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Concussion Management inPrimary Care

Patrick F. Leary DO FAOSM FACSMDirector of Sports Medicine

Lake Erie College of Osteopathic MedicineMarch 4th, 2011

Learning Objectives

• Definition of Concussion

• Epidemiology & Statistics of Concussions

• Anatomy & Mechanism of a CNS injuryy j y

• Evaluation & treatment of the athlete

• Current Concussion Grading Scales

• Return to Play guidelines

• Second Impact Syndrome & complication

• Treatment

Sentinel Issues

• More Concussions than we know about

• Children and females suffer

• Multiple concussions have consequences• Multiple concussions have consequences

• Early RTP can be catastrophic

• Long term deficits can result from repetitive head injury

Definitions of Concussion

• Concussus in Latin means• Concussus in Latin means

– “to shake violently”

– 90% resolve within 10 days

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Concussion- Committee on HeadInjury Nomenclature of the Congress of

Neurological Surgeons, 1966

• “a clinical syndrome characterized by immediate and transient impairment ofimmediate and transient impairment of neural function such as alteration of consciousness, disturbance of vision, equilibrium, due to mechanical forces.”

Definitions of Concussion

• Temporary disturbance of brain function that occurs without a structural change in the brain.

• Clinical syndrome characterized by immediate & transient post-traumatic impairment of neural function, such as:– alteration of awareness or consciousness

– disturbance of vision, equilibrium, memory

Three Components of Concussion

• Trauma

• Change in Neural Function

• NO STRUCTURAL DEFECTS!• NO STRUCTURAL DEFECTS!

Definitions

• Structural defects are lesions that can be seen on neuro-imaging (possibly psychological testing)p y g g)

• Structural defects are synonymous with brain damage

• Structural defects=no return to competition

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Facts About Concussion

• Concussion occurs most often in males and children, adolescents and young adultsy g

• Risk of concussion in football is 4-6 times higher in players with a previous concussion

• Changing perceptions:

• There is no such thing as a minor concussion!

Structural Defect vs. Concussion

• Structural defects are lesions that can be seen on neuro-imaging

• No structural defects present on neuro-imaging

• Possibly seen on neuropsych testing

• Structural defects are synonymous with brain damage

• Structural defects=no return to competition

• May be present on neuropysch testing

• Concussion more akin to a syndrome: a constellation of sxs

• Concussion=possible return to competition

Anatomy of Concussion

• The brain is a jello-like substance vulnerable to outside trauma. Sk ll h b iSkull protects the brain against trauma, but does not absorb impact forces. – During concussion, the

brain rotates and twists inside the skull, causing damage to brain tissue

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Anatomy of Concussion

• Cervical spine --allows the head to rotate to avoid blunt trauma– However, rotational

forces can be the most damaging during concussion

Spectrum

• Concussion

• Post Concussion Syndrome

• Prolonged Post Concussion Syndrome• Prolonged Post Concussion Syndrome

• Chronic Traumatic Encephalopathy

Sedney & Bailes

Journal of PediatricsER Concussion Study

August 2010

• 14-19 yoa 3x 7,000-22,000 1997-2007

8 13 oa 2 3800 8 000 1997 2007• 8-13 yoa 2x 3800-8,000 1997-2007

Incidence• High School 136,000 Football, Women’s Soccer• Bigger Stronger Faster• More Females• NCAA Division I, II,III• Professional, International1.6-3.8 million concussions yearly in sport CDCy y p60 Billion spent in 2000

Meehan 2010 Harvard

•

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Sports

• Women’s Ice Hockey

• Spring Football

• Women’s Soccer• Women s Soccer

• Men’s Soccer

• Women’s Basketball

• Men’s Wrestling

• 84% back in one week 2% >month

• 75% contact with other player

• 5% LOC• 5% LOC

• 95% Headache

NFL Statistics

• According to the NFL Commissioner’s Office, brain injuries

foccur at a rate of one in every 3.5 games

Steve Young

Statistics

• Football head injuries are TWICE as frequent as neck injuries.

• Where do most concussions occur duringWhere do most concussions occur during football– 43% Making the tackle D Secondary

– 23% Being tackled Kick Unit

– 20% Blocking Running Back

– 10% Being Blocked Linebackers

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NCAA Facts on Concussion

• Concussions per every 100,000 games and/or practices at the collegiate level– Football: 27

– Ice Hockey: 25

– Men’s soccer: 25

– Women’s soccer: 24

– Wrestling: 20

– Women’s basketball: 15

– Men’s basketball: 12(Head and Neck Injury in Sports, R.W. Dick)

Epidemiology

• National Health Interview Survey, 1991– estimated 306,000 TBI in sports/ year

• (20% of the 1.54 million TBI occurring in 1991)( g )

– 34% saw no physician

– 55% outpatient care only (ER, Dr’s office)

– 12% hospitalized

Epidemiology

• High Risk activities– Gymnastics

– Horse-back ridingHorse back riding

– Mountain Climbing

– Parachuting/ sky diving

– Ski-jumping

– Snow-mobiling

– trampoliningBrian Sloan, MD & Copter at the Indy 500

Evaluation of An Unconscious Athlete

• “An unconscious athlete cannot tell you his neck is broken”

• Always prepare for the worst!!– Access to Emergency Personnel

– CPR trained personnel

– Oral airways

– Equipment for neck immobilization and transfer

• Stabilize neck, monitor airway, & transport

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Mechanism of Injury

– Change in momentum may be:

– Linear (straight vector)( g )

– Rotational (curved vector)

• rotational changes more likely to cause concussions

Mechanism of Injury

• Coup injury: a direct blow that injures underlying brain at the point of impact

• Contra-coup: injury to brain tissue on theContra coup: injury to brain tissue on the opposite side of a blow or force as a result of a moving brain rebounding against the skull or from tearing of subarachnoid vessel

• Rotational: injury to brain tissue as a result of shearing forces between the skull and brain tissue.

Mechanism of Injury

• A change in the movement of the head:– By moving object striking stationary head

– Through moving head hitting fixed object.Through moving head hitting fixed object.

– Caused by acceleration or deceleration

• Misconception: need significant force to cause LOC to cause a concussion

Pivotal Symptoms of Concussion

• I. Loss of consciousness

• II Post Traumatic Amnesia• II. Post-Traumatic Amnesia

• III. Cognitive impairment

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Frequently Observed Featuresof Concussion

• Symptoms:– Headache (94%)

– dazed feeling

Dinged– Dinged

– Woozy

– Foggy

– Feel “not right”

– Bell ringing

– blurry vision, diplopia

– nausea- with vomiting and stupor/sub-dural

Frequently Observed Featuresof Concussion

• Signs:– Vacant stare- “lights on, but nobody home”

– Delayed verbal & motor responsesDelayed verbal & motor responses

– Confusion & inability to focus attention

– Disorientation

– Emotional

– Slurred or incoherent speech

– Perseveration

– Detachment from game, asocial, withdrawn

Pathophysiology of Concussion

• CNS is NOT capable of axonal regeneration and repair like PNS.

• No gross structural changes in brain, but can see the following histological changescan see the following histological changes after a concussion– Interstitial Edema

– Petechial hemorrhages

– Micro-infarcts

– Axonal shearing

– Tau Proteins on Histology

Loss of Consciousness

• 1st Pivotal event in concussion grading

• Difficulty in definition-most define LOC as a flaccid paralysis in an athletea flaccid paralysis in an athlete unresponsive to verbal and motor stimuli

• Described as momentary, brief, transient, seconds or minutes

• Seizure activity not unusual

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Duration of LOC

• Neuropsychological functioning and Recovery after mild TBI in Collegiate athletes– 2300 collegiate football athletes

– 196 head injuries

– 9 with LOC• all < 5 minutes

• 7 < 1 minute

• (Macciocchi S, Barth J, Alves W: Neurosurg, 1996:39:510-514)

Early Symptoms(Minutes to Hours)

• Headache

• Amnesia or memory loss

• Visual disturbances• Visual disturbances

• Dizziness or Vertigo

• Nausea or Vomiting

• Confusion

• Balance

Late Symptoms (Days to Weeks)

• Persistent low grade headache

• Lightheadedness

• Poor attention & concentration• Poor attention & concentration

• Memory dysfunction

• Easy fatiguability

• Irritability & Low frustration tolerance

Late Symptoms (Days to Weeks)

• Intolerance of bright lights

• Difficulty focusing vision

• Occasional ringing in the ears (tinnitus)• Occasional ringing in the ears (tinnitus)

• Anxiety

• Depressed mood

• Sleep disturbance

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Sideline Evaluation

• Mental Status Exam– Orientation:

• Time, Place, Person, Situation, , ,

– Concentration:• Serial 7’s

• Months backwards (Dec, Nov, Oct,...)

– Memory:• Names of prior teams

• Recall 3 words & 3 objects

• Details of the game (plays, score,etc)

My Fellows evaluating ND FB players

Sideline Evaluation of Concussion

• Subjective symptoms

• Orientation & Concentration

• Memory: immediate recent remote• Memory: immediate, recent, remote

• Amnesia: retrograde and antegrade

• Physical exam

• Cognitive Ability

• Provocative maneuvers

Physical Exam

• General appearance

• pupils, eyes

• Facial muscles• Facial muscles

• Neck motion

• Balance

• Reaction time

• GOOD NEURO EXAM!

Physical Exam

• Neurologic Tests:– General

• Reflexes

• Strength

• Sensation

• Rhomberg’s

• Coordination

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Physical Exam

• Neurologic Tests– Neck:

• Palpate: deformities, spinous processesp , p p

• MMT: Strength of neck muscles

• ROM at neck (flex/ext, side-bend, lateral-rotation)

• Spurling’s Manuever– 5lbs of pressure/ vertebra

AMNEESIA

Post-Traumatic Amnesia

• 2nd pivotal event in grading

• Not necessary for impact to occur to experience amnesia (Macciochi Barth &experience amnesia (Macciochi, Barth, & Alves: 60/196 no contact)

• May be delayed for up to 20-30 minutes

PTA-Diagnoses

• Retrograde-before the event– Did we win last week? Who did we play?

What play did we score on? p y

• Antegrade-after the event– State, river, color. Who brought you off the

field? What quarter are we in?

• Termination of PTA is reacquisition of continuous memory

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PTA-Duration

• Length of PTA correlates well with time to recovery– < 30 minutes better prognosis for return 30 minutes better prognosis for return

– > 30 minutes require longer recovery

• Retrograde amnesia considered to represent a more serious concussion than antegrade amnesia

Memory Exam

• Immediate– number recall, repeat sentences

• Recent• Recent– score, quarter,opponent, pre-game meal

• Remote– mother’s maiden name, place of birth, name

of grade school

Antegrade Memory Loss Questions

• “I want you to remember the state of Nevada, the river Snake, and the color purple.”p p

• “Come and find me with 2 minutes left in the half.”

3 Things to Remember

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Cognitive Dysfunction

• Most common finding and best predictor of outcome

• Marker of higher reasoning abilityMarker of higher reasoning ability

• Independent from amnesia, orientation, number recall

• Best identified by psych testing

Cognitive Exam Questions

• “What is the square root of 81?”

• “Name me 10 fruits?”

• “Tell me the months of the year in reverse• Tell me the months of the year in reverse order starting with today’s month?”

• “If pencils are 3 for a nickel, how many can you buy for 15 cents?”

Cognitive Exam Questions

• “What is the square root of 81?”

• “Name me 10 fruits?”

• “Tell me the months of the year in reverse• Tell me the months of the year in reverse order starting with today’s month?”

• “If pencils are 3 for a nickel, how many can you buy for 15 cents?”

• Spell “WORLD” Backwords

Cognitive Dysfunction

• 3rd pivotal event in concussion grading

• In my opinion, the most important

• Requires patient questioning• Requires patient questioning

• Is the best marker for termination of the concussion

• Correlates well with neuropsyche testing

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Grading Concussion

• Common language to communicate severity

• Determines necessity for removal from contestcontest

• Defines time period before return to competition

Congress of Neurological Surgeons (1966)

• Mild – no LOC, mild confusion

• Moderate• Moderate – LOC < 5min, retrograde amnesia

• Severe– LOC > 5min

Cantu’s Guidelines (1986)

Symptoms Return to Play

Grade 1 No LOC, Observe, RTPMild Amnesia < 30 min in some casesGrade 2Moderate

LOC < 5 min,Amnesia > 30 min,< 24 hrs

No RTP,Evaluate atmed. facility

Grade 3Severe

LOC > 5 min,Amnesia > 24hrs

Back-board toER, watch 24h

Colorado Medical Society (1991)

Symptoms Return to Play

Grade 1 No LOC,N i

After 20 min, if nlNo amnesia,Confusion

exam

Grade 2 No LOC,Amnesia,Confusion

1 week sx-free

Grade 3 Any LOC 1 month sx-free

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American Academy of Neurology (1997)Symptoms Return to Play

Grade 1 Confusion, No LOC Single: 15 min,Sxs < 15 min

gMulti: 1 week

Grade 2 Confusion, No LOCSxs > 15 min

Single: 1 weekMulti: 2 weeks

Grade 3 Any LOCBrief: secondsProlong: minutes

Brief: 1 weekProlong: 2 weekMulti: 1 month

Vienna Guidelines

• Simple

• Complex

Unanimous Agreement USELESS

Zurich Guidelines

• NP Testing, Biomarkers, fMRI

• Gender Women>Men Chronicity

• Elite vs Non Elite Athletes• Elite vs Non Elite Athletes

• Pediatric <15

• SCAT2

• Depression

Initial Management of Concussion

• Be aware of differences in guidelines for LOC

• If transported to ER, CT scanning & b iobservation

• If no LOC, observe closely on sideline or locker room

• Re-exam within one hour; if PTA still present strong consideration for CT

• Follow up care arranged before athlete leaves locker room

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Field Management

• Symptoms < 15-20 minutes– Remove from contest (take helmet)

– Examine immediately & q 5 minutes forExamine immediately & q 5 minutes for development of mental status abnormalities or post-concussive symptoms at rest or exertion

– May return to play if mental status abnormalities & clear w/in 15 minutes.

Field Management

• Symptoms >15-20 minutes

• Remove from play & not allow return that dayday.– Examine on-site frequently for signs of

evolving intra-cranial pathology.

– A trained person (MD, DO, ATC) should re-examine the athlete the following day.

– A physician should perform a neurologic examination to clear the athlete for RTP after 1 full asymptomatic week at rest & exertion.

Criteria for Removal From Game

• An athlete should be removed from competition that day if there is:– any LOCany LOC

– PTA

– continuing symptoms

– cognitive dysfunction

– exacerbation of symptoms with exercise

Clinical Workup of Concussion

• PPE with Neuropsych baseline• Initial Management• Follow up examFollow up exam• Medical Treatment• Return to Play

– 34% saw no physician– 55% outpatient care only (ER, Dr’s office)– 12% hospitalized

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Post Concussion Syndrome • Definition: Athletes with persistent sleep

disturbance, somatic, emotional, and cognitive symptoms past 24 hours and no evidence for structural injury are said to be

ff i f t i dsuffering from post concussion syndrome

• Most athletes with PCS recover in 5 days with some persisting up to 3 weeks to 3months and a small percentage as long as one year

• Females and under 15 YOA

Post Concussion Syndrome

• Etiology of PCS unclear.

• PET scanning shows slowing of glucose uptake Possible increase in cholinergicuptake. Possible increase in cholinergic neurons activity. Microscopic changes in axons

• MRI neuroimaging of choice for persistent PCS

Psychological Testing

• Can be useful adjunct to evaluate athletes with Concussion

• Baseline Testing during PPEBaseline Testing during PPE

• Most common parameters affected are memory and reaction time coupled with information processing

Neuroimaging

Structural versus FunctionalCT

• MRI• Spect PET PET/MRI (positron emission tomograms)• Spect,PET, PET/MRI (positron emission tomograms)• fMRI (cerebral blood flow)

• DWI, DTI, MRS,ASL,MEG Research

Prabhu

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SAC/SCAT 2 Questionaire

Concussion Testing

• Impact

• Axon Sports (Cogsport)

• CNS Vital Signs• CNS Vital Signs

• Headminer

• Mindstreams

• BESS

• King-Devick Test

Computer NeuroPsych Testing

• FOUR

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Medical Therapies

• Rest

• Sleep

• Nutrition

• OMM

• Biofeedback

• Medications (Ritalin, Amantadine, Midrin, Amytriptaline, NSAIDS, SRIs )

• Low level exercise (Majerske 2008)

Second Impact Syndrome

• The Team Doctor’s Nightmare!!

• Definintion: The disruption of the brain’s autoregulatory system in someone who isautoregulatory system in someone who is still symptomatic from a concussion after sustaining a second head injury which may cause massive brain injury.

• Time from second impact to brain stem failure is RAPID!! (2-5 minutes)

• Does this Exist?

Common Sense (is not common)

• Times when it is not advisable to return an athlete to competition who has suffered a head trauma but with no evidence of concussion– the very young

– a second “ding”in a contest

– recent concussion

– reluctance to participate

Follow Up Instructions

• If full recovery not apparent at post game exam, full instructions to responsible party for worsening of symptoms g y p

• Schedule follow-up appointment for next day

• No contact activity allowed

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Follow Up Instructions

• If full recovery not apparent at post game exam, full instructions to responsible party for worsening of symptoms g y p

• Schedule follow-up appointment for next day

• No contact activity allowed

7.5 Million $

• Preston Plevretes, now 23, claimed that he was improperly treated by La Salle medical staff after sustaining a concussion during a practice in O b 2005 D i h i i iOctober 2005. Despite having continuing symptoms, the lawsuit said, Plevretes was cleared to play in a subsequent game in which a tackle caused brain damage that has left him with speech impediments, memory loss and other issues that require 24-hour care.

Return to Play Criteria

• What all agree on:– No athlete who has experienced a head injury

should return to competition if still p fsymptomatic

– Loss of consciousness is not a requirement for concussion to be diagnosed

– Athletes deserve caretakers who are knowledgeable about head injury and the demands of the sport

Follow Up Exam• History

– symptoms, sleeping habits, reading skills, emotions

– “When did you start to feel normal again?”W e d d you s o ee o g ?

• Exam– Re-perform sideline exam including testing

for memory, cognitve skills, amnesia, reaction times, and provocative maneuvers

• For persistent symptoms or abnormalities on exam, CT scan indicated

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Return To Play

• No Activity

• Light Aerobic Activity

• Sports Specific Exercise• Sports Specific Exercise

• Non Contact Training Drills

• Full Contact Practice

• Full Contact

Return To Play Criteria

• Criteria for return to play that day

• Criteria for removal from competition

• Common sense• Common sense

Return to Play

• Exertional Provocative Tests– 50 yard dash (straight) away from you

– 50 yard dash (cutting) back to you50 yard dash (cutting) back to you

– 10 push-ups

– 10 sit-ups

– 10 one-legged jumps

• ALL PLAYERS MUST DO THIS (w/o sxs returning) IN ORDER TO RTP!!!

Return To Play That Day

• In a”dinged”player suspected of having a potential concussion, return to play may be allowed if– the exam is normal

– no PTA

– no cognitive disability

– a wait time of 20-30 minutes

• Development of headache, vertigo or nausea precludes further play

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Return To Play Criteria

• Criteria for return to play that day

• Criteria for removal from competition

• Common sense• Common sense

Common Sense (is not common)

• Times when it is not advisable to return an athlete to competition who has suffered a head trauma but with no evidence of concussion– the very young

– a second “ding”in a contest

– recent concussion

– reluctance to participate

Return to Play That Day

• In a”dinged”player suspected of having a potential concussion, return to play may be allowed if– the exam is normal

– no PTA

– no cognitive disability

– a wait time of 20-30 minutes

• Development of headache, vertigo or nausea precludes further play

Criteria for Removal From Game

• An athlete should be removed from competition that day if there is:– any LOCany LOC

– PTA

– continuing symptoms

– cognitive dysfunction

– exacerbation of symptoms with exercise

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Condition Mimicking Concussion

• Heat Exhaustion and Heat Stroke

• Dehydration

• Migraine

• First week of contact football

• Medication

• Weight lifters headache

• Hypoglycemia

• Soccer Heading

• Altitude sickness

Post Concussion Syndrome I

• Athletes with persistent physical, emotional, and cognitive symptoms past 24 hours and no evidence for structural injury are said to j ybe suffering from post concussion syndrome

• Most athletes with PCS recover in 5 days with some persisting up to 3 weeks to 3 months and a small percentage as long as one year

Conclusions

1. Concussion results in a complex physiological cascade that triggers neuronal dysfunction in the absence of significant cell death.

2. Physiological dysfunction can leave the brain in a state vulnerable to a second injury, either ACUTELY (second impact) or due to a CHRONIC accumulation of mild injuriesimpact) or due to a CHRONIC accumulation of mild injuries.

3. The concussed brain is in a state of impaired activation that can result in diminished responsiveness and cognitive deficits.

4. In light of both potential vulnerability and impaired responsiveness, proper timing of return to activity after concussion is crucial.

Unreliable

• Literature

• Neuropsch Results

• Symptom Reporting• Symptom Reporting

• Concussion definitions

• Statistics

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Genetic Markers

• APOE4 & APOE3 9x more likely to develop dementia• 1/1000 men develop signs of dementia by age 50• 1/54 ex professional football players develop signs of

dementia by age 50• Punch Drunk, Dementia Pugilistica, Chronnic Traumatic

EncephelopathyEncephelopathy

• Cantu 2011

Dave Duerson

Future

• Better Education• Better Equipment• Less Contact during practice• PPE with neuropsych base line testing• PPE with neuropsych base line testing• When in doubt hold them out• No RTP with symptoms at rest or exertion• Age restrictions• Intelligent Sports options based upon access,

physique, talent and desire.

Zak Lystetd Law

• Education

• Symptomatic NO RETURN

• Qualified Physicians??Q y

Primary Care Sports Medicine

Orthopedic Surgeons

Neurologists

Psychologists

HB301 Briggs of Pennsylvania

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References

• Kelly, JP, Current Therapies in Sports Medicine, “Concussion”, 1994, p21-4.

• Kelly, JP, Rosenberg, JH,“Diagnosis & management of concussion in sports,” Neurology, March 1997, 48: 575-588.

• LeBlanc, KE, American Family Physician, “Concussion in Sports: Guidelines for Return to Competition”, 50(4), 9/15/94, p801-6.

• Mellion, MB, The Team Physician’s Handbook, 2nd ed. 1997, p.391-406.

• Putukian, M. The Physician & Sportsmedicine, 24(11) Nov. 1996, p25-38.

• Moriairty, J: Lecture on Closed Head Injuries, July 11th, 2001

Focal Brain Injuries

• Subdural Hematoma– Low ICP

– Venous bleeding from blunt trauma progressiveVenous bleeding from blunt trauma progressive deterioration over several hours to days

– Veins between brain and dura rupture

• Epidural Hematoma– High ICP, arterial bleed, may have skull fx

– Rupture of meningeal arteries

– Surgical evaluation needed