Concussions: Evaluation & ManagementWhat is old? What is New? What is the

Future?

Laurel Rudolph, MDMedical DirectorMarshfield Clinic Sports Medicine

Third Annual School Health Skills

August 12, 2015

I, Laurel Rudolph, MD have no relevant financial interest or other relationship(s) with a commercial entity producing health-care related products and/or services.

Financial Disclosures

To provide the most current definition, evaluation, and treatment guidelines for a concussion in a student-athlete

To discuss the role of educators in evaluation and management of concussions in students

To provide information on return-to-school and return-to-play guidelines for youth and high school student-athletes

To discuss school accommodations for students who have suffered a concussion

To share the history and information pertaining to Wisconsin Act 172

Objectives

Concussion - DefinitionDefined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.The disturbance of brain function is related to neurochemical dysfunction, rather than structural brain injury.

“The primary circuit is out”

Traumatic blow does not have to be head to head

LOC not necessary

From: Br J Sports Med 2013

Concussion A METABOLIC CRISIS WITHOUT ISCHEMIA FUNCTIONAL INJURY, NOT ANATOMICAL

Neurometabolic Changes and ConcussionNeurometabolic cascade following experimental concussion. K+, potassium; Ca2+, calcium; CMRgluc, oxidative glucose metabolism; CBF, cerebral blood flow. (Reprinted with permission. Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100.).

Concussion Myths If CAT scan is normal, athlete is OK

Functional -NOT anatomical injury! If athlete feels fine, can return to play

Symptoms may become more severe a few hours after injury

Athlete may not recognize symptoms If no LOC, student does not have a

concussion Over 90% of concussed children have

no LOC Mild concussions are not a big deal

It is a BRAIN injury!!! Concussions not labeled “mild”,

“moderate”, etc…

Wait one week, then may return as “not that bad” Cannot return until symptom

free, which can take days, weeks or even months

Adolescents heal faster than adults Over 20% of adolescent

concussions last longer than 2 weeks

Adolescents have higher risk of injury than adults

Concussion Myths

ER Visits

Data Reasons?

Between 2001 and 2009, ER visits for TBIs in American youth under 20 years old ↑ 60 %

CDC data: 153,375 youngsters were seen in the ER in 2001 vs. 248,418 in 2009

Bicycling and football leading causes

↑ awareness due to local, CDC, media, educational programs (NFL #1)

↑ number of youth participating in activities

↑ parental vigilance↑ self-reporting

Signs and Symptoms

What should I look for?

Physical Headache Dizzy/Lightheaded Nausea/Vomiting Clumsiness/Balance

problems Blurry Vision Poor coordination Intolerance of

light/sound Loss of consciousness

Concussion Symptoms

Emotional Nervousness Anxiety Sad Irritable Personality Changes Emotional swings Inappropriate mood

Cognitive Confusion Disorientation Memory Loss “Head is in a fog” Slow to answer

questions/follow commands

Poor attention

Commonly Reported SymptomsHigh School & College Athletes

Within 3 days of injury Delayed Symptoms

Headache 71%

Feeling slowed down 58% Difficulty concentrating 57% Dizziness 55%

Fogginess 53%

Fatigue 50%

Visual blurriness 49% Light sensitivity 47% Memory dysfunction 43% Balance problems 3%

Lovell, Collins et al, 2004 N=215

Decreased processing speed

Short term memory impairment

Concentration deficit Irritability/depression Fatigue/sleep disturbance General feeling of

“fogginess” Academic difficulties

What symptom at 3 days is most predictive of a protracted recovery?

Answer: Fogginess

Followed by : difficulty concentratingvomitingdizzinessnauseaheadacheslownessbalance difficultylight sensitivitynoise sensitivitynumbness

Lau, Lovell, Collins et al. CJSM 2009

Standard emergency management principles should be used, particularly as they pertain to the spine and to cardiorespiratory compromise.

Appropriate disposition is to be determined by the treating healthcare provider.

Once first aid issues are addressed then further sideline assessment may include the SCAT 3 or similar tool.

The student should not be left alone and serial monitoring should take place.

The student should not return to physical activity the same day.

Sideline Assessment

Evaluate for potential cervical spine injury Remember: student does not have to hit his/her head to have a concussion Assess neurocognitive status If any abnl findings on neuro exam or worsening sx → ER Utilize concussion evaluation tool(s) Do not leave student unattended. Document exam findings!!! Symptom Score Sheet

Initial Care

Sideline Assessment Tool-Not validated in the use of grade school athlete--Cannot detect for impairment from sub-concussive blows

CT-only if suspicion for intra-cerebral structural lesion

fMRI, PET-investigational only Objective balance test (BESS=Balance

Error Scoring System)-identifies postural stability deficits, best used in first 72 hrs

Neuropsychological assessments-computerized testing (ImPACT, Cogsport, etc…), formal neuropsych consult

Genetic testing-experimental

Concussion Evaluation Tools

Noninvasive Measures changes in the state of

oxygenated Hgb Abnormal activation patterns in

the DLPC have been consistently identified in concussion

Time to Recovery: 15 days 25% 25 days 50% 45 days 75% 92 days 90%

Lovell, Pardini, Collins et al. Neurosurgery 2007

Functional MRI

REST-physical & cognitiveNo drivingNo computerNo video games,

moviesLimit textingNo exertional

activitiesNo readingAvoidance of noise,

bright lights

Instructions

Concussion Management Changes

OLD NEW

Cognitive brain rest? Waking person from

sleep at night Not attending school

for ___ # of days Medications for

headache

Rest, rest, rest Maintain a consistent

schedule Seek medical care for

evaluation and treatment

Return to school as sx allow; may require restrictions/accommodations

Physical rest Cognitive rest Academic accommodations Vestibular therapy Visual therapy Physical therapy Headaches may be due to neck strain Medication

Melatonin Low dose amitriptyline Amantadine

Treatment Modalities for Post-Concussion Syndrome

Brain bleedsGet worse as time goes onNeurologic deficits, severe pain, disoriented, LOC

Second Impact SyndromeLeads to brain damage or deathGetting hit while still symptomatic

Post-Concussion SyndromeProlonged symptoms (can last MONTHS!)Affects school & grades, relationships

Future problemsParkinson’s, Dementia, Depression (substance abuse,

suicide), persistent symptoms

What’s the big deal?

Occurs in athletes with prior concussion following often relatively minor second impact

Second impact has been shown to occur up to 14 days post injury

Athlete returns to competition before resolution of symptoms Catastrophic increase in intracranial pressure

Vasomotor paralysis, edema, massive swelling, herniation, death

Most often occurs in athletes <21 yrs oldNeurochemical processes appear to differ in developing

brain

Second Impact Syndrome

Illinois: First law suit filed at the high school level (2014)

Legal Implications

Graduated Return to Play Protocol

1. No Activity2. Light aerobic exercise3. Sport-specific exercise4. Non-contact training drills5. Full contact practice6. Return to play

Each step takes 24 hrs

Progress to next level if no symptoms

If symptomatic, drop back to previous step and try to progress after 24 hr rest

Return to Play

As symptoms allow May limit the

number of hours in school

May not attend certain classes (PE, music, band, shop)

May need to delay return to classes such as math, science

Return to School

Adjust class room seating avoiding exposure to noisy hallways, outdoor light, other distractions

Limit computer/tablet use

Computer/tablet dimming screens

Computer>printed>audio Brimmed hats, sun glasses

Return to School

May require multi-disciplinary approach: health care provider, therapist(s), neuropsychologist, educators, counselor, parents, student

Communication IEP (intervene early) Reassurance Advocate for the student (many experience

guilt, pressure from parents, coaches, self)

Concussed Student with Prolonged Symptoms

Teacher has key role! Knowledge &

recognition that a concussion (mTBI) is a real medical problem

Reassurance Academic

accommodations Psychological support

for student AND parents

Communication

Role of Educator in Return to Academics

ImPACT most widely used Baseline not needed Skilled & experienced provider for

interpretation of test results Results are only one part of decision in

regards to return to academics/sports Not a pass/fail test

Role of Neurocognitive Testing

Age of student Learning disability ADHD Environment Requires experienced provider to administer

test Many students need formal neuropsych

testing

Limitations of Computerized Neurocognitive Testing

Accurately diagnose early R/O more serious intracranial pathology Begin active treatment early Appropriate restrictions on activity Earliest safe RTP decision Prevent post-concussion syndrome Prevent cumulative effects of injury

Cumulative neurobehavioral deficitsLowered threshold to injury

Prevent Second Impact Syndrome

Concussion Management Areas of Focus

Healing Concussions in the Field

Why I love what I do!!!

The Difficult Diagnosis

Alabama (2011) Alaska (2011) Arizona (2011) Arkansas California (2012) Colorado (2011) Connecticut (2010) Delaware (2011) Florida (2012) Georgia Hawaii (2012) Idaho(2010) Illinois (2011) (Chicago has an

ordinance) Indiana(2011) Iowa(2011) Kansas (2011) Kentucky (2012) Louisiana(2011) Maine (2011) Maryland(2011) Massachusetts(2010) Michigan (2012)

Minnesota(2011) Mississippi Missouri(2011) Montana Nebraska (2011) Nevada (2011) New Hampshire (2012) New Jersey(2010) New Mexico (2010) New York(2011) North Carolina(2011) North Dakota (2011) Ohio Oklahoma(2010) Oregon(2010) Pennsylvania(2011) Rhode Island(2010) South Carolina South Dakota (2011) Tennessee Texas(2011) Utah(2011)

State LegislationVermont (2011)Virginia(2010)**Washington(2009)West VirginiaWisconsin (2012)Wyoming

Red-unknownGreen-legislation introduced

2011 Wisconsin Act 172Sideline For Safety Act

Coalition Members Assembly Bill 259 History

Marshfield Clinic UW-HealthChildren’s Hospital of WisconsinNFLGreen Bay PackersWIAAWMSWATAWPTAState Chiropractic AssocWYSA

WIAA defines concussion assessment rules during game conditions-2009April 19, 2011 Wisconsin State Medical Society approves resolution to support State legislatureAB 259 passes WI assembly 11/2/2011Senate passage 3/13/2012Governor Walker signs bill April 2, 2012

Purpose: To educate coaches, student-athletes, and their parents or guardians about the nature and risk of concussions and head injury in youth activities

Wisconsin Act 172

An organized athletic activity in which the participants, a majority of whom are under 19 yrs of age, are engaged in an athletic game or competition against another team, club, or entity

Does not include a college or university activity

Youth Athletic Activity Definition

Coordinators of all youth organized sports shall distribute a concussion and head injury info sheet to all members of coaching staff and participants

No participation until information sheet is signed by the person, and, if he or she is under the age of 19, by his/her parent or guardian

Wisconsin Act 172

An athletic coach, or official involved in a youth activity, or health care provider shall remove a person from the youth activity if coach, official or health care provider determines that the athlete exhibits signs, symptoms, or behavior consistent with a concussion or head injury

Or the coach, official, or health care provider suspects the person has sustained a concussion or head injury

Wisconsin Act 172

Athlete may not return to play until he/she is evaluated by a health care provider and receives written clearance from the health care provider to return-to-play

Wisconsin Act 172

Holds a credential that authorizes the person to provide health care

Practicing within the scope of his or her credentials

Trained and has experience in evaluating and managing pediatric concussions and head injuries

Health Care Provider

Bill SigningApril 2, 2012

Lambeau Field Green Bay

http://www.cdc.gov/concussion http://wiaawi.org http://ww.nfhslearn.com http://www.marshfieldclinic.org/patients/

?page=sportsMedicine_newsletter theconcussionblog.com/state-legislation

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Concussion Information

THANK YOU for caring for concussed students!

Your dedication and commitment to the health and education of our youth is greatly appreciated!

Contact Info: rudolph-kniech.laurel@marshfieldclinic.org

Work # 715-389-3265Cell # 715-223-7108