric SSRIs, Therapy Physical Migraine Prophylaxis -TCAs, β-blockers, CCB, SSRIs Vestibular Therapy Cognitive Stimulants -Ritalin, Strattera* -Amantadine* Sleep Disturbance Melantonin, Trazadone * Off label use TCA (i.e. Elavil) Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010

26. Graded Return to Play Complete Rest Until Asymptomatic Light Aerobic Exercise Sports Specific Exercise/Resistance Training Non-Contact Training Drills Contact Training (after medical clearance) GAME DAY

27. Future Directions • Structural MRI modalities (including gradient echo, perfusion, and diffusion weighted images) • PET scan/fMRI • Genetic testing: ApoE4 • Electrophysiological studies (Evoked Response Potentials/EEG) • Biochemical markers of brain injury (S-100b, NSE, MBP, GFAP)

28. Summary • Concussion (MTBI) is a common ailment that you will see in your practice! • A graded return to play is now recommended “When in doubt, sit them out!”

30. References McCrory P et al. Concussion Statement on Concussion in Sport 3rd International Consensus on Concussion in Sport Held in Zurich, November 2008. Cl J of Sports Med Vol 19, #3 May 2009. Lovell M et al. The Management of Sports-Related Concussion: Current Status and Future Trends. 2009. 28 (1). Lovell M et al. Grade 1 or “Ding” Concussion in High School Athletes. AJSM. Vol 32 2004 Lovell M et al. Neuropsychological assessment of the college football player. J Head Trauma Rehab 1998; 13:9-26. Lovell M et al. Return to play following sports-related concussion. Clinics in Sports Medicine. 23 (2004) 421-441. Hunt T, Asplund C. Concussion Assessment and Management. Clin. Sports Med 2010 Jan;29 (1) 5-17. Green W et al. Accomodation in mild traumatic brain injury. JRRD, 47(3), 2010. Grindel SH et al. The Assessment of Sports-Related Concussion: The Evidence Behind Neuropsychological Testing and Management. Clin J of Sports Med 11: 134-143, 2001. Stiell HG et al. Comparison of the Canadian Head rules and New Orleans Criteria in patients with minor head injury. JAMA, Sep 2005; 294(12). Collins M. ImPACT Training Workshop. Providence, RI. 2010.