Concussion Management: Current Concepts and Clinical Guidelines

1. Concussion Management:Current Concepts and Clinical Guidelines Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation UniversityHospital SUNY Upstate Medical University Director, CNY Sports Concussion Center NYSPHSAA Concussion Team & Safety Committee NYS TBI Coordinating Council  Public Education Committee February 2009

2. What is a concussion? • Mild traumatic brain injury • A disruption in normal brain function due to a blow or jolt to the head • CT or MRI is almost always normal • Invisible injury

3. Definition of ConcussionAmerican Congress of Rehabilitation Medicine • Blow or jolt to the head AND • Loss of consciousness (≤ 30 min) OR • Post-traumatic amnesia (≤ 24 hrs) OR • Neurological finding OR • Slurred speech, diplopia, etc. • Alteration in mental state • Dazed or disoriented or confused • After 30 minutes, an initial GCS of 13-15

4. Outdated AAN Criteria forSports-related Concussion Grade 1 Transient Confusion Symptoms resolve in <15 minutes No LOC Grade 2 Transient Confusion Symptoms last >15 minutes No LOC Grade 3 LOC: a) brief b) prolonged

5. Prague 2004 Guidelines (McCrory et al., 2004) • Simple concussion • LOC < 1 minute • resolves in 7-10 days • first concussion • Complex concussion • LOC > 1 minute • symptoms last longer than 7 – 10 days • history of multiple concussions IOC • IIHF • FIFA

6. Prague 2004 Guidelines • No return to play in current game or practice • Return to play only when symptom free at rest and with exertion • Graduated return to play with exertional challenge • Recognition of differences in children • Neurocognitive testing recommended Manage each concussion individually

7. Epidemiology • 1.6 to 3.8 million sports concussions each year in the United States • Football, hockey, and soccer are the riskiest male team sports • Up to 10% of high school football players suffer a concussion each year • Soccer and lacrosse are the riskiest female team sports

8. Epidemiology • In HS sports played by both sexes, girls have a higher rate of concussion • Collegiate athletes have a higher rate of concussion than HS athletes • Concussion represents a higher proportion of all injuries in HS athletes vs. collegiate • Approximately 10% of sports concussions involve LOC

9. Multiple Concussions What are the risks ? • Second Impact Syndrome • A second concussion within 2 weeks of first • Athlete is still symptomatic • Mostly males < 21 years old • Rapid increase in intracranial pressure • Rare but almost always fatal • Possible cumulative effects • Increasing concussability • Prolonged or incomplete recovery • Increased risk of later depression or dementia How many is too many ?

10. Mechanisms of Injury • A complex physiological process induced by traumatic biomechanical forces • sudden chemical changes • traumatic axonal injury • Structural brain imaging (CT or MRI) is almost always normal

11. Neurometabolic Cascade(Giza and Hovda 2001) • Abrupt neuronal depolarization • Release of excitatory neurotransmitters • Changes in glucose metabolism • Altered cerebral blood flow • The brain goes into an ENERGY CRISIS that usually last up to 7 – 10 days symptoms often get worse before they get better

12. Traumatic Axonal Injury • Results from rotational and/or acceleration-deceleration forces • Typically occurs in specific sites • junction of gray and white matter • long fibers of the internal capsule • corpus callosum • upper brainstem

13. Common Physical Symptoms • Headache • Nausea and vomiting • Clumsiness and poor balance • Dizziness and lightheadedness • Blurred vision and light sensitivity • Fatigue and lack of energy • Sleep disturbance

14. Common Emotional Symptoms • Irritability • Anxiety • More extreme moods • Easily overwhelmed • Emotional and behavioral outbursts • Personality change • Lack of motivation

15. Common Cognitive Symptoms • Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ • Easily confused • Slowed processing • Easily distracted • Memory problems • Trouble reading • Poor mental stamina

16. Exertion effects • Symptoms are worsened by . . . • mental effort • environmental stimulation • emotional stress • physical activity

17. 9 mos. after injury 6 mos. after injury Chen et al. (2004)

18. Recovery from Concussion • Full recovery in 7-10 days. . .in most cases • About 95% recover in 3 months • Symptoms generally thought to have a primarily neurological basis at first • When symptoms persist, non-injury factors appear to play an increasingly significant role over time a ‘miserable minority’ experience complicated recovery

19. Outcome after concussion is difficult to predict • Early markers weakly related to recovery • LOC • GCS score • PTA

20. Recovery From Sports ConcussionHow Long Does it Take on ImPACT? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 N=134 High School athletes Collins et al., 2006, Neurosurgery

21. Sideline Evaluation • Head trauma (blow or jolt) • LOC or amnesia for the trauma • Focal neurologic finding • Signs & Symptoms (SCAT card) • confused, wobbly, emotional. . . • Assess cognition • 3 word recall • Months backwards • Standardized testing • SAC • BESS • NO RETURN TO PLAY THAT DAY • When in doubt—sit ‘em out

22. Prague Return to Play Guidelines • Prague 2004 guidelines recommend that when a player shows ANY symptoms or signs of a concussion: • 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

23. Prague 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 after medical clearance • Game play Also should be symptom-free after mental exertion and have normal neruocognitive test results

24. Medical Protocol • Any athlete who suffers a concussion needs medical clearance before RTP • Anyone with a LOC should be evaluated that day • If confused or not fully conscious, transport by EMS with immobilization • Follow athlete until asymptomatic • First medical clearance is to begin RTP progression • If no return of symptoms with exertion, then final clearance for game play

25. It takes a team. . . • Athlete and parents • Athletic Trainer • Coaches and Athletic Director • Physician, school physician, and school nurse • Psychologist • Teachers and school administrators

26. Managing Complex Concussion • Consider referral to specialized provider or program if . . . • History of multiple concussions or other risk factors • Prolonged recovery (> 2 weeks) • Worsening symptoms

27. Neuropsychological Testing In Sports Concussion • Computerized tests that measure attention, memory, and processing speed (reaction time) • Sensitive to effects of concussion • Tests can be repeated multiple times to monitor recovery • Ideally, pre-injury baseline testing done for all athletes • ImPACT, CogSport, HeadMinder

28. Unique Contribution of Neurocognitive Testing to Concussion Management Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion N=215, MANOVA p<.000000 (Lovell et al., 2004)

29. Guidelines for Return to School after Concussion • Out of school at first if necessary, and then gradual re-entry as tolerated • Avoid re-injury in sports, gym classs and crowded hallways or stairwells • Provide academic accommodations • Communicate and Educate

30. Academic Accommodations • Rest breaks during school in a quiet location (not always the nurse’s office) • Reduced course and work load • Drop unnecessary classes • Decrease homework • Avoid over-stimulation, (e.g., cafeteria or noisy hallways) • Extra time and a quiet location for tests

31. Summary • CDC now recognizes sports concussion as a significant public health issue • Proper recognition and management of concussion can prevent serious problems • No RTP in current game or practice • No RTP until symptom free, at rest and with exertion • Manage every athlete and concussion individually • Neurocognitive testing is recommended

32. Remember to wear your helmet ! upstate.edu/concussion riegerb@upstate.edu

33. Concussion Management Program & CNY Sports Concussion Center UniversityHospital Clinical Evaluation and Treatment Community Education Research upstate.edu/concussion riegerb@upstate.edu