concussion management: primary care like the pros david m. smith, m.d., faafp march 17, 2014

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Concussion Management:Primary Care Like the Pros

David M. Smith, M.D., FAAFPMarch 17, 2014

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Level the Playing Field

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NFL Concussion Protocol

• Sideline concussion assessment

• Remove from play• Evaluate in locker room• Ipad modified SCAT3• Compare to baseline• Serial assessments

including ImPACT• Initiate follow up plan

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Zurich 2012 Concensus Statement

• Concussion definition– A brain injury with a

complex pathophysiological process affecting the brain, induced by biomechanical forces

– Direct blow or any blow elsewhere causing “impulsive force” to head

Clin J Sport Med 2013;23:89-117

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Concussion

• Concussion typically results in a rapid onset of short-lived impairment of neurologic function that resolves spontaneously

• In some cases, symptoms and signs may evolve over a number of minutes or hours

• Acute clinical symptoms reflect a functional disturbance rather than a structural injury

• May or may not involve loss of consciousness• Symptoms may be prolonged

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Symptom Categories

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Symptom Categories

• Physical– Headache– Visual changes– Nausea– Light or noise sensitivity

• Cognitive– Fogginess– Memory dysfunction– Inattentiveness– Slowed mentation

• Emotional– Lability– Sadness– Irritability– Nervousness

• Sleep– Insomnia– Hypersomnia

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Loss of Consciousness

• 90% of concussions involve no loss of consciousness

• NOT predictive of the severity of concussion

• Nature, burden, and duration of clinical postconcussive symptoms determine severity

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Concussion Symptoms:How Long Do They Last?

• 85% of concussions fully recover in 3 – 4 weeks• 10 – 15 % of concussions result in persistent

symptoms > 10 days• Cases of concussion where clinical recovery falls

outside of expected window should be managed in a multidisciplinary manner by providers experienced in concussion management

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Concussion Management• Acute – “Sideline” assessment– Thorough evaluation– R/O more serious

intracranial pathology

• Post injury– Serial assessmants– Determine “return to play”– Prevent “Second Impact

Syndrome”– Prevent cumulative effects

Best Practice

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Neurological Exam

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Concussion Management: Acute Evaluation

• Maddocks Score– What venue are we at

today?– Which half is it now? – Who scored last in this

match?– What team did you play

last week?– Did your team win the

last game?

• SCAT 3 (Sports Concussion Assessment Tool, 3rd Edition)– Adult and Child versionshttp://links.lww.com/JSM/A30

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SCAT 3

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Acute Cognitive Testing

• Immediate recall– Say 5 words and repeat

them back

• Concentration– Reverse string of digits– Serial 7 substractions

• Delayed recall– Recite 5 words from

previous

Elbow 4 – 9 – 3

Apple 3 – 8 – 1 – 4

Carpet 6 – 2 – 9 – 7 – 1

Saddle 7 - 1 - 8 - 4 - 6 - 2

Bubble

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Neurophysical Balance Evaluation:Vestibular and Visual

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Neurophysical Balance Evaluation:Vestibular and Visual

• Saccades • Optokinetic stimulation

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Neurophysical Balance Evaluation:Visual

• Convergence • Accommodation

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Neurophysical Balance Evaluation:Visual

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Concussion Management:Neurocognitive Evaluation

• ImPACT, AXON Sports, HeadMinder, CNS Vital Signs

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Concussion Management:Return to Activity Guidelines

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Concussion Management:Return to Activity Guidelines

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Case Example # 1

• Veteran NFL FB player with h/o 3 concussions hit right side of head on turf when tackled, no LOC

• Stumbled and walked toward opposite sideline• Appeared dazed and confused• Walked w/o assist to locker room with Team MD• IPAD SCAT3 completed • Blurred vision, no HA, no dizziness or fogginess• Neurologic, balance WNL• Visual: convergence 12 cm, accommodation 15 cm

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Case Example # 1 (cont.)

• Post-injury day 1– Visual symptoms resolved, no new symptoms reported– ImPACT back to baseline– Seen by neurosurgeon per protocol and cleared to begin

functional progression (advance from Phase 1)

• Post-injury day 2– TM walking and light squats w/o symptoms– HA developed several hours later

• Post-injury day 3– Same exercise, same delayed HA response

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Case Example # 1 (cont.)

• Post-injury day 4– Seen by Neurosurgeon at request of ATC and Team MD– MRI with DTI (diffusion tensor imaging) negative– Allowed to return to Phase 2 of functional progression

• Post-injury day 5– Walked on TM, light strengthening and reported mild

dizziness attributed to watching TV while walking– No delayed HA– Decision to hold out of away game and advance functional

progression over next week with RTP 3 wks post-injury

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Teaching Points: Case # 1• On field assessment significantly positive• Serial assessments showed significant subjective

(delayed HA) but mild objective findings• ImPACT post-injury day 1 returned to baseline but

player still symptomatic• Imaging study done due to delayed symptoms • Remote h/o multiple concussions may complicate

recovery but not shown to cause protracted recovery• Establishing trust essential

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Case Example # 2

• High school FB player hit by opposing player’s helmet left side of head

• Felt pain at point of impact but kept playing• Does not recall much of 2nd quarter or half time

(post-traumatic amnesia)• Father observed son kneeling and rubbing head• Evaluated by Team MD and ATC in 4th quarter• Marked dizziness, fogginess, and HA• Required cart to get to car but told to go home

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Case Example # 2 (cont.)

• Parents took son to ER, required assistance• ER MD evaluation and negative CT scan completed• Parents insisted on admission for neurology

consultation• Neurologist diagnosed “complex migraine” and

informed parents he did not think son had concussion

• Discharged home with clearance to play FB in 5 days– Rx for hydrocodone/acetaminophen and phenergan

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Case Example # 2 (cont.)

• Post-injury day 3– Team MD, ATC, and PCP intervened and restricted

athlete to no physical activity and half day school– Fogginess, dizziness, fatigue, light/noise

sensitivity, and mental slowness reported– ImPACT done at school by ATC

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ImPACT: DOI 9/27/13

Baseline (8/16/13) Post-injury #1 (9/30/13) Delayed recovery

Memory (verbal) 82 Memory (verbal) 59 60.5

Memory (visual) 79 Memory (visual) 33 44.5

Visual motor speed 30.42

Visual motor speed 17.02 22.5

Reaction time 0.63 Reaction time 1.07 0.86

Total symptom score 31 Total symptom score 75

Cognitive Efficiency Index 0.38 Cognitive Efficiency Index 0.14

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ImPACT: DOI 9/27/13

Baseline (8/16/13) Post-injury #1 (9/30/13) Post-injury #2 (10/23/13)

Memory (verbal) 82 59 64

Memory (visual) 79 33 38

Visual m. speed 30.42 17.02 23.43

Reaction time 0.63

1.07 0.69

Total sx score 31 75 35

Cog Efficiency Ind 0.38 0.14 0.21

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ImPACT: DOI 9/27/13

Baseline (8/16/13) Post-injury #1 (9/30/13)

Post-injury #2 (10/23/13)

Post-injury #3(11/19/13)

Memory (verbal) 82 59 64 70 (88)

Memory (visual) 79 33 38 55 (78)

Visual m. speed 30.42 17.02

23.43 30.85 (40)

Reaction time 0.63

1.07 1.03 0.61 (0.55)

Total sx score 31 75 47 19

Cog Efficiency Ind 0.38 0.14 0.14 0.27

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Case Example # 2 (cont.)

• F/U evaluation (DOI: 9/27/13; DOE: 12/16/13)– Achieved Return to Learn Step 4 with school

accommodating by allowing him to drop two classes and catch up in remaining classes

– Achieved Return to Play step 3 under ATC guidance– Asymptomatic except for residual intermittent left parietal

headache which resolves spontaneously– F/U with MD scheduled in one month with possible

ImPACT test at that time – PC 1/29/14 mother reports son doing well

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Teaching Points: Case # 2• Learn the signs and symptoms which can predict

prolonged recovery (acute dizziness, subacute fogginess)

• Establish good communication lines with those who can assist in patient accommodations

• Neurocognitive tests are helpful tools • Know when and where to refer for “outliers”• Do not prescribe narcotics or any medications which

may mask symptoms of concussion

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Concussion Management:Primary Care “Do’s and Don’ts”

Do’s• Get educated and gain

experience• Be available• Know your patient and

establish trust• Maximize lines of

communication• Know when and where

to refer

Don’ts• Rush the evaluation or

ignore serial assessments• Hesitate to contact the

experts• Allow pressure to cloud

judgement• Disregard input from those

who know patient well (parents, trainers, coaches, teammates, teachers)

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Thank YouDavid M. Smith, M.D., FAAFPCenter for Sports MedicineClinical Assistant Professordsmith15@kumc.edu

University of Kansas HospitalCenter for Concussion Managementconcussionreferrals@kumc.edu913-945-8006