David S Edwards MD¹ amp Wendy Sheppard MS LAT ATC² ¹Department of Family amp Community Medicine Texas Tech University Lubbock ²Assistant Director of Sports amp Risk Management University of Richmond ID: 776395
Download Presentation The PPT/PDF document " From Sideline to Exam Room" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
From Sideline to Exam Room
David S. Edwards MD¹ & Wendy Sheppard MS, LAT, ATC²
¹Department of Family & Community Medicine, Texas Tech University, Lubbock
²Assistant Director of Sports & Risk Management, University of Richmond
Slide2Objectives
Recognize concussion as a form of traumatic brain injury in adolescents and young adults.
Identify the student who may be at risk for increased morbidity associated with concussion.
Demonstrate use of the SCAT5 concussion assessment tool and vestibular/oculo-motor screening (VOMS) to assess a concussed student.
Implement evidence-based guidelines to formulate treatments plans for return to the classroom and return to sport.
Slide3Case
You see an 18 year old woman in clinic for persistent headache after a vacation to Mexico last week. She states that she hit her head on the pool. There was no loss of consciousness. She was feeling better until she drove 2 hours to see a friend on arrival back to Lubbock. Now she is dizzy.
Image: http://www.xtns.org
Slide4Key Questions to Consider:
What is a concussion?How do I test for this?Time to recovery?
https://newsnetwork.mayoclinic.org/files/2014/05/shutterstock_116611456.jpg
Slide5Evolving Definition of Concussion
“Sports concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” First International Symposium on Concussion in Sport, Vienna, 2001
McCrory P, et al., 2005
Slide6Evolving Definition of Concussion
“Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.” Fourth International Conference on Concussion, Zurich, 2012
McCrory P,
Meeuwisse
WH,
Aubry
M, et al., 2013
Slide7Evolving Definition of Concussion
“Sport-related concussion is a traumatic brain injury induced by biomechanical forces.” Direct trauma or transmitted forceRapid onset of transient neurologic symptoms, may evolve over hoursLack of obvious structural defect on neuroimagingRange of signs and symptoms, sometimes prolonged not due to medications, other injuries, or co-existing medical/psychiatric diagnoses Fifth International Conference on Concussion, Berlin, 2016
McCrory P,
Meeuwisse
WH, Dvorak J, et al., Br J Sports Med 2018; 51:838-847
Slide8What happens to the brain during/after a concussion?
During an impact, the brain is pushed against the inside of the skull and can be bruised.This bruising can damage nerve cell tissue and can temporarily or permanently impair the brain cells from communicating with each other.
Coronado VG, Haileyesus T, Cheng TA, et al, . J Head Trauma Rehabil 2015
Concussions alter the balance of ions
and chemicals in the brain.
Increases energy consumption
Decrease in cerebral flow
“Metabolic mismatch
”
Slide9Rising Incidence
Cohort of 8.8 million AmericansChart review 2007-201460% increase in concussion diagnosesAges 10-14 increased 143%Ages 15-19 increased 87%Highest incidence: age 15-19, age 10-14LOC: 29%Place of initial diagnosis and evaluation:ED in 56%, physician’s office in 29%
Zhang AL, Sing DC, Rugg CM, et al., 2016
Slide10Sport Concussion Statistics
1.6-3.8 Million concussions are reported each year90% of most diagnosed concussions do not involve a loss of consciousness5-10% of athletes will sustain a concussion in any given sport season33% of concussions occur at practices78% of concussions occur during games (as opposed to practices)Headache (85%) and dizziness (70-80%) are most commonly reported symptoms immediately following concussions for injured athletesEstimated 47% of athletes do not report feeling any symptoms after a concussive blow Once an athlete sustains a concussion they are 3-6 times more likely to sustain another concussion
Coronado VG,
Haileyesus
T, Cheng TA, et al,
. J Head Trauma
Rehabil
2015
Slide11Mechanism of Injury
Acceleration and deceleration of the freely moving head
Direct/rotational forceAxonal stretch injuryComplicationsBrain bruising, swellingBleeding within the brain
Grady MF, Master CL, & Gioia GA, 2012
Slide12Characteristics of Concussion
Confusion
Disorientation
Difficulty recognizing people or places
Amnesia
No memory of events before/after injury
Cannot recall details of plays
Repeatedly asks a question that has been answered
Slide13Symptoms of Concussions
Headache or pressure in the head
Dizziness, imbalance
Thinking, reasoning, and remembering are “slowed down.”
Nausea
Sensitivity to light or noise
Neck Pain
Not “feeling right”
Slide14Types/Trajectories¹ of Concussion
VestibularOcularCognitive/FatigueAnxiety/MoodPost-traumatic migraineCervical
COACH CV² – 7 phenotypesCognitive FunctionOculomotor ManifestationsAffective DisturbancesCervicalHeadachesCardiovascularVestibular
1 http://
rethinkconcussions.upmc.com
, accessed 5/10/18. 2 Craton N. COACH CV: The Seven Clinical Phenotypes of Concussion. Brain Sci. 2017, 7, 119.
Slide15Case
20 year old men’s rugby player is tacked to the ground during a game and complains of head pain where his head hit the turf, but no other symptoms. Fifteen minutes later he reports dizziness, and a headache.
Slide16Diagnosis: The Tool Box
History
Pre-participation physical exam questionnaire if available
Basic Physical Exam
Neuropsychiatric testing
Evaluation tools:
Sport concussion assessment tool (SCAT) 5
Symptom checklist
Memory
Concentration
Cervical spine (if alert and oriented)
Balance, coordination
Imaging?
Slide17History
Describe your pain? How did it start? Severity?
Prior injury / surgery / degenerative joint disease?
Radiation of pain?
Weakness?
Numbness / tingling? Don’t forget the legs.
Bowel/bladder symptoms?
Clumsy? Gait difficulty?
Aggravating / alleviating factors?
Previous treatments?
Past Medical Hx & Family Hx
Slide18Physical Exam
Vital signs : tachycardicAirway / Breathing / Circulation, Secondary Survey PEARLNumbness/Weakness in ExtremitiesSCAT5Cervical SpineExtremitiesVestibular function
Slide19Neuropsychiatric Testing
Memory, cognitive processing speed, reaction time
Helpful adjunct in select cases
Do not use in isolation
Identifies subtle cognitive impairments
History of multiple concussions
Student athlete who denies symptoms to play sooner
High risk student athletes
Computerized testing vs Paper/pencil tests
Interpretation by trained individuals
When? How often?
Slide20Imaging?
PECARN Rule: Features Associated with Low Likelihood of Significant Intracranial/Skull Injury: Age 2-18Normal mental statusNo loss of consciousness (LOC)Non-severe mechanism of injuryNo emesisNon-severe headacheNo signs of basilar skull fracture
Kuppermann
N. et al., 2009
Slide21Danger Signs of Severe TBI
Worsening headacheLoss of consciousnessDrowsiness, difficulty awakeningRepeated vomitingUnusual behavior, irritable or violent SeizuresWeakness or numbness in the arms, legsSlurred speechPoor coordination, balance
Slide22Neuroimaging Options
CTImmediately post-injury if “red flags” Evaluate for:Skull fractureHemorrhageCerebral contusionBrain stem herniationRapid
MRI
Persistent or worsening symptoms
Underlying anomalies
Chiari malformation
AVM
Posterior fossa
Need for sedation?
Slide23When to image the neck?
Nexus Criterialow likelihood of fracture if:No post. midline TTPNo neuro deficitAlertNot intoxicatedNo painful distracting injury
Canadian C-Spine Rules
1.
High risk
: age > 64, fall >
3 feet or 5 stairs, axial load, MVA > 60 MPH, bicycle accident
2.
Low risk
: simple rear-end collision, sitting in ER, walking, delayed onset of neck pain, no midline TTP, can rotate neck 45 L & R without difficulty
Slide24Evaluating Concussions
SCAT5ImPactKing DevickVOMS
Slide25SCAT5
PROSStandardizedWell-establishedUseful for immediate assessmentSymptom checklist useful for tracking recoveryCost effective (paper/pen/online) test
CONSPoor inter-rater reliabilityLimited VOMS assessmentDecreased utility 48-72 hrs post injuryNot the “gold standard”Test should be administered by medical professional
http://scat5.cattonline.com/Image: collegExpress.com
Slide26SCAT 5 Symptom Checklist
“If 100% is perfectly normal, then what % of normal do you feel?”If not 100%, why?
http://scat5.cattonline.com/
Slide27Pocket Concussion Recognition Tool
Not a diagnostic tool.
Used to help non-medical personnel identify signs and symptoms of a head injury Provides guidance for removal from activity and to seek medical attention.
http://
bjsm.bmj.com
/content/
bjsports
/47/5/267.full.pdf
Slide28ImPACT
ImPACT is a computerized neurocognitive assessment tool to help licensed healthcare providers evaluate and manage a suspected concussion.Industry Leader for concussion testing may be cost prohibitive for some programsResults should be administered/reviewed by a healthcare professionalCan test multiple students at one time (computer Lab)National Norms make it difficult to “sandbag” test
https://
impacttest.com
/
Slide29King Devick
Vision test that measures rapid eye movement, visual tracking, and related cognitive responses.Doesn’t require medical training.Takes about 2 min to administerCost efficient
https://
kingdevicktest.com
/
Slide30VOMs (Vestibular/ocular-motor screening)
Screening takes approximately 5 min to administerPatient rates changes of symptoms on a 0-10 scale for symptoms. (Dizziness, Nausea, Fogginess)Items needed for test:Scoring sheetTarget with 14 Font size writing
Slide31VOMS
SMOOTH PURSUIT Patient to follow a moving target while the patient and the examiner are seated. Examiner holds a target at a distance of 3 ft from the patient. The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft to the right and 1.5ft to the left of midline. One repetition is complete when target moves back and forth to the starting position and 2 repetitions are performed. Horizontal: Target is moved at a rate of 2 seconds for each direction (right to left and left to right). Vertical: Repeat at the same rate (2 seconds) moving the target vertically 1.5 ft above and 1.5ft below midline for 2 complete repetitions up and down.
A.
Mucha
, DPT,
*
M. Collins PhD, et. al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
Slide32VOMS
SACCADES Horizontal and Vertical Patient to follow a target between two points as quickly as possible. Patient and the examiner are seated. Horizontal: Examiner holds two single points (fingertips/ targets) Horizontally at a distance of 3 ft from patient and 1.5 ft to the right and 1.5 ft to the left of midline so that the patient must gaze 30 degrees to the left and 30 degrees to the right. One repetition is complete when the eyes move back and forth to the starting position. 10 repetitions are to be completed. Vertical: Repeat the test with 2 points held vertically at a distance of 3 ft from the patient and 1.5 ft above and 1.5 ft below midline so that the patient must gaze 30 degrees upward and 30 degrees downward.
A.
Mucha
, DPT,
*
M. Collins PhD, et. al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
Slide33VOMS
NEAR POINT OF CONVERGENCE Measure the ability to view a near target without double vision. The patient is seated and wearing corrective lenses (if needed). Examiner sits in front of the patient and observes their eye movement during this test. Patient focuses on a small target (approximately 14 font size) at arm’s length and slowly brings it toward the tip of their nose. The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye. The distance in cm between the target and the tip of the nose is measured and recorded (ABNORMAL >_ to 6cm)Repeat 3 times
A.
Mucha
, DPT,
*
M. Collins PhD, et. al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
Slide34VOMS
VESTOBULO-OCULAR REFLEX (VOR) Horizontal and Vertical Assess the ability to stabilize vision as the head moves. The patient and the examiner is seated. The examiner holds a target of approximately 14 point font size in front of the patient in midline at a distance of 3 ft. Use a metronome to help with speed at about 180 beats/min. Horizontal: Patient rotates head horizontally and maintains focus on the target. Amplitude of movement is 20 degrees to each side. Perform 10 revolutions. Vertical: Repeated with the patient moving their head vertically. Perform 10 revolutions.This test is most likely to provoke symptoms
A.
Mucha
, DPT,
*
M. Collins PhD, et. al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
Slide35VOMS
VISUAL MOTION SENSITIVITY Test visual motion sensitivity and the ability to inhibit vestibular –induced eye movements using vision. Patient stands with feet shoulder width apart, facing a busy area (in the clinic or on a field/court).Examiner stands slightly behind patient (to guard the patient without interfering with movement).Patient holds arm outstretched and focuses on their thumb. Maintaining focus on their thumb, the patient rotates together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the left and 80 degrees to the right. Use a metronome to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction). Repeat 5 revolutions: One revolution is from right to left to the starting position is one revolution.
A.
Mucha
, DPT,
*
M. Collins PhD, et. al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions
Slide36Concussion Management
If you suspect an athlete has a concussion:
Remove the athlete from the game immediately.
Do not allow return to play while signs or symptoms are present at rest or with exertion.
Do not allow the athlete to drive a motor vehicle home.
E
nsure that someone is available at home to monitor and observe the athlete.
Slide37Concussion Management
A player who is experiencing symptoms should never be allowed to return to the game or practice.Individualized based on signs and symptoms“When in doubt, sit them out!”
Slide38Treatment
Monitor for deteriorationNo driving Must stay hydrated and eat (bland diet)Physical rest, no strenuous activityOptimum duration?Cognitive restUnplug! Limit academic activities while experiencing symptoms.Especially important in adolescents / young adults
Slide39Treatment: Acute Symptom Control
Headache
Acetaminophen
Environment
Persistent: HA type?
Neck pain
Modalities
Formal Physical Therapy
Sleep disturbance
Sleep hygiene, avoid medications
Slide40Treatment: Gradual return to learning and exercise
Recommendations from a recent S.R., Kamins et al. 1. Clinical recovery occurs before physiologic recovery.“buffer zone”2. There should be a minimum “stand-down” period following concussion.Based on clinical assessment3. Is the duration of graded return to play protocols appropriate?Yes
Kamins
J, et al. Br J Sports Med 2017; 51:935-940.
Slide41Rx: P.T. Please Evaluate and Treat: Neck Pain & Dizziness, modalities as needed
Double blind RCT pilot study, Reneker JC et al., 2017Dx of sport-related concussion @ sports medicine clinicsAges 10-23 years, n = 41Rx: Physical Therapy at 10 days post injury Treatment group: manual therapy and vestibular rehabilitation, 2x/wkPatient specificProgressive intensityHome-exercise programControl group: sub-therapeutic treatments, no increase in intensityNo adverse events in either group Median time for medical release in treatment group: 10.5 days soonerMedian time for symptom recovery: 3.5 days sooner
Reneker
JC, Hassen A, Phillips RS, et al. Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scan J Med Sci Sports. 2017;27-2009-2018
Slide42A 20 yo softball player remains symptomatic with headache and fatigue 6 weeks after a collision with another player while attempting to steal a base. She initially lost consciousness for about 90 seconds, and a head CT was normal in the ER. Her mother is present with her today and is investigating additional diagnostic and therapeutic modalities. Which is the next best step in diagnosis and/or management?
A. Continue protocol of cognitive and physical rest
B. Start omega-3 fatty acid capsules over the counter
C. Obtain a functional MRI
D. Order an APO E4 genotype
E. Refer for Neuropsychological testing
Slide43Recovery is Variable
History of previous concussionsProlonged LOCAmnesiaDizzinessYounger ageFemalesMedical historyADHD, migraine headaches, learning disability, sleep disorders, depressionBehavior Sport
Slide44Still symptomatic after 10 days of rest: Help!!
Persistent post-concussive symptoms
Post-concussion syndrome
Look for coexisting pathology
Multidisciplinary approach
Neuropsychiatric testing
Sub-symptom threshold activity (activity that does not worsen symptoms)
Slide45Return to School
After cognitive rest and return to baselineGradual increases in cognitive loadIdeally initiated at homeSub-symptom thresholdsFrequent breaksSchool accommodationsBreaks PRN in a quite environmentAccess to notes / outlinesAdditional time / tutoringNo double workload (make-up + new work)No tests until tolerating a full day of school
http://www.cdc.gov/concussion/headsup, Master CL et al., 2012
Slide46“Return to Learn” Protocol
Decrease activity –
Unplug!
Gradual cognitive loading, 5-15 min increments
Homework at home, 20-30 min increments
School re-entry, part-time with accommodations, 1-2 hours of homework
Full day of school, wean accommodations
Resume full class schedule, testing
Slide47Return to Play
Athletes must be monitored in the period of time following a concussion to ensure that symptoms resolve and they are not in danger of further injury.When symptoms resolve, our athlete can begin the process of safely returning to sport!
Slide48Return to Play
Slide49Complications of Concussion
Second impact syndromeRepetitive injurySlower recoveryPost-concussion syndromeLong-term effectsDementia?Depression?
Slide50Dizziness / Disequilibrium
Vestibular rehabilitationGaze stabilization exercisesVOR x 1https://www.youtube.com/watch?v=4HkkGI7_8Vs VOR x 2 https://www.youtube.com/watch?v=vChuwinJigU 2 target VOR exerciseshttps://www.youtube.com/watch?v=B_hIS1hHXU0
Image:
www.earandbalance.co.uk
Slide51Resources for Educating Students, Parents, & Coaches:
NCAA Concussion program
NCAA.org/concussion
CDC Concussion Education/Heads Up
http://www.cdc.gov/concussion/sports
NFL Health and Safety
NFLhealthandsafety.com
Slide52Time-Out!! Isn’t there a blood test for this?
FDA news release: 2/14/2018“The FDA authorizes marketing of the first blood test to aid in the evaluation of concussion in adults.”Banyan Brain Trauma Indicator Protein assay – UCH-L1 + GFAPCheck within 6-12 hours of injury, results take 3-4 hoursElevated levels correlate with intracranial lesion on head CTMulticenter prospective trial, 1947 samplesPredictive of intracranial lesion 97.5% of the timeNegative test associated with absence of lesion 99.6% of the time
https://
www.fda.gov
/
newsevents
, accessed 2/19/2018
Slide53Essentials
No “same day” return to play. Oral and written instructions are given to the patient and a responsible adult. Serial clinical evaluations are needed.Treatment must be individualized.Younger patients require more conservative management.No equipment will prevent concussion.
Herring SA et al., 2015, NCAA Sport Science Institute
http://www.ncaa.org
Slide54Summary
Concussion is a common head injury associated with collision and contact sports. Treatment involves rest. Most concussions clear in 7-10 days.
Symptoms may be nonspecific:
Headache & dizziness are most common
Were symptoms present prior to injury?
No athlete should play while still experiencing symptoms.
“When in doubt, sit them out.”
Slide55References
Broglio
S, P, Cantu R,
Gioia
G, et al. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic
Training 2014; 245-265.
Coronado VG, et al. Trends in sports- and recreation- related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma
Rehabil
2015; 30 (3): 185-197
Grady MF, Master CL,
Gioia
GA. Concussion Pathophysiology: Rationale for Physical and Cognitive Rest.
Ped Annals
2012; 41(9): 377-382.
Goodson JD. “Neck Pain”, Chap 51. The Patient History – An Evidence-Based Approach to Differential Diagnosis. Henderson MC, Tierney LM, Smetana GW editors. Lange, 2
nd
ed. 2012
Guskiewicz
KM, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA concussion study.
JAMA
2003; 290:2549-2555.
Harmon KG,
Drezer
JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport.
Br J Sports Med
2013; 47:15-26.
Herring SA,
Kibler
WB,
Putukian
M, et al. Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement.
Med Sci
Sp
Exer
. 2015, accessed from
http://www.acsm-msse.org
in July 2016.
Hoge CW, et al. Mild traumatic brain injury in U.S. soldiers returning home from Iraq.
NEJM
2008 358 (5):453-463.
Johnson DL &
Mair
SD.
Clinical Sports Medicine
. Mosby, Philadelphia. 2006. pp 129-140.
Kuppermann
N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study.
Lancet
2009: 374: 1160-70.
Slide56References
Kushner DS. Concussion in sports: minimizing the risk for complications.
Am Fam Phys
Sept 15 2001;64 (6):1007-1014.
Master CL, Gioia GA, Leddy JL, Grady MF. Importance of “Return-to-Learn” in Pediatric and Adolescent Concussion.
Ped Annals
2012; 41(9):1-6.
McCrory P, et al. Summary and agreement statement of the 2
nd
International Conference on Concussion in Sport, Prague 2004.
Br J Sports Med
2005; 39:196-204.
McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4
th
International Conference on Concussion in Sport held in Zurich, November 2012.
Br J Sports Med
2013; 47:250-258.
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport: the 5
th
International Conference on Concussion in Sport held in Berlin, October 2016.
Br J Sports Med
2018; 51:838-847.
Mueller FO, and Cantu RC. Sports Medicine: Reducing Brain & Spinal Injuries in Football and Other Athletic Activities. National Federation of State High School Associations home page.
http://www.nfhs.org
Zhang AL, Sing DC, Rugg CM, et al. The Rise of Concussions in the Adolescent Population. Ortho Jnl of Sports Med Aug 2016; 4(8), accessed from
http://ojs.sagepub.com
in September 2016.