Current Concepts in Concussion and Concussion Management

1. Current Concepts in Concussion and Concussion Management Matt Leiszler, MD Office-Based Sports Medicine Symposium May 17, 2014

2. I have no relevant financial disclosures.

3. OUTLINE • Key Points • Background • Definitions • Presentation • Investigations/Studies • Management • Key Points

4. Key Points • These are the CURRENT concepts—very likely to evolve • 80-90% of concussions resolve in 7-10 days • Majority of concussions do not involve loss of consciousness • No same day return to play • Sports Concussion Assessment Tool (SCAT-3) • New Imaging and Treatment options are on the horizon • State of the Art treatment currently: Rest

5. Background • Concussion

6. Background • CDC estimates 1.6 – 3.8 million concussions occur annually in sports/rec activities in the US each year • 33% of all concussions are sports-related (ages 5-19)

7. Background

8. Definition: Concussion (Zurich 2012) “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: Concussion 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. 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. Concussion 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. However it is important to note that in some cases, post-concussive symptoms may be prolonged.”

9. Definition: • Concussion (AMSSM): “A traumatically induced transient disturbance of brain function and involves a complex pathyphysiological process. Concussion is a subset of mild traumatic brain injury which is generally self-limited and at the less-severe end of the brain injury spectrum”

10. Definitions • Concussion and Traumatic Brain Injury

11. Definitions • Post-Concussion Syndrome • AMSSM Position Statement 2013: • “Difficult to determine where concussion ends and post-concussion syndrome begins” • “Symptoms and signs that persist for weeks to months” • Zurich 2012: “Prolonged Symptoms”: • Symptoms > 10 days • 10-20% of concussions

12. Definitions • Second Impact Syndrome • Numerous case reports, essentially all under 22 years old • Rare, but devastating event • Unclear whether this has occurred in an asymptomatic person • Head trauma on already injured brain  worsening metabolic changes in the cells • Coherent for 15-60 seconds  rapid coma and respiratory failure

13. Concussion Legislation Colorado’s Senate Bill 40 “The Jake SnakenbergYouth Concussion Act” Signed March 29, 2011

14. Colorado Senate Bill 40

15. Senate Bill 40 Requirements • Training of coaches • Removal from play • Notification of a parent • Sign-off on return to play be medical provider

16. Concussion Presentation • Multiple manifestations • No two concussions are exactly the same • Headache most common symptom; dizziness second • 90% do not include loss of consciousness

17. Signs and Symptoms

18. Symptoms • Randolph, et al (2009): • 12 Validated Symptoms: Concussion Symptom Inventory • Headache • Nausea • Balance problem/dizziness • Fatigue • Drowsiness • “In a fog” • Difficulty concentrating • Difficulty remembering • Sensitivity to light • Sensitivity to noise • Blurred vision • Feeling slowed down

19. On-field/Sideline Evaluation of Acute Concussion • Should occur if concussion even suspected • Player evaluated by physician or other licensed healthcare provider • If no healthcare provider available  remove from practice/play, refer • ABC’s, Exclude cervical spine injury • After first aid issues addressed  Sideline assessment tool • Do not leave player alone  monitor over a few hours • A player with a diagnosed concussion should NOT be allowed to return to play on the day of injury • When in doubt—sit them out!

20. Sport Concussion Assessment Tool

21. SCAT 3

22. Symptoms

23. SCAT 3

24. SCAT 3

25. SCAT 3

26. Referral to Emergency Department? • Worsening/Severe headache • Deteriorating mental status • Active vomiting • Focal neurologic findings • Numbness, tingling, weakness, seizure, unequal pupils

27. Office or Emergency Department Evaluation • Full history, detailed neurological exam • Essentially perform a SCAT3 • Determine clinical status—improving or deteriorating? • Determine need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality

28. Investigations/Studies

29. Investigations/Studies • Postural stability testing • Often returns to normal after 72 hours post-conc • Force plate technology • Balanced Error Scoring System

30. Investigations/Studies • Imaging of the Brain • CT, MRI—typically normal • If suspicion of intracerebral or structural lesion exists  Imaging • Prolonged disturbance of conscious state • Focal neurological deficits • Worsening symptoms

31. Investigations/Studies • Imaging of the Brain • Alternative imaging • Several methods being investigated • Exciting area of research

32. Investigations/Studies • Electrophysiological Recording Techniques • Electroencephalogram (EEG) • Evoked response potential (ERP) • Cortical magnetic stimulation • Reproducible abnormalities in post-concussive state • Not all studies differentiate concussed athletes from controls

33. Investigations/Studies • Neuropsychological Assessment—Computer Testing • Evaluating cognitive recovery • Important component in overall assessment and return to play • Baseline testing useful • Aids in clinical decision making—but not the sole basis of management decisions

34. Investigations/Studies • Neuropsychological Assessment • Formal Neuropsych testing • Trained Neuropsychologist • Not required for all • May be beneficial in prolonged symptoms • Help identify other conditions

35. Investigations/Studies • Genetic testing and Biomarkers • Insufficient evidence for routine clinical use • Apo E4, ApoEpromotor gene, Tau polymerase • IGF-1, IGF binding protein 2, Fibroblast growth factor, Cu-Zn superoxide dismutase, nerve growth factor, S-100 • Serum and Cerebral Spinal Fluid biomarkers being evaluated

36. Management • Cornerstone REST

37. Management • Rest • Physical Rest • No training, playing, exercise, weight lifting • Exertion with ADLs • Cognitive rest • Minimize TV, extensive reading, video games • Limit to exacerbation of symptoms

38. Management • Return to school and social activities • Encouraged • School Accommodations • Extra time or delay tests and quizzes until student is asymptomatic • Partial days • CDC: educational materials for teachers/administrators

39. Management • Gradual resolution • 80-90% of concussions resolve in a short period (7-10 days) • Recovery may be longer in children and adolescents • May require multiple office visits

40. Recovered? • Everyone says they “feel fine” • Ask: • “On a scale of 0–100%, how do you feel?” • “What makes you not 100%?” • Symptom Checklist—SCAT 3

41. Graduated Return to Play Protocol • 24 Hours per step (so almost a week for full protocol) • If symptoms recur return to previous level • Evaluation by health care provider required for school age athletes

42. Difficult cases—persistent symptoms • Symptoms >10 days • Sports-related concussions less likely to result in PCS • Consider other issues:Depression? Chronic headaches? Learning disorders? • Multidisciplinary clinic • Children’s Hospital Complex Concussion Clinic • Sub-symptomatic exercise may be beneficial

43. Management • Pharmacotherapy • Useful for prolonged symptoms • Sleep disturbance • Anxiety • Anti-depressants • Upon return to play should not be on medications that could mask symptoms • Avoid NSAIDs in first 48-72 hours • TCAs, Amantadine, Methylphenidate commonly reported as being used for management • Antioxidants?

44. Other Treatment • Vestibular Therapy • Balance Therapy • Transcranial LED—Chronic TBI • Red and Near-Infrared LED applied transcranially

45. Chronic Sequelae? • Chronic cognitive dysfunction • Chronic Traumatic Encephalopathy • Chronic Neurocognitive Impairment • CTE unknown incidence in athletic populations, cause/effect not yet demonstrated between CTE and concussions or exposure to contact sport • Acknowledge potential for long-term problems in all athletes To Be Determined

46. Prevention • Protective equipment • Mouth guards • Prevent oral injuries • Head gear and helmets • Reduce impact forces, not concussions • Reduce head and facial injury • Cervical muscle strengthening?

47. Other Issues • Rule Changes • Checking • Limiting contact practices • Heading in soccer (50% of concussions are due to arm to head contact) • Education of athletes, parents, coaches • Awareness of concussion symptoms and signs • Web-based resources, social media

48. Questions • How many concussions is “too many”? • Who will develop CTE? Number of hits? More “significant” concussions? • Evolving role of advanced imaging? • What treatments may prove beneficial in concussion? • Validation of tools? • Prevention?

49. Key Points • These are the CURRENT concepts—very likely to evolve • 80-90% of concussions resolve in 7-10 days • Majority of concussions do not involve loss of consciousness • No same day return to play • Sports Concussion Assessment Tool (SCAT-3) • Imaging and Treatment options are on the horizon • State of the Art treatment: Rest

50. References • Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November2012. BrJ Sports Med 2013;47:250-258. • McCroryP, Johnston K, Meeuwisse Wet al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196–204. • Efficacy of amantadine treatment on symptoms and neurocognitive performance among adolescents following sports-related concussion. Reddy CC, Collins M, Lovell M, KontosAP. J Head Trauma Rehabil. 2013 Jul-Aug;28(4):260-5. • Management strategies and medication use for treating paediatric patients with concussions. KinnamanKA, Mannix RC, Comstock RD, Meehan WP 3rd. Acta Paediatr. 2013 Sep;102(9):e424-8. • Vestibular and balance treatment of the concussed athlete.AligeneK, Lin E. NeuroRehabilitation. 2013;32(3):543-53. • Should we treat concussion pharmacologically? The need for evidence based pharmacological treatment for the concussed athlete. McCrory P. Br J Sports Med. 2002 Feb;36(1):3-5. • AmericanMedical Society for Sports Medicinepositionstatement: concussion in sport. Harmon KG, Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A, Putukian M, Roberts W; AmericanMedical Society for Sports Medicine. ClinJ Sport Med. 2013 Jan;23(1):1-18.