© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (2): ITC2-1.

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in the clinic

Concussion


Who is at risk for a concussion?

Youths aged 10–19 years (highest risk)

Males more than females

Participants in sports

Concussions 13.2% of all reported H.S. sports injuries

Highest rates occur in:

Boys: Football, ice hockey, lacrosse

Girls: soccer, lacrosse, basketball

In sports with similar rules (basketball, soccer) rate of concussions higher among girls than boys

Other risk factors: falls, motor vehicle accidents


Are certain types of head trauma more likely to result in concussion?

Any event in which forces result in the brain moving within the skull may result in concussion

Direct trauma to head is not necessary

Indirect forces transmitted to the head from an impact to the body may cause a concussion


How can concussions be prevented?

Primary prevention

Minimize exposure to forces that lead to brain injury

Wear seat belts in motor vehicles

Wear well-fitted protective equipment during sports

Both measure prevent catastrophic brain injury

Less effective for preventing concussion or mild TBI

Change rules to decrease exposure to concussive forces

Such as raising the body-checking age in youth ice hockey


Secondary prevention

Eliminate unnecessary risk for repeated head trauma

Full recovery from initial concussion is essential

Second concussion may prolong signs and symptoms

Possible increased risk for catastrophic death or disability from second head injury after a recent head injury


CLINICAL BOTTOM LINE: Prevention…

Primary concussion prevention

Reduce exposure to concussive forces and injury

Rule changes in sports

Enactment of laws for safety reasons

Secondary prevention

Appropriate, knowledgeable clinical management is essential

Full recovery from initial concussion is essential before exposure to any risk for second head injury


What acute symptoms immediately following head injury should prompt consideration of concussion?Early (minutes to hours later)

Headache

Dizziness or vertigo

Lack of awareness of surroundings

Nausea or vomiting

Balance problems

Visual disturbance

Mental confusion

Amnesia (retro-/anterograde)

Perseveration

Late (days to weeks later)

Persistent low-grade headache

Lightheadedness

Poor attention, concentration

Memory dysfunction

Easy fatigability

Irritability, frustration

Intolerance of loud noises

Anxiety or depressed mood

Numbness or tingling

Sleep disturbance


If symptoms present but no history of head injury

Participants in contact or collision sports: consider concussion due to the many impacts sustained routinely

Otherwise: consider other causes than concussion

If symptoms are minimal or absent after a head injury

Observe patient over subsequent hours and days


What evaluation should be performed immediately following head injury?

Assess for cervical or intracranial injury

If cervical tenderness or limitation of cervical ROM: immobilize + use spine board for emergency transport

If patient is conscious, engage verbally while immobilized

Evaluate various domains of brain function

Neurocognitive; balance; eye tracking

Refer patient to emergency department

If loss of consciousness or traumatic convulsive activity

If mental status deteriorates

If focal neurologic signs develop


What imaging tests should be used in the evaluation of possible concussion?

CT imaging

Consider on an individual basis: not universally indicated

If there’s concern for intracranial hemorrhage based on clinical signs and symptoms

If neurologic status deteriorates

Imaging methods under investigation

Diffusion tensor imaging

Functional MRI

Magnetic resonance spectroscopy


When head injury occurs during sport, how should the safety of returning to play be made, and by whom? Remove injured athlete from play

Athlete should never return to play on the same day a head injury occurs

Assess and monitor on the sideline if appropriate, depending on severity and symptoms

Refer to emergency dept if any deterioration in clinical status causes concern

Physician should oversee the safe return to play

49 states require clearance from a licensed medical professional with concussion experience to return to play

Physician should have experience and training in concussion management and return-to-play issues


What items are important in the history and physical examination of a patient with suspected concussion?

Elements of history

Mechanism of injury

Timing of the development of symptoms after injury

Subsequent course of events (delayed-onset symptoms, activities that exacerbate symptoms)

Assessment of preinjury function and ability to tolerate return to full function

History of concussion and any comorbid conditions

Anxiety, depression, ADHD, or preexisting migraine


Physical Examination: Tests Smooth pursuits: Examiner’s finger moves horizontally,

progressively increasing speed

Saccades: Examiner’s fingers held at shoulder-width and forehead and chin distance to test horizontally & vertically

Gaze stability: Patient fixes gaze on examiner’s thumb while nodding (vertical) and then shaking (horizontal) head

Convergence insufficiency: Patient takes a pen with letters and holds at arm’s length and brings towards their nose

Balance: Tandem heel-toe gait forward and backward with eyes opened and closed

Signs of concussion deficits: Unable to perform or can only perform a few repetitions before symptoms or signs are provoked

Such as headache, dizziness, eye fatigue, blurry vision

Physical signs, such as watering of eyes or swaying of body


What other tests should be performed?

Concussion symptom scales

Help delineate severity and extent of symptoms after injury

Can be followed serially

Computerized neurocognitive testing

Now widely used in h.s. and college sports as well as pro

Helps quantify cognitive effects of injury

Accurate preinjury information contributes to a more individualized assessment

? Test for serum biomarkers for acute concussion

? Test for alleles that may predispose to concussion


How is the severity of a concussion assessed?

Concussion grading systems have been abandoned

Data are lacking with which to predict prognosis

Severity can only be assessed after recovery complete

However, there are predictors of prolonged recovery

Younger age and female

History of multiple concussions

Diagnosed learning disability

Slowed reaction time and impaired visual memory

Post-traumatic migraine

Subacute (within 3 to 7 days) symptoms


CLINICAL BOTTOM LINE: Diagnosis…

Concussion was once defined as constellation of subjective symptoms after head injury

Now specific areas affected in concussion have been identified Neurocognitive

Vestibular

Oculomotor

Balance

Use physical exam to assess & identify deficits in these areas

Obtain a detailed and accurate history


Should patients with a concussion be restricted from work, school or other activities?

Immediately after the injury

Patients benefit from brief physical + cognitive rest

Then resume activities gradually

Modify cognitive activities as needed

Return to normal physical activity as tolerated

Pay close attention to symptom threshold

Noncontact aerobic activity probably isn’t harmful

Athletes can enter a formal return-to-play progression once able to tolerate a full cognitive load


What behavioral interventions are helpful in the management of concussion?

Return to school

Cognitive rest—No school, homework, or electronic devices

Relative rest—Reintroduce short periods of aforementioned activities that don’t trigger severe symptom exacerbation

Homework at home—Longer periods of cognitive activity

Return to school—Partial-day school with accommodations after tolerating 1-2 cumulative hours of homework at home

Ramp up to full day—With accommodations for full work load, limited make up work

Full return to school—Full day, full work load, fully caught up with makeup load


Return to play

Physical rest—avoid activities that result in sustained increased heart rate or breaking a sweat or severe symptom exacerbation; additional sleep may be needed

Light activity associated with everyday life avoiding triggering severe symptoms—walking

Light aerobic exercise—To increase heart rate without triggering severe symptom exacerbation

Sport-specific aerobic exercise—Noncontact skating, dribbling, or running drills as tolerated

Advance to complex noncontact sport-specific training drills and add resistance training as tolerated

After medical clearance, full contact practice

Normal game play


Are there pharmacological measures known help in treating patients with a concussion? Analgesics: may be helpful (acetaminophen, ibuprofen)

But symptoms best managed with behavioral interventions, such as rest and modification of activities

Avoid daily use (prevent rebound headaches)

Melatonin: if sleep is disordered

Amantadine: for mental slowing or fogginess

Amitriptyline or topiramate: for chronic daily headaches outside of the acute phase of concussion

Methylphenidate: persistent attention issues after TBI

Referral for anxiety and depression medication may be warranted in the chronic post-concussion phase


What are the complications of concussion?

Complications vary and may include:

Vestibular deficits

Oculomotor and visual convergence deficits

Anxiety and depression

Chronic headaches

Attention or concentration issues

Slowed processing speed or memory issues

Postconcussion syndrome

Term reserved for prolonged and persistent symptoms

May involve multiple domains of brain function


When should rehabilitation therapies be considered?

If vestibulo-ocular deficits persist beyond acute phase

Directed therapy reduces symptoms, improves function

Aerobic rehabilitation with exercise training is beneficial

Formal binocular vision therapy may be indicated

If unable to resume preinjury level of cognitive function

Cognitive or speech therapy may be indicated

Modification of school activities may be sufficient to rehabilitate cognitive deficits

Refer for cognitive or speech therapy if more significant accommodations are needed


When should a specialist be consulted for the treatment of a concussion?

Concerns about the timing of return to a contact or collision sport

Concerns about a prolonged recovery from concussion

Rehabilitation may be required

Hx multiple concussions or preexisting neurologic issues

Such as migraines, anxiety, or depression


CLINICAL BOTTOM LINE: Treatment…

Management for patients with a typical recovery

Brief period of early physical and cognitive rest after injury

Then gradual reentry into physical and cognitive activities

Modify activities to minimize symptom exacerbation

Refer to specialist with experience managing concussion if:

Patient has preexisting comorbid conditions / risk factors

Symptoms are prolonged


What factors predict the prognosis of patients with concussion?

Poorer prognosis + prolonged recovery more likely with:

Greater number of symptoms

Greater severity of symptoms

History of concussion

Younger age

Apolipoprotein e4 genotype (may be associated with more significant neurologic deficits)

Loss of consciousness and impact seizure (not consistently correlated w/ poorer outcome)


Symptoms associated with prolonged recovery:

Amnesia

Prolonged headache

Fatigue or fogginess

Cognitive problems

Dizziness at the time of injury


CLINICAL BOTTOM LINE: Prognosis… Patients may recover with few, if any, long-term sequelae

Risk factors predictive of a prolonged recovery:

History of concussion

Greater number and severity of symptoms

Deficits that persist despite rehabilitation

Discuss the future risk for concussion vs. the benefits of a high-risk activity

© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. * For Best Viewing:...

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