concussion ppt june 20101

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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

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Page 1: Concussion PPT June 20101

Assessment of Concussion from the Sideline to

Your Clinic

Eugene Hwang, M.D., M.S.June 10, 2010Family Medicine, Emory University School of Medicine, PGY-3Sports Medicine, University of Nevada Las Vegas, PGY-4 Fellow

Page 2: Concussion PPT June 20101

Ahhhh… memories… or lack there of…

Page 3: Concussion PPT June 20101

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

Page 4: Concussion PPT June 20101

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

Page 5: Concussion PPT June 20101

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 OR Post-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

Page 6: Concussion PPT June 20101

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

Page 7: Concussion PPT June 20101

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

Page 8: Concussion PPT June 20101

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

Page 9: Concussion PPT June 20101

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

Page 10: Concussion PPT June 20101

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

Page 11: Concussion PPT June 20101

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

Page 12: Concussion PPT June 20101

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

Page 13: Concussion PPT June 20101

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)

Page 14: Concussion PPT June 20101

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).

Page 15: Concussion PPT June 20101

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 timeTiming - injuries close together in time‘‘Recency’’ - recent concussion or TBI

Threshold Repeated concussions occurring withprogressively less impact force or slowerrecovery after each successive concussion

Page 16: Concussion PPT June 20101

Concussion Modifiers (Table 2, Continued)

Factors: Modifier:Threshold Repeated concussions occurring with

progressively less impact force or slowerrecovery after each successive concussion

Age Child and adolescent (< 18 years old)

Co- and Pre-morbidities Migraine, depression or other mental healthdisorders, attention deficit hyperactivitydisorder (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

Page 17: Concussion PPT June 20101

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.

Page 18: Concussion PPT June 20101

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.

Page 19: Concussion PPT June 20101

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.

Page 20: Concussion PPT June 20101

Graduated Return to Play Protocol

Step-wise process

Each step = 24 hours

Progress to next step if asymptomatic for at least 24 hours at that current level

If symptomatic, rest for 24 hours, then drop athlete down to previous asymptomatic step and try to progress again

Page 21: Concussion PPT June 20101

Graduated Return to Play Protocol

TABLE 1. Graduated Return to Play Protocol

Rehabilitation Stage Functional Exercise at Each Stage of Rehabilitation Objective of Each Stage1. No activity Complete physical and cognitive rest Recovery

2. Light aerobic exercise Walking, swimming or stationary cycling keeping Increase HRintensity, <70% MPHR; no resistance training

3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; Add movementno 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

5. Full contact practice Following medical clearance, participate in normal Restore confidence and assess training activities functional skills by coaching staff

6. Return to play Normal game play

Page 22: Concussion PPT June 20101

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

Page 23: Concussion PPT June 20101

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)

Page 24: Concussion PPT June 20101

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

Page 25: Concussion PPT June 20101

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

Page 26: Concussion PPT June 20101

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

Page 27: Concussion PPT June 20101

Repeated Concussive Injury

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

Page 28: Concussion PPT June 20101

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

Page 29: Concussion PPT June 20101

Ongoing research…

Pediatric population

Genetic/biomarker testing

Second Impact Syndrome

Male vs. female athlete

Protective equipment (i.e. helmets, mouthgards)

Page 30: Concussion PPT June 20101

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

Page 31: Concussion PPT June 20101

The End

Page 32: Concussion PPT June 20101

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