Concussion Management 2012: Where Are We Now?

1. Concussion Management 2012: Where Are We Now? Andrew Getzin, MD Cayuga Medical Center Ithaca, NY

2. Challenging Injury • Variability in presentation, can be subtle • No clear marker, no definitive test • Ideal management ? • Track recovery ? • Prevention? • When “is it safe?” • Research Evolving

3. What is a Concussion? A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces McCrory, 3rd international Concusion in Sport, Zurich, Clin J Sport Med 2009

4. NEJM Case “Concussion refers to an immediate and transient loss of consciousness accompanied by a brief period of amnesia following a blow to the head” Ropper and Gorson, NEJM 2007

5. Loss of Consciousnes Brief LOC does not correlate with severity of concussion Developed from studies with animal models and more severe head injuries Most likely related to subcortical involvement (Reticular Activating System) Lovell, Clin J Sports Med 1999;8:193

6. Giza and Hovda, J Athl Training 2001

7. Pathophysiology Alterations in intracellular/extracellular glutamate, potassium, and calcium A relative decrease in cerebral blood flow in the setting of an increased requirement for glucose- Mismatch Work by Vagnozzi demonstates metabolic period of increased vulnerability Vagnozzi, Neurosurgery 2005, 2007 Len, MSSE 2011

8. Second Impact Syndrome? Abnormal cerebral blood flow that occurs shortly after an individual sustains a second concussion prior to fully recovering from a previous concussion Vascular engorgement leads to massive increase in intracranial pressure and brain herniation Usually severe brain damage or death “The scientific evidence to support this concept is nonexistent” Diffuse cerebral swelling (DCS) occurs in children> adults with a poor outcome Saunders and Harbaugh, JAMA 1984 McRory, CSMR 2012

9. High School Football Player Dies October 2008

10. Recovery from Concussion 80-90% of concussions resolve in 7-10 days Post-concussion syndrome (PCS) is the term used to describe prolonged or incomplete recovery Non-injury factors often play a role in the persistence of symptoms

11. Exertion Effects Symptoms are exacerbated by: Mental effort Environmental stimulation Emotional stress Physical activity

12. Goals of Initial Office Visit • Determine if Individual sustained a concussion • Protect his/her brain to allow for recovery • Activity limitation • School work modification • Potential support with medication for symptoms • Provide reasonable patient expectations

13. Signs and Symptoms Concussion: Team Physician Consensus Statement, MSSE 2011

14. Risk Factors That May Prolong or Complicate Recovery Concussion: Team Physician Consensus Statement, MSSE 2011 Makdissi, AJSM 2011

15. Early Concussion Guidelines Cantu: 1-post traumatic amnesia <30 minutes, 2- LOC < 5 minutes, post traumatic amnesia > 30 minutes, 3- LOC > 5 minutes, post traumatic amnesia > 24 hours Colorado Medical Society: 1- no LOC, no post-traumatic amnesia, confusion, 2- no LOC, post-traumatic amnesia, confusion, 3- LOC of any duration American Academy of Neurology: 1- no LOC, Confusion symptoms <15 minutes, 2- No LOC, Confusion symptoms >15 minutes, 3- LOC of any duration

18. PE: Concussion in the Office Regular physical exam including HEENT, neck, and neurological exam 5 Word Recall- immediate and 5 minutes Months of the year backwards Digits backwards Speech Pronator drift: Rhomberg Finger-to-nose Gentle push with their eyes closed

19. Rx: Concussion in the Office “The art of medicine consists in amusing the patient while nature cures the disease.” Voltaire

20. Initial Rx: Concussion in the Office Mental and Physical Rest 92% of repeat in-season concussions occur within 10 days Initial medication to support Anti-nausea Headache medication Sleep medication? Schoo/work support Guskiewicz, JAMA 2003 Majerske, J AthlTra2008

21. Follow-up Office Visits • Is the individual improving? • Obtain information from other sources: family, teachers, work • Gradual progression back to normalcy • Is it time to intervene?

22. Additional Rx: Concussion in the office Physical & Occupational Therapy Neck & back problems Balance (fall prevention) Vision and Cognition Neuropsychological Testing Additional Medication Headache: elavil Mental Health: SSRI Stimulant Exercise trial Leddy, Clin J Sport Med 2010

23. What Information Guides Return to Activity • Symptoms • Physical Exam including balance testing • Cognitive assessment: neuropsychological assessment? Hutchison, AJSM 2011

24. What Is Symptom Free? • Dependent on time and day of measurement, emotional status, attitude, motivation, and honesty • Postconcussion-like symptoms are prevalent in the non-concussed population • Perhaps return to baseline symptoms Alla, Br J Sports Med 2011

25. Zurich Return to Play Guidelines • Athlete should not return-to-play in the current game or practice • Athlete should be monitored for deterioration for 24 hours • Return-to-play must follow a medically supervised stepwise process • Athlete must be symptom-free at rest AND after exertion

26. Zurich Return to Play Progression No activity, complete rest Light aerobic exercise but no resistance training Sport specific exercise and progressive addition of resistance training Non-contact training drills Full contact training and scrimmage Game play

27. Preparticipation Evaluation: Hx of Previous Concussions Mechanism of injury Length of time for full recovery Time out of school/work Special Treatment

29. Preparticipation Evaluation: BESS

30. Concussion Prevention • There are currently no personal protective equipment that prevents concussions including mouth guards and helmets • Improper fit of equipment may increase risk for concussion • Rule changes

31. Thank You