IT’S ALL IN YOUR HEAD!CARING FOR CONCUSSIONS IN YOUR COMMUNITY

Stephen K Stacey, DOCPT, MC, USA

OUTLINEDefinitionEpidemiologyDiagnosisEvaluationRecoverySequelaePreventionResources for providers

CASEAn 18-year-old high school senior is playing soccer when she collides with the goalpost, hitting her head and falling to the groundShe gets up immediately and tries to keep playingDid she sustain a concussion?

DEFINITION

DEFINITION OF CONCUSSIONConcussion 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 reflect 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.

4th International Conference on Concussion in Sport held in Zurich, November 2012

DEFINITION SIMPLIFIEDAny head-injury event that causes symptoms falls on the traumatic brain injury (TBI) spectrumMild TBI (AKA concussion) has no structural damage and more limited symptomsSymptoms can include:

Headache, sleep disturbance, phonophobia, photophobia, dizziness, weakness, fogginess, difficulty concentrating, more irritable or emotional than baseline, unsteadiness or ataxia, loss of consciousness

CONCUSSION VS. MTBIMTBI: Mild Traumatic Brain InjurySame thing as concussionShown that patients are more concerned about the condition when called MTBI“Concussion” is the more common terminology, even in medical contexts

CLOSED TBI CLASSIFICATION

SEVERITY MILD (CONCUSSION) MODERATE SEVERE

Structural imaging

Normal Normal or abnormal

Normal or abnormal

Loss of consciousness

0 to 30 minutes ≥30 minutes and ≤24 hours >24 hours

Alteration of consciousness

A moment up to 24 hours

>24 hoursSeverity based on other criteria

Post-traumatic amnesia

A moment up to 24 hours

>1 day up to 7 days > 7 days

EPIDEMIOLOGY

EPIDEMIOLOGYConcussions account for nearly 15% of all sports-related injuriesHighest-risk sports: boxing, football, hockey, wrestling, rugby, soccerBike riding is the leading cause of concussion for kidsNot just athletes

Leading causes of TBI

Falls40.5%

Unknown/other19%

Collision15.5%

Motor vehicle14.3%

Assaults10.7%

cdc.gov

CASE CONTINUEDThe athlete is called to the sideline She says she feels “fine” and wants to return to playDoes she require an evaluation?

EVALUATION

ASSESSMENT TOOLSSCAT3

Sports Concussion Assessment ToolFrom Concussion in Sport GroupIncorporates physical examShould be administered by trained medical professionalWidely adopted, multiple derivatives

Child SCAT3Use for patients <13 years old

Pocket concussion recognition toolFrom Concussion in Sport GroupUseful for laypeople or those with limited experienceDoes not incorporate physical exam

MORE ASSESSMENT TOOLSACE

Acute Concussion EvaluationFrom Centers for Disease Control (CDC)Simpler to administer, requires less trainingDoes not take physical exam into account MACECould be administered by MA screening for clinic visit

Military Acute Concussion EvaluationFrom Defense and Veterans Brain Injury Center (DVBIC)Utilized in deployed and non-deployed settingsRequires trained medical professionalCombined with algorithm for comprehensive evaluation and management guidelines

SYMPTOMSSomatic (e.g. headache)Cognitive (e.g. feeling like in a fog)Emotional symptoms (e.g. lability) Physical signs (e.g. loss of consciousness, amnesia) Behavioral changes (e.g. irritability) Cognitive impairment (e.g. slowed reaction times)Sleep disturbance (e.g. drowsiness, insomnia)

4th International Conference on Concussion in Sport held in Zurich, November 2012

EXAMFull neurological exam

GCS?AVPU simpler; as accurate when compared head-to-head

EyesSpeechMotor Balance

Cognitive examOrientationMemory

Immediate and delayedConcentration

ADVANCED IMAGINGNeuroimaging (CT, MRI) is by definition normal in concussionUsed when red flags indicate the possibility of a cerebral or cranial structural lesion, including fracture and bleedingRed flags include:

Progressively declining level of consciousness, pupil asymmetry, seizures, repeated vomiting, GCS <15, motor or sensory deficit, worsening/severe headache

Other modalities such as fMRI have not been shown to be clinically useful, and are not routinely recommended outside of a research setting

NEUROPSYCHOLOGICAL TESTINGNot required for diagnosisMay aid rehabilitationMore useful if baseline testing is performedRequires special training to administer

CASE CONTINUEDYou evaluate the patient and discover that she reports a headache and she seems irritableShe was unable to perform immediate and delayed recallHer neurological exam shows she is unsteady on her feet, though she has no focal neurologic deficits

RECOVERY

RECOVERYMajority (80%-90%) recover within a weekMay take longer in pediatric patientsCornerstone of therapy is physical and cognitive rest until symptoms resolve

Physical Rest No training, playing, exercise, weightsBeware of exertion with activities of daily living

Cognitive Rest No television, extensive reading, video games, homework

Stepwise return to full activityOur job is to educate!

RETURN-TO-PLAY GUIDELINESNever return to play the same day, no matter how “small” the concussionMust be asymptomaticGraded return to play

Same guidelines for “elite” and “non-elite” athletesConsider the patient’s concerns

Are they confident to return?Do they want to continue with the activity?

These guidelines apply to non-sport concussions

GRADUATED RTP PROTOCOLRehabilitation stage Functional exercise at each stage of

rehabilitationObjective of each stage

1. No activity Symptom 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 practice Following medical clearance participate in normal training activities

Restore confidence and assess functional skills by coaching staff

6.Return to play Normal game play

• 24 hours per step (therefore about 1 week for full protocol)• If recurrence of symptoms at any stage, return to previous asymptomatic level and

resume after further 24 hr period of rest4th International Conference on Concussion in Sport held in Zurich, November 2012

BEHAVIORAL HEALTHConcussions may cause behavioral symptoms

Personality changesSleep issues (hypersomnolence vs. insomnia)Depression may result from concussionAnxiety may result, especially as it applies to the activity that caused the concussion

Medications may be used for prolonged symptomsAntidepressants are often usedUse medication that best treats the combination of symptoms

Consider trazodone if insomnia,Consider tricyclic antidepressants if headache is persistent

Multidisciplinary approach

OTHER PROBLEMSNeuroendocrine dysfunctionDizziness

CASE CONTINUEDThe patient is pulled from play and sent to her primary care physician the next dayShe is given a graded return-to-play handout and instructed on physical and cognitive restHer father is in the room and he acknowledges and agrees with the plan

SEQUELAE

POST-CONCUSSION SYNDROMEMost common complication of concussionPersistence of symptoms past 3 monthsReported in up to 40%–80% of concussion patients, though most sources agree it’s the minority of patientsOffer reassurance—most patients fully recoverRefer if primary care management does not resolve symptoms

Consider MRI to evaluate possible other cause of symptomsPsychiatry referralMultidisciplinary TBI team, if available

SECOND-IMPACT SYNDROMEDiffuse cerebral edema occurring when a patient sustains a concussion while still symptomatic from the first concussionCan result in increased intracranial pressure, herniation, coma, deathPatients who survive are often severely disabledExtremely rare

CHRONIC TRAUMATIC ENCEPHALOPATHY

Progressive degenerative disease found in people who have had a severe blow or repeated blows to the headPreviously known as dementia pugilistica due to its association with boxersEducate the patient on the potential for long-term problems and to seek care if concerns arise

CASE CONTINUEDFour months later the patient returns, stating she has had difficulty concentrating and has continued headaches since the collisionShe has been withdrawn and doesn’t spend as much time with friendsHer grades this semester are slightly worse than usual

PREVENTION

PREVENTIONHelmets are designed to prevent skull fracture, not concussionMouthguards prevent dental injury, no effect on concussionRule changes in the sportViolent behavior that increases concussion risk should be eliminated

Promote fair play and respect

RESOURCES

RESOURCES FOR PROVIDERSDefense and Veterans Brain Injury Center

https://dvbic.dcoe.mil/resourcesMACE: https://dvbic.dcoe.mil/files/resources/DVBIC_Military-Acute-Concussion-Evaluation_Pocket-Card_Feb2012.pdfConcussion algorithm: http://www.dcoe.mil/content/Navigation/Documents/DCoE_Concussion_Management_Algorithm_Cards.pdf

SCAT3http://bjsm.bmj.com/content/47/5/259.full.pdf

Heads Uphttp://www.cdc.gov/headsup/index.htmlACE: http://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf

QUESTIONS?

Feel free to email me at stephenstacey@gmail.com

DVBIC CONCUSSION ALGORITHM

MACE ALGORITHM

OTHER QUESTIONS?

Feel free to email me at stephenstacey@gmail.com