active rehabilitation for concussion management · 2018-10-29 · presentation objectives •...

10/29/2018

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Active Rehabilitation for Concussion Management

Hannah Jepson Slaughter, ARNP, PC‐CPNP

Presentation Objectives

• Review of the pathophysiology of a concussion

• Overview of epidemiology, Iowa law, and best practice standards

• Discuss acute post-injury management

• Highlight the importance of immediate evaluation and symptom management

• Review the latest evidence that support active rehabilitation

• Discuss graduated return to learn and return to play protocols

Defining Concussion

Traumatic brain injury (mTBI) induced by biomechanical forces and a pathophysiological process affecting the brain

• Direct or indirect blow to any part of body

• Acute rapid onset of symptoms due to neurologic impairment

• Neuropathological changes that present primarily as functional disturbances

• Absence of structural lesions on traditional neuroimaging

• Range of symptoms that follow a sequential course

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Pathophysiology

• Linear and rotational forces acting on brain

• Sudden stretching of the neuronal and axonal membranes causes mass disruption of ion channels

• Damage can continue over a matter of days

Signoretti, S. et al, 2011

“Energy Crisis”

Post-concussive Brain Vulnerability

Signoretti et al, 2011

Energy CrisisWindow of Vulnerability

Second Impact

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Epidemiology

• 2005‐2009 more than 2 million outpatient visits and almost 3 million ED visits for mTBI in children

• ED visits and hospitalizations for TBI related events have increased

• 82% of youth concussions diagnosed in primary care setting

• 14‐18 year olds represent about half of children dx with concussion

• Younger children and those with medicaid tend to seek initial care in ED.

TBI in Youth

• Most common causes of ED visits for TBI in youth:

• < 10: playground accidents and falls

• 10-19 years boys: football and biking

• 10-19 years girls: soccer and biking

• 15-24: MVC

CDC 2001‐2009

Marar M, et al 2012

Concussion rates among high school athletes by sport, 2008‐2010 school years

Rate of Occurrence

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Haarbauer‐Krupa et al. 2018

Occurrence by Level of Contact

Contact Limited Contact

No Contact Other

Football Cheerleading Swimming Playing

Soccer Baseball Dancing Gym Class

Basketball Volleyball Swinging Playground

Ice Hokey Bike riding Monkey bars Recess

Lacrosse Softball Track Other

Signs and Symptoms

• Acute

– Headache

– Dizziness

– Nausea

– Vomiting

– Dazed/Stunned

– Confused

– Paresthesia

– Amnesia

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• Post acute

– Balance problems

– Visual problems

– Light sensitivity

– Noise sensitivity

– Emotional changes

– Sleep disturbances

– Cognitive changes

Signs and Symptoms

12Rochefort et al., 2017

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Symptom Resolution

• Adults: 10-14 days

• Children (13-18 years): 4-6 weeks

• Generally have favorable outcome

• 70-80% of times symptoms resolve 1-3 months

• 10-30% of time symptoms > 3 months

• Severity of initial symptoms = longer recovery

• Low level symptoms = quicker recovery

• Physiological dysfunction > clinical measures

Post Concussion Goals

• Healthy child

• Successful return to learn (RTL)

• Safe return to play (RTP)

• Prevention of second injury

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Concussion Challenges

• Recognition difficult

• Post injury physical examination typical

• Recovery road individualized

• Comorbid conditions complicate recovery

• Until recently no clinical practice guidelines

• Lack of expertise in clinical setting

• Lack of RTP protocols

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Iowa Code 280.13C HF 2442

• School sports

• Grades 7-12 only

• Distribution of concussion information to families

• Staff annual education about concussions

(IHSAA and IGHSAU websites )

• Immediate removal from play

• No return to play that day

• Written clearance by LHCP

• EMCP added

• Required adoption of RTL and RTP

• Limited liability for schools who follow RTP protocols.

Best Practice

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Best Practice

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Best Practice

www.iashaa.org

Best Practice

Law

• School sports only

• Grades 7‐12 only

• Annual Concussion information to families

• Staff education

• Immediate removal from play

• No return to play that day

• Written clearance by LHCP

• RTL before RTP

Best Practice

• ALL sports

• ALL ages

• Concussion education in school

• Monitoring and no driving

• LHCP evaluation < 24 hrs

• Concussion protocol activated ASAP

• Multidisciplinary

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CDC Clinical Guidelines

• Diagnosis of mTBI

• no CT

• Identify risk factors to warrant CT

• No routine MRI

• No SPECT

• No X‐ray

• Use age appropriate validated symptom scale

• No use of biomarkers

• Counsel 70‐80% of children no symptoms > 1‐3 months

• Counsel individual trajectory of recovery

• Standard assessment tools should not be exclusively used

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• Prognosis of mTBI

• Assess premorbid hx as part of sports physicals

• Counsel risks for delayed recovery

• Screen for known risk factors of persistent symptoms

• May use validated prediction rules to provide prognostics

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• Assessment of mTBI

• A: Use combination of tools to assess recovery of mTBI

• B: Use validated symptoms scales to assess recovery

• C: Cognitive computer testing

• D: Balance testing

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• RTL of mTBI

• Medical and school based teams to help guide increase in academic activities as tolerated

• RTL to based on severity of symptoms

• Consider long term accommodations (504) for prolonged symptoms

• Collaboration to monitor and adjust RTL

• Refer for neurocognitive testing

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• Management of mTBI

• Consider head CT with severe headaches or worsening symptoms

• Nonopoid management

• Rebound headache counseling

• Chronic headaches multifactoral

• Vestibular ocular therapy may be beneficial

• Sleep hygiene

• Identify etiology of cognitive dysfunction

• Multidisciplinary evaluation

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Community Resources

• 2016 Berlin Consensus Guidelines released in 2017

• IDPH Concussion management Guidelines for Iowa Schools

• REAP

• CDC Heads Up

• Brain Injury Alliance of Iowa (BIAI)

• Iowa Concussion Consortium (ICC)

• Local specialty concussion clinics

• Sports Medicine

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So Now What!?

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Continuum of Care

Immediate Care

Acute CareFollow‐up

Care

Injury 0‐72 hours > 72 hours

Immediate Care

1. Cervical spine assessment

2. Red Flags

3. Standardized sideline assessment tool

4. Remove from Play

Immediate Care

1. Cervical spine assessment

• Not lucid or fully conscious a SCI should be assumed until proven otherwise.

• Neck pain at rest?

• If NO pain active ROM of neck?

• Can athlete feel and move arms and legs?

• Parasthesia?

• Loss of bowel and/or bladder control?

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Immediate Care

• Red Flags

• Neck pain at rest

• Double vision

• Weakness or tingling (paresthesia) in arms or legs

• Severe or increasing headache

• Seizure or convulsion

• Loss of consciousness

• Deteriorating conscious state

• Vomiting

• Restless, agitation, or combativeness

Immediate Care

3. Assess for signs and symptoms of a concussion

Symptoms and Severity Concentration

Orientation Neurological

Memory Balance

Acute Care

• Follow up with PCP within 24 hours• Recent CDC practice guidelines for HCP

• Physical examination (typically normal)

• Scat 5 (symptom checklist)

• Pursuits, saccades, convergence

• Education

• Hydration

• Nutrition

• Sleep hygiene

• Activate Return to Learn (RTL)

• Activate Return to Play (RTP)33

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Follow Up Care

• Follow up > 72 hours• PCP, Concussion Clinic if available, sports medicine

physician.

• SCAT5 (symptom checklist)

• Returned to school or work

• Ongoing or new symptoms

• Sleeping

• Exacerbating factors

• Alleviating factors

• Re-evaluation of RTL and RTP protocols

• Medication management34

Referrals

Concussion Clinic/ Sports Medicine Multidisciplinary evaluation

Occupational Therapy Vison concerns

Physical Therapy Balance and coordination concerns

Vestibular Therapy Dizziness, tinnitus

Speech Language Therapy Executive functioning and cognitive

Developmental Optometry Nystagmus, overshooting, convergence

Mental Health Depression , anxiety

Neurology Headaches lasting > 6 months

Massage Therapy Cervical pain

Chiropractor Cervical pain

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ChildServe Concussion Clinic

Physician Services

Therapy Services

Vestibular Ocular

Ocular motor

Balance and Coordination

Physical Conditioning

Education

Accommodations

CommunityMultidisciplinary

Team

Return‐to‐academics

Return‐to‐play/activity

Education

Accommodations

Education

Prevention

Collaboration

Support

Physical Exam

Neuro Exam

SCAT 5

ImPACT

Cognitive

Active Rehabilitation

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Evidence for Early Physical Activity

• Howell et al. (2016)• Participants aged 13-18, higher levels of physical activity

after the injury were associated with a shorter symptom duration

• Grool et al. (2016)• Lower rates of Post Concussive Syndrome of those who

completed early physical activity (within 7 days of injury)

• Buckley e. al. (2016)• Non-rest group of college students achieved asymptomatic

status sooner than the rest group


• Physical Activity Progression

• Light Aerobic activity (walking the dog)

• Impact related aerobic activity (Jogging, running, jumping)

• Head below heart activity (mountain climbers, sit ups)

• Resistance training (weight lifting)

• Sport or activity specific training (strengthening, speed, agility, reaction time)


• Comprehensive Medical History

• Physical Exam

• Balance and Coordination

• Vestibular/Ocular Motor Testing

• Computerized Neurocognitive Testing

• Cognitive Linguistic Assessment

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Balance

Balance Error Scoring System (BESS)

Vestibular/Ocular Motor Testing

- VOR: Associated with the highest percentage of concussed patients reporting symptom provocation (61%)

- Concussed Patients:

• Total symptom score of ≥2

• NPC ≥5 cm

Headache Dizziness Nausea Fogginess

Baseline Symptoms 0‐10 0‐10 0‐10 0‐10

Smooth pursuits

Saccades‐horizontal

Saccades‐vertical

Convergence

VOR‐horizontal

VOR‐vertical

Visual Motion Sensitivity

Mucha, et al 2014

Vestibular Ocular Motor Screen (VOMS)

Vestibular/Ocular Motor Testing

VOMS video

https://www.youtube.com/watch?v=CJF6kJcFGqE

Abbreviated version

https://www.youtube.com/watch?v=LyxcLTSsF_w

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King Devick

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Visual Scanning Testing

King Devick

• Journal of Neurological studies (Rizzo et al.)

• 2016

• King Devick Objective Measures:

– 25 concussed patients compared to 42 controls

– Concussed patients demonstrated

• Significantly longer reading times

• Significantly longer intersaccadic intervals

• Larger deviation of saccade endpoints from

the center of the numbers

• Greater number of saccades

Rizzo, et al 2016

Vestibular-Ocular Motor Testing

Dynavision

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Computerized Neurocognitive Testing

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

• Verbal Memory• Visual Memory • Reaction Time• Processing Speed• Impulse Control

Computerized Neurocognitive Testing

Schatz et al, 2012• Athletes 81 symptomatic concussed athletes compared to

non‐concussed controls tested within 3 days of injury

Sensitivity Specificity

91.4% 69.1%

Sensitivity Specificity

94.6% 97.3%

• 37 asymptomatic concussed athlete compared to non‐concussed controls tested within 3 days of injury

Cognitive Linguistic Assessment

• Orientation

• Immediate recall

• Concentration

• Executive functioning

• Short term memory

• Long term memory

• Cognitive strategies to be successful in school or work

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Return-to-Academics

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Return-to-Play/Activity

Post-Concussion Syndrome (PCS)

• Diagnosis• ICD 10 definition: “persistence of a constellation of physical,

cognitive, emotional, and sleep symptoms beyond the usual recovery period”

• No tests available to diagnose

• 3-month duration or more of concussion related symptoms:

DSM (5th ed), 2013, Makdissi et al 2017

Headaches Dizziness

Fatigue Irritability

Difficulty concentrating Impaired memory

Difficulty with mental tasks Difficulty sleeping

Reduced tolerance to stress

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Post-Concussion Syndrome (PCS)

• Risk Factors for PCS

• On field dizziness – 6.3 fold increase in PCS risk (Iverson, 2007)

• Lack of early physical activity (Grool, 2016)

• High initial symptom load (Howell, 2016)

• Female sex (Howell, 2016)

• Premorbid conditions (Asken, 2017)

Previous concussion Headache/migraine history

Learning disability ADHD

Depression Anxiety

How many is too many?

• No evidenced-based guidelines

• Individualized

• Comorbidities

• Modifying factors to consider

• Multiple lifetime concussions

• Structural abnormality on imaging

• Persistent decreased academic or workplace performance

• History of prolonged recovery with past concussions

• Post-concussion syndrome (PCS)

• Student/family priorities

• Realistic expectations

Prevention

• Helmets do NOT prevent concussions

• Safe techniques in practices and games and on playgrounds

• Safe playground equipment

• Enforcement of rules

• Checking in ice hockey

• Heading in soccer

• Preseason baseline testing adopted by schools or with sports physicals

• Health education curriculum

• Community based concussion management

• Creating positive and open culture

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Clinical Community

• Advanced neuroimaging techniques to help demonstrate concussion is associated with changes in the brain structure and function which correlate with symptoms

• Assessment of blood, saliva, CSF biomarkers

• Role of genetics in predicting risk of injury, prolonged recovery, long term neurological health problems, and effects of repetitive head impact exposure

• Research to develop diagnostic criteria for CTE prior to death

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Chronic Traumatic Encephalopathy

• Degenerative brain condition

• 4 stages

• Repetitive brain trauma (concussion or subconcussive)

• Not just associated with football (boxing, military)

• Postmortum diagnosis

• Been around for years (punch drunk, dementia pugilistica)

• Tau protein tangles

• Wide range of symptoms

• Multi-factorial: # of concussions, genetics, alcohol, drugs

• Some may have tangles but don’t present clinically

• Many of professional athletes without CTE

• Keep a positive attitude56

Iowa Community

• Iowa Concussion Consortium (ICC)

• REAP distributed to all schools April 2016

• New legislation for concussion management April 2018

• BIAI

• IDPH Concussion Management

guidelines

• CTE Hope

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Future

• Best practice recommendations required by law

• More specialized training in community

• Trained brain injury HCP on sidelines for all sporting events

• Baseline testing requirements for all students all schools

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Case Study #1

• 16 year old female

• Volleyball concussion

• PID #31

• Concussion #6

• Headaches, occasional dizziness, neck pain

• Med hx: no depression, no anxiety, no trouble sleeping, no migraines, no family history of above, 3 week resolution of previous mTBI

• No medications

• Returned to school with some symptoms, but keeping grades up and has returned to driving

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Case Study #1

• SCAT 5 20/22 30/132

• VOMS mild increase in symptoms

• King Devick some impairment

• Dynavision no impairment

• Balance no impairment

• IMPACT high average functioning

• Stage 5 of RTL

• Stage 2 of RTP

• Active Rehab

• No volleyball rest of season

• Chiropractor 60

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Case Study #2

• 15 year old male

• Football concussion

• PID #17

• Concussion #3

• headaches, dizziness, and sensitivity to noise

• Med hx: ADHD, no depression or anxiety, trouble sleeping, quick recovery of previous mTBIs

• No medications

• Returned to school with some symptoms, but

keeping grades up

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Case Study #2

• SCAT 5 14/22 22/132

• VOMS moderate increase in symptoms

• King Devick some impairment

• Dynavision no impairment


• IMPACT average functioning

• Stage 4 of RTL

• Stage 3 of RTP

• Active Rehab

• No football rest of the season, but baseball

drills, no active batting and no scrimmaging62

Case Study #3

• 18 year old male

• Drag racing concussion with other ICI hospitalized

• PID #14

• Concussion #4

• Reports no symptoms

• Med hx: depression, anxiety, trouble falling asleep, long recovery of other mTBI

• Tylenol and ibuprofen prn

• Graduated from high school works for family mechanic garage, no college plans

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Case Study #3

• SCAT 5 6/22 10/132

• VOMS moderate increase in symptoms

• King Devick moderate impairment

• Dynavision some impairment


• IMPACT low average functioning

• Stage 3 of RTP- long term

• Active Rehab

• No more contact sports including drag racing

ever64

Websites

Berlin consensus statement https://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097699

CDC Heads Up Campaignhttps://www.cdc.gov/HEADSUP

CDC clinical practice guidelineshttps://jamanetwork.com/journals/jamapediatrics/article-abstract/2698456

SCAT 5https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

IDPH Concussion Management Guideline for Schoolshttps://idph.iowa.gov/Portals/1/userfiles/32/Iowa%20Concussion%20Guidelines%202017%20-%20electronic.pdf

REAPhttp://www.iahsaa.org/wp-content/uploads/2016/09/reap-publication-20-pages_092016.pdf

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Breton M. Asken, Aliyah R. Snyder, James R. Clugston, Leslie S. Gaynor, Molly J. Sullan, Russell M. Bauer; Concussion-Like Symptom Reporting in Non-Concussed Collegiate Athletes, Archives of Clinical Neuropsychology, https://doi.org/10.1093/arclin/acx018

3. Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F 2016). Sports and recreation-related concussion in US youth. Pediatrics. 138(1):e20154635.

4. Buckley, Thomas A., Barry A. Munkasy, and Brandy P. Clouse (2016). Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time.The Journal of head trauma rehabilitation ;31.4 ; p. 233–241. PMC.

Web. 16 Oct. 2017.

5. Centers for Disease Control and Prevention (2011). Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009. 60(39); P. 1337–1342.

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References

6. “Concussion Management Guidelines for Iowa Schools”.(2017)https://idph.iowa.gov/Portals/1/userfiles/32/Iowa%20Concussion%20Guidelines%202017%20-%20electronic.pdf. Date accessed: 10/16/17.

7. Covassin T, Moran R, Elbin RJ. (2016). Sex differences in reported concussion injury rates and time loss from participation: an update of the National Collegiate Athletic Association Injury Surveillance Program from 2004-2005 through 2008-2009. J Athl Train ; 51, p.189–94.10.4085/1062-6050-51.3.05

8. Davis GA, et al. (2017). Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017- 097506SCAT5

9. Elbin RJ, Sufrinko A, Schatz P, et al. (2016). Removal From Play After Concussion and Recovery Time. Pediatrics; 138(3).

10.Giza CC, Hovda DA. (2001)The Neurometabolic Cascade of Concussion. Journal of Athletic Training. 36(3); p. 228-235.

References

11. Grool AM,et al. (2016), Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 316(23); p. 2504–2514. doi:10.1001/jama.2016.17396

12.Halstead, M., Walter, K. (2010). The Council on Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics.126(3); p. 597-615.

12. Harmon, KG et al. (2013). American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports; 47:1; p.15-26 doi:10.1136/bjsports-2012-091941.

13.Howell DR, Mannix RC, Quinn B, Taylor JA, Tan CO, Meehan WPIII. Physical activity level and symptom duration are not associated after concussion. Am J Sports Med;44(4); p.1040-1046.

References

13. “Iowa Code 280.13C”. https://www.legis.iowa.gov/docs/code/280.13C.pdf. Wed Feb 08 03:27:40 201. Date accessed: 10/16/17.

14. Iverson, G. (2007). Predicting slow recovery from sport-related concussion: the new simple-complex distinction. Clin. J. Sport Med; 17; p.31–37

15.Marar M, McIlvain NM, Fields SK, Comstock, D. (2012). Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med; 40; p. 747–755.

17.McCrory, P., Meeuwisse WH, Aubry M, et al. (2017). Consensus Statement on concussion in sport: the 5h international conference on Concussion in Sport held in Berlin, October 2016. The Journal of Sports Medicine; 0; p. 1-10.

18. McCrory, P., Meeuwisse WH, Aubry M, et al. (2012) Consensus Statement on concussion in sport: the 4th international conference on Concussion in Sport held in Zurich.The Journal of Sports Medicine; 47; p. 250-258.

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References

19. McAvoy, Karen. (2016) “REAP the benefits of good concussion management.” http://www.iahsaa.org/wp-content/uploads/2016/09/reap-publication-20-pages092016.pdf. HCA HealthONE. Date accessed: 10/16/17.

20. Mucha A. et al. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. Am. J. Sports Med;42; p. 2479–2486.

21.Makdissi M, Schneider KJ, Feddermann-Demont N, et al. (2017). Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med Published Online doi: 10.1136/bjsports-2016-097470.

22.Rizzo, J. et al. (2016), Rapid number naming in chronic concussion: eye movements in the King–Devick test. Ann Clin Transl Neurol, 3: 801–811. doi:10.1002/acn3.345

References

23. Rochefort, C., Walters-Stewart, C., Aglipay, M. (2017). Balance Markers in Adolescents at 1 Month Postconcussion. The Orthopaedic Journal of Sports Medicine. 5(3), March. DOI: 10.1177/2325967117695507

24.Schatz P., Sandel N. (2012). Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes, American Journal of Sports and Medicine.

25. Signoretti S, Lazzarino G, Tavazzi B, Vagnozzi R. (2011). The pathophysiology of concussion. PM&R. 3(10); p.359–68.

26. Zemek R, Barrowman N, Freedman SB, et al. (2016). Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 315(10); p.1014-1025

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active rehabilitation for concussion management · 2018-10-29 · presentation objectives •...

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