Objectives - cdn.ymaws.com · NATA Special Topic 2013 June 27, 2013 © Tamara Valovich McLeod, 2013...

NATA Special Topic 2013 June 27, 2013

© Tamara Valovich McLeod, 2013 1

Management of the Concussed Adolescent

Tamara C. Valovich McLeod, PhD, ATC, FNATAJohn P. Wood, D.O., Endowed Chair for Sports Medicine

Professor and Director, Athletic Training ProgramDirector, Athletic Training Practice-Based Research Network

Objectives1. Increase awareness of current

best practices for sport-related concussion.

2. Discuss best practices for the management of concussion in adolescents.

3. Describe return to physical activity and return to school progressions.

4. Demonstrate concussion assessment using a variety of validated clinical tools.

Top 10 Things to Know

1. Definition

2. Epidemiology

3. Imaging

4. Symptoms

5. Assessment

6. Management

7. Treatment

8. Return to Activity

9. Effects

10. Prevention



1. What is a Concussion

AMSSM (2012)

• A traumatically induced transient disturbance of brain function and is caused by a complex pathological process

AAN (2013)

• A clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness

Zurich (2013)

• A complex pathophysiological process affecting the brain, induced by biomechanical forces

1. 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.

2. Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.

– However, in some cases, symptoms and signs may evolve over a number of minute to hours

3. May result in neuropathological changes– Acute clinical symptoms largely reflect a functional disturbance rather than a

structural injury – No abnormality is seen on standard structural neuroimaging studies

4. 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

– In some cases symptoms may be prolonged.

Features of Concussion

McCrory et al, Br J Sport Med. 2013

• Only 6.3%-8.9% of collegiate athletes demonstrated LOC following a concussion (Guskiewicz et al, 2000 & 2003; McCrea et al, 2003)

• LOC does not necessarily imply severity, nor predict recovery (McCrory et al, 2004)



What is a Concussion?

A Mild Traumatic Brain Injury

2. Who Gets Concussed?



Epidemiology of Pediatric Sport-Related Concussion

• 1.6-3.8 million concussions annually(Langlois, 2006)

– 8.9% of all high school athletic injuries (Gessel, 2007)

• Nationwide estimates of sport-related mTBI hospital charges ~$6 million annually (Yang, 2007)

• Limited epidemiological data in patients under high school age– ~144,000 pediatric (0-19y) patients report to ER

(Meehan, 2010)

Guskiewicz & Valovich McLeod, 2011



3. How Useful is Imaging?

Neuroimaging

• Primary use to rule out intracranial hemorrhage

• CT and MRI – Often used but have little value in assessing less

severe injuries

– CT should not be used to diagnose concussion

– No use in contributing to recovery or return to activity decisions

– Identified as one of the top 5 procedures that should not be ordered regularly

Giza, 2013; McCrory, 2013; Schurr, 2014

The Future of Neuroimaging

• Functional MRI (Chen 2004, 2008; Jantzen, 2004; Lovell, 2007; Slobounov, 2010)

– Abnormal activation patterns consistently reported across studies during working memory tasks

• Diffusion tensor imaging (Zhang, 2010)

• Magnetic resonance spectroscopy (Vagnozzi, 2008; Henry, 2010)



fMRI and Concussion

Lovell et al, Neurosurg, 2007

4. What are the Symptoms?

• Headache• Nausea• Vomiting• Dizziness• Balance problems

• Fatigue• Sleeping less than

usual• Trouble falling asleep• Drowsiness

• Sensitivity to light/noise

• Difficulty concentrating

• Feeling foggy• Feeling slowed • Difficulty

remembering• Vision problems

Cognitive-Sensory

Sleep-Arousal

AffectiveVestibular-Somatic

• Sadness• Feeling more

emotional• Nervousness• Irritability

Kontos et al, 2012



TBI

Anxiety

Depression

Fatigue

Mood States

PCS

HeadacheFatigue

Social

Emotional

School

Dizziness

5. How Should I Assess Concussion?

Concussion Assessment

Clinical Exam

Symptoms

Vestibular -Ocular

Postural Control

Mental Status

Neurocognitive

Acute Concussion: Evaluation

• Signs and symptoms– Any ONE or more present to suspect concussion

• Clinical domains– Cognitive symptoms– Somatic symptoms– Emotional symptoms– Physical signs– Behavioral changes– Cognitive impairment– Sleep disturbances



Concussion Assessment

Broglio, 2014

Acute Concussion Evaluation

(ACE)

http://www.cdc.gov/ncipc/tbi/TBI.htm

• Background– Parent questionnaire

• Prior concussion history

• Past medication and imaging history

• Comorbid factors



• Cognitive and physical evaluation– Standardized Assessment of Concussion – Child

version

– Balance assessment• Modified BESS and/or tandem gait

– Neck Examination• ROM, strength, tenderness

– Coordination

Clinical Tests of Vestibular Function

• Interview / patient history• Oculomotor screening

– Smooth pursuits– Saccades– Gaze stability

• SCC and otoliths– Head shake/thrust– Dynamic visual acuity

• Functional tests– Gaze stability– Balance



6. How Are Concussions Managed?

REST

Physical Rest

Cognitive Rest

Physical and Cognitive Rest

• 1 week of cognitive and physical rest decreased symptoms and increased ImPACT scores regardless of time between concussion and onset of rest (Moser, 2012)

– 1-7d, 8-30d, 31+ d



(Moser, 2012)

Cognitive Rest

No activity

Full activity

Asleep or comatose

Normal school

Goal: limit cognitive activity to a level that is tolerable and does not

exacerbate symptoms

Academic Decline• Have you personally encountered a situation

where a student athlete that you have treated experienced a decrease in school and academic performance as a direct result of a symptomatic concussion?– Yes 79% (n=549)

– No 21% (n=142)

• ~44% of concussions resulted in some form of academic accommodations

Mayfield, RM, In press



Temporary Academic Adjustments

• Excused absence

• Rest periods

• Deadline extensions

• Postpone/stagger tests

• Extend test time

• Light/noise accommodations

• Excuse from PE

• Monitor backpack weight, stair use

• Reader/recorded books

• Note taker

• Smaller, quiet exam room

• Preferential seating

• Tutor McGrath, J Athl Train, 2010

Communication

Athletic Trainer

Coach

School Nurse

Counselor

Teachers

Student

Parents

Outside referral sources

Primary Care

Provider

Piebes et al, J School Nursing, 2009

ACE Return to School



Referral• Neurologist

– Prolonged symptoms, sleep disturbances

• Neuropsychologist– Cognitive deficits, school issues

• Vestibular therapist– Dizziness and balance issues

ED Management

• Rule out more serious injury– With concussion we expect negative imaging

• Instructions for red flags

• Instructions for rest (physical and cognitive)

• Do not clear to RTP– Follow-up with AT/PCP for continued evaluation

and clearance

– Avoid giving RTP timelines

7. What Treatments are Effective?



Pharmacological

• No treatment has been shown to speed recovery

• Management of specific or prolonged symptoms

• Symptoms affecting QOL that benefit of treatment outweighs risks of medication

• Provider is experienced with sport-related concussion

• Concern with masking symptoms or side effects of medications increasing symptoms

McCrory, 2013; Meehan, 2011; Petralgia, 2012

Activity During Recovery?

No school or exercise activity

School activity only

School activity and light activity at home

School and sports practice

School and sports gamesMajerske, JAT, 2008

Active Rehabilitation

• Exercise has a positive effect on mental health

• Closely monitored rehabilitation in post-acute phase improved recovery time in adolescents who were slow to recover (Gagnon, Brain Inj, 2009)

• Controlled subsymptom threshold aerobic exercise improved recovery in athletes with PCS (Leddy, CJSM, 2010, 2011)



Vestibular Rehabilitation After Concussion

Intervention

• Gaze stabilization (X1)• Standing balance• Walking with balance

challenges• Canilith repositioning

Outcomes

• ↓ Dizziness rating• ↑ Activities-specific

balance confidence scale• ↓ DHI• ↑ Dynamic gait index• ↑ Functional gait

assessment• ↓ TUG• ↑ SOT (all conditions)

Alsalaheen, JNPT, 2010

8. When Should a Patient Return to Activity?

Return to Activity

• Progression that begins when asymptomatic– Off medications

– No S&S at rest

– Full return to school

• Return to baseline on adjunct assessments– Neurocognitive

– Balance

Guskiewicz, J Athl Train. 2004



Modifying Factors

More ConservativeManagement

McCrory, 2009

Prolonged Recovery

Authors Sample Size

Population Tests Utilized

Total DaysCognitive

Resolution

Total Days Symptom Resolution

IndividualRecovery

Rates

McCrea et al.2003

94 College Paper and Pencil

3-5 Days 7 Days 91% recoveredw/in 7 days

Iverson et al.2006

30 High School ComputerImPACT

10 days 7 Days 50% recovered w/in 7 days

CollinsLovell, et al.

2006

134 High School ComputerImPACT

NR NR 40% recovered w/in 7 days

Slide Courtesy of Gerry Gioia, PhD

McCrory et al, 2013

~24 hours between each stage



http://www.biacolorado.org/resources/reap.pdf

9. What are the Short- and Long-Term Concerns?

Concerns

Short-term

•SIS•Repeat Injury

Long-term

•MCI•Depression•CTE



Giza & Hovda, J Athl Train, 2001.

Pathophysiology of SIS

Relatively minor second

trauma

Loss of autoregulation

Increases intracranial

pressure

Herniation through the

foramen magnum

Brain stem failure

Mortality rates near 50% and

morbidity rates of 100%



Repeat Concussion

• 4-6 times ↑ risk for subsequent concussion (Gerberich et al, 1983; Wilberger, 1993; Zemper, 1994)

• 3 times more likely to sustain 2nd in same season (Guskiewicz et al, 2000)

• Increased severity with subsequent concussion (Guskiewicz et al, 2000)

0

5

10

15

20

25

30

Basel i

neInj

ury2 H

rsDay 1

Day 2Day 3

Day 5

Day 7

Day 90

Assessment Point

Sym

pto

m S

ever

ity

Control

Concussion

CRITICAL FIRST WEEK:• Average of 7 days for full recovery

• 75% of repeat concussions within first 7 days

• 92% of repeat concussions within first 10 days

Guskiewicz et al, JAMA 2003

Courtesy of Kevin M. Guskiewicz, PhD, ATC

10. Can Concussion Be Prevented?



Protective EquipmentHelmetsProtect against head and facial injury in high velocity sports

Do not reduce the risk of concussions

Helmet CoversNo protective benefit

Concerns with adding weight to helmet (c-spine risk)

HeadbandsLimited research, not encouraged or discouraged

MouthguardsReduces dental and orofacial injuries

No evidence to support reduction in concussion risk

Broglio, 2014; Benson, 2009; Halstead, 2001; ACSM, 2011; Hagel, 2005; Mueller, 2008; Sulheim, 2006

Education

• Concussion symptom video game improved identification in youth hockey players (Goodman, 2006)

• Concussion education increased reporting of concussion symptoms to coaches (Bramley, 2012)

• Every state concussion law requires education

Proper Assessment• Good pre-participation examination to identify

concussion history– Have you ever had an injury to your face, head, skull

or brain that resulted in confusion, memory loss or headache from a hit to your head, having your "bell rung" or getting "dinged" while participating in sports or recreational activities?

• Thorough clinical examination• Use of adjunct assessments• Appropriate follow-up and RTP



Concussion Legislation

Jan 2014

May 2009

AIA Policy

• Education– Training coaches, athletes, parents

– Information sheet and consent

AIA Policy

• Removal From Play– Athlete, coach, AT, team physician, official, or

parent can remove an athlete

• Return to Play– No same day return

– Medically cleared by an appropriate health-care professional prior to resuming

• After medical clearance, RTP should follow a step-wise protocol



Bonus: What Resources Are Available?

Arizona Resources

Concussion Research Registry

Concussion Consultation



OnePass Medical Providers Community



www.atsuconcussion.com

[email protected]

480-219-6035

www.atpbrn.org

Objectives - cdn.ymaws.com · NATA Special Topic 2013 June 27, 2013 © Tamara Valovich McLeod, 2013...

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