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Concussion: Where are we in 2012?

Concussion: Where are we in 2012?. Alex A. Homaechevarria MD St.Luke ’ s Sports Medicine US Ski Team Physician Kurt J. Nilsson, MD, MS Medical Director, St. Luke ’ s Concussion Clinic. October 5, 2012.

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Concussion: Where are we in 2012?

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  1. Concussion: Where are we in 2012? Alex A. Homaechevarria MD St.Luke’s Sports Medicine US Ski Team Physician Kurt J. Nilsson, MD, MS Medical Director, St. Luke’s Concussion Clinic October 5, 2012

  2. “The occurrence and management of sports concussion provokes more debate and concern than virtually all other sports injuries combined.” • Paul McCrory, Clin Sports Med, 2011

  3. Objectives • Discuss the epidemiology and pathophysiology of concussion • Discuss short and long term implications of concussion • Discuss the role of neurocognitive testing in concussion • Discuss management of sports related concussion, with attention to return to play issues • Discuss issues surrounding the current and future approach to concussion

  4. Concussion Re-defined: • Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces

  5. Concussion Re-defined: • Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces

  6. Concussion Re-defined: • Typically results in the rapid onset of short-lived neurological impairment that resolves spontaneously

  7. Concussion Re-defined: • The acute clinical symptoms largely reflect a functional disturbance rather than a structural injury

  8. Concussion Re-defined: • May or may not involve LOC • Grossly normal neuroimaging studies McCrory, J Neurosci, 2009

  9. Epidemiology • 8.9% of high school sports injuries, • 5.8% of collegiate (Gessel, JAT, 2007) • Majority of concussions come from 4 sports: • football (47.1%) • girl’s soccer (8.2%) • boys wrestling (5.8%) • girl’s basketball (5.5%) (Marar)

  10. Epidemiology • In sports played by both genders, girls actually run a higher risk of sustaining concussion • U.S. female high school soccer athletes suffered almost 40% more concussions than males • In high school basketball, female concussions were nearly 240% higher • Female college athletes who play soccer, basketball, softball and hockey also bear higher concussion risks than their male counterparts Gessel, Journal of Athletic Training, 2007

  11. Complications • Decreased threshold for recurrent concussion: Athletes with 3 or more concussions were 9.3 times more likely to have prolonged loss of consciousness, anterograde amnesia, or confusion with subsequent concussion • Also 4-6 times more likely to have recurrent concussions and take longer for symptoms to clear Collins, Neurosurgery, 2002; Guskiewicz, JAMA, 2003

  12. Post-concussion syndrome • ICD-10 criteria: Head injury and 3 of following 8 within 4 weeks: headache, dizziness, fatigue, irritability, sleep disturbance, difficulty concentrating, memory problems, low tolerance for stress, emotion, or alcohol

  13. Second Impact Syndrome • Occurs in athlete who return to play before symptoms from 1st concussion completely resolve • Second blow/impact can be minor • Loss of autoregulation of the brain’s blood supply leading to vascular engorgement and subsequent brain swelling, increase intracranial pressure and herniation of the brain stem • Usually fatal • All cases in the literature <22 yr old

  14. Longer term consequences? – Retired football players reporting a history of 3+ previous concussions were 5X more likely to be diagnosed with mild cognitive impairment (Guskiewicz et al. Neurosurgery. 2005;57:719-24) – Retired football players reporting a history of 3+ previous concussions were 3X more likely to be diagnosed with depression(Guskiewicz et al. Med Sci Sports Exerc. 2007;39(6):903-9) – Increased prevalence of Alzheimer’s Disease in retired football players (Guskiewicz et al. Neurosurgery. 2005;57:719-24)

  15. Diagnosis • Clinical

  16. Diagnosis • Clinical

  17. Diagnosis • Clinical • Imaging • Postural / Balance testing / Vestibular testing • Neurocognitive testing

  18. Role of Neuroimaging • Initial CT/MRI: prolonged disturbance of consciousness, focal neurologic deficit, clinical deterioration, persistent clinical or cognitive symptoms • Most typically contributes very little to the evaluation of concussion

  19. Neuroimaging • Based on study of > 42,000 ED visits, CT is unnecessary : • in children <2 with normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents • in children >2 with normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache Kuppermann, et al, Lancet, 2009

  20. Postural control • Regulated by visual-spatial, somatosensory, and vestibular input • Inefficient integration of vestibular information likely cause of observed deficits in postural control Guskiewicz, CJSM, 2001; Sosnoff, JAT, 2011

  21. Postural control • Impaired postural stability (ie balance deficit) is present for at least 72 hours following concussion • BESS – Balance Error Scoring System Riemann, JSR, 1999

  22. Diagnosis • Clinical • Imaging • Postural / Balance testing / Vestibular testing • Neurocognitive testing

  23. Neurocognitive testing • Baseline tests administered to high risk athletes and utilized for comparison in the event of concussion • Baselines encouraged as part of concussion programs (McCrory, PMR, 2009)

  24. Neurocognitive testing issues • Baseline performance affected by group testing, amount of sleep, psychological distress, effort • Can have learning effect across testing sessions (Register-Mihalik, JAT, 2012) • 6-11% can have indicator of invalidity (Schatz, JAT, 2012) Moser, AJSM, 2011; Brown, JAT, 2007; Bailey, CJSM, 2010,

  25. Neurocognitive testing issues • 8/75 athletes able to sandbag without triggering internal validity indicators (Erdal, Arch Clin Neuropsych, 2012)

  26. Neurocognitive testing issues • Utility - some suggest not only not helpful, but has capacity to worsen outcome (Randolph, Curr Sports Med Rep, 2011) • Has no utility as a diagnostic or screening tool when used in isolation in the military (Coldren, Mil Med, 2012)

  27. ImPACT Clinical Report Exam Type: Baseline Composite Scores: Memory composite (verbal): 99%ile Memory composite (visual): 94%ile Visual motor speed composite: 98%ile Reaction time composite: 73%ile ImPACT Clinical Report Exam Type: Post-Injury 2 Composite Scores: Memory composite (verbal): 99%ile Memory composite (visual): 93%ile Visual motor speed composite: 99%ile Reaction time composite: 86%ile Example:

  28. Recovery From Concussion:How Long Does it Take? How long do symptoms last? WEEK 5 WEEK 4 WEEK 3 WEEK 1 WEEK 2 N=134 High School athletes Collins et al., 2006, Neurosurgery

  29. Duration of Neurocognitive Deficits • Average number of days to return to baseline (ImPACT) were greater for 13 to 16 year-olds than for 18 to 22 year-olds on the following variables: Verbal Memory (7.2 vs 4.7, P = 0.001), Visual Memory (7.1 vs 4.7, P = 0.002), Reaction Time (7.2 vs 5.1 P = 0.01), and Post Concussion Symptom Scale (8.1 vs 6.1, P = 0.026). (Zuckerman, Neurosurg, 2012)

  30. Duration of Neurocognitive Deficits • Prolonged neuropsychological impairments following a first concussion in female university soccer athletes • Concussed athletes were significantly slower on tasks that required decision making (complex reaction time), inhibition and flexibility, and planning for up to 6-8 months post concussion • Short- and long-term verbal memory, attention, and simple reaction time were normal – Impact test • Ellumburg et al., Clin J Sports Med, Sept. 2007

  31. Duration of Neurologic Deficits • Differential rate of recovery in athletes after first and second concussion episodes • All patients asymptomatic at Day 10, cleared for sport participation based on clinical symptoms resolution. • Balance deficits, were present at least 30 days after injury (P < 0.001). • Most importantly, the rate of balance symptom restoration was significantly reduced after a recurrent, second concussion (P < 0.001) compared with those after the first concussion • Slobounovet al., Neurosurgery Aug 2007

  32. Concussion management • The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter

  33. Management • At least 26 professional guidelines on the diagnosis and management of concussion • The number of treatments for any disease is inversely proportional to how much we know about that disease Returning the asymptomatic athlete to play: What does asymptomatic mean? (Alla, BJSM, 2012) If we cannot agree on what asymptomatic means, how can we agree on safety of contact sports?

  34. International Conference on Concussion in Sport

  35. Management • Use of multifaceted system – Neurocognitive, vestibular, postconcussion symptom scale – more reliable than any test used alone (Register-Mihalik, J Head Trauma Rehab, 2012)

  36. Stepwise Return to Play • No activity. Complete physical & cognitive rest • Light exercise, walking or stationary bike • Sport-specific activity such as running or skating. • Progressive addition of resistance training at steps 3 or 4. • On the field practice, without body contact. • On-field practice, with body contact. • Often progress from controlled hitting/drilling to full contact. • Must be cleared by physician before this step. • Game Play. McCrory P, Johnston K, Meeuwisse W, et al: Summary and agreement statement on the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:i78-i86. Goldberg, LD & Dimeff RJ: Sideline Management of Sport-related Concussions. Sports Med Arthrosc Rev 2006;14:199-205

  37. Multidisciplinary Approach • Team approach is necessary for concussion management: • MDs • Athletic trainers • Coaches • School Nurses • Neuropsychologist • Parents • Athlete • Other disciplines might become involved with protracted symptoms: • Speech therapy (academic issues, compensatory strategies) • Physical therapy (i.e., whiplash, vestibular) • Occupational therapy (i.e., vision) • Counseling (i.e., depression, anxiety)

  38. Concussion management • The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter

  39. Active treatment approaches • Supplementation with DHA (docosahexaenoic acid) can reduce cell death in rodent model of TBI (Bailes, J Neurotrauma, 2010)

  40. Active treatment approaches • Amantadine 100 mg BID may facilitate more rapid resolution of neurocognitive deficits in athletes with symptoms greater than 3 weeks. (Reddy, J Head Trauma Rehabil, 2012)

  41. Active treatment approaches • Exercise assessment and aerobic exercise training for postconcussion syndrome (PCS) may reduce concussion-related physiological dysfunction and symptoms by restoring autonomic balance and improving cerebral blood flow autoregulation. (Leddy, Rehabil Res Practice, 2012)

  42. Thank You

  43. Thank You Kurt J. Nilsson, MD, MS St. Luke’s Sports Medicine knilsson@slhs.org 208-383-0201 St. Luke’s Concussion Clinic 208-381-2665 Kristi Pardue, clinical coordinator Matthew Kaiserman, outreach coordinator

  44. Thank You

  45. http://headgamesthefilm.com/

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