Sports Concussion Update

1. Sports Concussion Update 10th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow

2. Action

3. What Is Concussion? It’s pretty simple…

6. Definition “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces”

7. Definition Concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases symptoms and signs may evolve over a number of minutes to hours. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies.

8. Pathophysiology • Still remains a topic of research and debate • Electrolyte and homeostasis of neurons disrupted; leading to impaired oxidative metabolism • Hypometabolic state • Acceleration-deceleration and rotational forces on the brain • Barkhoudarian et al. Clin Sports Med. 2011. • Pathophysiology is not totally understood • Functional… not structural

9. Metabolic Mismatch

10. Signs and Symptoms

11. Signs and Symptoms Physical Cognitive Attention difficulties Concentration Memory problems Orientation Behavioral • Headaches • Dizziness • Insomnia • Fatigue • Gait • Nausea • Vision • Seizures • Irritability • Depression • Anxiety • Sleep Disorders • Emotional Control • Relationships, marriage, • school and employment

12. Sideline Evaluation The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician is arranged Once the first aid issues are addressed an assessment of the concussive injury should be made using the SCAT 3 or other sideline assessment tools The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury A player with diagnosed concussion should not be allowed to return to play on the day of injury

13. “OLD”

14. “NEW”

16. Outpatient Assessment • Head CT and MRI’s are not recommended as part of sports-related concussion routine management Unless suspicion of intracranial or cervical spine injury • Worsening and severe headaches • Seizures • Focal objective neurologic findings • Repeat emesis • Prolonged loss of consciousness

17. Grading / Classification of Concussion • Many different guidelines and classification systems in the past • There has been nearly one new guideline every year for the past 20 years • As of the 4th International Symposia on Concussion in Sport (Zurich), concussion is no longer graded or classified

18. Neuropsychological Evaluation • Important in overall assessment and RTP • Should not be sole basis of management decisions • Aid to clinical decision making • Formal NP testing not required for all • Best done when asymptomatic but may be beneficial at other stages in certain situations • Baseline testing is not mandatory

19. Rest

20. Cocoon Therapy • Physical • Removal from strenuous exercises • Aerobic conditioning • Strength training • Cognitive • Adjust academic workload and school attendance • Adjust non-academic activities • Leisure reading • Video games • Texting and computers

21. Management • Cornerstone  initial period of rest until acute symptoms resolve • 80 – 90% resolve in short period • 7 – 10 days • Children and adolescents • May take longer • Expect gradual resolution • Gradual return to school and social activities that does not significantly exacerbate symptoms

22. Return to Play Zurich’s CIS Conference general consensus: • Conservative • Suspicion of a sustained concussion? • Withhold from returning to sport the same day, regardless of severity • Complete “shut-down” until asymptomatic • Cognitive • Physical

23. Return to Play • McCrory et al. (2013) • Subjective symptoms • Neuropsychological assessment • Balance testing • RTP criteria • Asymptomatic at rest • Asymptomatic with full cognitive and physical exertion • Baseline balance testing • Baseline neurocognitive testing

24. Graduated RTP Protocol

25. Graduated RTP • Each step should take at least 24 hours • Concussed athlete will require at least a week to complete the protocol • If symptomatic, a 24-hour asymptomatic rest period is required prior to repeating the previous step

26. Same Day Return To Play? NO!

27. Postconcussive Symptoms • Persistent symptoms > 10 days • 10-15% • Consider other issues • Depression • Anxiety • Should be managed in multidisciplinary manner • Pharmacotherapy

28. Child And Adolescent Athlete • Child SCAT3 • Adult recommendation may apply down to age 13 • Modify school attendance and activities • No return to sport or activity until successful return to school • More conservative RTP approach recommended • Extend symptom free period before RTP protocol • Consider extended graded exertion steps

29. Elite Athletes Managed the same regardless of level of participation

30. Prevention • Protective equipment • Mouthguards • No evidence of concussion reduction • Helmets • Reduction in biomechanical forces but no evidence in reducing concussion incidence

31. Foolproof ?

32. Multidisciplinary Team

34. Take Home • Management of concussions may be very complex • Guidelines and protocols continue to be refined and evolve • Equipment may be important but preventive medicine may be the single most important element in decreasing mortality • More solid evidence-based medicine is needed • May require a multidisciplinary approach

35. Education Proper tackling techniques Rules against helmet to helmet or spear tackling Understanding seriousness of concussion and its sequelae Traumatic Brain Injury Darwinism

36. Darwinism

37. Thank You Chae Ko, MD cko@ghs.org

38. Resources Barkhoudarian G, Hovda DA, Giza CC. The Molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011 Jan; 30 (1): 33-48, vii-iiii. Campbell A, Ocampo C, DeShawn Rorie K, Lewis S, Combs S, Ford-Booker P, Briscoe J, Lewis-Jack O, Brown A, Wood D, Dennis G, Weir R, Hastings A. Caveats in the neuropsychological assessment of African Americans. J Natl Med Assoc. 2002 Jul;94(7):591-601. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Heads up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). www.cdc.gov/NCIPC/pub-res/tbi_toolkit/physicians/mtbi/mtbi.pdf. Accessed 2012 September 21. Charles, JD, Bejan A. The Evolution of Speed, Size, and Shape in Modern Athletics. J Experimental Bio. 2009 May; 212: 2419-25. Iverson G. Predicting Slow Recovery From Sport-Related Concussion: The new Simple-Complex Distinction. Clin J Sport Med. 2007 Jan;17(1): 31-7. Ma R, Miller C, Hogan M, Diduch B, Carson E, Miller M,. Sports-Related Concussion: Assessment and Management. J Bone Joint Surg Am. 2012 September; 94(17): 1618 – 1627. Mills JD, Bailes JE, Sedney CL, Hutchins H, Sears B. Omega-3 Fatty Acid Supplementation and Reduction of Traumatic Axonal Injury in a Rodent Head Injury Model. J Neurosurg. 2011 Jan; 114(1):77-84. McCrory P, Meeuwisse W, Aubry M, Cantu B, Dvorak J, et al. Consensus statement on Concussion in Sport 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med 2013;23:89–117. Putukian M. The Acute Symmptoms of Sport-related Concussion: Diagnosis and On-Field Management. Clin Sports Med. 2011 Jan;30(1):49-61, viii. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006 Oct;34(10):1630-5.

39. Child SCAT3 Differences • Child Maddocks questions • Symptom scale • Child specific • 4 point rating scale • Parent rating of child’s symptoms • Orientation • No time of day • Reverse days of the week • No single leg stance

40. Canadian Head CT Rule • Applies to patients with GCS=13-15 following minor head trauma with witnessed LOC. • Patients with any of the below need a CT: • GCS<15 after 2hrs. • Suspected open or depressed skull fracture. • Any sign of basilar skull fracture. • Two or more episodes of vomiting. • Age 65 or older.

41. New Orleans Criteria • Applies to patients with GCS=15 following minor head trauma. • Patients with any of the below need a CT: • Headache • Vomiting • Age > 60 • Intoxication • Persistent anterograde amnesia • Visible trauma above the clavicle • Seizure

42. NEXUS II Criteria • “BEAN BASH” Criteria Behavioral Abnormality Emesis (intractable) Age >65 Neurological Deficit Bleeding Disorder Altered Mental Status Skull Fracture Hematoma of the Scalp

43. Age and Developmental Level • Younger athletes take longer to recover • High school versus college • High school versus professional • Children undergo more cerebral swelling with more severe mild TBI, which may account for delayed recovery compared to older athletes • Immature brain is up to 60x more sensitive to glutamate (part of the metabolic cascade that follows concussion) • All this may account for SIS only occurring in children.

44. Gender Differences • Females have a higher rate of concussion • Females are cognitively impaired 1.7x more frequently than males • Females had significantly more post-concussive symptoms as well as poorer performance on follow-up testing (ImPACT)