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Current Concepts in Concussion and Concussion Management Matt Leiszler, MD Office-Based Sports Medicine Symposium May 17, 2014

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I have no relevant financial disclosures.

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OUTLINE Key Points Background Definitions Presentation Investigations/Studies Management Key Points

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These are the CURRENT conceptsvery likely to evolve 80-90% of concussions resolve in 7-10 days Majority of concussions do not involve loss of consciousness No same day return to play Sports Concussion Assessment Tool (SCAT-3) New Imaging and Treatment options are on the horizon State of the Art treatment currently: Rest

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Background Concussion

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Background CDC estimates 1.6 3.8 million concussions occur annually in sports/rec activities in the US each year 33% of all concussions are sports- related (ages 5-19)

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Background

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Definition: Concussion (Zurich 2012) Concussion is a brain injury and is dened as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in dening the nature of a concussive head injury include: Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However in some cases symptoms and signs may evolve over a number of minutes to hours. Concussion may result in neuropathological changes but the acute clinical symptoms largely reect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However it is important to note that in some cases, post-concussive symptoms may be prolonged.

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Definition: Concussion (AMSSM): A traumatically induced transient disturbance of brain function and involves a complex pathyphysiological process. Concussion is a subset of mild traumatic brain injury which is generally self-limited and at the less-severe end of the brain injury spectrum

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Definitions Concussion and Traumatic Brain Injury

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Definitions Post-Concussion Syndrome AMSSM Position Statement 2013: Difficult to determine where concussion ends and post-concussion syndrome begins Symptoms and signs that persist for weeks to months Zurich 2012: Prolonged Symptoms: Symptoms > 10 days 10-20% of concussions

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Definitions Second Impact Syndrome Numerous case reports, essentially all under 22 years old Rare, but devastating event Unclear whether this has occurred in an asymptomatic person Head trauma on already injured brain worsening metabolic changes in the cells Coherent for 15-60 seconds rapid coma and respiratory failure

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Concussion Legislation Colorados Senate Bill 40 The Jake Snakenberg Youth Concussion Act Signed March 29, 2011

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Colorado Senate Bill 40

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Senate Bill 40 Requirements 1.Training of coaches 2.Removal from play 3.Notification of a parent 4.Sign-off on return to play be medical provider

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Concussion Presentation Multiple manifestations No two concussions are exactly the same Headache most common symptom; dizziness second 90% do not include loss of consciousness

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Signs and Symptoms

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Symptoms Randolph, et al (2009): 12 Validated Symptoms: Concussion Symptom Inventory Headache Nausea Balance problem/dizziness Fatigue Drowsiness In a fog Difficulty concentrating Difficulty remembering Sensitivity to light Sensitivity to noise Blurred vision Feeling slowed down

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On-field/Sideline Evaluation of Acute Concussion Should occur if concussion even suspected Player evaluated by physician or other licensed healthcare provider If no healthcare provider available remove from practice/play, refer ABCs, Exclude cervical spine injury After first aid issues addressed Sideline assessment tool Do not leave player alone monitor over a few hours A player with a diagnosed concussion should NOT be allowed to return to play on the day of injury When in doubtsit them out!

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Sport Concussion Assessment Tool

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SCAT 3

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Symptoms

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SCAT 3

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Referral to Emergency Department? Worsening/Severe headache Deteriorating mental status Active vomiting Focal neurologic findings Numbness, tingling, weakness, seizure, unequal pupils

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Office or Emergency Department Evaluation Full history, detailed neurological exam Essentially perform a SCAT3 Determine clinical statusimproving or deteriorating? Determine need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality

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Investigations/Studies

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Postural stability testing Often returns to normal after 72 hours post-conc Force plate technology Balanced Error Scoring System

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Investigations/Studies Imaging of the Brain CT, MRItypically normal If suspicion of intracerebral or structural lesion exists Imaging Prolonged disturbance of conscious state Focal neurological deficits Worsening symptoms

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Investigations/Studies Imaging of the Brain Alternative imaging Several methods being investigated Exciting area of research

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Investigations/Studies Electrophysiological Recording Techniques Electroencephalogram (EEG) Evoked response potential (ERP) Cortical magnetic stimulation Reproducible abnormalities in post- concussive state Not all studies differentiate concussed athletes from controls

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Investigations/Studies Neuropsychological AssessmentComputer Testing Evaluating cognitive recovery Important component in overall assessment and return to play Baseline testing useful Aids in clinical decision makingbut not the sole basis of management decisions

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Investigations/Studies Neuropsychological Assessment Formal Neuropsych testing Trained Neuropsychologist Not required for all May be beneficial in prolonged symptoms Help identify other conditions

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Investigations/Studies Genetic testing and Biomarkers Insufficient evidence for routine clinical use Apo E4, ApoE promotor gene, Tau polymerase IGF-1, IGF binding protein 2, Fibroblast growth factor, Cu-Zn superoxide dismutase, nerve growth factor, S-100 Serum and Cerebral Spinal Fluid biomarkers being evaluated

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Management Cornerstone REST

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Management Rest Physical Rest No training, playing, exercise, weight lifting Exertion with ADLs Cognitive rest Minimize TV, extensive reading, video games Limit to exacerbation of symptoms

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Management Return to school and social activities Encouraged School Accommodations Extra time or delay tests and quizzes until student is asymptomatic Partial days CDC: educational materials for teachers/administrators

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Management Gradual resolution 80-90% of concussions resolve in a short period (7-10 days) Recovery may be longer in children and adolescents May require multiple office visits

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Recovered? Everyone says they feel fine Ask: 1.On a scale of 0100%, how do you feel? 2.What makes you not 100%? 3.Symptom ChecklistSCAT 3

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Graduated Return to Play Protocol 24 Hours per step (so almost a week for full protocol) If symptoms recur return to previous level Evaluation by health care provider required for school age athletes Rehabilitation stageFunctional exercise at each stage of rehabilitation Objective of each stage 1. No activitySymptom limited physical and cognitive rest. Recovery 2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training. Increase HR 3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities. Add movement 4.Non-contact training drills Progression to more complex training drills e.g. passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load 5.Full contact practiceFollowing medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff 6.Return to playNormal game play

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Difficult casespersistent symptoms Symptoms >10 days Sports-related concussions less likely to result in PCS Consider other issues:Depression? Chronic headaches? Learning disorders? Multidisciplinary clinic Childrens Hospital Complex Concussion Clinic Sub-symptomatic exercise may be beneficial

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Management Pharmacotherapy Useful for prolonged symptoms Sleep disturbance Anxiety Anti-depressants Upon return to play should not be on medications that could mask symptoms Avoid NSAIDs in first 48-72 hours TCAs, Amantadine, Methylphenidate commonly reported as being used for management Antioxidants?

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Other Treatment Vestibular Therapy Balance Therapy Transcranial LEDChronic TBI Red and Near-Infrared LED applied transcranially

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Chronic Sequelae? Chronic cognitive dysfunction Chronic Traumatic Encephalopathy Chronic Neurocognitive Impairment CTE unknown incidence in athletic populations, cause/effect not yet demonstrated between CTE and concussions or exposure to contact sport Acknowledge potential for long-term problems in all athletes To Be Determined

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Prevention Protective equipment Mouth guards Prevent oral injuries Head gear and helmets Reduce impact forces, not concussions Reduce head and facial injury Cervical muscle strengthening?

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Other Issues Rule Changes Checking Limiting contact practices Heading in soccer (50% of concussions are due to arm to head contact) Education of athletes, parents, coaches Awareness of concussion symptoms and signs Web-based resources, social media

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Questions How many concussions is too many? Who will develop CTE? Number of hits? More significant concussions? Evolving role of advanced imaging? What treatments may prove beneficial in concussion? Validation of tools? Prevention?

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Key Points These are the CURRENT conceptsvery likely to evolve 80-90% of concussions resolve in 7-10 days Majority of concussions do not involve loss of consciousness No same day return to play Sports Concussion Assessment Tool (SCAT-3) Imaging and Treatment options are on the horizon State of the Art treatment: Rest

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References Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. McCrory P, Johnston K, Meeuwisse Wet al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196204. Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. Reddy CC, Collins M, Lovell M, Kontos AP. J Head Trauma Rehabil. 2013 Jul-Aug;28(4):260-5. Management strategies and medication use for treating paediatric patients with concussions. Kinnaman KA, Mannix RC, Comstock RD, Meehan WP 3 rd. Acta Paediatr. 2013 Sep;102(9):e424-8. Vestibular and balance treatment of the concussed athlete.Aligene K, Lin E. NeuroRehabilitation. 2013;32(3):543-53. Should we treat concussion pharmacologically? The need for evidence based pharmacological treatment for the concussed athlete. McCrory P. Br J Sports Med. 2002 Feb;36(1):3-5. American Medical Society for Sports Medicine position statement: concussion in sport. Harmon KG, Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A, Putukian M, Roberts W; American Medical Society for Sports Medicine. Clin J Sport Med. 2013 Jan;23(1):1-18.

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Thank You!