concussion management: sideline assessment and injury recovery by jeffrey s. kutcher

UMIC Sport Concussion Injury Summit

Concussion Management: Sideline Assessment and Injury Recovery

September 24, 2015Jeffrey S. Kutcher, MD

Associate Professor, University of MichiganDirector, Michigan NeuroSport

• Team Physician, University of Michigan• Team Neurologist, US Ski & Snowboard

Team• Director, NBA Concussion Program• Consultant, NHLPA• Consultant, NFLPA• Consultant: ElMindA, Ltd.

Disclosures

1. Things to keep in mind about concussion

2. Know your sport and environment

3. Know your players

4. Concussion Diagnosis

5. Injury management and return to play

Topics

“Concussion” Clinical Timeline

Concussion: transient alteration of brain function as the direct result of a biomechanical force. Days to weeks.

Post-concussion syndrome: complex pathophysiology, both biological and psychological, that occurs after the concussion is over. Months to years.

Chronic effects: unknown pathophysiology, unclear epidemiology. Chronic Traumatic Encephalopathy (CTE), depression, cognitive decrement. Lifetime

Not every injury to the brain causes a clinical syndrome

Not every brain symptom or clinical sign following exposure to mechanical force is due to concussion

During the clinical syndrome of concussion, symptoms may be from something other than than the injury itself

Three concussion axioms

1

1: Injury Threshold

22: Symptom Threshold

FORCE

Injury vs. effect

The initial approach

No Injury Concussion Emergency

Emergency action required

Safety first…

• ABCs• C-spine• Seizure• Level of consciousness• Focality

Common Symptoms

Kutcher and Giza. Continuum, December, 2014

SCAT 3

SCAT 3

Concussion examination

Mental Status – talk to the patientlevel of consciousnessorientationconcentrationmemory

Cranial Nerveseyes: pupils, duction, smooth pursuit, saccades, nystagmus

Concussion examination

Motor and motor controlstrengthcoordinationreaction time

Balance, coordination, vestibular controlRombergFakudacomplex balance maneuvers

Diagnostic (Un)certainty

Kutcher and Giza. Continuum, December, 2014

TIME

INJU

RY

Resolution

Clinical dynamics

FORCE

TIME

INJU

RY

RTP Protocol: R.R.E.S.D

FORCE

Rest (physical)Rest (mental)EatSleepDrink

Common Symptoms

Kutcher and Giza. Continuum, December, 2014

TIME

INJU

RY

RTP Protocol: B.R.A.I.N

FORCE

BikeRunAgility“In red”No restriction

• Get a sense of the timing• Look for inactivity related symptoms• Past medical history• Psychological factors & personality

TIME

INJU

RY

Concussion vs. PCS

Post-Concussion Syndrome

Peel back the layers…• Unplugged Syndrome• Primary headache• Mood• Sleep• Neck• ADHD

Lodestone vs.. Keystone symptoms

Post-Concussion Syndrome

Clinical Approach to Medications

24 hours

“Typical” Conc.

Persistent Conc.

PCS

HA Sleep Mood Attent.

Summary: Key Points

1. Getting the diagnosis right is important

2. Getting the management right is more so

3. These are complex medical decisions

4. Tools only gather information

5. Manage for patient’s overall brain health

Thank you!