New Insights in Concussion Management...• NCAA Division I soccer coaches (n=40) and athletes...
Transcript of New Insights in Concussion Management...• NCAA Division I soccer coaches (n=40) and athletes...
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New Insights in Concussion Management
Jim Chesnutt, M.D.OHSU Sports Medicine
OHSU Concussion ProgramOrthopaedics & Rehabilitation
and Family MedicineOCAMP
Recognize: Remove: Refer : Return
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Concussion: Objectives
• Learn about state laws regarding concussion recognition and management
• Learn and apply current guidelines for concussion management and rehabilitation
• Develop strategies to help our patients recover from a concussion
• Highlight recent research and collaborations I have no conflicts of interest.
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Clinical Concussion Care
• Sideline Evaluation:– SAC, SCAT, Impact, ??
• Home Eval• ED Eval• Clinic Eval• Clinic follow- up care• Rehab and speciality care
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What is a Concussion?• A concussion is a mild
traumatic brain injury that interferes with normal function of the brain
• Evolving knowledge- “dings” and “bell ringers” are brain injuries- no such thing as a mild concussion
• Loss of consciousness is not common in concussion(<10%)
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Concussion: Helmet to helmet hit
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Concussion Mechanics/ Biology• Aceleration/ Deceleration • Linear/ rotational• Neurometabolic energy crisis• Decreased cerebral blood flow, glucose• Abnormalities Glutamate, K, Na, Ca, etc• Endocrine, neurochemical abnormalities• Neuron injury and Axon shearing• Bleeding is unusual
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Concussion• Symptoms are variable for each individual
in terms of type, intensity and duration• Classified into four main areas:
– physical ( HA, dizzy)– emotional ( agitated, quiet, depressed), – cognitive ( memory, processing)– sleep (falling and/or staying asleep)
• Cumulative impairment can occur• 3x more likely to get a second concussion
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Symptoms• Headache 75%• Blurred vision 75%• Dizziness 60%• Nausea 54%• Memory/ confusion 40-60%• Double vision 11%• Noise sensitivity 4%• Light sensitivity 4%• Loss of consciousness 5-10% Carney, Ghajar et al 2014
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New Definitionevidence- based systematic review
1.) a change in brain function;2.) following a force to the head( +/- hit)
-a potentially concussive event; 3). may (or may not) be accompanied by temporary LOC; 4.) identified in awake individuals; and 5.) includes measures of neurologic and cognitive dysfunction. (Carney, Ghajar et al., 2014.)
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Concussion -consistent and prevalent diagnostic indicators
1.) observed and documented disorientation or confusion immediately after the event; 2.) impaired balance within 1 day after injury; 3.) slower reaction time within 2 days after injury; and /or 4.) impaired verbal learning and memory within two days after injury. (Carney,Gjahar, et al., 2014.)
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Dynamic Model of Concussion
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Newer Data High School RIO 2012Injury rate per 10,000 player exposures competition• Football 22.9• Boys’ ice hockey 14.6• Boys’ lacrosse 10.4• Girls’ soccer 9.2• Girls’ lacrosse 8.6• Girls’ basketball 5.5• Boys’ soccer 5.3• Boys’ wrestling 4.8• Girls’ field hockey 4.1• Boys’ basketball 3.9
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Concussions• Estimated 3 mil sports-
related head injuries in US athletes yearly
• 9% of all sports injuries• 700-2000? head-injuries
in Oregon HS athletes based on OSAA participation #s
• Pros: lower incidence possibly 10x lower
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Soccer-Football and Concussion
• Estimate 270 million players world wide• 27 mil in N America• 60% concussions- contact related to headers
but not headers themselves• 40% - arm/ elbow to head• Female more ground contact• Heading may be related to brain injury
– Some NP changes if 1000yr > if over 1800?
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Concussions: The Problem
• We now realize concussions occur more often than previously thought
• Young athletes are at risk for serious short-term and long-term problems
• There is much variation in the knowledge of Health Care Providers managing concussed athletes
• New and emerging technologies will lead to a continuing evolution of care
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Concussions:The Oregon Plan
State-wide concussion management program involving all high schools• Establish state-wide
physician network • Uniform evaluation and
management protocol• Consultation service for
coaches, athletes, parents, and physicians
• ImPACT baseline suggested for contact and collision sport athletes
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Oregon Concussion Awareness and Management Program (OCAMP)
Multi-disciplinary group across the state:Educators, Physicians, Neuropsychologists,
Certified athletic trainers, Rehab TherapistsBrain Injury Association of OregonAthletic Directors(OADA), Center for Brain Injury Research and TeachingRepresentatives from OSAA , OR Dept of Ed.
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Concussions: The Oregon Plan
Portland: OHSUDr Chesnutt/King/Wilhelm
Eugene: SlocumDr. Mick Koester
Bend: The Center-St Charles Hosp.Dr. Sondra MarshallDr. Viviane Ugalde
Regional OCAMP Concussion Centers
^^^^^^^^^^^^^^^^^^^
Each helps “oversee” programs at the “satellite” sites and help local doctors/trainers care for their own athletes
*
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Max’s Law: Sports Concussion(SB 348- April 2009, 1st one passed!)
Max Condradt is an OR brain- injured athlete hurt in football.• No return-to- play the same day as
concussion • Medical release needed to return to play• Yearly coach concussion education required
– Free for coach : www.osaa.org/healthandsafety/concussion.asp
• Effective: July 2009
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Max's Law - Sports Concussion SB 348
Left to right: David Kracke, Max Conradt, Governor Ted Kulongoski, Tootie Smith, Sherry Stock
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Max’s Law: The 4 R’s
1. RECOGNIZE:– all coaches must receive annual training in recognizing
the symptoms of concussion.2. REMOVE:
– no same day return to play3. REFER :
– must be evaluated by a properly trained medical professional.
4. RETURN :– all symptoms resolved, graded return to play over
about one wk and a medical release has been obtained
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New 2013 Oregon Bill Concussions in Club sports
Jenna Sneva, ski racer, >12 concussionsJenna’s Law
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Concussions: New Science
• Research indicates that HS athletes with less than 15 min of on- field symptoms exhibit deficits on formal neuropsychologic testing and re- emergence of active symptoms, lasting up to one week post-injury.
• Symptoms often return with exertion• Suggests we are returning athletes too early
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New Concussion Science• Baseline neuropsych testing of Pro Athletes
in NFL, NHL, Baseball and other sports • Higher incidence ( 3X) of depression if >3
concussions in Pro athletes in some studies• Risk of premature dementia• Possible brain damage
– Brain lesion : tau protein deposition– Similarities to Alzheimer's/Parkinson’s– Higher risk if certain genes (APO E -4) – CTE chronic traumatic encephalopathy
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?Technologic
cure?
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New Guidelines published in 2013!
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AAN 2013 Concussion Guidelinehttp://www.neurology.org/content/80/24/2250.full.pdf+html
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Signs on the Field• Appears dazed• Confused about play• Moves clumsily• Answers question slowly• Personality/behavior change• Forgets plays prior to hit
– **Retrograde amnesia**• Forgets plays after hit
– Anterograde amnesia• Loses Consciousness
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The Knowledge and Decision Making Behaviors of NCAA Division I Soccer
Coaches and Athletes toward Concussions Jessica Tsao, Jacqueline D. Van Hoomissen and Terence G. Favero
• NCAA Division I soccer coaches (n=40) and athletes (n=66) Rosenbaum Concussion Knowledge and Attitudes
• coaches and athletes demonstrated moderate to strong knowledge but deficits in the areas concerning concussion diagnosis and severity.
• athletes exhibited statistically significantly more unsafe attitudes than coaches regarding concussion management during games and practices (p < 0.002). Many athletes indicated a willingness to play
• with a concussion• This study highlights the need for intentional concussion education that
moves beyond identification of concussion and begins to change the
attitudes of athletes towards playing while concussed.
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Later Signs of Concussion(Post-Concussion Syndrome)
Decreased Processing Speed
Short-Term Memory Impairment
Concentration Deficit
Irritability/Depression
Fatigue/Sleep Disturbance
General Feeling of “Fogginess”
Academic Difficulties
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Assessment and Management
• When to go to ER– Difficult to arouse or
awaken or walk– Ongoing nausea and
vomiting– Worsening headache– Changes in vision– Unequal pupils– Severe Confusion or
disorientation
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Second Impact Syndrome
• Injury before recovery from the previous head injury
• May cause brain swelling from loss of normal control of brain blood flow– Rare but deadly, more common in teenagers
• Prevention is the key…….– Do not return to play too early
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Head Injury Data in the EDA five ED study in Canada of 10,000 patients
Clin J Sport Med 2001;11:77–81. ED pts with non-Sport/Recreation-related
injury were most commonly involved in• falls (38.5%)• vehicle-related injury (31.3%) • victims of intentional injury (11.4%)• LOC 40%• Cycling and playground > “sports”
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CT ?MRI ?fMRI?DTI?
90% normal
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Brain Imaging in Acute TBI• The Canadian Head CT decision rule-
for predicting positive CT – 100% sensitive ( picks up all problems)– 46% specific ( picks up more unrelated
problems)– 13 % positive if meet criteria– All negative if no criteria
– Therefore can limit scanning safely!
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Sport Concussion Assessment Tool ( SCAT)
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The Goal of Appropriate Treatment
• Minimize the duration of symptoms• Return to play as soon as safely
possible• Avoid entirely the risk of second impact
syndrome• Minimize the rate of chronic post
concussion syndrome
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Concussion Guidelines
1. No Same Day Return to Play
2. Return to Play Recommendations*approximately one week out*
Symptoms fully resolved-and-
Complete a structured, graded exertion protocol over approximately 5-7 days without symptoms
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Quick Recommendations• Stay home from school/ work for at least 2
days until significant improvement• Use tylenol for the first 3 days post injury• Some nausea/vomiting is common and OK• No need to awaken all night if stable at 2-4 hrs
post concussion• Light exercise is OK and maybe beneficial• Avoid screen time, extreme noise + light
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Concussion recovery: How long does it take?
n = 134 male football athletes
Collins et al; Neurosurgery 2006
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Concussion prognostic Factors
• Athlete pre-injury characteristics:– Previous concussions– Migraine ( personal and family)– Vestibular or occular issues– ADD or learning issues– Genetics ( apoE 4)– Age/ gender?
• Am J Sports Med 399110:2311-2318
suggesting slower recovery
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Concussion Prognostic Factorssuggesting slower recovery
• Post concussion symptoms:– Early dizziness/ imbalance( 7x risk >21 days)– Nausea and Vomiting– Diff concentrating and fogginess– Photo/ phonosensitivity
– Early intervention seems to impact recoveryAm J Sports Med 399110:2311-2318
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Return to Play considerations• All symptoms need to resolve
– This includes HA in acute phase ( 3 months) – Follow symptom log
• Neurocognitive scores usually normalize after symptoms resolve
• Start return to play protocol• If symptoms recur with exercise, school, work
or play: remove from activity/ modify RTP plan
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Balance screening after concussion
• Balance assessment recommendations in 2009
• BESS (modified) is used • (subjectively counting errors)
• Sensitivity 34%–64% to detect mTBI• ↑ in scores with exertion or fatigue (~20 min)• ↑ in scores if ankle instability• Balance reportedly resolves after 3-5 days
But may be due to insensitive testing
Need better balance tests- developed at OHSU
(Zurich 2008; McCrory 2009, Guskiewicz 2001, Finnoff 2009, King 2013, Giza 2013)
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Wearable sensors to instrument clinical balance and gait testing
to improve objective assessment after concussion.
Laurie King, PhD, PTJim Chesnutt, M.D.
Oregon Health & Science University Dept. of Neurology and Sports Medicine
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Instrument the BESS using an inertial sensor
Inertial sensors: similar to force plate -Portable-Automatic analysis
New portable, wearable and wireless technology
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Instrumenting the BESS could best classify chronic concussion vs healthy
(Mancini et al., 2012, King et al 2013)
King LA, Horak FB, Mancini, Pierce D, Priest KC, Chesnutt JC, Sullivan P, Chapman JC. Instrumenting the Balance Error Scoring System for use with patients reporting persistent balance problems after mild traumatic brain injury. Arch Phys Med Rehabil. 2013 Nov 4.
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Return to play
Also – balance tends to worsen after return to play as suggested in our data and data from Howell at Univ Oregon*
3.8 x increase in ortho injuries in 90 days post concussion RTP 2013
*King et al, 2014*Howell D. MS, Osternig L. Chou L. 2015 .
*
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Dynamic balance during walkingGait variability larger after concussion
worse with dual task
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Conclusions
• Approximately half of acutely concussed athletes had abnormal balance and a subset returned to play before normal balance was restored
• In acutely concussed athletes, instrumented mBESS was more sensitive than clinical mBESS
• Gait may be most impaired under dual task and using variability measures.
• Balance appears to worsen after RTP
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AcknowledgementsFunding:• NIH; Research reported in this publication was supported by the Eunice
Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number R21HD080398.
• Oregon Clinical and Translational Research Institute (OCTRI), grant number (KL2TR000152) from the National Center for Advancing Translational Sciences (NCATS) at the National Institutes of Health (NIH). CTSA grant number(UL1TR000128)
• Medical Research Foundation of OregonCollaborators:• Laurie King, PhD, DPT• Jim Chesnutt MD, Department of Sports Medicine, OHSU• Martina Mancini, PhD Department of Neurology, OHSU• Fay Horak PhD, PT, Department of Neurology, OHSU• Chapman JC PsyD (Dept of Neurology, Washington, DC VAMC)
Participating Universities: Portland State University, Lewis and Clark Univ,George Fox University, Pacific University, Concordia
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Neuropsychologic testing:ImPact/ Axon Testing
:• Standardized, computerized, validated
– Memory, attention. processing speed• Documents subtle impairments• 60-70% correlation with symptoms• Worse at 48hrs and recovers 1-4 weeks• 94.6% sensitive and 97.3% specific
– Schatz,Sandel Am J Sports Med 41(2);321-326. 2012
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N=215, MANOVA p<.000000 (Lovell et al., 2004)
Testing revealscognitive deficitsin asymptomaticathletes within 4 days post-concussion
Unique Contribution Of Neurocognitive Testing To Concussion Management
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Impact testing in computer labRyan Rockwood, ATC
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Module 1: Word Discrimination
Module 2: Design Memory
Module 3: X's and O’s
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Concussions: Return to PlayA Step-wise symptom limited program
1. Rest until asymptomatic ( Recovery: physical,mental )2. Light aerobic exercise ( HR: 70% max, jog, exercise bike)3. Sport- specific exercise( Add movement: No head impact)4. Non-contact training drills (Exercise intensity,Coordination
and cognitive load: add wt lifting, passing, plays )5. Full contact training (After medical clearance: Restore
confidence and asess functional skills by coach/ ATC)6. Return to competition( game play)
Each stage is 24 hrs or longer, lower stage if symptoms recur
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Return to Academic Plan1. RECOGNIZE:
Concussion management team identifies student’s concussion and informs teachers
2. REMOVE/REST:Students remain home for 2 days or more with physical and cognitive rest
3. REFER :Students suspected of sustaining a concussion must be evaluated and cleared by a properly trained medical professional.
4. RETURN :Develop return to academic plan with educational accommodations with modified environment and work load. Consider freezing grades early and be flexible with transitions. Back to school before athletics!
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Heads Up: CDC Concussion Tool Kit• Coaches Guide• Athlete and parent Packets• Videos and Educational programs• Media informationwww.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
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Resources
• www.ohsusportsmedicine.com• CDC “Heads Up”: www.cdc.gov/concussion/• Oregon Concussion Awareness and Management Program:
www.ocamp.org• Center on Brain Injury Research and Training: www.cbirt.org• Brain 101: http://brain101.orcasinc.com• Neuro-Optometric Rehabilitation Association (NORA):
www.nora.cc• Brain Injury Association of Oregon: www.biaoregon.org/• Brain Injury Association of Washington:
www.braininjurywa.org/
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OHSU Concussion Center
The NW’s most comprehensive, multidisciplinary concussion care center • Cutting edge research and clinical care
– Concussion rehab and clinical outcomes– Sensory Integration: balance & auditory processing– Chronic traumatic encephalopathy(CTE)-tau protein– Informatics and clinical guidelines
Partnerships- academics, community and industry
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OCAMP
Brain Injury Rehabilitation Center (BIRC)
Stanford
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OHSU TBI- PTSD Research to Rehabilitation Scientific Symposium
School of MedicineResearch Roadmap
Collaboration Advancement Award
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OHSU TBI/ PTSD ConsortiumDr. Jim Chesnutt, SM, Orthopaedics & Rehab, FM
Dr. George Keepers, Chair of PsychiatryDr Nathan Selden, Vice chair Neurosurgery
• Over 150 clinicians and researchers• Research on basic science pathophys &
imaging• Clinical research: trauma, balance, education• Multidisciplinary teams, inpt, outpt, outreach• VA Collaboration, auditory processing, neuro
trauma, PTSD, research, rehab protocols• Medical Informatics, EBM, policy
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OHSU Concussion Management
• Pre-season Impact baseline testing– Can do whole team or individuals
• Athletic trainers on- field and in injury clinic• Post –concussion evaluations
– Physician and ATC evaluations & Impact testing• Concussion Rehabilitation Team
– PT, Vestibular/ENT, SLP/ cognitive,OT/vision• Severe/Chronic: Neuropsych, Neuro, NSurg
Sport Concussion Support Group (student/family)
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Interdisciplinary approach: OHSU Model
ATC Sports Med
On the field
Comprehensive Neurological Rehab Team
OT
SLP
PT
3 wks
Vision Therapist
School coordinator
Neuropsychologist
ED
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OHSU Concussion Rehab TeamA. Physical Therapy: for vestibular therapy and neck and
associated orthopaedic issues and exercise prescription and therapy.
B. Speech –language Pathologist: for evaluation and treatment to address cognitive and executive function issues
C. Occupational Therapy: for visual and functional therapy.
D. Concussion Coping Clinic and Support GroupThis is on the 1st floor of OHSU Center for Health and Healing.Please call 503-494-3151 to schedule an appointment but this will likely need to be approved by your insurance
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OHSU Concussion TeamSports Medicine Doctors
Jim Chesnutt, M.D. Charles Webb, D.O. Ryan Petering, M.D. Melissa Novak D.O.
Rachel Bengtzen M.D. Doug McKeag, M.D.
Physical/ Vestibular Therapy Jennifer Wilhelm, PT, DPT,NCS Jeff Schlimgen, PT, MSPT,NCSMarvin Smith, PT, DPT Kitty Leelaamornvichet, PT, DPTSarah McCollister, P.T.,DPTJyndia Schaible, PT, D.P.T.Amy Woods, PT, DPTMargaret McReynolds, P.T., M.S.ED
NeuropsychologySara Walker, PhDMuriel Lezak, PhDLeeza Maron, PhDBonnie Nagel, PhDTrevor Hall, PhDSue Gritzner, PhD
Occupatioanl / Visual TherapyRosane Yee , O.T.R./L., Anne Marie Banasky, OTR/L
Speech/ Cognitive TherapyMichal Rubin, MS, CCC-SLPHaley Landau, MS, CCC-SLP
Certified Athletic TrainersRyan Rockwood, Juliet Baker,
Orthopeadics / SpineFamily MedicineNeurology Peds/ AdultNeurosurgeryPsychiatryAnesthesia/ Pain CenterENT/ vestibularOphthalmologyEmergency MedTraumaInternal MedicinePediatricsRadiology
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Interdisciplinary Approach: Concussion Symptoms
Adapted from Collins MW et al; Knee Surg Sports Traumatol Arthosc 2014
Concussion
Anxiety/Mood
Ocular
Cognitive
Migraine
Cervical
VestibularAuditory
Autonomic
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Physical Therapy and concussion management
• Address musculoskeletal problems: headache and neck pain
• Balance and coordination exercises including dual task activities
• Gaze Stabilization, VOR, balance master/SOT• Exercise tolerance- stress testing• Step wise return to play• Education
– Diagnosis, prognosis and timeline• Reassurance of favorable prognosis
– Symptom management– Assist with proper referrals
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Occupational Therapy and Concussion Management
• Visual deficits – Reaction time– Scanning– Eye movement skills– Accommodation– Convergence– Slowly integrate
visual activities (age appropriate)
– Ciuffreda et al Optometry 2007
60%of patients with mTBI have various oculomotor deficits
90% of visually-symptomatic mTBI had some form of oculomotor dysfunction• Behavior: Self regulation• Pacing• School/work
accommodations for vision
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Visual deficits: Vestibular Ocular Reflex (VOR)
• Dynamic visual acuity (DVA)– Stand 20’ from Snellen
chart– Head moved at 2 Hz
(horizontal and vertical)– (+) if > 2 lines– Vestibular: Sensitivity
94.5%; Specificity 95.2%
Schubert et al Phys Ther. 2004Peterson MD J Head Trauma Rehabil 2010
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Speech Language Pathology and Concussion Management
• Memory• Speed of processing• Word finding• Attention• Executive function
– Planning, – Problem solving – Organization
• Social cognition• School interventions
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Summary• Must improve early identification & diagnosis
• Coach, athlete, parent, Correction officer, medical education
• Careful individualized clinical assessment and tracking from time of injury• SCAT3• Neuropsychological Testing ( Impact, Axon, or full)
• Innovations in researchimprove evaluation & treatment • Implement active treatment in home & school
school accommodations, 504 plan, OCAMP.orgMax’s Law Implementation Guide- download
• Free coaches education: You too can take this… www.osaa.org/healthandsafety/concussion.asp
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Concussion Final thoughts…Even helmets won’t prevent concussions!
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Sports Concussion ManagementContact our sports medicine team for questions:
Jim Chesnutt, M.D. [email protected] Webb, D.O. [email protected] Petering, M.D. [email protected] Novak, D.O. [email protected]
Rachel Bengtzen, M.D. [email protected] Doug McKeag, M.D. [email protected]
www.ohsusportsmedicine.com or 503-494-4000