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Deep Impact:

Evaluating Concussion and its

After Effects

Mim Smith MD

Swedish First Hill Family Medicine Residency

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Objectives Perform initial in-office evaluation

Know when to refer

Implement general return to play program

Understand potential long-term consequences

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Epidemiology 3.8 million sports concussions annually in US

2.5 concussions per 10,000 athletic exposures in high

school students

American football has highest number followed by girls

soccer

M:F ratio of 2-2.8:1

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Clinical case 18 yo female high school soccer player. She collided

heads with another player during a game at a tournament over the weekend and was removed from the game due to concern for concussion. There was no LOC

Comes to your office for evaluation 2 days after the initial injury

PMH: depression/anxiety (sees a therapist)

Current sx: headache, difficulty sleeping and concentrating, fatigue, photophobia

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Which is true of concussions?

A. LOC is common

B. Requires a direct blow to the head

C. Requires neuroimaging for diagnosis

D. Is diagnosed clinically

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Definition Complex pathophysiological process affecting the brain

induced by biomechanical forces.

Common features include:

Direct blow to head, face, neck or elsewhere w/impulsive

force transmitted to head

Rapid onset of impairment in neurological fxning that

resolves spontaneously

Functional rather than structural injury

May or may not involve LOC

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Which is true of concussions?

A. LOC is common

B. Requires a direct blow to the head

C. Requires neuroimaging for diagnosis

D. Is diagnosed clinically

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“Concussions are like snowflakes…”

Accurate/focused hx

Pertinent physical exam

Mental status

Focused neuro exam

MSK

Ocular

Balance

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Clinical Tools

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SCAT 3 Background hx

Symptom score

Cognitive exam

Neck exam

Balance exam

Coordination

Delayed recall

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Acute Concussion Evaluation Form

Injury characteristics

Symptom checklist

Risk factors for protracted recovery

Red flags

Diagnosis

Follow up action plan

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At Risk Populations Hx of > 3 concussions

Women, children

Hx of mood or learning disorders

Hx of migraine

Family hx (migraine, mood, learning d/o)

ApoE4 gene?

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Clinical Case Remains symptomatic 2 days after initial dx

ACE evaluation completed

Hx of mood d/o

Current high school student

What should we recommend for:

Current management

Return to learn

Return to play

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Which is true regarding prevention and

managementof concussions?

A. Medication can hasten recovery

B. Helmets can prevent concussions

C. Most concussions resolve in 7 – 10 days

D. Increased cognitive activity helps in recovery

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Management 80 – 90% of concussions resolve in 7-10 days

Cornerstone of rx is physical and cognitive rest

Tailor management to each individual

Serial evaluation and management

Medications and supplements are not helpful

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Prescribed Rest?? Journal of Pediatrics – November 2012

Small study of 49 high school students referred to a

sports concussion center

Prescribed 1 week of complete rest

Participants had significantly improved performance on

cognitive assessment and decreased symptoms

following rest

Limitations

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Too much rest?? Recent study in Pediatrics – Feb 2015

2 groups 5 days of strict rest at home vs usual care

(gradual return to activity)

Rest group slower resolution of sx and higher sx

burden in the first 10 days

No significant difference in balance scores, neuropsych

testing, or neurocognitive assessments

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Return to Learn 24 – 48 hours of complete rest

Includes activities such as reading, video games,

screen time, social interactions

Return to school when able to concentrate 30 – 45

minutes without symptoms

May need accommodations

Anticipatory guidance to avoid activities that worsen

symptoms

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Return to Play Graduated protocol no same day RTP!

Criteria to start protocol

Each step should take minimum 24 hours

Drop down a step if any sx occur and wait 24 hours

before attempting next step again

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Return to Play 1. Light aerobic exercise

2. Sport-specific exercise

3. Non-contact training drills

4. Full-contact practice

5. Return to play

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When to Refer Anything outside expected normal course of recovery

Worsening of sx

Medical or psychiatric complications

Prolonged recovery (>3 – 4 weeks)

Concern for post-concussion syndrome

Physician discomfort

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Long-term Consequences Post-concussion syndrome

Symptom complex that includes headache,

dizziness, neuropsychiatric symptoms, and cognitive

impairment

Consider if sx remain > 3 weeks after injury

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Long Term Consequences Chronic traumatic encephalopathy

Neuropsychological deficits following multiple

concussions

Diagnosed on autopsy

NFL players, boxers

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Are Helmets Helpful? No consistent evidence that they prevent concussion

Sport specific

Risk compensation

Can prevent skull fractures

Consider rule changes

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Which is true regarding prevention and

management of concussions?

A. Medication can hasten recovery

B. Helmets can prevent concussions

C. Most concussions resolve in 7 – 10 days

D. Increased cognitive activity helps in recovery

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Key Points Concussion remains a clinical diagnosis

Clinical assessment tools – SCAT3, ACE form

Develop individualized rx plan with gradual RTL/RTP

There are limitations to protective equipment for

concussions

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Resources Providers

SCAT3/Child SCAT3

ACE form – cdc.gov

AAFP webinars – aafp.org/concussion-awareness

Consensus statement on concussion in sport

Parents

ACE care plan

AAFP pt education brochure (Sports Related

Concussions in Youth)

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References Centers for Disease Control and Prevention. Injury Prevention & Control: Traumatic Brain Injury.

Traumatic Brain Injury. Available at: http://www.cdc.gov.offcampus.lib.washington.edu/TraumaticBrainInjury/index.html)

Evans, R. (2013). Postconcussion syndrome. UpToDate. Retrieved from http://www.uptodate.com

Evans, R. (2015). Concussion and mild traumatic brain injury. UpToDate. Retrieved from http://www.uptodate.com.

Guerriero, R, Proctor, M, Mannix, R, Meehan. (2012). Epidemiology, trends, assessment and management of sport-related concussion in United States high schools. Current Opinion Pediatrics 6: 696-701.

Halstead, M, McAvoy, K, Devore, C, Carl, R, Lee, M, Logan, K. (2013) Returning to learning follow a concussion. Pediatrics. 132(5): 948-57.

Kutcher, J, Eckner J. (2010). At-risk populations in sports-related concussion. Current Sports Medicine Report. 1, 16-20.

McCrory, P, Meeuwisse, W, Aubry, M, et al. (2013). Consensus statement on concussion in sport: the 4th internation conference on concussion in sport held in Zurich, November 2012. British Journal of Sports Medicine, 47, 250-258.

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References Meehan, W, O’brien, M. (2015). Concussion in children and adolescents – management.

UpToDate. Retrieved from http://www.uptodate.com

Powell, J, Barber-Foss, K. (1999). Traumatic brain injury in high school athletes. JAMA.

282(10): 958.

Sulheim, S, Fkeland A, Bahr. (2006). Helmet use and risk of head injuries in alpine skiers and

snowboarders. JAMA, 298(8), 919.

Thomas, D, Apps, J, Hoffman R, McCrea M, Hammek T. (2015). Benefits of strict rest after

acute concussion: a randomized controlled trial. Pediatrics, 135(2).