Joint Session with ACOFP and Mayo Clinic:

Concussion

Rashmi Halker Singh, M.D., FAHS

9/1/2016

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©2013 MFMER | slide-1

Concussion

Rashmi Halker, MD, FAHS

@rashmihalker

halker.rashmi@mayo.edu

Disclosures

No financial disclosures

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Objectives

• Review the current understanding of concussion pathophysiology

• Review the outpatient evaluation and management of concussion

• Determine how to make return-to-learn and return-to-play decisions

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Epidemiology of Concussion

• Estimated 3.8

million

concussions per

year

> 50% of high

school athletes

may not report

symptoms

www.cdc.gov/TraumaticBrainInjury. 2010

McCrea et al. CJSM. 2004;14:13-17.

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What is a concussion?

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• A complex pathophysiological process induced by biomechanical forces resulting in alteration of brain structure & function

There must be “blow to the head” to produce a concussion.

• FALSE

WHIPLASH INJURY CAN CAUSE A CONCUSSION

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ATP DEMAND

ATP SUPPLY

ENERGY MISMATCH

Giza CG, Hovda DA. Neurosurgery 2014;75:S24–S33

Kan, EM, et al. Brain Res Bull 2012;87: 359– 372

Rosenfeld JV, et al. Lancet 2012; 380: 1088–98

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Alterations in Function AND STRUCTURE

Rutgers DR et al. AJNR 2008;29:514-519.

What is happening in a concussion?

• Biomechanical forces to the brain

Abnormal function at the cellular level

resulting in a neurometabolic cascade & energy crisis

Leading to inflammation, altered proteolysis, cell death, and axonal injury

Leading to microstructural changes in BBB and white matter tracts

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Management of concussion

• Pre-participation counseling

• Pre-participation assessment

• Sideline assessment

• Post-injury evaluation

• Return to learn

• Return to play

• When to recommend retirement

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Pre-participation counseling

• What is a concussion?

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Concussion is a form of mild traumatic brain injury

CONCUSSION IS A TRAUMATIC BRAIN INJURY

Loss of consciousness is NOT required for a concussion

< 10% of concussions will result in a loss of consciousness

McCrory P et al. Br J Sports Med 2013;47:250-258.

Giza CC et al. Neurology 2013;80:2250-2257.

McCrea et al. , 2013

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Pre-participation counseling

• What is a concussion?

• What are the symptoms after a concussion?

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PHYSICAL COGNITIVE EMOTIONAL SLEEP

Headache

Photo/phonophobia

Nausea/Vomiting

Concentration Irritability Hypersomnia

Dizziness

Lightheadedness

Balance problems

Memory Depression Insomnia

Blurry vision Feeling slowed down

Mood lability Trouble falling asleep

Loss of energy Inability to multitask

Anxiety Trouble staying asleep

• Any symptom or sign should raise concern and requires an immediate and ongoing evaluation

• Symptoms and signs may be delayed in onset

Symptoms after a Concussion

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Pre-participation counseling

• What is a concussion?

• What are the symptoms after a concussion?

• Who is at risk?

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Who is at risk?

• Contact sports

• Female gender

• Youth

• History of a concussion is a risk factor for concussion

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www.cdc.gov/TraumaticBrainInjury, 2010. Giza CC et al. Neurology, 2013

Marar et al. Am J Sports Med, 2012. Hollis et al. Am J Sports Med, 2009

.

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Who is at risk?

• Sports-related TBI ranges from 1.6 to 3.8 million affected individuals annually in the US

• Adolescents, aged 15-19 years are at risk

www.cdc.gov/TraumaticBrainInjury. 2010

Younger athletes recover from concussion faster than older athletes.

A. True

B. False

Giza CC et al. Neurology 2013;80:2250-2257.

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Recovery Time Following Concussion in Collegiate Football Players

90% “resolve” within 7 days

McCrea et al. JAMA 2003;290:2556-2563

Sports Med 2015

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“. . . a single sports-related

concussive incident during

childhood (m= 2.1 years prior

to testing) may lead to subtle,

yet pervasive alterations in

the behavioral and neural

indices of attention and

executive control, and age at

injury may moderate injury

outcomes”

Int J Psychophys 2015

• 42 former NFL players (40-69)

• Participation in tackle football prior to age 12 was

significantly associated with greater later-life

cognitive impairment.

• Sustaining repeated head impacts during a critical

neurodevelopmental period may increase the risk of

later-life cognitive impairment.

Stamm JM, et al. Neurology 2015;84:1114–1120

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Youth are at risk for prolonged recovery

• Cognitive and other symptoms may

take at least 6 weeks to resolve

• 15-30% have persistent impairment in

memory and other cognitive functions

for > 3 months

• 44-50% have > 3 symptoms at 1 year 1. Covassin T., et al. Phys Sportsmed 2010;38:87-93

2. Sroufe, N.S., et al Pediatrics 2010;125:1331-1339

3. Konrad C, et al. Psychol Med 2010:1-15

4. Chuah YM, et al. Brain Cog 2004;56:304-312

5. Vasterling JJ, et al. Clin Psychol Rev 2009;29:674-684

Who else is at risk for prolonged recovery after a concussion?

• History of migraine

• Family history of migraine

• History of learning disability

• History of psychiatric illness

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Vargas, 2012

Register-Mihalik, 2009

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Pre-participation counseling

• What is a concussion?

• What are the symptoms after a concussion?

• Who is at risk?

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Pre-participation assessment

• Baseline graded symptoms checklist

• King Devick Testing

• Computerized neuropsychometric testing

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1. Baseline graded symptom checklist

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50-70% will have symptoms at baseline

Lovell et al., Applied Neuropsych, 2006

2. King-Devick Test

• 2 minutes to administer

• Practical for sideline/office use

• Captures common concussion abnormalities:

• Attention, Language, Processing speed, Eye movements

• Validated for use by non-medical professionals

• Sensitivity 86%; specificity 90%

• Any worsening=5x greater likelihood of concussion

Galetta KM, et al. Neurology 2011;76:1456-1462

Leong DF, et al. J Sports Med Phys Fitness 2013;54:70-77

Galetta KM, et al. Concussion 2015.

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3. Computerized neuropsychometric testing

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Pre-participation counseling and assessment: How to do this efficiently?

• Complete background information and baseline symptom score

• Review for risk factors for concussion/prolonged recovery. Provide verbal and written information.

• King Devick Testing

• Computerized neuropsychometric testing

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http://www.cdc.gov/headsup/resources/custom.html

What to do after a suspected concussion?

• Remove from play until formally evaluated by concussion expert

• For rapidly progressive symptoms, go to emergency room

• CT Head should be used only to rule out hemorrhage or skull fracture

• Symptom-limited return to school/work

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Outpatient evaluation of concussion

• Prioritize

• Appropriate management

• Limit symptom exacerbation

• Treat symptoms

• Prevent premature return-to-learn and return-to-play

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Initial visit: Injury characteristics

• Date of injury

• Post injury day number

• Injury description

• Mechanism of injury

• Location of impact

• Whiplash

• Loss of consciousness

• Presence or absence of retrograde and/or anterograde amnesia

• Immediate and delayed symptoms

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PHYSICAL COGNITIVE EMOTIONAL SLEEP

Headache

Photo/phonophobia

Nausea/Vomiting

Concentration Irritability Hypersomnia

Dizziness

Lightheadedness

Balance problems

Memory Depression Insomnia

Blurry vision Feeling slowed down

Mood lability Trouble falling asleep

Loss of energy Inability to multitask

Anxiety Trouble staying asleep

• Symptoms and signs may be delayed in onset

Initial visit: Symptoms after a concussion

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Adapted from McCrory P et al. Br J Sports Med 2013;47:250-258.

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Initial visit: Risk factors for prolonged recovery

• Pre-injury headache history

• Family history of migraine

• Development history and learning disabilities

• Psychiatric history

• Concussion history

• Number of prior concussions

• Symptom duration

• History of reduced threshold

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Giza et al., Neurology 2013;80:2250-2257

Initial visit: Headache characteristics

• Screen for headache red flags

• I ntractable vomiting

• F ocal neurologic symptoms/signs

• L evel of awareness

• O rthostatic headache

• P rogressively worsening headache

• If present neuroimaging

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Initial visit: Headache characteristics

• Duration

• Quality and severity of pain

• Location of pain

• Associated features

• Sensory sensitivities

• Nausea and/or vomiting

• Exacerbation with movement

• Neck pain

• Autonomic symptoms

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Initial visit

• Medication history

• Pre-injury and post-injury

• Prescription and over the counter

• Allergies

• Past medical history

• Family history

• Social history

• Level of education

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Initial visit

• Baseline testing

• Computerized neurocognitive testing

• King Devick Test (KDT)

• Neuropsychometric testing

• Neurologic examination

• Neuroimaging

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Physical examination

• Vitals

• Orthostatic

• HEENT

• Trauma, ecchymosis, lacerations, abrasions

• Identify trigger points

• Dix-Hallpike maneuver

• Musculoskeletal

• Detailed neurologic exam

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Detailed neurologic exam

• Mental status exam

• Standardized assessment of concussion (SAC)

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McCrory P et al. Br J Sports Med, 2013

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Detailed neurologic exam

• Mental status exam

• Standardized assessment of concussion (SAC)

• MMSE

• MOCA

• Kokmen

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McCrory P et al. Br J Sports Med, 2013

Detailed neurologic exam

• Cranial nerve examination

• CN I: anosmia

• CN II: pupillary assessment

• CN III, IV, VI

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CN III, IV, VI

• Nystagmus

• Smooth pursuit

• Vergence: near point convergence (NPC)

• Abnormal: NPC > 6cm

• Saccades

• Vestibulo-ocular reflex

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Ventura et al., Lancet Neurol 2014;13:1006-1016

Detailed neurologic exam

• Cranial nerve examination

• CN V: sensory loss or allodynia

• CN VII: weakness

• CN VIII: hearing loss and/or vertigo

• CN IX, X, XII

• CN XI

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Detailed neurologic exam

• Motor exam

• Reflexes

• Sensory exam

• Coordination

• Gait

• Tandem gait

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Timed Tandem Gait (TTG)

• 3m tandem heel-to-toe walk, turn, and return to starting position

• Time <14s in non-concussed individuals

• TTG 87% accurate (KDT 92%; SAC 68%)

• TTG plus KDT = 97% accurate

Galetta KM, et al. Concussion 2015.

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Concussion toolbox

• King Devick Test (KDT)

• Timed Tandem Gait (TTG)

• Neuropsychological testing

• Computerized screening tools

• Gold standard, paper and pencil testing

• Objective vestibular testing

• Autonomic testing

• Neuroimaging

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Ventura et al., Seminars in neurology 2015;35:599-606

Galetta KM et al. Concussion, 2015

Concussion neuroimaging

• CT Head

• Intracranial bleeding or skull fracture

• Otherwise unhelpful

• MRI Brain

• Susceptibility-weighted imaging (SWI)

• Diffusion tensor imaging (DTI)

• Spectroscopy (MRS)

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Ventura et al., Seminars in neurology 2015;35:599-606

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SWISusceptibility weighted MRI Gradient echo MRI

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Management of concussion

• Provide symptomatic treatment while the brain is healing• Prevent re-injury while the brain is healing

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Lexi

• 19 year old collegiate soccer player

• She was kicked in the head 13 days ago

• Diagnosed with concussion

• Since then she has had no improvement of symptoms

• “I have a headache, I’m dizzy, I feel sick to my stomach, I feel like I’m going to pass out, I can’t read, I can’t think, I can’t remember anything, I can’t sleep, I just feel awful…” at which point she breaks down in tears and then exclaims “and I can’t stop crying!!!”

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Lexi

What shall we do for Lexi?

A. Treat headache

B. Treat dizziness and lightheadedness

C. Treat oculomotor abnormalities

D. Treat cognitive difficulties

E. Treat insomnia

F. Treat emotional lability

Why is it so important to have a multidisciplinary approach to

concussion?

Makdissi et al., Br J Sports Med 2013

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PHYSICAL COGNITIVE EMOTIONAL SLEEP

Headache

Photo/phonophobia

Nausea/Vomiting

Concentration Irritability Hypersomnia

Dizziness

Lightheadedness

Balance problems

Memory Depression Insomnia

Blurry vision Feeling slowed down Mood lability Trouble falling asleep

Loss of energy Inability to multitask Anxiety Trouble staying asleep

Multidisciplinary symptoms requiremultidisciplinary treatment

Multidisciplinary symptoms requiremultidisciplinary treatment

Most common symptoms

• Headache

• Neck pain

• Autonomic

• Balance

• Oculomotor

• Cognitive

• Emotional

• Insomnia

Treatment options

• PTH tx based on phenotype

• Physical therapy/TPIs

• Start with nonpharm tx

• Vestibular therapy

• Vision therapy

• Cognitive rehabilitation

• Biofeedback/CBT/therapy

• Biofeedback/melatonin

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“I have a headache…”

• Headache history/characteristics

• Constant with exacerbations lasting greater than 4 hours

• Throbbing

• Severe

• Holocephalic, but worse occipitally

• Sensitive to light/sound

• Nauseous

MIGRAINE

PHENOTYPE

PTH, migraine phenotype

How would you treat her headache?

A. Provide reassurance that her headache will improve over time without any other treatment

B. Treat with a triptan for acute relief

C. Consider a preventive medication

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Treatment of PTH

• Why treat?

• Pain, disability, inability to function, concentrate, or participate in active rehabilitation

• Risk of medication overuse

• Risk of chronification

• Limited by the lack of randomized, prospective, double-blind treatment trials

Lucas et al., PM&R 2011;3:S406-412

Systematic approach to posttraumatic headache

1. Look for red flags, I FLOP

2. Identify phenotype

3. Elicit prior history of headache

4. Initiate acute treatment early, within days

5. Monitor for medication overuse

6. Consider preventive treatment early, within weeks

7. Consider comorbidities

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Comorbidities

• Avoid topiramate in patients with cognitive domain symptoms

• Avoid sedating medications in patients with fatigue

• Avoid certain antidepressants in patients with autonomic symptoms

• Avoid steroids in patients with significant emotional and sleep domain symptoms

PHYSICAL COGNITIVE EMOTIONAL SLEEP

Headache Concentration Irritability Hypersomnia

Vestibular

Autonomic

Memory Depression Insomnia

Blurry vision Feeling slowed down

Mood lability Trouble falling asleep

Loss of energy Inability to multitask

Anxiety Trouble staying asleep

Erin

• 17F gymnast

• Head to ground 4 weeks ago

• Immediate symptoms were present, but symptoms continue to worsen over time

• Now with headache, nausea, dizzy, cannot sleep

• Prior history of headache and anxiety as well as a family history of headache

• 1 prior concussion, symptom-free within 3 days

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What has she been doing since the concussion?

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Initiate symptom-limited cognitive and physical activity

Avoid the “dark closet effect”

Does strict rest after concussion improve recovery?

• RCT

• Control

• 1-2 days rest, followed by return to school and stepwise return to activity

• Intervention

• 5 days of strict rest (no school, no physical activity)

Thomas et al., Pediatrics 2015;135:213-223

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Does strict rest after concussion improve recovery?

• Intervention group: strict rest x 5 days

• No difference in neurocognitive or balance outcomes

• Higher symptom severity scores

• PCSS 187.9 vs 131.9, p < 0.03

• Slower symptom recovery

Thomas et al., Pediatrics 2015;135:213-223

Initiate symptom-limited cognitive and physical activity

Avoid the “dark closet effect”

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Return to learn goals

• Stage 1: Brain rest, but not sensory deprivation

• Stage 2: Brain warm ups

• Symptom and time-limited reading/screen time

• Stage 3: Back to school with accommodations

• Hours, curriculum, & environmental adjustments

• Stage 4: Full day school with accommodations

• Stage 5: RTL complete

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DeMatteo et al., Clinical Pediatrics 2015;54(8):783-792

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Initiate symptom-limited cognitive and physical activity

Avoid the “dark closet effect”

Buffalo Concussion Treadmill Test (BCTT)

• Non-randomized pilot study

• Individualized aerobic exercise treatment

• Improved symptoms based on PCSS

• Faster rate of recovery

• Small, controlled study

• Controlled aerobic exercise may normalize cerebral blood flow abnormalities during a cognitive task in concussion patients

Leddy et al., Clin J Sport Med 2010;20:21-27

Leddy et al., Curr Sports Med Rep 2013;12:370-376

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Symptom-limited activity

• Initial period of rest, 24-72h

• Active rehabilitation, even in the presence of symptoms

• Subthreshold exercise

• Reduced symptom score

• Full recovery

• Faster recovery

Gagnon et al., Brain Injury 2009

Leddy et al., Clin J Sport Med 2011

Baker et al., Rehabil Res Pract 2012

Active Rehabilitation

• Prescriptive instructions regarding intensity and duration of exercise

• Symptom-limited, sub-threshold activity

• Slow, monitored progression of the level of physical activity

Makdissi et al., Br J Sports Med 2013

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Case: “It was a hard hit, but I’m fine now”

• 15M

• Hit to the head Friday night with immediate sxs

• Resolution of symptoms by office visit on Monday

• Exam is at normal/baseline

• He has a practice tonight

• He has a tournament tomorrow...

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Case: “It was a hard hit, but I’m fine now”

A. He did not have a concussion. He is medically cleared to play.

B. He did have a concussion, but he is now medically cleared to play.

C. He did have a concussion and he is not medically cleared to play.

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Return-to-Play Decision

1. Symptom-free at rest

2. Return-to-learn

3. Exertion protocol

4. Normal objective testing

• Exam, KDT, vestibular, and cognitive testing

5. Sport specific return-to-play protocol

6. Consider return to full practice and game play

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May et al., Int J Sports Phys Ther 2014;9:242-255

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“Consider” return-to-play

• Re-establish baseline measures

• Counsel athlete

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When to recommend retirement?

• Reduced threshold for concussion

• Persistent cognitive impairment

• Neuroimaging abnormalities

• Debilitating post-traumatic headaches

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Starling and Giza, Quick Questions in Sports-related Concussion, 2015

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Take home points: before the injury

• Concussion is a traumatic brain injury which results in both changes in brain function & structure

• Concussion pathophysiology results in an energy mismatch and a neurometabolic cascade that can result in BBB breakdown, inflammation, and cell death

• Youth are at greater risk

• Youth, migraine history, learning disabilities, psychiatric comorbidities are at risk for longer recovery

• Pre-participation counseling and baseline assessments are critical for the management of concussion

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Take home points: after the injury

• Key history components: injury characteristics, headache history, risk factors

• Key exam components: orthostatic vitals, Dix-Hallpike, CN with focus on eye movements, UMN exam, TTG

• Concussion toolbox

• Keys to management:

• Symptomatic treatment

• Phenotype specific treatment of PTH

• Prevent re-injury during recovery

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Take home points: during recovery

• Excessive rest may not be beneficial

• Graduated return-to-learn goals

• Symptom-limited return-to-physical activity

• Exertion protocol

• Sport-specific return-to-play

• Use objective measures to assess return to baseline

• Re-establish baselines and counsel prior to full RTP

• Know when to recommend retirement

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