IT’S ALL IN YOUR HEAD!CARING FOR CONCUSSIONS IN YOUR COMMUNITY
Stephen K Stacey, DOCPT, MC, USA
OUTLINEDefinitionEpidemiologyDiagnosisEvaluationRecoverySequelaePreventionResources for providers
CASEAn 18-year-old high school senior is playing soccer when she collides with the goalpost, hitting her head and falling to the groundShe gets up immediately and tries to keep playingDid she sustain a concussion?
DEFINITION
DEFINITION OF CONCUSSIONConcussion 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.
4th International Conference on Concussion in Sport held in Zurich, November 2012
DEFINITION SIMPLIFIEDAny head-injury event that causes symptoms falls on the traumatic brain injury (TBI) spectrumMild TBI (AKA concussion) has no structural damage and more limited symptomsSymptoms can include:
Headache, sleep disturbance, phonophobia, photophobia, dizziness, weakness, fogginess, difficulty concentrating, more irritable or emotional than baseline, unsteadiness or ataxia, loss of consciousness
CONCUSSION VS. MTBIMTBI: Mild Traumatic Brain InjurySame thing as concussionShown that patients are more concerned about the condition when called MTBI“Concussion” is the more common terminology, even in medical contexts
CLOSED TBI CLASSIFICATION
SEVERITY MILD (CONCUSSION) MODERATE SEVERE
Structural imaging
Normal Normal or abnormal
Normal or abnormal
Loss of consciousness
0 to 30 minutes ≥30 minutes and ≤24 hours >24 hours
Alteration of consciousness
A moment up to 24 hours
>24 hoursSeverity based on other criteria
Post-traumatic amnesia
A moment up to 24 hours
>1 day up to 7 days > 7 days
EPIDEMIOLOGY
EPIDEMIOLOGYConcussions account for nearly 15% of all sports-related injuriesHighest-risk sports: boxing, football, hockey, wrestling, rugby, soccerBike riding is the leading cause of concussion for kidsNot just athletes
Leading causes of TBI
Falls40.5%
Unknown/other19%
Collision15.5%
Motor vehicle14.3%
Assaults10.7%
cdc.gov
CASE CONTINUEDThe athlete is called to the sideline She says she feels “fine” and wants to return to playDoes she require an evaluation?
EVALUATION
ASSESSMENT TOOLSSCAT3
Sports Concussion Assessment ToolFrom Concussion in Sport GroupIncorporates physical examShould be administered by trained medical professionalWidely adopted, multiple derivatives
Child SCAT3Use for patients <13 years old
Pocket concussion recognition toolFrom Concussion in Sport GroupUseful for laypeople or those with limited experienceDoes not incorporate physical exam
MORE ASSESSMENT TOOLSACE
Acute Concussion EvaluationFrom Centers for Disease Control (CDC)Simpler to administer, requires less trainingDoes not take physical exam into account MACECould be administered by MA screening for clinic visit
Military Acute Concussion EvaluationFrom Defense and Veterans Brain Injury Center (DVBIC)Utilized in deployed and non-deployed settingsRequires trained medical professionalCombined with algorithm for comprehensive evaluation and management guidelines
SYMPTOMSSomatic (e.g. headache)Cognitive (e.g. feeling like in a fog)Emotional symptoms (e.g. lability) Physical signs (e.g. loss of consciousness, amnesia) Behavioral changes (e.g. irritability) Cognitive impairment (e.g. slowed reaction times)Sleep disturbance (e.g. drowsiness, insomnia)
4th International Conference on Concussion in Sport held in Zurich, November 2012
EXAMFull neurological exam
GCS?AVPU simpler; as accurate when compared head-to-head
EyesSpeechMotor Balance
Cognitive examOrientationMemory
Immediate and delayedConcentration
ADVANCED IMAGINGNeuroimaging (CT, MRI) is by definition normal in concussionUsed when red flags indicate the possibility of a cerebral or cranial structural lesion, including fracture and bleedingRed flags include:
Progressively declining level of consciousness, pupil asymmetry, seizures, repeated vomiting, GCS <15, motor or sensory deficit, worsening/severe headache
Other modalities such as fMRI have not been shown to be clinically useful, and are not routinely recommended outside of a research setting
NEUROPSYCHOLOGICAL TESTINGNot required for diagnosisMay aid rehabilitationMore useful if baseline testing is performedRequires special training to administer
CASE CONTINUEDYou evaluate the patient and discover that she reports a headache and she seems irritableShe was unable to perform immediate and delayed recallHer neurological exam shows she is unsteady on her feet, though she has no focal neurologic deficits
RECOVERY
RECOVERYMajority (80%-90%) recover within a weekMay take longer in pediatric patientsCornerstone of therapy is physical and cognitive rest until symptoms resolve
Physical Rest No training, playing, exercise, weightsBeware of exertion with activities of daily living
Cognitive Rest No television, extensive reading, video games, homework
Stepwise return to full activityOur job is to educate!
RETURN-TO-PLAY GUIDELINESNever return to play the same day, no matter how “small” the concussionMust be asymptomaticGraded return to play
Same guidelines for “elite” and “non-elite” athletesConsider the patient’s concerns
Are they confident to return?Do they want to continue with the activity?
These guidelines apply to non-sport concussions
GRADUATED RTP PROTOCOLRehabilitation stage Functional exercise at each stage of
rehabilitationObjective of each stage
1. No activity Symptom limited physical and cognitive rest. Recovery
2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training.
Increase HR
3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities.
Add movement
4.Non-contact training drills
Progression to more complex training drills e.g. passing drills in football and ice hockey. May start progressive resistance training.
Exercise, coordination, and cognitive load
5.Full contact practice Following medical clearance participate in normal training activities
Restore confidence and assess functional skills by coaching staff
6.Return to play Normal game play
• 24 hours per step (therefore about 1 week for full protocol)• If recurrence of symptoms at any stage, return to previous asymptomatic level and
resume after further 24 hr period of rest4th International Conference on Concussion in Sport held in Zurich, November 2012
BEHAVIORAL HEALTHConcussions may cause behavioral symptoms
Personality changesSleep issues (hypersomnolence vs. insomnia)Depression may result from concussionAnxiety may result, especially as it applies to the activity that caused the concussion
Medications may be used for prolonged symptomsAntidepressants are often usedUse medication that best treats the combination of symptoms
Consider trazodone if insomnia,Consider tricyclic antidepressants if headache is persistent
Multidisciplinary approach
OTHER PROBLEMSNeuroendocrine dysfunctionDizziness
CASE CONTINUEDThe patient is pulled from play and sent to her primary care physician the next dayShe is given a graded return-to-play handout and instructed on physical and cognitive restHer father is in the room and he acknowledges and agrees with the plan
SEQUELAE
POST-CONCUSSION SYNDROMEMost common complication of concussionPersistence of symptoms past 3 monthsReported in up to 40%–80% of concussion patients, though most sources agree it’s the minority of patientsOffer reassurance—most patients fully recoverRefer if primary care management does not resolve symptoms
Consider MRI to evaluate possible other cause of symptomsPsychiatry referralMultidisciplinary TBI team, if available
SECOND-IMPACT SYNDROMEDiffuse cerebral edema occurring when a patient sustains a concussion while still symptomatic from the first concussionCan result in increased intracranial pressure, herniation, coma, deathPatients who survive are often severely disabledExtremely rare
CHRONIC TRAUMATIC ENCEPHALOPATHY
Progressive degenerative disease found in people who have had a severe blow or repeated blows to the headPreviously known as dementia pugilistica due to its association with boxersEducate the patient on the potential for long-term problems and to seek care if concerns arise
CASE CONTINUEDFour months later the patient returns, stating she has had difficulty concentrating and has continued headaches since the collisionShe has been withdrawn and doesn’t spend as much time with friendsHer grades this semester are slightly worse than usual
PREVENTION
PREVENTIONHelmets are designed to prevent skull fracture, not concussionMouthguards prevent dental injury, no effect on concussionRule changes in the sportViolent behavior that increases concussion risk should be eliminated
Promote fair play and respect
RESOURCES
RESOURCES FOR PROVIDERSDefense and Veterans Brain Injury Center
https://dvbic.dcoe.mil/resourcesMACE: https://dvbic.dcoe.mil/files/resources/DVBIC_Military-Acute-Concussion-Evaluation_Pocket-Card_Feb2012.pdfConcussion algorithm: http://www.dcoe.mil/content/Navigation/Documents/DCoE_Concussion_Management_Algorithm_Cards.pdf
SCAT3http://bjsm.bmj.com/content/47/5/259.full.pdf
Heads Uphttp://www.cdc.gov/headsup/index.htmlACE: http://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf
DVBIC CONCUSSION ALGORITHM
MACE ALGORITHM