laurel rudolph, md medical director marshfield clinic sports medicine
TRANSCRIPT
Concussions: Evaluation & ManagementWhat is old? What is New? What is the
Future?
Laurel Rudolph, MDMedical DirectorMarshfield Clinic Sports Medicine
Third Annual School Health Skills
August 12, 2015
I, Laurel Rudolph, MD have no relevant financial interest or other relationship(s) with a commercial entity producing health-care related products and/or services.
Financial Disclosures
To provide the most current definition, evaluation, and treatment guidelines for a concussion in a student-athlete
To discuss the role of educators in evaluation and management of concussions in students
To provide information on return-to-school and return-to-play guidelines for youth and high school student-athletes
To discuss school accommodations for students who have suffered a concussion
To share the history and information pertaining to Wisconsin Act 172
Objectives
Concussion - DefinitionDefined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.The disturbance of brain function is related to neurochemical dysfunction, rather than structural brain injury.
“The primary circuit is out”
Traumatic blow does not have to be head to head
LOC not necessary
From: Br J Sports Med 2013
Concussion A METABOLIC CRISIS WITHOUT ISCHEMIA FUNCTIONAL INJURY, NOT ANATOMICAL
Neurometabolic Changes and ConcussionNeurometabolic cascade following experimental concussion. K+, potassium; Ca2+, calcium; CMRgluc, oxidative glucose metabolism; CBF, cerebral blood flow. (Reprinted with permission. Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100.).
Concussion Myths If CAT scan is normal, athlete is OK
Functional -NOT anatomical injury! If athlete feels fine, can return to play
Symptoms may become more severe a few hours after injury
Athlete may not recognize symptoms If no LOC, student does not have a
concussion Over 90% of concussed children have
no LOC Mild concussions are not a big deal
It is a BRAIN injury!!! Concussions not labeled “mild”,
“moderate”, etc…
Wait one week, then may return as “not that bad” Cannot return until symptom
free, which can take days, weeks or even months
Adolescents heal faster than adults Over 20% of adolescent
concussions last longer than 2 weeks
Adolescents have higher risk of injury than adults
Concussion Myths
ER Visits
Data Reasons?
Between 2001 and 2009, ER visits for TBIs in American youth under 20 years old ↑ 60 %
CDC data: 153,375 youngsters were seen in the ER in 2001 vs. 248,418 in 2009
Bicycling and football leading causes
↑ awareness due to local, CDC, media, educational programs (NFL #1)
↑ number of youth participating in activities
↑ parental vigilance↑ self-reporting
Signs and Symptoms
What should I look for?
Physical Headache Dizzy/Lightheaded Nausea/Vomiting Clumsiness/Balance
problems Blurry Vision Poor coordination Intolerance of
light/sound Loss of consciousness
Concussion Symptoms
Emotional Nervousness Anxiety Sad Irritable Personality Changes Emotional swings Inappropriate mood
Cognitive Confusion Disorientation Memory Loss “Head is in a fog” Slow to answer
questions/follow commands
Poor attention
Commonly Reported SymptomsHigh School & College Athletes
Within 3 days of injury Delayed Symptoms
Headache 71%
Feeling slowed down 58% Difficulty concentrating 57% Dizziness 55%
Fogginess 53%
Fatigue 50%
Visual blurriness 49% Light sensitivity 47% Memory dysfunction 43% Balance problems 3%
Lovell, Collins et al, 2004 N=215
Decreased processing speed
Short term memory impairment
Concentration deficit Irritability/depression Fatigue/sleep disturbance General feeling of
“fogginess” Academic difficulties
What symptom at 3 days is most predictive of a protracted recovery?
Answer: Fogginess
Followed by : difficulty concentratingvomitingdizzinessnauseaheadacheslownessbalance difficultylight sensitivitynoise sensitivitynumbness
Lau, Lovell, Collins et al. CJSM 2009
Standard emergency management principles should be used, particularly as they pertain to the spine and to cardiorespiratory compromise.
Appropriate disposition is to be determined by the treating healthcare provider.
Once first aid issues are addressed then further sideline assessment may include the SCAT 3 or similar tool.
The student should not be left alone and serial monitoring should take place.
The student should not return to physical activity the same day.
Sideline Assessment
Evaluate for potential cervical spine injury Remember: student does not have to hit his/her head to have a concussion Assess neurocognitive status If any abnl findings on neuro exam or worsening sx → ER Utilize concussion evaluation tool(s) Do not leave student unattended. Document exam findings!!! Symptom Score Sheet
Initial Care
Sideline Assessment Tool-Not validated in the use of grade school athlete--Cannot detect for impairment from sub-concussive blows
CT-only if suspicion for intra-cerebral structural lesion
fMRI, PET-investigational only Objective balance test (BESS=Balance
Error Scoring System)-identifies postural stability deficits, best used in first 72 hrs
Neuropsychological assessments-computerized testing (ImPACT, Cogsport, etc…), formal neuropsych consult
Genetic testing-experimental
Concussion Evaluation Tools
Noninvasive Measures changes in the state of
oxygenated Hgb Abnormal activation patterns in
the DLPC have been consistently identified in concussion
Time to Recovery: 15 days 25% 25 days 50% 45 days 75% 92 days 90%
Lovell, Pardini, Collins et al. Neurosurgery 2007
Functional MRI
REST-physical & cognitiveNo drivingNo computerNo video games,
moviesLimit textingNo exertional
activitiesNo readingAvoidance of noise,
bright lights
Instructions
Concussion Management Changes
OLD NEW
Cognitive brain rest? Waking person from
sleep at night Not attending school
for ___ # of days Medications for
headache
Rest, rest, rest Maintain a consistent
schedule Seek medical care for
evaluation and treatment
Return to school as sx allow; may require restrictions/accommodations
Physical rest Cognitive rest Academic accommodations Vestibular therapy Visual therapy Physical therapy Headaches may be due to neck strain Medication
Melatonin Low dose amitriptyline Amantadine
Treatment Modalities for Post-Concussion Syndrome
Brain bleedsGet worse as time goes onNeurologic deficits, severe pain, disoriented, LOC
Second Impact SyndromeLeads to brain damage or deathGetting hit while still symptomatic
Post-Concussion SyndromeProlonged symptoms (can last MONTHS!)Affects school & grades, relationships
Future problemsParkinson’s, Dementia, Depression (substance abuse,
suicide), persistent symptoms
What’s the big deal?
Occurs in athletes with prior concussion following often relatively minor second impact
Second impact has been shown to occur up to 14 days post injury
Athlete returns to competition before resolution of symptoms Catastrophic increase in intracranial pressure
Vasomotor paralysis, edema, massive swelling, herniation, death
Most often occurs in athletes <21 yrs oldNeurochemical processes appear to differ in developing
brain
Second Impact Syndrome
Illinois: First law suit filed at the high school level (2014)
Legal Implications
Graduated Return to Play Protocol
1. No Activity2. Light aerobic exercise3. Sport-specific exercise4. Non-contact training drills5. Full contact practice6. Return to play
Each step takes 24 hrs
Progress to next level if no symptoms
If symptomatic, drop back to previous step and try to progress after 24 hr rest
Return to Play
As symptoms allow May limit the
number of hours in school
May not attend certain classes (PE, music, band, shop)
May need to delay return to classes such as math, science
Return to School
Adjust class room seating avoiding exposure to noisy hallways, outdoor light, other distractions
Limit computer/tablet use
Computer/tablet dimming screens
Computer>printed>audio Brimmed hats, sun glasses
Return to School
May require multi-disciplinary approach: health care provider, therapist(s), neuropsychologist, educators, counselor, parents, student
Communication IEP (intervene early) Reassurance Advocate for the student (many experience
guilt, pressure from parents, coaches, self)
Concussed Student with Prolonged Symptoms
Teacher has key role! Knowledge &
recognition that a concussion (mTBI) is a real medical problem
Reassurance Academic
accommodations Psychological support
for student AND parents
Communication
Role of Educator in Return to Academics
ImPACT most widely used Baseline not needed Skilled & experienced provider for
interpretation of test results Results are only one part of decision in
regards to return to academics/sports Not a pass/fail test
Role of Neurocognitive Testing
Age of student Learning disability ADHD Environment Requires experienced provider to administer
test Many students need formal neuropsych
testing
Limitations of Computerized Neurocognitive Testing
Accurately diagnose early R/O more serious intracranial pathology Begin active treatment early Appropriate restrictions on activity Earliest safe RTP decision Prevent post-concussion syndrome Prevent cumulative effects of injury
Cumulative neurobehavioral deficitsLowered threshold to injury
Prevent Second Impact Syndrome
Concussion Management Areas of Focus
Healing Concussions in the Field
Why I love what I do!!!
The Difficult Diagnosis
Alabama (2011) Alaska (2011) Arizona (2011) Arkansas California (2012) Colorado (2011) Connecticut (2010) Delaware (2011) Florida (2012) Georgia Hawaii (2012) Idaho(2010) Illinois (2011) (Chicago has an
ordinance) Indiana(2011) Iowa(2011) Kansas (2011) Kentucky (2012) Louisiana(2011) Maine (2011) Maryland(2011) Massachusetts(2010) Michigan (2012)
Minnesota(2011) Mississippi Missouri(2011) Montana Nebraska (2011) Nevada (2011) New Hampshire (2012) New Jersey(2010) New Mexico (2010) New York(2011) North Carolina(2011) North Dakota (2011) Ohio Oklahoma(2010) Oregon(2010) Pennsylvania(2011) Rhode Island(2010) South Carolina South Dakota (2011) Tennessee Texas(2011) Utah(2011)
State LegislationVermont (2011)Virginia(2010)**Washington(2009)West VirginiaWisconsin (2012)Wyoming
Red-unknownGreen-legislation introduced
2011 Wisconsin Act 172Sideline For Safety Act
Coalition Members Assembly Bill 259 History
Marshfield Clinic UW-HealthChildren’s Hospital of WisconsinNFLGreen Bay PackersWIAAWMSWATAWPTAState Chiropractic AssocWYSA
WIAA defines concussion assessment rules during game conditions-2009April 19, 2011 Wisconsin State Medical Society approves resolution to support State legislatureAB 259 passes WI assembly 11/2/2011Senate passage 3/13/2012Governor Walker signs bill April 2, 2012
Purpose: To educate coaches, student-athletes, and their parents or guardians about the nature and risk of concussions and head injury in youth activities
Wisconsin Act 172
An organized athletic activity in which the participants, a majority of whom are under 19 yrs of age, are engaged in an athletic game or competition against another team, club, or entity
Does not include a college or university activity
Youth Athletic Activity Definition
Coordinators of all youth organized sports shall distribute a concussion and head injury info sheet to all members of coaching staff and participants
No participation until information sheet is signed by the person, and, if he or she is under the age of 19, by his/her parent or guardian
Wisconsin Act 172
An athletic coach, or official involved in a youth activity, or health care provider shall remove a person from the youth activity if coach, official or health care provider determines that the athlete exhibits signs, symptoms, or behavior consistent with a concussion or head injury
Or the coach, official, or health care provider suspects the person has sustained a concussion or head injury
Wisconsin Act 172
Athlete may not return to play until he/she is evaluated by a health care provider and receives written clearance from the health care provider to return-to-play
Wisconsin Act 172
Holds a credential that authorizes the person to provide health care
Practicing within the scope of his or her credentials
Trained and has experience in evaluating and managing pediatric concussions and head injuries
Health Care Provider
Bill SigningApril 2, 2012
Lambeau Field Green Bay
http://www.cdc.gov/concussion http://wiaawi.org http://ww.nfhslearn.com http://www.marshfieldclinic.org/patients/
?page=sportsMedicine_newsletter theconcussionblog.com/state-legislation
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Concussion Information
THANK YOU for caring for concussed students!
Your dedication and commitment to the health and education of our youth is greatly appreciated!
Contact Info: [email protected]
Work # 715-389-3265Cell # 715-223-7108