Concussion Management

Significant changes towards

more individualized, specific

management.

Increased knowledge has

lead to State and Local

legislation.

Jeff Anthony DO, FAAFP, FAOASM

San Diego Sports Medicine Center

Olympic Training Center; SDSU; SDCC

No Disclosures

Concussion Management

‘The cornerstone of concussion management is

physical and cognitive rest until the acute symptoms

resolve and then a graded program of exertion prior

to medical clearance and return to play.’

No play day of injury

No Play if any symptoms

85-90% resolve by 10 days

Consensus Statement on Concussion in Sport—the 4th

International Conference on Concussion in Sport. Held in Zurich,

November 2012

Post Concussion Management Timeframe

Concussions are:

Evolving, multifactorial, and individual.

No longer graded

Acute: 1-7 days

Rest; start easy re-introduction

Sub acute: 5 – 14 days

Gradually increase activity

Protection

Chronic: 10 - 21 days and longer

Consider other therapies: scrutinize circumstances, Rx;

Physical / Ocular / Counseling therapy.

Concussion Management RTP overview, stages:

No activity -Protection

Light Aerobic -Increased HR

Sport Specific -Add movement

Non contact drills -Coordination/Cognitive

Full contact practice -Assess fcnal /Confidence

Return to play

Consensus Statement, Zurich, 2012

Concussion Management

Risk factors that influence recovery:

Severity

Previous concussions / timing

H/o Headaches / Migraines

LD / ADHD

Depression / Anxiety disorders

Age: younger may take longer

Sex: Female may take longer

H/o Motion sensitivity/vertigo

Ocular issues (amblyopia)

Management is directed by

Evaluation

History

MOI

Physical exam

R/o ICB

Evaluate for concussion

CN

Cerebellar / Balance

Vestibular - Ocular eval

Neurocognitive

Multi-System Approach targeted at manifestations

Musculoskeletal injuries

Headache

Cervical strain

Neurocognitive issues

Memory, mentation, calculations

Vestibular Dysfunction

Balance

‘Dizziness’

• Vertigo

• Light headedness

Visual/ocular disturbance

Exertional component

Post concussive Headache

Very common (70%)

30% do not

Ms Tension HA

‘whiplash’

Management:

Ergonomics, BM

HEP

OMT, PT, Acupuncture

Biofeedback, visualization techniques

Post Concussion HA Other Causes

Migraine: Rx

Brain injury:

Related to concussion

• Tx: unloading brain

Rebound:

Chronic NSAIDS, Tylenol

Dehydration/metabolic:

Tx: correct disturbance

Neuro impingement: Occipital N.; injection

Neurocognitive

NC used for evaluation and monitoring

Neuropsych testing: ‘cornerstone’ of

concussion management*

• *Consenses statement, Zurich, 2012

Memory, mentation, calculations

Face-face, paper/pencil

Computerized:

• ImPact, Concussion VS, C3 logic

Return to learning (RTL):

Gradually increase mentation and academics

ImPact

Vestibular: Balance / Coordination

Concussions can affect the afferent

(proprioception) or integration (brain

stem) signals, reducing balance

Balance testing is valuable for Dx and

management.

Program:

balance exercises, both with eyes open and

closed (utilizing somatosensory and

vestibular inputs)

Progressive difficulty

• Single leg, unstable surface, surfing,

jump/twist/catch, etc.

Vestibular: ‘Dizziness’

Diagnosis malady, then treat specifically

Light headed or Vertigo?

Light headedness

Cervical muscle tightness

Metabolic, hypoglycemia, etc.

Anxiety

Vertigo

Room is spinning

Uneasy or queasy feeling, like on a boat

Treated differently

Vestibular-Ocular Reflex (VOR)

Activation of the vestibular

system causes compensatory

eye movements

The ability for the eyes to

maintain vision on an object

with head movement

Eg., running down street while

reading a sign.

VOR keeps image on Fovea of eye

Vestibular issues Symptoms

Dizziness, fogginess, nausea, anxiety, overwhelmed,

can’t multi-task, off balance.

Dx with VOMS (Vestibular Oculomotor Screen)

Sensitive for dx and monitoring concussion

Pursuit, Saccades, Convergence, VOR (Vestibulo-

Ocular reflex)

Goal is to restore brain’s ability to sense and

respond to motion; (Reduce dizziness, help balance)

Canalith repositioning

BPPV

Can occur with concussions.

Positional vertigo

Dx: Dix-Hallpike maneuver

Tx: Epley maneuver

Concussion and Vision

46% concussed pts have visual problems (Vision Dx…, Clinical Pediatrics, 2015; The neuro-opth of head trauma,

Lancet Neuro 2014)

Photophobia: dysfunctional pupillary response

Blurred vision: dysfunctional accommodation

Diplopia: dysfunctional binocularity

Loss of place while reading: dysfcn. ocular motility

(Carl Hillier, OD FCOVD)

Ocular motor

Coordinate eyes for vision during head motions

Testing:

Saccadic movements, smooth pursuits,

convergence deficits, or symptoms during exam

Rehab

Performing similar motions, allowing brain to re-

build these mechanisms, allowing accurate vision

with motion.

May use prisms, lenses, etc.

Dynamic exertion training:

Patient focuses on one object while running

Neuro-Optometric Rehab

Vision Rehab. goals:

Recapture accommodative (CN 3) and

binocular (CN 3, 4, 6) skill and endurance

Recapture saccadic skill and endurance

Recapture pupillary response (CN 3) to

reduce photophobia.

Using specific procedures and

instrumentation (stereo-scopes, plus

and minus lenses, prisms)

(Carl Hillier, OD FCOVD)

Concussion Management

Sleep disturbance, common

Causal factors: Brain trauma, anxiety,

depression, lack of exercise

Tx: progressive relaxation; visualization

Rx: melatonin, benedryl, Trazodone

Anxiety / Depression

Assess for pre-injury issues

Psychotherapy (inform. / formal)

SSRIs: Zoloft, Lexapro

-other-

Rx Treatment Somatic:

HA:

• NSAIDs, muscle relaxers; removal of Rx!

• Amitriptyline, Magnesium (500mg), B2 (400mg), Topamax

Emotional:

Psychotherapy, SSRIs (Lexapro, Zoloft, Prozac)

Sleep disturbance:

Behavioral, Melatonin, Trazodone 50mg,

Amitriptyline 30mg

Cognitive:

Amantadine

Stimulants: Adderall, Ritalin, Stratera

Concussion management

Musculoskeletal

Neurocognitive

Vestibular Dysfunction

Visual/ocular disturbance / other

Exertion and Sport specific training

As pt improves, ‘test’ the brain by exertion and sport

specific activity (coordination, proprioception, etc.)

Treatment needs to be specific; prioritize malady

Team approach

California State Law Re: Concussion, HS

AB (Assembly Bill) 2127 (1/15)

License Health care provider (LHCP)

Head injury, not just concussion

Requires graduated return to activity > 7 days

Encourages CIF to develop protocols

(CA Interscholastic Federation)

CIF protocols (3/15)

Physician (MD/DO), rather than LHCP

Concussion specifically

RTP, RTL protocols

Return to Play protocol

Essentials for RTP (CIF)

No physical activity for at least 2 days after athlete seen by Dr.

Dr. must clear athlete before RTP protocol starts

Return to sport cannot be sooner than 7 days AFTER seen by Dr

If the concussion injury does not resolve in 7-10 days, treatment

should also consider:

Further Reduction of aggravating factors, mental and physical

Consider Rehab for balance, oculomotor, CT strain, etc.

Consider medications as appropriate

Keys to RTP

Athlete needs to see a Physician (MD/DO) asap after injury to

start the clock for recovery

The athlete must do a supervised, graduated RTP protocol to

return to sport

The athlete needs written notification:

to begin protocol, and

for release to full sport (stage 3) by a licensed physician (MD/DO).

If concussion is not improving, recommend seeing a physician

experienced in the field to facilitate safe recovery

Baseline testing is recommended

Clinical case

Athlete injured on Friday night

with a mild concussion (Day 0).

Seen Monday by physician

(Day 3). If Now asymptomatic,

Begin Stage I: no activity for at

least 2 full symptom-free days

Case

Begin Stage II-A : light aerobic activity. Must

be performed under direct supervision by designated individual (Day 5).

Begin Stage II-B : moderate activity (Day 6).

Begin Stage II-C : strenuous activity (Day 7).

Begin Stage II-D : non-contact training (Day 8)

Must have written physician clearance for return

to play prior to Stage III.

Case

Stage III : Limited contact practice (Day 9).

Stage III(second level): Full contact (Day 10).

Must complete at least one contact practice

before return to competition. Highly

recommended divided into 2 contact practices.

Stage IV: Return to play(competition) (Day 11).

(If Asx on day of concussion AND seen by Dr.,

Day 9)

CIF Return to Learn Protocol

CIF Return to Learn Protocol

Brain rest- usually 2-5 days after injury, can

progress to next stage when begins to

improve

Return to School – Partial Day – usually

ends 5-21 days after injury. If no sx’s, can

attend full days of school

CIF Return to Learn Protocol

Return to School – Full Day- no more than 1

test or quiz per day, extra time for

homework/tests, light physical activity

Full Recovery- normal home, social and

school activities. May begin and must

complete CIF RTP Protocol before

strenuous physical activity or contact sports

Concussion Management

Summary

Significant change in management of concussions:

from grading/cookie cutter approach to:

individual care with focus on manifestations.

Relative rest for brain and body; allow healing without

re-incident; gradual progression as tolerates.

Prioritize treatment to specific manifestations

Utilize Rx; Vestibular/Ocular/Physical/and

Psychological therapy as needed

Guidelines per state / organizations;

RTP and RTL protocols

Thank You

San Diego Sports Medicine Center

References

California Interscholastic Federation (CIF)

CIF.org

AB 2127; Assembly Bill 2127, interscholastic

sports

Consensus statement on concussion in

sport: 4th international, Zurich, 2012

The neuro-opth of head trauma, Lancet

Neuro 2014

ImPact, Clinical Trajectories