sportsperformance.stvincent.org concussion: current evaluation and management guidelines david m....

sportsperformance.stvincent.org

Concussion:Current Evaluation and Management Guidelines

David M. Harsha, M.D.St. Vincent Sports Performance

What is new?

• New State Law for concussion management

• Much heightened awareness of long-term effects – NFL players and lawsuits

• Increased public awareness

SENATE ENROLLED ACT No. 93 AN ACT to amend the Indiana Code concerning education

• Before July 1, 2012– Requires the department of education disseminate

guidelines, information sheets, and forms to school corporations for distribution to schools to inform and educate coaches, student athletes, and parents of student athletes of the nature and risk of concussions and head injuries.

• Before July 1, 2012– Requires that a high school student athlete and the

student athlete's parent be given information concerning head injuries and concussions and return a form acknowledging receipt of the information to the student athlete's coach each year before beginning practice for a sport.

Indiana Department of Education

• Provided “Heads Up-A Fact Sheet for Athletes” and “Heads Up-A Fact Sheet for Parents” to meet this requirement.

• Provided the “Concussion Acknowledgment and Signature Form for Student Athletes and Parents” to record receipt of this information.

• Schools can develop their own forms• Forms should be provided and completed annually.

– Coaches are responsible for collection and storage of all forms.

• Before July 1, 2012– Requires that a high school student athlete who is

suspected of sustaining a head injury or concussion be removed from play at the time of the injury. Provides that the student athlete may not return to play until the student athlete has been evaluated and received written clearance from a licensed health care provider trained in evaluating head injuries.

• Clarifications:– Game Officials may request player

assessment by a healthcare professional if they suspect concussion.

– If healthcare professional confirms athlete did not sustain a concussion, head coach may advise officials and athlete may reenter competiton.

• Designated health care professional does not clearly athlete for return:– Only an M.D. or D.O. may clear the individual

to return to competition– The clearance must be in writing– The clearance may not be on the same date

on which athlete was removed from play

• SEA 93 states that only a licensed healthcare provider trained in the evaluation and management of concussions and head injuries may provide a release for return to play– Hold a license to practice in their field– He listed as a healthcare provider in Indiana code– Be trained in the evaluation and management of

concussion and head injuries

• Before July 1, 2012– Provides that a health care provider who, as a

volunteer in good faith and gratuitously, provides head injury evaluations to student athletes has immunity from civil liability for acts or omissions arising from the evaluations, except for gross negligence or willful or wanton misconduct

Traumatic Brain Injury (TBI)

► Silent epidemic► Under reporting► Under recognized

3.8 millionnew cases each year

Concussions in Sports andRecreational activity (TBI)

Traumatic Brain Injury (TBI)

50%MVA

(adult and pediatric)

30%Sports/Recreation

20%Violence

Concussion Epidemiology

• Highest incidence rates by athlete exposure– Football– Ice Hockey– Soccer– Lacrosse

Concussion Epidemiology

• Competition Concussion rates are consistently higher than practice rates

• In sports with same rules (BB and soccer), incidence rates higher in females

Athletic Head Injury: Incidence

► Head injury 2X as common as neck injury

► 20% of athletes affected each year

► 43% head to head

Athletic Head Injury: Incidence

► 33% head to ground

► Accounts for 3-5% of all HS sports injuries

► Low reporting► Player not aware of significance of

symptoms► Wants to avoid disqualification

Risk Factors

Increased body size

Risk Factors

Increased Speed

Risk Factors

Higher Skill Level

Risk Factors

Helmet Used as Weapon

Risk Factors

Poorly Fitting Equipment

Risk FactorsMay prolong or complicate recovery

– History of multiple concussions• Number, proximity and severity

– Prolonged LOC- (>1 minute)– Age

• Youth and Adolescent

– Susceptibility• Concussions occurring with lower impact or

requiring longer to recover

Risk FactorsMay prolong or complicate recovery

– Preexisting Conditions• Migraine• ADD, ADHD • LD• Depression• Anxiety/panic attacks• APOE Promoter gene ?Tau genotypes

What is aconcussion

► Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.► Direct blow to head, face, neck or elsewhere

on the body with “impulsive” force transmitted to the head

► Rapid onset of short-lived impairment of neurological function that resolves spontaneously, in most cases in 7-10 days

► Acute clinical symptoms largely reflect a functional disturbance rather than a structural injury

Concussion Defined

► May or may not involve loss of consciousness.► Prolonged post-concussive symptoms in a

small percentage of cases► No abnormality on standard structural

neuroimaging studies

Concussion Defined

Pathophysiology

• Imparted linear and rotational accelerations to the brain

• No currently known threshold for concussive injury because of modifying factors– Concussion hx– Neck strength– Anticipatory reaction– Varying frequency and locations of impact

Pathophysiology

• Alterations in intracellular/extracelluar glutamate, potassium and calcium

• Relative decrease in cerebral blood flow in the setting of an increased requirement for glucose (hyperglycolysis)

• Mismatch in metabolic supply and demand may potentially result in cell dysfunction and increase vulnerability of cells to second insult

Figure Neurometaboli...

Figure: Neurometabolic cascade after traumatic injury. 1. Nonspecific depolarization and initiation of action potentials. 2. Release of excitatory neurotransmitters (EAA). 3. Massive efflux of potassium. 4. Increased activity of membrane ionic pumps to restore homeostasis. 5. Hyperglycolysis to generate more adenosine triphosphate (ATP). 6. Lactate accumulation. 7. Calcium influx and sequestration in mitochondria leading to impaired oxidative metabolism. 8. Decreased energy (ATP) production. 9. Calpain activation and initiation of apoptosis. A. Axolemmal disruption and calcium influx. B. Neurofilament compaction via phosphorylation or sidearm cleavage. C. Microtubule disassembly and accumulation of axonally transported organelles. D. Axonal swelling and eventual axotomy. AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid; Ca2+, calcium; Glut, glutamate; K+, potassium; Mg2+, magnesium; Na+, sodium. (Reprinted from Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athle Train. 2001; 36(3):288-35. Copyright © 2001 National Athletic Trainers' Association. Used with permission.)

Ω-3 Polyunsaturated Fatty Acids and Concussions: Treatment or Not?Trojian, Thomas H.; Jackson, EricCurrent Sports Medicine Reports. 10(4):180-185, July 2011.doi: 10.1249/JSR.0b013e31822458d5

Concussion Grading Systems

Controversies in Guidelines

► Lack of scientific method in guidelines

► No data to support return to play guidelines

► Standard use for all groups and playing levels

► Does not account for individual variation in symptoms and vulnerabilities to concussion at different ages

► LOC grades concussions

Summary Consensus Statements

► Concussion grading scales abandoned

► Combined measures of recovery to determine injury severity and or prognosis

► Individually guide return to play decisions

► International Conference on Concussion in Sport ► Vienna 2000► Prague 2004► Zurich 2008

Team Physician Consensus Statement 2011

• Published in MSSE and other publications• Includes guideline, sideline assessment tool, and Post-

injury care form• 6 major organizations participated

– AAFP– ACSM– AAOS– AMSSM– AOSSM– AOASM

Zurich 2008 Consensus Statement

► Focus questions are Foundation of statement► Acute simple concussion► Return to play issues► Complex concussion and long-term issues► Pediatric concussion► Future directions

Concussion Evaluation

Assessment of range of domains

ClinicalSymptoms?

Behavior?PhysicalSigns?

Balance?Sleep &

Cognition?

Suspect Concussion if ANY

or More!

► Symptoms (headache)

► Physical Signs (loss of consciousness)

► Behavioral changes► Balance► Cognitive impairment► Sleep disturbance

Concussion symptom scale

• Headache• Nausea/vomiting• Drowsiness• Balance problems• Dizziness• Fatigue/low-energy• Confusion• Feeling foggy• Difficulty remembering• Difficulty concentrating

• Feeling slowed down• Sensitivity to noise• Sensitivity to light• Blurred vision• Sleeping more than usual• Sleeping less than usual• Trouble falling asleep• Sadness• Nervous or anxious• Feeling more emotional• Irritability• Numbness or tingling

On-field or Sideline Evaluationof Acute Concussion

►Player should be medically evaluated on site with attention to C-spine injury

►Appropriate disposition of player must be determined by treating healthcare provider

►If no healthcare provider available, player should be safely removed from practice or play and urgent referral to a physician arranged

On-field or Sideline Evaluationof Acute Concussion

► Assessment of concussive injury with SCAT2 or similar tool

► Player should not be left alone following injury ► Serial monitoring for deterioration over several

► Concussed player should not be allowed to return to play on the day of injury

Same-Day Return to Play

►Evidence that NFL football players RTP more quickly without risk of recurrence or sequelae

►Evidence shows collegiate and high school athletes allowed to RTP same day may demonstrate NP deficits post injury that may not be evident on sidelines

►Children should not be returned to practice or play until completely symptom-free, which may require a longer time frame than adults

Sideline Cognitive Function

Maddock’s questions:

At what venue are we?

Which half/period is it?Who scored last?

Opposing team name?

Did we win last game?

Sideline Cognitive Function

Standard orientation questions (time, place, person) unreliable!

Concussive symptoms might be delayed several hours!

Office Medical Assessment

► History and neurological examination►Focus on Mental status, cognitive function,

gait and balance assessment

►Determine need for emergentneuroimaging

Neuroimaging

► Brain CT or MRI contributes little to concussion evaluation

► Obtain when suspicion of intracerebral structural lesion exists► Prolonged disturbance of conscious state► Focal neurological deficit► Worsening symptoms

Balance Assessment

► Office assessment of gait and balance

► Modified BESS balance testing► Double leg stance► Single leg stance► Tandem stance

►Number of errors in 3 20-sec tests►Maximum of 10

Computerized NP Testing

► Developed in response to time and cost demands, as well as limitations in NP expertise

► Modified from standard pencil/paper tests to best assess changes seen in concussion; ► Attention and concentration

► Cognitive processing (speed & efficiency)

► Learning and memory

► Working memory

► Executive functioning

► Verbal fluency

Neuropsychological (NP) Assessment

► Cognitive recovery occasionally precedes or more commonly follows symptom resolution► Suggests that assessment of cognitive function an

important component in any return to play protocol► NP testing usually done when symptom-free

►NP assessment should not be sole basis of management decisions

Neuropsychological (NP) Assessment

Multiple web-based tools available

NP Assessment

► ImPACT► Computerized neuropsychological battery

► Baseline and post-concussive testing► Used by NFL, NHL► Certification process

► Credentialed ImPACTConsultant (CIC)

► Cogstate

► Axon Sports►Used by the NBA, WNBA

NP Testing Recommendations

► Use NP testing when available► Once you use it, you can’t imagine not

having it!

► Baseline test for high risk sports► Computerized tests + additional P/P tests

► Establish relationship w/ Neuropsychology for high risk or complicated patients

► Repeat tests every 6mo - 1yr for those <15 yr to account for developmental changes in cognition

► Use some form of cognitive tests during initial assessment and follow-up care of the injured athlete

► Do not allow symptomatic athletes to RTP

► Follow up NP tests once athlete asymptomatic

► Repeat as necessary if not back to or above baseline, understanding limitations of tests used

► Rely on clinical markers, burden & duration of symptoms, and athletes individual history of prior concussion to make RTP decisions.

Acute Concussion Management

► Should not be left alone for 24-48 hrs

► Wake concussed athlete every 2-3 hours during the night to assess arousability and gross cognitive function

► Avoid NSAIDs (Aleve, ibuprofen, Motrin, Advil, aspirin) in the first 24-48 hrs due to increased bleeding risk

► Avoid narcotics in the first 24-48 hrs as they impair ability to assess patient

► Tylenol for headache pain if needed

► Cornerstone of management is physical and cognitive rest until symptoms resolve, followed by a graded program of exertion prior to return to play (RTP)► Activities that require concentration and

attention may exacerbate symptoms and possibly delay recovery

► Consider limiting children’s scholastic and cognitive stressors such as text messaging and video games

Concussion Management

• Fish oil– Ω3 PUFA, especially DHA

• Animal model evidence is convincing that especially DHA is beneficial after mild traumatic brain injury

• Evidence is missing in humans. Potential benefit seems to be greater than risk yet caution should be used. Further research needed to determine clinically measurable benefits

Return to Play

Rest until asymptomatic (physical and mental)

Step-wise symptom limited program

Light aerobic exercise (stationary bicycle)

Sport specific exercise

Non-contact training drills (resistance training)

Full contact training after medical clearance

Return to competition

Return to Play

Approximately 24 hrs (or longer) for each stage,if symptoms recur, return to previous asymptomatic level and try to progress after 24 hrs

Postconcussion syndrome

• Persistent postconcussion symptoms lasting 3 months or longer

• Indicator of concussion severity

• Absolute contraindication to return to play

• Increased risk of depression

Postconcussion syndrome

• Evaluation– Neuropsychological evaluation– Consider MRI

• Treat– Headaches– Depression– Exercise recommendations

Complications of Concussions

► Second impact syndrome►Occurs within minutes of concussion in

athletes still symptomatic from prior brain injury►Vascular engorgement leads to massive

increase in intracranial pressure and brain herniation resulting in severe brain damage or death

►May occur with associated small subdural hematoma

►Except for boxing, most cases in literature in adolescent athletes.

► Chronic traumatic encephalopathy►Progressive neurodegenerative disease

(tauopathy) caused by total brain trauma►Incidence and prevalence not known►Diagnosed only after death

►NFL player Registry

►Decline of recent memory and executive function, mood, and behavioral disturbance

►Initial signs and symptoms typically manifest decades after trauma (40-50-yr).

• Depression– Increased risk after

multiple concussions– Athletes with

depression may experience worsening symptoms after sustaining concussions

• Mild cognitive impairment– Increased risk later in

life after multiple concussions

– Multiple concussions associated with earlier onset of mild cognitive impairment

Prevention

• Helmets– Do Not Prevent

Concussion!!!– Incidence of skull

fracture and major head trauma

Prevention

• Personal Protective Equipment– Mouthguards

• Decrease risk of dental or oral injury

– Headgear for soccer, rugby, wrestling, boxing

• Decrease risk of lacerations and soft tissue trauma

Prevention

• Coaching– Rules against

• Spearing• Head-to-head contact• Leading with the head

– Report symptoms of head injury!!!!

When to Consider Retiring an Athlete?

• Possible season ending– Prolonged postconcussion

syndrome– Diminished academic

performance– CT or MRI brain scan

abnormality– 3 or more concussions in

single season– 2 or more major

concussions in single season

When to Consider Retiring an Athlete?

• Possible career ending– Chiari malformation– Intracranial hemorrhage– Diminished academic

performance or cognitive abilities

– Lowering of threshold for concussion

– CT or MRI structural brain injury

– CTE symptoms

Future Directions

• Brain Imaging– fMRI– DTI– sMRI– MRS– Magnetoencephalogra

phy (MEG) / Magnetic Source Imaging (MSI)

– Positron Emission Tomography (PET)

• Rehabilitation– Balance– Sports Psychology– Sport-specific exercise

Future Directions

• Concussive, Subconcussive impacts– ?Effect on cognitive decline

and aging– Current tests not designed to

detect long term effects– Talavage. J Neurotrauma

• Cortical dysfunction not clinically apparent

References

• www.cdc.gov Heads up program. Great resources and information

• www.acaindiana.com Athletes Concussion Alliance. Resources for concussion care and ImPACT training

• MSSE Team Physician Statement-2011– American College of Sports Medicine Web site. Clinicians,Team

Physician Consensus Statements. Available from: http://www.acsm.org/AM/Template.cfm?Section=clinicians1

• Zurich Consensus Statement on Concussion in Sport. 3rd International Conference held in Zurich, 2008.– Clin J Sport Med. 2009; 19:185-200.

Thank You!

The End

sportsperformance.stvincent.org concussion: current evaluation and management guidelines david m....

orgsuspect concussion

play issues complex

calcium influx

play guidelines standard

domainsclinical symptoms

injury severity

traumatic injury

calcium glut

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