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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
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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)
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What is a Concussion?
A Mild Traumatic Brain Injury
2. Who Gets Concussed?
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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
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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)
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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
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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
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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
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• 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
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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
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(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
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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
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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?
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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)
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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
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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
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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
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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%
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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?
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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
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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
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Bonus: What Resources Are Available?
Arizona Resources
Concussion Research Registry
Concussion Consultation
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OnePass Medical Providers Community
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www.atsuconcussion.com
480-219-6035
www.atpbrn.org