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© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. in the clinic Concussion
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Who is at risk for a concussion? Youths aged 10–19 years (highest risk) Males more than females Participants in sports Concussions 13.2% of all reported H.S. sports injuries Highest rates occur in: Boys: Football, ice hockey, lacrosse Girls: soccer, lacrosse, basketball In sports with similar rules (basketball, soccer) rate of concussions higher among girls than boys Other risk factors: falls, motor vehicle accidents
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Are certain types of head trauma more likely to result in concussion? Any event in which forces result in the brain moving within the skull may result in concussion Direct trauma to head is not necessary Indirect forces transmitted to the head from an impact to the body may cause a concussion
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. How can concussions be prevented? Primary prevention Minimize exposure to forces that lead to brain injury Wear seat belts in motor vehicles Wear well-fitted protective equipment during sports Both measure prevent catastrophic brain injury Less effective for preventing concussion or mild TBI Change rules to decrease exposure to concussive forces Such as raising the body-checking age in youth ice hockey
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Secondary prevention Eliminate unnecessary risk for repeated head trauma Full recovery from initial concussion is essential Second concussion may prolong signs and symptoms Possible increased risk for catastrophic death or disability from second head injury after a recent head injury
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. CLINICAL BOTTOM LINE: Prevention… Primary concussion prevention Reduce exposure to concussive forces and injury Rule changes in sports Enactment of laws for safety reasons Secondary prevention Appropriate, knowledgeable clinical management is essential Full recovery from initial concussion is essential before exposure to any risk for second head injury
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What acute symptoms immediately following head injury should prompt consideration of concussion? Early (minutes to hours later) Headache Dizziness or vertigo Lack of awareness of surroundings Nausea or vomiting Balance problems Visual disturbance Mental confusion Amnesia (retro-/anterograde) Perseveration Late (days to weeks later) Persistent low-grade headache Lightheadedness Poor attention, concentration Memory dysfunction Easy fatigability Irritability, frustration Intolerance of loud noises Anxiety or depressed mood Numbness or tingling Sleep disturbance
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. If symptoms present but no history of head injury Participants in contact or collision sports: consider concussion due to the many impacts sustained routinely Otherwise: consider other causes than concussion If symptoms are minimal or absent after a head injury Observe patient over subsequent hours and days
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What evaluation should be performed immediately following head injury? Assess for cervical or intracranial injury If cervical tenderness or limitation of cervical ROM: immobilize + use spine board for emergency transport If patient is conscious, engage verbally while immobilized Evaluate various domains of brain function Neurocognitive; balance; eye tracking Refer patient to emergency department If loss of consciousness or traumatic convulsive activity If mental status deteriorates If focal neurologic signs develop
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What imaging tests should be used in the evaluation of possible concussion? CT imaging Consider on an individual basis: not universally indicated If there’s concern for intracranial hemorrhage based on clinical signs and symptoms If neurologic status deteriorates Imaging methods under investigation Diffusion tensor imaging Functional MRI Magnetic resonance spectroscopy
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. When head injury occurs during sport, how should the safety of returning to play be made, and by whom? Remove injured athlete from play Athlete should never return to play on the same day a head injury occurs Assess and monitor on the sideline if appropriate, depending on severity and symptoms Refer to emergency dept if any deterioration in clinical status causes concern Physician should oversee the safe return to play 49 states require clearance from a licensed medical professional with concussion experience to return to play Physician should have experience and training in concussion management and return-to-play issues
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What items are important in the history and physical examination of a patient with suspected concussion? Elements of history Mechanism of injury Timing of the development of symptoms after injury Subsequent course of events (delayed-onset symptoms, activities that exacerbate symptoms) Assessment of preinjury function and ability to tolerate return to full function History of concussion and any comorbid conditions Anxiety, depression, ADHD, or preexisting migraine
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Physical Examination: Tests Smooth pursuits: Examiner’s finger moves horizontally, progressively increasing speed Saccades: Examiner’s fingers held at shoulder-width and forehead and chin distance to test horizontally & vertically Gaze stability: Patient fixes gaze on examiner’s thumb while nodding (vertical) and then shaking (horizontal) head Convergence insufficiency: Patient takes a pen with letters and holds at arm’s length and brings towards their nose Balance: Tandem heel-toe gait forward and backward with eyes opened and closed Signs of concussion deficits: Unable to perform or can only perform a few repetitions before symptoms or signs are provoked Such as headache, dizziness, eye fatigue, blurry vision Physical signs, such as watering of eyes or swaying of body
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What other tests should be performed? Concussion symptom scales Help delineate severity and extent of symptoms after injury Can be followed serially Computerized neurocognitive testing Now widely used in h.s. and college sports as well as pro Helps quantify cognitive effects of injury Accurate preinjury information contributes to a more individualized assessment ? Test for serum biomarkers for acute concussion ? Test for alleles that may predispose to concussion
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. How is the severity of a concussion assessed? Concussion grading systems have been abandoned Data are lacking with which to predict prognosis Severity can only be assessed after recovery complete However, there are predictors of prolonged recovery Younger age and female History of multiple concussions Diagnosed learning disability Slowed reaction time and impaired visual memory Post-traumatic migraine Subacute (within 3 to 7 days) symptoms
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. CLINICAL BOTTOM LINE: Diagnosis… Concussion was once defined as constellation of subjective symptoms after head injury Now specific areas affected in concussion have been identified Neurocognitive Vestibular Oculomotor Balance Use physical exam to assess & identify deficits in these areas Obtain a detailed and accurate history
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Should patients with a concussion be restricted from work, school or other activities? Immediately after the injury Patients benefit from brief physical + cognitive rest Then resume activities gradually Modify cognitive activities as needed Return to normal physical activity as tolerated Pay close attention to symptom threshold Noncontact aerobic activity probably isn’t harmful Athletes can enter a formal return-to-play progression once able to tolerate a full cognitive load
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What behavioral interventions are helpful in the management of concussion? Return to school Cognitive rest—No school, homework, or electronic devices Relative rest—Reintroduce short periods of aforementioned activities that don’t trigger severe symptom exacerbation Homework at home—Longer periods of cognitive activity Return to school—Partial-day school with accommodations after tolerating 1-2 cumulative hours of homework at home Ramp up to full day—With accommodations for full work load, limited make up work Full return to school—Full day, full work load, fully caught up with makeup load
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Return to play Physical rest—avoid activities that result in sustained increased heart rate or breaking a sweat or severe symptom exacerbation; additional sleep may be needed Light activity associated with everyday life avoiding triggering severe symptoms—walking Light aerobic exercise—To increase heart rate without triggering severe symptom exacerbation Sport-specific aerobic exercise—Noncontact skating, dribbling, or running drills as tolerated Advance to complex noncontact sport-specific training drills and add resistance training as tolerated After medical clearance, full contact practice Normal game play
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Are there pharmacological measures known help in treating patients with a concussion? Analgesics: may be helpful (acetaminophen, ibuprofen) But symptoms best managed with behavioral interventions, such as rest and modification of activities Avoid daily use (prevent rebound headaches) Melatonin: if sleep is disordered Amantadine: for mental slowing or fogginess Amitriptyline or topiramate: for chronic daily headaches outside of the acute phase of concussion Methylphenidate: persistent attention issues after TBI Referral for anxiety and depression medication may be warranted in the chronic post-concussion phase
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What are the complications of concussion? Complications vary and may include: Vestibular deficits Oculomotor and visual convergence deficits Anxiety and depression Chronic headaches Attention or concentration issues Slowed processing speed or memory issues Postconcussion syndrome Term reserved for prolonged and persistent symptoms May involve multiple domains of brain function
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. When should rehabilitation therapies be considered? If vestibulo-ocular deficits persist beyond acute phase Directed therapy reduces symptoms, improves function Aerobic rehabilitation with exercise training is beneficial Formal binocular vision therapy may be indicated If unable to resume preinjury level of cognitive function Cognitive or speech therapy may be indicated Modification of school activities may be sufficient to rehabilitate cognitive deficits Refer for cognitive or speech therapy if more significant accommodations are needed
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. When should a specialist be consulted for the treatment of a concussion? Concerns about the timing of return to a contact or collision sport Concerns about a prolonged recovery from concussion Rehabilitation may be required Hx multiple concussions or preexisting neurologic issues Such as migraines, anxiety, or depression
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. CLINICAL BOTTOM LINE: Treatment… Management for patients with a typical recovery Brief period of early physical and cognitive rest after injury Then gradual reentry into physical and cognitive activities Modify activities to minimize symptom exacerbation Refer to specialist with experience managing concussion if: Patient has preexisting comorbid conditions / risk factors Symptoms are prolonged
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. What factors predict the prognosis of patients with concussion? Poorer prognosis + prolonged recovery more likely with: Greater number of symptoms Greater severity of symptoms History of concussion Younger age Apolipoprotein e4 genotype (may be associated with more significant neurologic deficits) Loss of consciousness and impact seizure (not consistently correlated w/ poorer outcome)
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. Symptoms associated with prolonged recovery: Amnesia Prolonged headache Fatigue or fogginess Cognitive problems Dizziness at the time of injury
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (2): ITC2-1. CLINICAL BOTTOM LINE: Prognosis… Patients may recover with few, if any, long-term sequelae Risk factors predictive of a prolonged recovery: History of concussion Greater number and severity of symptoms Deficits that persist despite rehabilitation Discuss the future risk for concussion vs. the benefits of a high-risk activity
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