Active Recovery Kenzie Johnston MD CAQSM Objectives Briefly define what is a sport related concussion SRC Touch on how to make a diagnosis Discuss newest management recommendations Discuss directions of research ID: 776333
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Slide1
Update on Concussion Management: Active Recovery
Kenzie Johnston, MD CAQSM
Slide2Objectives
Briefly define what is a sport related concussion (SRC)
Touch on how to make a diagnosis
Discuss newest management recommendations
Discuss directions of research
Slide3Take it with a grain of salt…
Most recommendations are consensus recommendations based on systematic review from 5th international conference in BerlinPlan to review recommendations and update in 2020
Slide4Why do we care?
About 400,000 sport related concussions/year in high school athletesPrimary care doctors likely to see and manage a majority of them!
Slide5What is sport related concussion (SRC)?
SRC is a mild traumatic brain injury induced by biomechanical forces
May be caused by direct blow or counter coup force
May result in neuropathological changes but the acute signs and symptoms reflect a functional disturbance rather than a structural injury so no abnormalities are seen on imaging
Signs and symptoms not explained by substances, medications, or other comorbidities
Slide6A majority of SRCs occur without loss of consciousness or frank neurological symptomsCurrently no perfect test or marker to diagnoseDelayed or evolving symptoms are well documentedNo evidence for helmet monitors or impact sensors at this time…but….
It can be difficult…
Slide7...CONCUSSION IS A CLINICAL DIAGNOSIS!
Slide8Sideline management
Removal from field and evaluate sideline or in training room
Multimodal assessment increases sensitivity and specificity (SCAT5)
R/o cervical spine injury
Should not be left alone, but does not need to be kept awake
Slide9Initial reassessment in office
Complete history including previous concussions and recovery time
Symptom score
Detailed neuro exam
Assessment of mental status
, cognitive functioning, sleep disturbances, ocular function, vestibular function, and balance
Determination of improvement vs deterioration and if any indication for emergent imaging
+/- SCAT5 or portions of it
Slide10Slide11Slide12Slide13Slide14Slide15Imaging
Purpose:
Identify serious injuries requiring early intervention (fracture, bleed…)
What to do:
Head CT without contrast
When to do it:
RED FLAGS
Impaired consciousness or declining consciousness
Suspected skull fracture
Multiple episodes of vomiting
New neurologic deficit
On blood thinner
Seizure
Intoxication or behavior that may impair your exam
Slide16Vestibular/Ocular Motor Screening (VOMS)
Slide17Brief computerized cognitive testing (aka IMPACT testing)
Useful tool as cognitive recovery may precede or lag behind clinical symptoms recovery
Often not affordable or realistic
Should be a just another tool in your decision making but should not be the sole basis for decisions
Slide18Clinical domains of concussion
Slide19Rest
Previously – complete physical and cognitive rest until symptom freeNow – just first 24-48 hrs (no evidence in adults for more than 3 days of rest)
Slide20Active recovery
Sub-symptom threshold, submaximal exercise is safe and may be of benefit in recoveryAka there is a sweet spot of not too much but not too little
Slide21Buffalo Treadmill Test
May be used in several ways
to see if someone really is physiologically recovered and ready to start return to play (acute concussion)
Exercise prescription for those with
postconcussive
symptoms
Identify those at risk for prolonged symptoms
Potentially able to use to provide exercise prescription for recovery
Slide22Buffalo Treadmill
Modification of the cardiac
Balke
protocol
Start at 3.6 mph at 0% incline
Incline increased 1% at min 2 and then every min after until max incline or no longer tolerated
Assess perceived exertion, symptoms every min
HR and/or BP every 2 min
Stopped if symptoms on VAS increase by 3 or more or at exhaustion
If reach max incline then speed increase 0.4 mph every min
Slide23Buffalo Bike
Slide24How do determine if recovered?
It’s hard!
Subjective symptom scores, imperfect testing
Newer evidence suggests that physiologic recovery is slower than clinical, so a buffer zone may be a good idea
Slide25Return to learn
Slide26Often send back with accommodations
Slide27Return to sport
Slide28When to consider referral
Persistent symptoms should reflect failure of normal recovery (beyond 10-14 in adults and 4 weeks in kids)To sports medicine or neurology Do not image these people
Slide29Prolonged recovery
Greater number and severity of symptoms predict slower recovery
Inconsistent findings regarding specific injury severity characteristics like LOC
Development of HA, dizziness, difficulties with oculomotor functioning, and depression may be associated with worse outcomes
History of mental health issues or headaches may put at risk (but not ADD/ADHD)
Teenage girls
Slide30The future…
Blood, saliva, CSF fluid
Functional MRI
Cerebral blood flow
Electrophysiology
Heart rate
Exercise performance
App based sideline diagnosis
Slide31…is promising
Looking for both diagnostic and prognostic markers
Slide32Slide33Prevention
Evidence for disallowing body checking under age 13 in youth hockeyPerhaps vision training in college football
Slide34Because of everyone will ask…
“CTE appears to represent a distinct tauopathy with an unknown incidence in the athletic population but a cause and effect relationship has not yet been demonstrated between CTE and SRCs or exposure to contact sports.”
Slide35Can we apply this to non sport concussions?
Sport vs non sport should not be viewed as dichotomous
https://bengalbouts.nd.edu/
Slide36Thank you!
Kenzie.johnston@duke.edu
Slide37References
Haider, Mohammad N., et al. “The Predictive Capacity of the Buffalo Concussion Treadmill Test After Sport-Related Concussion in Adolescents.”
Frontiers in Neurology
, vol. 10, 2019
Harmon, Kimberly, et al. “American Medical Society for Sports Medicine Position Statement on Concussion in Sport.”
Clinical Journal of Sport Medicine
, vol. 29, no. 3, 2019, p. 256.
Leddy, John J., and Barry
Willer
. “Use of Graded Exercise Testing in Concussion and Return-to-Activity Management.”
Current Sports Medicine Reports
, vol. 12, no. 6, 2013, pp. 370–376.
McCrory, Paul, et al. “Consensus Statement on Concussion in Sport—the 5th International Conference on Concussion in Sport Held in Berlin, October 2016.”
British Journal of Sports Medicine
, 2017.