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Concussion Management: Primary Care Like the Pros David M. Smith, M.D., FAAFP March 17, 2014

Concussion Management: Primary Care Like the Pros David M. Smith, M.D., FAAFP March 17, 2014. Level the Playing Field. NFL Concussion Protocol. Sideline concussion assessment Remove from play Evaluate in locker room Ipad modified SCAT3 Compare to baseline

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Concussion Management: Primary Care Like the Pros David M. Smith, M.D., FAAFP March 17, 2014

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  1. Concussion Management: Primary Care Like the Pros David M. Smith, M.D., FAAFP March 17, 2014

  2. Level the Playing Field

  3. 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

  4. 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

  5. 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

  6. Symptom Categories

  7. 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

  8. Loss of Consciousness • 90% of concussions involve noloss of consciousness • NOT predictive of the severity of concussion • Nature, burden, and duration of clinical postconcussive symptoms determine severity

  9. 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

  10. 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 BestPractice

  11. Neurological Exam

  12. 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 versions http://links.lww.com/JSM/A30

  13. SCAT 3

  14. 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

  15. Neurophysical Balance Evaluation:Vestibular and Visual

  16. Neurophysical Balance Evaluation:Vestibular and Visual • Saccades • Optokinetic stimulation

  17. Neurophysical Balance Evaluation:Visual • Convergence • Accommodation

  18. Neurophysical Balance Evaluation:Visual

  19. Concussion Management:Neurocognitive Evaluation • ImPACT, AXON Sports, HeadMinder, CNS Vital Signs

  20. Concussion Management:Return to Activity Guidelines

  21. Concussion Management:Return to Activity Guidelines

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. ImPACT: DOI 9/27/13

  30. ImPACT: DOI 9/27/13

  31. ImPACT: DOI 9/27/13

  32. 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

  33. 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

  34. Concussion Management:Primary Care “Do’s and Don’ts” Do’s 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) • Get educated and gain experience • Be available • Know your patient and establish trust • Maximize lines of communication • Know when and where to refer

  35. Thank You David M. Smith, M.D., FAAFP Center for Sports Medicine Clinical Assistant Professor dsmith15@kumc.edu University of Kansas Hospital Center for Concussion Management concussionreferrals@kumc.edu 913-945-8006

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