Closed Head Injury and Concussion

Stephen M. Simons, MD, FACSM Director, Sports Medicine

Saint Joseph Regional Medical Center Co-Director, South Bend - Notre Dame Sports Medicine Fellowship

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Objectives

• Concussion principles.

• Presentation of concussion

• Presentation of more serious brain injury

• Sideline evaluation of the injured athlete

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Disclosures

• Nothing to disclose.

• Assumption: Not currently head injured.

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Focal Brain InjuryMentioned but not discussed in detail

• Subdural Hematoma

• Epidural Hematoma

• Intracerebral Hemorrhage

• Uncommon

• Catastrophic / Life Threatening

• The Physician MUST be alert to these possibilities.

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1.Kutcher JS, Giza CC, Alessi AG. Continuum Lifelong Learning Neurol 2010;16(6):41-54

Hype vs. Evidence More publications!!!!

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2012 - 4th International Consensus Conference on Concussion

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Concussion #’s/ Incidence #’s

• 1.6 to 3.8 million concussions related to sports.

• How many reported concussions?

• How is this data collected?

• How about subconcussive mTBI?

• Gender Difference

• F > M

• Real or Reporting differences? Br J Sports Med 2009;43:i46-i50Is there a gender difference in concussion incidence and outcomes?

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Am J Sports Med 2011;39(5);958-963.

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2020 2040

Figure 1. Concussion rates from 1997-1998 to 2007-2008: overall and for boys’ and girls’ sports.

Trends in Concussion Incidence in High School Sports

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Concussion Rates Sports-Related Concussions in Youth: Improving the Science, Changing the Culture

2013 National Academies Press

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• Late 2013 Report

• Comprehensive Report from the National Research Council

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• “Compared with previous generations, today’s youth, due to an earlier average age of puberty (Biro et al 2010), may have a greater mismatch between the propensity to engage in risk taking (which arises with the onset of puberty) and behavioral inhibition (which is associated with development of the prefrontal cortex)”

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Concussion Definition• Common Features

• Rapid onset of short lived impairment, resolves spontaneously

• Functional disturbance more than structural

• Graded set of clinical symptoms +/- L.O.C.

• Typically normal neuroimaging

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What occurs during Concussion?

• Neurometabolic cascade; ionic fluxes, hyperglycolysis

• Concussed brain in energy/ metabolic crisis with potential loss for microstructure neuronal/ axonal integrity.

• With more severe injury; shear injury & diffuse axonal injury (DAI)

• Recovery metabolically appears to lag behind symptom resolution

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Biochemistry of brain injuryTime Course and Recovery

16Giza and Howda. J Athletic Training 36:229,2001

Gender Differences• Women have an

increased incidence of concussion vs men in sports with same rules

• Reporting bias?

• Hormonal influence?

• Head size/ Neck strength?

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Evaluation for Concussion

• Sideline

• Office

• Neuropsych Tests

• Imaging

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Sideline Evaluations• Historically previous generations of athletes were encouraged to “shake it off”.

Therefore no need for detailed recognition of concussion.

• 50% of collegiate athletes eventually diagnosed with concussion did not experience “immediate or near immediate” onset of symptoms.

• Responsibility to recognize signs / symptoms of a concussion lies with all observers.

• The Athlete

• Teammates

• Coaches

• Officials

• Athletic Trainers

• Physicians

• Parents

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SidelineSigns and Symptoms

Education• Since most athletic activity DOES NOT take

place with skilled medical personnel present, the CDC developed the “HEADS UP” program.

• Designed to EDUCATE parents, coaches, athletes, offices.

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Signs Observed• Appears dazed or stunned (such as glassy eyes)

• Is confused about assignment or position

• Forgets an instruction or play

• Is unsure of score or opponent

• Moves clumsily or has poor balance

• Answers questions slowly

• Loses consciousness (even briefly)

• Shows mood, behavior, or personality changes

• Can’t recall events prior to hit or fall

• Can’t recall events after hit or fall21

Symptoms Reported by Athlete

• Headache or “pressure” in head• Nausea or vomiting• Balance problems or dizziness• Double or blurry vision• Sensitivity to light or noise• Feeling sluggish, hazy, foggy, or groggy• Concentration or memory problems• Confusion• Feeling more emotional, nervous, or anxious• Does not “feel right” or is “feeling down”

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Relying on Symptoms??Under-reported symptoms??• McCrea 2004

• 41% “did not want to leave the game”

• 66% “did not think injury was serious enough

• Dziemianowicz 2012; Anderson, Coyne, Kroshus

• Majority thought it was “okay” to play.

• McCrory 2013, Duhaime 2012

• Delayed symptoms

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Sideline Examination Tools• 20 Different Symptom Checklists

• SAC - Standardized Assessment of Concussion

• SCAT3 or Child SCAT3 - Sport Concussion Assessment Tool

• MACE - Military Acute Concussion Evaluation

• Maddock’s Questions24

Challenges to Sideline Evaluation

• “Gold-Standard” for diagnosing a concussion is NOT objective — it is an “experienced clinician…”

• The evaluators familiarity with the athlete probably improves accuracy.

• Comparison to baseline testing is also helpful, but there are many confounding variables.

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Sideline Evaluation• ABC’s

• Neurologic & Mental Status

• R/O c-spine, skull fx, bleed

• Spine board & Transport to appropriate facility if indicated

• Remove from play; close observation

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Standardized Assesment of ConcussionSAC

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SAC in HS & College FB McCrea, JAT ’01

Putukian - Zurich 2012

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SAC Summary

• The SAC is likely to identify the presence of concussion in the early stages postinjury.

• Sensitivity - 80-94%

• Specificity - 76-91%

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Sideline EvalImmediate Memory and Orientation

• Maddock’s Questions

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Maddock’s Questions Putukian - Zurich 2012

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SCAT Symptom

Score

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SCAT 3 - For Child

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SCAT — SymptomsMakdissi- Zurich 2012

• Symptoms are not specific

• Symptoms at baseline

• Predominately studied in high school and collegiate athletes

• Average number = 2-3, Average Score = 5-10

• Common symptoms: headache, fatigue, difficulty concentrating or remembering

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Symptoms Checklist/ ScalesSummary

• Sensitivity - 64-89%

• Specificity - 91-100%

• Self-report of symptoms differs between athletes and their parents, with parent reports demonstrating greater diagnostic utility than youth self-report. (Gioia 2013)

Summary of evidence-based guideline update:Evaluation and management of concussion in sportsReport of the Guideline Development Subcommittee of the American Academy of Neurology

© 2013 American Academy of Neurology

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Sideline Evaluation Balance Testing

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Balance TestingMakdissi- Zurich 2012

• Initial studies used sophisticated/ computerized test platforms- which are not practical for sideline assessment.

• Simple clinical tests - BESS - validated for concussion.

• Baseline Test-ReTest reliability is high.

• Consistent demonstration that balance is affected by concussion.

• Field Side - Modified BESS

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Balance Assessment Putukian - Zurich 2012

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Sideline Tests Sensitivity/ Specificity Summary

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Other Sideline Tools

• Catch a suspended vertical shaft

• Head Telemetry

• Voice Recognition

• Video Replay

• King Devick

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Weighted Stick TestClinical Reaction Time Test

• 80 cm rigid measuring stick coated in friction tape with a weighted rubber disk affixed to one end.

• Athletes sit with dominant forearm resting on a table with hand positioned over the stick edge.

• Examiner releases the stick and the athlete catches as quick as possible.

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Weighted Stick TestClinical Reaction Time Test

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Weighted Stick TestClinical Reaction Time Test

• Authors conclusion:

• Any slowing of reaction time from baseline was significant.

• Sensitivity 75%; Specificity 68% - similar to other current tests.

• Simple to use.

• Low Cost43

Head Telemetry

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Voice Recognition• An IPAD app for voice recognition

• Developed at Notre Dame

• Baseline tests.

• Athlete reads words as they appear on screen.

• Timing, quality of voice recorded.

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Voice Recognition

• Post injury tests compared to baseline.

• Algorithms compare acoustic metrics for multiple voice samples.

• Validity in testing.

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King-Devick Test

• Subjects read numbers on a card. Read from left to right, top to bottom. Timed for a total of three cards.

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King-Devick Test

Neurology 2011;76:1456-1462

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King-Devick Test

• Currently, there is not enough evidence to determine whether the test is effective in diagnosing or monitoring a concussion.

• Sports Related Concussions in Youth

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ER/ Office Evaluation of Concussion

• Symptoms

• Examination

• Imaging

• Computer Neuropsych Tests

• Biomarkers

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ER/ Office Evaluation of Concussion

• Initial Exam focused on need to determine life-threatening head injury.

• Same Symptom checklists as field-side.

• Evaluate for focal neurologic deficits.

• Evaluate neck.

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Monitor Symptom Checklists

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ER/ Office Evaluation of Concussion

• Imaging

• CT - Used when concerned for intra-cranial bleeding, cerebral swelling, skull fractures.

• American Academy of Neurology recently recommended that CT NOT be used to evaluate sports-related concussion in the absence of signs and symptoms of more serious traumatic brain injury.

• (Concern for unnecessary radiation exposure)

• MRI - rarely helpful in acute setting.

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Neuropsychological tests• Tests Available

• ANAM - Automated Neuropyschological Assessment Metrics

• CNS Vitals Signs

• Cogstate Sport

• Headminder

• ImPACT

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Neuropsychological tests• Computer Neuropsych Tests

• Tests domains typically involved in athletic concussion

• Less expensive than paper / pencil

• Less time to administer

• Groups of athletes simultaneously

• Instant information to the provider

• More precise measures of reaction time

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Neuropsych Tests

• Factors that impact the results of neuropsychological tests. McCrory 2005

Test Performance

Psychological FactorsTest AnxietyDepression/ other emotional states

Past historyPrevious concussionsOther head injuriesEducational backgroundPrevious testingDrug useAlcohol use

Other factorsCognitive functionTest setting/ distractionsMotivationFatigueRandom variance/chance

Genetic factorsAgeIntelligenceSexRaceHandednessVisual acuityAuditory acuity

Methodological factorsTesting situationPractice/ learning effectsAdministrator expertise

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Neuropsychological tests• USE FOR DIAGNOSIS?

• Mixed results of the DIAGNOSTIC utility of neuropsychological testing.

• General agreement that Neuropsychological tests should NOT be used in isolation for diagnosis.

• However, high scores on neuropsychological tests, indicating good cognitive function, are predictive of NOT having a concussion.

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Abnormal Neuropsych Test 5-6 daysSymptoms 3-4 days

Neuropsychological tests

• Use for Tracking Recovery and Informing management?

• More sensitive than examination.

• Several studies document persistent post-injury scores even after symptoms resolve.

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Neuropsychological tests• Baseline Tests necessary?

• It is currently unclear if baseline testing vs comparison to normative standards provide clinically useful reduction of risk associated with concussive injury.

• “Although baseline testing is a common practice, studies provide mixed (and limited) evidence concerning the utility and cost-effectiveness of such testing.”

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• 502 athletes ages 10-18 preseason baseline tested with ImPACT.

• Separated into “large groups” or “small groups”

• Younger athletes= more invalid baseline tests

• Larger group testing = more invalid baselines

2013

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Investigations• Neuroimaging (CT, MRI)

• Generally not needed.

• Consider when:

• Focal Neurological deficit

• Worsening symptoms

• Prolonged disturbance of conscious state

• Future imaging modalities

• fMRI, DTI, MRS

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Biomarkers• S100β

• Neuron specific enolase (NSE)

• Glial fibrillary acidic protein (GFAP)

• Tau (cleaved tau, phospo tau, total tau)

• Neurofilament light protein (NFL)

• Microtubular associated protein 2 (MAP2)

• CPK-BB

• Spectrin breakdown products

• β amyloid protein (Aβ)

• Apoliprotein (Apoe)

• Myelin basic protein (MBP)

• Ubiquitin C-terminal hydrolase L1 (UCH-L1)

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Biomarkers

• Active Research

• Insufficient evidence for routine use.

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Return to Play

• NO same day return to play

• Begin when symptom free

• Guidelines will be discussed in next lecture

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Summary• The clinical approach to concussion is evolving.

• Concussion incidence is probably greater than reported.

• There are many clinical advances to the assessment and management of the head injured athlete.

• Sideline evaluation

• Office evaluation

• Return to play decisions

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Key ReferencesAmerican Medical Society for Sports Medicine position statement: concussion in sportKimberly G Harmon, et al. Endorsed by the National Trainers’ Athletic Association and the American College of Sports MedicineBr J Sports Med 2013;47:15–26. doi:10.1136/bjsports-2012-091941

Sports-Related Concussions in YouthImproving the Science, Changing the CultureCommittee on Sports-Related Concussions in Youth Board on Children, Youth, and FamiliesRobert Graham, Frederick P. Rivara, Morgan A. Ford, and Carol Mason Spicer, Editors2013 - THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

Summary of evidence-based guideline update:Evaluation and management of concussion in sportsReport of the Guideline Development Subcommittee of the American Academy of Neurology Christopher C. Giza, , Jeffrey S. Kutcher, MD et al Neurology 80 June 11, 2013

Consensus statement on concussion in sport:the 4th International Conference on Concussionin Sport held in Zurich, November 2012McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313

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