Transcript presentation, part 1 ( format)

Evaluation and Management of
Concussion
C. S. Nasin, MD
Team Physician
University of Rhode Island
Evaluation
“Its just a ding….right?”
• 43 High School football
players with grade I AAN
concussions
• All cleared within 15
minutes
• Is it safe to return to
the competition?
Lovell MR et al. American Journal of Sports Medicine, Vol. 32, 2004.
“It’s just a ding…right?”
Physical Exam…
in the office
History: particular
attention to Risk Factors
(Prior concussions, ADD,
migraines, learning
disabilities, and co-morbid
mental illness)
Office Physical Examination
HEENT: pupils,
fundoscopic exam
Neck: C-spine
tenderness
Neurologic: Cranial
nerves, Motor, DTRs,
Rhomberg
*Mental Status exam:
3 word recall, Serial 7’s,
“WORLD” backwards
Physical Examination, continued
Dysfunction of Visual
Accommodation/Convergence
•Visual Accommodation: changes optical
power to maintain a clear image (focus) NPA (Near
point of accommodation) “Push up test” use
relatively small letters (0.4M or 0.5M) to help
better control accommodation. Slowly move these
letters closer to the eye until they become blurry.
Measure the distance the letters became blurry.
This is the near point of accommodation.
Increased with dysfunction and age. Children
have NPA of approximately 7cm from the bridge of
the nose.
•NPC (Near point of convergence)- as above.
Note when patients lose ability maintain
binocular vision. Up to 10cm.
Physical Examination, continued…
Posturography
Although the somatosensory
aspects of balance remain
intact, the integration
between the visual and
vestibular components show
dysfuntion after mTBI.
Balance Error Scoring System
(BESS) testing
Neurocom Sensory Organization
test (SOT)
“To CT or not to CT…That is the question…”
Certainly indicated if:
• Focal neurological exam
• Progressive symptoms
CT Head Algorithms
Sensitivity 100%
Specificity 51%
Sensitivity 100%
Specificity 13%
Neuropsychological Testing
Used to provide a sensitive index of
higher brain functioning by measuring:
•
•
•
•
Memory
Attention
Executive function
Speed and flexibility of cognitive processing
Neuropsychiatric Testing
Computer Based Neurocognitive Testing
• Offers some advantages to
traditional paper and pencil
testing
• Allows for evaluation of large
numbers with minimal manpower
• Data is easily stored
• More accurate measurement of
certain cognitive processes (reaction
time/processing speed)
• Randomization of test stimuli reduces
“practice effects”
• Provides a concise clinical report
Computer Based Neuropsychiatric
Testing…Disadvantages
• Has never been validated for use
with concussed athletes
• Is a SCREENING tool, does not
replace formal neuropsychiatric
testing and evaluation
• Normal score≠ No concussion
• Normal score ≠ Return to play
• Does not replace clinical
evaluation
• Simply a “piece of the puzzle”
Treatment
REST!!
Physical Rest
Not only limited to
contact sport
activity
•No heavy exertion
•No resistance
training
Cognitive Rest
A major challenge in a
college setting!
•Education of the college
community
•Communication with
Disability Services and the
Dean’s office.
Pharmacologic Treatment
Medical Treatment
Neuropsychiatric
•Emotional
• Depressed
• Nervous/Irritable
Physical
•Headache
• Visual
• Dizziness
• Noise/Light Sensitivity
• Nausea
Cognitive
•Inattention
• Memory deficits
• Fatigue
•“Fogginess”
Sleep Disturbance
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
Medical Treatment
Neuropsychiatric
SSRIs, Therapy
Physical
Migraine Prophylaxis
-TCAs, β-blockers, CCB,
SSRIs
Vestibular Therapy
Cognitive
Stimulants
-Ritalin*,
Strattera*
-Amantadine*
Sleep Disturbance
Melantonin, Trazadone
* Off label use
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
Medical Treatment
Neuropsychiatric
SSRIs, Therapy
Physical
Migraine Prophylaxis
-TCAs, β-blockers, CCB,
SSRIs
Vestibular Therapy
Cognitive
Stimulants
-Ritalin, Strattera*
-Amantadine*
Sleep Disturbance
TCA
Melantonin, Trazadone
* Off label use
(i.e. Elavil)
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
Graded Return to Play
Complete Rest Until Asymptomatic
Light Aerobic Exercise
Sports Specific Exercise/Resistance Training
Non-Contact Training Drills
Contact Training (after medical clearance)
GAME DAY
Future Directions
• Structural MRI modalities (including
gradient echo, perfusion, and diffusion
weighted images)
• PET scan/fMRI
• Genetic testing: ApoE4
• Electrophysiological studies (Evoked
Response Potentials/EEG)
• Biochemical markers of brain injury (S100b, NSE, MBP, GFAP)
Summary
• Concussion (MTBI) is a common ailment that you
will see in your practice!
• A graded return to play is now recommended
“When in doubt, sit
them out!”
References
McCrory P et al. Concussion Statement on Concussion in Sport 3rd
International Consensus on Concussion in Sport Held in Zurich, November
2008. Cl J of Sports Med Vol 19, #3 May 2009.
Lovell M et al. The Management of Sports-Related Concussion: Current
Status and Future Trends. 2009. 28 (1).
Lovell M et al. Grade 1 or “Ding” Concussion in High School Athletes. AJSM.
Vol 32 2004
Lovell M et al. Neuropsychological assessment of the college football player. J
Head Trauma Rehab 1998; 13:9-26.
Lovell M et al. Return to play following sports-related concussion. Clinics in
Sports Medicine. 23 (2004) 421-441.
Hunt T, Asplund C. Concussion Assessment and Management. Clin. Sports
Med 2010 Jan;29 (1) 5-17.
Green W et al. Accomodation in mild traumatic brain injury. JRRD, 47(3),
2010.
Grindel SH et al. The Assessment of Sports-Related Concussion: The
Evidence Behind Neuropsychological Testing and Management. Clin J of
Sports Med 11: 134-143, 2001.
Stiell HG et al. Comparison of the Canadian Head rules and New Orleans
Criteria in patients with minor head injury. JAMA, Sep 2005; 294(12).
Collins M. ImPACT Training Workshop. Providence, RI. 2010.