management of concussion parley m. williams, md · 2014-09-29 · lovell mr, collins mw, iverson...

Management of Concussion

Parley M. Williams, MD

Director, Intermountain Neuroscience Concussion Clinic, Intermountain Healthcare; Salt Lake City, Utah

Objectives: • Detail concussive symptoms • Review literature review background for evidenced based

concussion treatments • Review current recommendations for treating concussions, short

and long term

Concussion Management

Parley Williams, MDPhysical Medicine & Rehabilitation

Intermountain Neurosciences Institute

Outline

I. DefinitionsII. Concussion Management PrinciplesIII. Conclusions

Definitions - Concussion

Must have at least one of the following:1. Any period of loss of consciousness2. Any loss of memory for events

immediately before or after the accident

3. Any alteration in mental state at the time of the accident (dazed, disoriented, confused)

4. Focal neurologic deficits which may not be transient

Must not exceed the following:1. Loss of consciousness of 30 minutes

or less2. GCS at 30 minutes of 13-153. Posttraumatic amnesia not greater

than 24 hours.

Adams et al., 1993

Definitions – Post Concussive Syndrome

ICD-10

ICD-10 Criteria• Must have head injury “usually sufficient to result in loss of

consciousness”• Must develop 3 of the following 8 symptoms in the first 4 weeks

following injury1. Headache2. Dizziness3. Fatigue4. Irritability5. Sleep problems6. Concentration Problems7. Memory problems8. Problems with emotional lability/stress tolerance/alcohol tolerance

Definitions – Post Concussive Syndrome

Kushluba et al., 2006

ICD‐10 appear to be good criteria for PCS diagnosis at 1 month, but lacking at 3 months compared to non‐concussed controls.

Using 5 of 8 symptoms as a threshold instead of 3 appears more optimal with sensitivity of 73% and specificity of 61%.

“I’m Batman”

Definitions – Chronic Traumatic Encephalopthy(CTE)

A brief word on CTE:• Occurs with repetitive (concussive and/or sub-

concussive) head trauma• No currently agreed upon clinical criteria• Currently a post-mortem diagnosis only• Limited study data as to pathophysiology but

accumulation of tau proteins appear to play major role• MRI may be helpful in identifying accumulations of

Tau• Treatment?

Definitions - Brain injury is a spectrum

Classification Glasgow Coma Scale

Loss of Consciousness

Post Traumatic Amnesia

Non-con Head CT Findings

Severe 3-8 >6 hours > 7 days ++Moderate 9-12 20 min – 6 hrs 1-7 days +

Mild 13-15 < 20 min <24 hours -

Sohlberg et al., 2001

Outline

I. DefinitionsII. Concussion Management PrinciplesIII. Conclusions


No “one size fits all” approach to concussion, but there are guiding principles

The Goal:• Recovery from symptoms and intracranial pathology as

quickly and safely as possible with the least permanent detriment to their life and functioning

• Future (especially early) injury prevention• Patient/family/workplace/coach EDUCATION


What I don’t want to see:Patient comes to see me after

• they have lost their job…• after 2nd impact…• failed to navigate a school term• damaged a family relationship• put themselves or others in danger• multiple unnecessary ER visits


Sleep DifficultiesDrowsinessTrouble falling asleepSleeping more than usualSleeping less than usual

Thinking Difficulties Feeling mentally foggyFeeling mentally slowed downConcentration difficultiesMemory difficulties

Physical Difficulties

FATIGUEHeadachesNauseaVomitingDizziness Balance problemsVisual ProblemsSensitivity to lightSensitivity to NoiseNumbness/tingling

MSK injuries


Emotional Difficulties

IrritabilitySadnessMore emotionalNervousnessPTSD-llike


Eisenberg et al., 2014

Guiding principles:1. Detailed history and physical are key to developing

comprehensive treatment plan


Atypical delayed Sx onset

Typical acute Sx onset


• How long ago?• Detailed mechanism of

injury• Witnessed?• LOC?• ER visits?• Imaging done/available?• Number of prior

concussions?• Pending legal issues?• Secondary gain issues?

• DETAIL current post concussive symptoms

• What treatment has been attempted already?

• Premorbid factors (ieinsomnia, chronic headaches / pain, mental health, coping abilities)

• Team play / return to activity concerns?

• Work / school concerns?• Other physical injuries?

Evaluation of the Patient

HISTORY


• General (overall level of discomfort)

• Affect• Cardiac, arrhythmias? (ie

syncope then fall…)• Detailed MSK exam• Skin exam (lacerations,

bruising, lack of?)• Thorough Neurologic exam:

• Eyes: EOM, tracking/ pursuit/ nystagmus/ pupils• King-Devick

• Sensation

• Strength• Fine motor coordination

/ ataxia• DTR / Abnormal

reflexes• Speech• Cognitive:

• Memory, insight, judgement, sequencing,

• MMSE / O-LOG / GOAT / Westmead

• Computer based (IMPACT)

• Balance• BESS

Evaluation of the PatientEXAM / Testing



EXAM / Testing• Laboratory Studies:

• Typically not needed• Endocrine screening• Na

• Additional Imaging Studies:• Typically not needed

unless red flags• Often for MSK injuries

that were not as high priority or apparent on the day of their injury.



comprehensive treatment plan2. Obtain objective data wherever possible

Photo credit: Women’s Magazine


Objective data is key!• Symptom index• BESS• O-log• GOAT• MMSE• Neuropsych testing• IMPACT (?)


King-Devick© (copyrighted test)


comprehensive treatment plan2. Obtain objective data wherever possible3. Watch for RED FLAGS


Red flags• Focal neurologic

deficits • IE subtle hemiplegia• CN findings• Numbness/tingling• Unusual history • Severe symptoms and

lack of imaging

Am I missing something else?

• Onset long after concussion

• Secondary gain• Conversionoid

symptoms• Other neurologic

pathology


Additional Tests



comprehensive treatment plan2. Obtain objective data wherever possible3. Watch for RED FLAGS4. Tailor plan to individual injury


Sleep disturbance Headaches

Neurocognitive symptoms:Mental fogginessConcentrationMemoryProcessing speedJudgment

Physical symptoms:DizzinessPain complaintsNauseaCoordinationVisual complaintsBalance

Emotional symptoms:Emotional labilitySaddness/depressionIrritibilityAnxiety


Sleep• Education

• Sleep hygiene

• Behavior modification

• Logs• Activity and

patterning

• Pharmacology• TCA’s, trazodone,

valproic acid, melatonin, atypical antipsychotics.

• Caution with ambien/lunesta/benzodiazepines


Headache• Can be challenging• Typical abortive medications have somewhat limited role

(ie tylenol, ibuprofen, naproxen, triptans)• Limit (if not avoid) opiates• Preventative medications typically more helpful• Patients with premorbid chronic headaches typically have

more problems• Limited concussion specific pharmacology data


Ramadan, et al., 2000



comprehensive treatment plan2. Obtain objective data wherever possible3. Watch for RED FLAGS4. Tailor plan to individual injury5. Early interdisciplinary approach and communication

is key


Appropriate referrals:• Concussion specialized physician (early)• Neuropsychology (typically early)• Appropriate therapies (timing for appropriate

referral varies)• PT• OT• SLP• Hearing & Balance Center


mTBI PatientDoctor

Neuropsychology

Physical therapist

Referring provider / PCP

Speech therapist

Occupational therapist

Hearing & Balance center

Family CoachTrainer

WorkSchool

Return To Play• Often rely on concussion grading systems with some

controversy in literature and on the turf• Various return to play guidelines exist

• All involve a gradual reintegration to activity and eventually game play as well as guidelines for terminating activity (ie season or sometimes career) when risks are great

• Only concussion trained providers should be guiding return to play decisions


Conclusions

Post concussive syndrome is common• Vast majority will get better

Treatment should be:• Interdisciplinary / comprehensive• Tailored to individual injury• Evidence-based• Return to play / activity decisions should be guided

by concussion specialist

1. Ahman S, Styrke J, Bjornstig U, Stalnake B, Long-Term Follow Up of Mild Traumatic Brain Injury: A Mixed Methods Study. J Rehabil Med 2013; 45: 758-764

2. Holm L, Cassidy JD, Carroll LJ, Borg J. Summary of the WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2005; 37: 137-141

3. Iverson GL, Outcome from mild traumatic brain injury. Current Opinion in Psychiatry 2005, 18:301–3174. Adams R, Anderson T, Berrol S, Cicerone K, Dahlberg C, Gerber D, Goka R, Harley P, Hilt J, Horn L, Lehmkuhl D,

Malec J. Definition of Mild Traumatic Brain Injury. J Head Trauma Rehabil 1993; 8(3): 86-87.5. Kushluba S, Casey JE, Paniac C. Evaluating the Utility of ICD-10 Diagnostic Criteria for Post Concussion Syndrome

following mild traumatic brain in jury. J Int Neuropsychol Soc 2006; Jan 12(1):111-8.6. Sohlberg MM, Mateer CA. “Cognitive Rehabilitation” ISBN: 15723061307. Bleiberg J, Cernich AN, Cameron K, et al. Duration of cognitive impairment after sports concussion. Neurosurgery

2004; 54:1073–1078; discussion 1078–10808. Lovell MR, Collins MW, Iverson GL, et al. Grade 1 or ‘ding’ concussions in high school athletes. Am J Sports Med

2004; 32:47–549. Macciocchi SN, Barth JT, Alves W, et al. Neuropsychological functioning and recovery after mild head injury in

collegiate athletes. Neurosurgery 1996; 39:510–51410. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate

football players: the NCAA Concussion Study. JAMA 2003; 290:2556–256311. Levin HS, Mattis S, Ruff RM, et al. Neurobehavioral outcome following minor head injury: a three-center study. J

Neurosurg 1987; 66:234–234312. Pellman EJ, Lovell MR, Viano DC, et al. Concussion in professional football: neuropsychological testing-part 6.

Neurosurgery 2004; 55:1290–1305

References

References14. Gentilini M, Nichelli P, Schoenhuber R, et al. Neuropsychological evaluation of mild head injury. J Neurol

Neurosurg Psychiatry 1985; 48:137–14015. Barkhoudarian G, Hovda DA, Giza CC. The Molecular Pathophysiology of Concussive Brain Injury. Clin Sports Med

30 (2011) 33–4816. Niogi, Mukherjee P, Ghajar J, et al. Structural dissociation of attentional control and memory in adults with and

without mild traumatic brain injury. Brain 2008;131:321217. Jantzen Anderson B, Steinberg FL, et al. A prospective functional MR imaging study of mild traumatic brain injury in

college football players. AJNR Am J Neuroradiol 2004;25(5):74118. Niogi SN, Mukherjee P, Ghajar J, et al. Extent of microstructural white matter injury in postconcussive syndrome

correlates with impaired cognitive reaction time: a 3T diffusion tensor imaging study of mild traumatic brain injury. AJNR Am J Neuroradiol 2008;29(5):967–73.

19. Wilde EA, McCauley SR, Hunter JV, et al. Diffusion tensor imaging of acute mild traumatic brain injury in adolescents. Neurology 2008;70(12):948–55

20. Huang MX, Theilmann RJ, Robb A, et al. Integrated imaging approach with MEG and DTI to detect mild traumatic brain injury in military and civilian patients. J Neurotrauma 2009;26(8):1213–26

21. Slobounov SM, Zhang K, Pennell D, Ray W, Johnson B, Sebastianelli W. Functional abnormalities in normally appearing athletes following mild traumatic brain injury: a functional MRI study. Exp Brain Res. 2010 Apr;202(2):341-54. doi: 10.1007/s00221-009-2141-6. Epub 2009 Dec 29.

22. Faux S, Sheedy J, A Prospective Controlled Study in the Prevalence of Posttraumatic Headache Following Mild Traumatic Brain Injury. PAIN MEDICINE Volume 9 • Number 8 • 2008.

23. Ramadan, Nabih M., Stephen D. Silberstein, Frederick G. Freitag, Thomas T. Gilbert, and Benjamin M. Frishberg. "Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine." (2000). AAN.com

24. Eisenberg M, Meehan W, Mannix R. Duration and Course of Post-Concussive Symptoms. Pediatrics 2014; 133;999

management of concussion parley m. williams, md · 2014-09-29 · lovell mr, collins mw, iverson...

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