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Concussion: Where are we in 2012? Alex A. Homaechevarria MD St.Luke’s Sports Medicine US Ski Team Physician Kurt J. Nilsson, MD, MS Medical Director, St.

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Presentation on theme: "Concussion: Where are we in 2012? Alex A. Homaechevarria MD St.Luke’s Sports Medicine US Ski Team Physician Kurt J. Nilsson, MD, MS Medical Director, St."— Presentation transcript:

1 Concussion: Where are we in 2012? Alex A. Homaechevarria MD St.Luke’s Sports Medicine US Ski Team Physician Kurt J. Nilsson, MD, MS Medical Director, St. Luke’s Concussion Clinic October 5, 2012

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3 “The occurrence and management of sports concussion provokes more debate and concern than virtually all other sports injuries combined.” Paul McCrory, Clin Sports Med, 2011

4 Objectives Discuss the epidemiology and pathophysiology of concussion Discuss short and long term implications of concussion Discuss the role of neurocognitive testing in concussion Discuss management of sports related concussion, with attention to return to play issues Discuss issues surrounding the current and future approach to concussion

5 Concussion Re-defined: Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces

6 Concussion Re-defined: Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces

7 Concussion Re-defined: Typically results in the rapid onset of short-lived neurological impairment that resolves spontaneously

8 Concussion Re-defined: The acute clinical symptoms largely reflect a functional disturbance rather than a structural injury

9 Concussion Re-defined: May or may not involve LOC Grossly normal neuroimaging studies McCrory, J Neurosci, 2009

10 Epidemiology 8.9% of high school sports injuries, 5.8% of collegiate (Gessel, JAT, 2007) Majority of concussions come from 4 sports: football (47.1%) girl’s soccer (8.2%) boys wrestling (5.8%) girl’s basketball (5.5%) (Marar)

11 Epidemiology In sports played by both genders, girls actually run a higher risk of sustaining concussion In sports played by both genders, girls actually run a higher risk of sustaining concussion U.S. female high school soccer athletes suffered almost 40% more concussions than males U.S. female high school soccer athletes suffered almost 40% more concussions than males In high school basketball, female concussions were nearly 240% higher In high school basketball, female concussions were nearly 240% higher Female college athletes who play soccer, basketball, softball and hockey also bear higher concussion risks than their male counterparts Female college athletes who play soccer, basketball, softball and hockey also bear higher concussion risks than their male counterparts Gessel, Journal of Athletic Training, 2007

12 Complications Collins, Neurosurgery, 2002; Guskiewicz, JAMA, 2003 Decreased threshold for recurrent concussion: Athletes with 3 or more concussions were 9.3 times more likely to have prolonged loss of consciousness, anterograde amnesia, or confusion with subsequent concussion Also 4-6 times more likely to have recurrent concussions and take longer for symptoms to clear

13 Post-concussion syndrome ICD-10 criteria: Head injury and 3 of following 8 within 4 weeks: headache, dizziness, fatigue, irritability, sleep disturbance, difficulty concentrating, memory problems, low tolerance for stress, emotion, or alcohol

14 Second Impact Syndrome Occurs in athlete who return to play before symptoms from 1 st concussion completely resolve Second blow/impact can be minor Loss of autoregulation of the brain’s blood supply leading to vascular engorgement and subsequent brain swelling, increase intracranial pressure and herniation of the brain stem Usually fatal All cases in the literature <22 yr old

15 Longer term consequences? – Retired football players reporting a history of 3+ previous concussions were 5X more likely to be diagnosed with mild cognitive impairment (Guskiewicz et al. Neurosurgery. 2005;57:719-24) – Retired football players reporting a history of 3+ previous concussions were 3X more likely to be diagnosed with depression (Guskiewicz et al. Med Sci Sports Exerc. 2007;39(6):903-9) – Increased prevalence of Alzheimer’s Disease in retired football players (Guskiewicz et al. Neurosurgery. 2005;57:719-24)

16 Diagnosis Clinical

17 Diagnosis Clinical

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20 Diagnosis Clinical Imaging Postural / Balance testing / Vestibular testing Neurocognitive testing

21 Role of Neuroimaging Initial CT/MRI: prolonged disturbance of consciousness, focal neurologic deficit, clinical deterioration, persistent clinical or cognitive symptoms Most typically contributes very little to the evaluation of concussion

22 Neuroimaging Based on study of > 42,000 ED visits, CT is unnecessary : –in children <2 with normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents –in children >2 with normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache Kuppermann, et al, Lancet, 2009

23 Postural control Regulated by visual-spatial, somatosensory, and vestibular input Inefficient integration of vestibular information likely cause of observed deficits in postural control Guskiewicz, CJSM, 2001; Sosnoff, JAT, 2011

24 Postural control Impaired postural stability (ie balance deficit) is present for at least 72 hours following concussion BESS – Balance Error Scoring System Riemann, JSR, 1999

25 Diagnosis Clinical Imaging Postural / Balance testing / Vestibular testing Neurocognitive testing

26 Baseline tests administered to high risk athletes and utilized for comparison in the event of concussion Baselines encouraged as part of concussion programs (McCrory, PMR, 2009)

27 Neurocognitive testing issues Baseline performance affected by group testing, amount of sleep, psychological distress, effort Can have learning effect across testing sessions (Register- Mihalik, JAT, 2012) 6-11% can have indicator of invalidity (Schatz, JAT, 2012) Moser, AJSM, 2011; Brown, JAT, 2007; Bailey, CJSM, 2010,

28 Neurocognitive testing issues 8/75 athletes able to sandbag without triggering internal validity indicators (Erdal, Arch Clin Neuropsych, 2012)

29 Neurocognitive testing issues Utility - some suggest not only not helpful, but has capacity to worsen outcome (Randolph, Curr Sports Med Rep, 2011) Has no utility as a diagnostic or screening tool when used in isolation in the military (Coldren, Mil Med, 2012)

30 Example: ImPACT Clinical Report Exam Type: Baseline Composite Scores: Memory composite (verbal): 99%ile Memory composite (visual): 94%ile Visual motor speed composite: 98%ile Reaction time composite: 73%ile ImPACT Clinical Report Exam Type: Post-Injury 2 Composite Scores: Memory composite (verbal): 99%ile Memory composite (visual): 93%ile Visual motor speed composite: 99%ile Reaction time composite: 86%ile

31 Recovery From Concussion: How Long Does it Take? How long do symptoms last? N=134 High School athletes WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 Collins et al., 2006, Neurosurgery

32 Duration of Neurocognitive Deficits Average number of days to return to baseline (ImPACT) were greater for 13 to 16 year-olds than for 18 to 22 year- olds on the following variables: Verbal Memory (7.2 vs 4.7, P = 0.001), Visual Memory (7.1 vs 4.7, P = 0.002), Reaction Time (7.2 vs 5.1 P = 0.01), and Post Concussion Symptom Scale (8.1 vs 6.1, P = 0.026). (Zuckerman, Neurosurg, 2012)

33 Duration of Neurocognitive Deficits Prolonged neuropsychological impairments following a first concussion in female university soccer athletesProlonged neuropsychological impairments following a first concussion in female university soccer athletes Concussed athletes were significantly slower on tasks that required decision making (complex reaction time), inhibition and flexibility, and planning for up to 6-8 months post concussionConcussed athletes were significantly slower on tasks that required decision making (complex reaction time), inhibition and flexibility, and planning for up to 6-8 months post concussion Short- and long-term verbal memory, attention, and simple reaction time were normal – Impact testShort- and long-term verbal memory, attention, and simple reaction time were normal – Impact test –Ellumburg et al., Clin J Sports Med, Sept. 2007

34 Duration of Neurologic Deficits Differential rate of recovery in athletes after first and second concussion episodesDifferential rate of recovery in athletes after first and second concussion episodes All patients asymptomatic at Day 10, cleared for sport participation based on clinical symptoms resolution.All patients asymptomatic at Day 10, cleared for sport participation based on clinical symptoms resolution. Balance deficits, were present at least 30 days after injury (P < 0.001).Balance deficits, were present at least 30 days after injury (P < 0.001). Most importantly, the rate of balance symptom restoration was significantly reduced after a recurrent, second concussion (P < 0.001) compared with those after the first concussionMost importantly, the rate of balance symptom restoration was significantly reduced after a recurrent, second concussion (P < 0.001) compared with those after the first concussion Slobounov et al., Neurosurgery Aug 2007Slobounov et al., Neurosurgery Aug 2007

35 Concussion management The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter

36 Management At least 26 professional guidelines on the diagnosis and management of concussion –The number of treatments for any disease is inversely proportional to how much we know about that disease Returning the asymptomatic athlete to play: What does asymptomatic mean? (Alla, BJSM, 2012) If we cannot agree on what asymptomatic means, how can we agree on safety of contact sports?

37 International Conference on Concussion in Sport

38 Management Use of multifaceted system – Neurocognitive, vestibular, postconcussion symptom scale – more reliable than any test used alone (Register-Mihalik, J Head Trauma Rehab, 2012)

39 Stepwise Return to Play 1. No activity. Complete physical & cognitive rest 2. Light exercise, walking or stationary bike 3. Sport-specific activity such as running or skating. –Progressive addition of resistance training at steps 3 or On the field practice, without body contact. 5. On-field practice, with body contact. –Often progress from controlled hitting/drilling to full contact. –Must be cleared by physician before this step. 6. Game Play. Goldberg, LD & Dimeff RJ: Sideline Management of Sport-related Concussions. Sports Med Arthrosc Rev 2006;14: McCrory P, Johnston K, Meeuwisse W, et al: Summary and agreement statement on the 2nd International Conference on Concussion in Sport, Prague Br J Sports Med 2005;39:i78-i86.

40 Multidisciplinary Approach Team approach is necessary for concussion management: –MDs –Athletic trainers –Coaches –School Nurses –Neuropsychologist –Parents –Athlete Other disciplines might become involved with protracted symptoms: –Speech therapy (academic issues, compensatory strategies) –Physical therapy (i.e., whiplash, vestibular) –Occupational therapy (i.e., vision) –Counseling (i.e., depression, anxiety)

41 Concussion management The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter

42 Active treatment approaches Supplementation with DHA (docosahexaenoic acid) can reduce cell death in rodent model of TBI (Bailes, J Neurotrauma, 2010)

43 Active treatment approaches Amantadine 100 mg BID may facilitate more rapid resolution of neurocognitive deficits in athletes with symptoms greater than 3 weeks. (Reddy, J Head Trauma Rehabil, 2012)

44 Active treatment approaches Exercise assessment and aerobic exercise training for postconcussion syndrome (PCS) may reduce concussion- related physiological dysfunction and symptoms by restoring autonomic balance and improving cerebral blood flow autoregulation. (Leddy, Rehabil Res Practice, 2012)

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46 Thank You

47 Kurt J. Nilsson, MD, MS St. Luke’s Sports Medicine St. Luke’s Concussion Clinic Kristi Pardue, clinical coordinator Matthew Kaiserman, outreach coordinator

48 Thank You

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51 Concussion legislation – HB 632 Went into effect in Idaho July 1 st, 2012 Section 1: SBOE and the IHSAA must provide a link on their websites to CDC guidelines and educational materials. Section 2: Applies to Middle School, Junior High School and High School athletics. Section 3: Mandates education to parents and athletes prior to the start of an athletic season. Coaches, AT’s and referees must review biannually.

52 Concussion legislation – HB 632 Section 4: Removal from play protocols established by schools. –Must Adhere to CDC guidelines –Athlete must be removed when “reasonably suspected” of sustaining an injury. Section 5: Return to play protocols –“An athlete may be returned to play once the athlete is evaluated and authorized to return by a qualified health care professional who is trained in the evaluation and management of concussions.” Physician or Physician Assistant Advanced Practice Nurse A licensed healthcare professional trained in the evaluation and management of concussions who is supervised by a directing physician

53 Concussion legislation – HB 632 Section 6: Liability – “If an individual reasonably acts in accordance with the protocol developed pursuant to subsection (4) of this section, then acting upon such protocol shall not form the basis of a claim for negligence in a civil action. Section 7: Youth Sport Organizations –Liability Protections


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