Concussion: Evidence-Based Blueprint for SuccessAaron Vaughan, MDMAHEC Sports Medicine DirectorMAHEC/Mission Primary Care Sports Medicine Fellowship Director

Pediatric Grand Rounds16 July 2014

Objectives

•Local, Regional, National Pulse/Resources•Diagnosis of Concussion/PCS•In-Office Framework/Algorithm

▫Vestibular-Ocular Motor System (VOMS)•Evidence-based•Pertinent, Practical

Teaching Points• Know your guidelines

▫NC: Gfeller Waller Concussion Act• Know what you don’t know (and where/who to

look for info)▫CDC, BIANC, Local Providers/Referral Sources

• Know your bonus prizes/red flags▫Cerebral bleeds, Orbital Floor

• Know your exam▫Vestibular-Ocular***

• Know your Options▫School is Key: Accommodate

Local, Regional, National

“Preliminary Approval in NFL Concussion Lawsuit”•Original settlement

▫$675 M for players with neurologic symptoms▫$75 M for baseline testing▫$10 M for medical research▫$112 M lawyers fees

•No cap

Local/Regional: WNC

• >60,000 seen in ER/yr (2007)• Sport-Related: 607/yr (1996-99)

• Football: 33/100k athlete exposures

National ED Visits Hosp Deaths Total2001 420.6 82.7 18.5 521.02002 433.9 85.6 18.3 537.22003 423.3 94.6 18.2 535.42004 486.3 97.6 18.1 601.32005 505.0 92.8 18.6 615.72006 478.9 98.7 18.2 595.12007 457.5 91.7 18.2 566.72008 616.4 95.5 17.7 728.92009 677.4 98.0 17.2 791.92010 715.7 91.7 17.1 823.7

CDC Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2001–2010Per 100,000National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits)

Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths----US, 2001-2010

National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits) National Hospital Discharge Survey — United States, 2001–2010 (Hospitalizations) National Vital Statistics System Mortality Data — United States, 2001–2010 (Deaths)

Rates of TBI-related Emergency Department Visits by Age Group — United States, 2001–2010

National

National Hospital Ambulatory Medical Care Survey — United States, 2001–2010 (Emergency Department Visits)

Case• JA is a 16 year old women’s soccer player who

goes up for a header and instead knocks heads with an opposing player. She has initial dizziness and a headache as well as a left occipital contusion. These symptoms last for 1 hour and by the time she presents to the ER her symptoms have totally resolved. Her parents push for a CT for “clearance” which is normal. She presents to your clinic the next day because her athletic trainer her told her to. She remains subjectively symptom free.

Case (cont)

•Was this a concussion▫Yes▫No

Concussion = Clinical Diagnosis

Mechanism + Symptoms

Algorithm: In-Office•Concussion Algorithm: In-Office

▫A complex vascular and neurochemical process affecting the brain, caused by direct or indirect traumatic forces to the head

Case (cont)

Keys:• Not a

Structural, but a Functional Problem

• Loss of consciousness only occurs in only 10% of concussions.

What is a Concussion?

Signs/Symptoms of a Concussion• Physical

▫ Headache▫ Nausea▫ Dizziness▫ Impaired Balance▫ Phonophobia/

Photophobia▫ Tinnitus▫ Cervicalgia

• Cognitive▫ Confusion▫ Mental “fogginess”▫ Feeling slowed down▫ Concentration difficulties▫ Memory Impairment

• Emotional▫ Irritability▫ Sadness▫ Anger▫ Nervousness/Anxiety▫ Mood lability

• Sleep▫ Drowsiness▫ Sleeping more than usual▫ Restless sleep▫ Increased sleep

latency/Trouble falling asleep

Case (cont)

Case (cont)

•Concussion Types▫Executive▫Psychogenic▫Cervicogenic▫Vestibular▫Ocular▫Migrainous

•Objective #1: Rule out ‘Badness’▫ie: When to send to ER or Need for

Imaging Signs of increasing pressure on brain

Loss of consciousness > 30 seconds Convulsions / seizures Deteriorating level of consciousness or behavior Headache that is rapidly worsening or

becoming severe Late onset of or persistent vomiting Late onset of or worsening amnesia / memory

loss Focal neurological signs (motor function, vision,

speech)

Case (cont)

Keys:• Do not interrupt

sleep to check for symptoms

Case (cont)• An appropriate evaluation in your office would include which

of the following? ▫ A review of her symptoms; a neurologic exam and send her

for a stat MRI▫ A review of her symptoms; a neurologic exam and a

concussion assessment tool ▫ A review of her symptoms; a few memory questions and a

balance test ▫ A review of her symptoms; order a stat MRI and blood

sample checking for elevated levels of S100 calcium binding protein B (S100B)

Algorithm: In-Office

•Concussion Algorithm: In-Office

Exam•Symptom Evaluation

▫SCAT3/Child SCAT3•Exam

▫Physical Orbits Dental Cervical Other distracting injuries

▫Neurologic CN II-XII Gross Motor/Sensory

Exam (cont)

•Vestibular-Ocular▫VOMS

Smooth Pursuits Saccades: Horizontal Saccades: Vertical Convergence (near point) VOR: Horizontal VOR: Vertical Visual Motor Sensitivity Test

VOMS•VOMS

▫Vestibular-Ocular injury: Rotational/Occipital blow Symptoms:

Migraine presentation On-field ‘dizziness’ Vision complaints (blurred, focus issues) Balance problems Motion sickness Anxiety in busy environments Problems with math/screen time/reading

Exam (cont)•Neurocognitive

Exam (cont)

•Neurocognitive: ImPACT▫ What is It?

One piece of the overall concussion evaluation and management process.

A sophisticated test of cognitive abilities. A tool to help health care professionals track recovery of cognitive

function A tool that helps health care professionals and educators make

decisions about academic needs following concussion▫ What isn’t It?

A cure-all for concussion. Concussions still happen.  A substitute for medical evaluation and treatment.

Not a tool to “Diagnose” The only tool out there

Case (cont)• Which of the following recommendations do you

have for her care?▫Have her go into “cocoon therapy” and go to

complete bed rest avoiding all electronic devices ▫She can warm up tonight at 50 % effort and if that

goes well, she can compete without any restrictions ▫Avoid any physical activities that raise her heart rate

and limit cognitive activities that “tire” her brain ▫Allow her to briskly walk the dog and do basic

tumbling moves and limit her Facebook time to less than 1 hour a day

Algorithm: In-Office

•Concussion Algorithm: In-Office

Rest• Gfeller Waller Accommodations• Physical Rest• Avoid activities that elevate heart rate• Applies to all activities: practice, competition, physical education,

dance, non-school based activities, household chores• Avoid further trauma / injury to the brain• Sleep is essential• Hydration/nutrition• 20-30 mins/light aerobic activity• Cognitive Rest• Limit concentration effort

▫ Homework, school work, job-related work▫ Texting, computer, video games or television use▫ May require changes to a normal academic day

• Bottom Line: Don’t do anything that makes symptoms worse!• Use symptom score

Case (cont)• Once she is asymptomatic, has a normal exam and

passes a concussion assessment tool, what level of exercise are you going to allow her first day back? ▫Allow her to briskly walk the dog and do basic tumbling

moves▫Light aerobic exercise (e.g. stationary cycle or walking

laps for 30 minutes) ▫Sport-specific exercises at moderate effort for less than

1 hour (e.g. moderate jog, moderate footwork drills, shooting drills)

▫Start out light for about ½ hour and if she tolerates that, allow her to progress to a full workout that first day

Algorithm: In-Office

•Concussion Algorithm: In-Office

Return to Play

PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSIONKeith H. May, David L. Marshall, Thomas G. Burns, David M. Popoli, John A. PolikandriotisInt J Sports Phys Ther. 2014 April; 9(2): 242–255.

Case (cont)

• What are you going to do for her if her symptoms plateau at 3-4 weeks?

▫ Arrange a referral to a concussion specialty clinic ▫ Arrange for a brain MRI and if it is normal she never really

had a concussion anyway ▫ Arrange for more extensive testing such as an ImPACT test

or CogState test ▫ Have her initiate a return to play protocol to see if it

aggravates her symptoms; if not, allow her to return to full activities once completing the protocol

• Be suspicious when:▫ A concussion seems to be stalling out after one week▫ Concussion symptoms continue after three weeks▫ Concussion symptoms come back shortly after increasing activities

• Is it still a concussion or is it something else (Bonus Prize)?▫ Inner ear problems▫ Cervical spine trigger points or facet problems▫ Migraine cluster▫ Post traumatic stress disorder▫ Something more serious?

Seizure disorder New presentation of brain mass/tumor Subdural hematoma

How do you evaluate someone for Post Concussive Syndrome?

Algorithm: In-Office

•Concussion Algorithm: In-Office

• Be suspicious of a concussion/PCS. “If in doubt hold them out”

• Be familiar with your algorithm; Know your exam (VOMS)• Signs/symptoms change. Evaluate the athlete looking at:

Cervicogenic, Psychogenic, Vestibular, Ocular, Migrainous, Executive dysfunction

• There are many tools to help you on the sidelines and in the office. The law recommends that you use one.

• Initial treatment is based on both physical and cognitive rest until the symptoms resolve.

• Returning to activities is gradual process once asymptomatic. RTP Protocols vary

• Work closely with all of the health care providers involved (athletic trainers, school nurses, consulting neurologist or neuropsychologists) to provide the best care for this complex problem.

Review

• Other web based Resources:▫ CDC Heads Up: Brain Injury in Your Practice

http://www.cdc.gov/concussion/headsup/physicians_tool_kit.html

▫ North Carolina High School Concussion Paperwork http://www.nchsaa.org/health-and-safety

▫ North Carolina Concussion Clearance Form http://gfellerwallerlaw.unc.edu/GfellerWallerLaw/gwl

aw.html▫ Brain Injury Association of North Carolina

http://bianc.net/ ▫ Zurich Concussion in Sport

Resources

Aaron Vaughan, MDMAHEC/Mission Sports Medicine

aaron.vaughan@mahec.nethttp://mahec.net/patient-information/family-health/sports-medicine

330-904-9273

@DrAJVaughan