Transcript Advancements in the Treatment and Management

Advancements in the Treatment
and Management of Concussions
to Improve Patient Outcomes
William R. Wellborn III, PhD
Director Carilion Sports Concussion Program
Department of Physical Medicine and Rehabilitation
Carilion Clinic
[email protected]
Objectives
• Explain Definition of Concussion – Signs & Symptoms
• Integral Parts of Initial Evaluation – History, Self Report
Symptoms & Neurocognitive Evaluation & Vestibular/Visual
Ocular Examinations
• Discuss Management & Treatment – Multidisciplinary
1. Specific Clinical Trajectories (Pathways)
2. Referral to Specialists
•Recent advancements in treatment
Disclosure
I have affirmed to have no relevant financial
relationship with any of the products,
manufacturers, or providers of services that may
be discussed in this presentation.
Why is sport concussion
such an important topic?
• National Football League:
– Media- TV, Newspapers, Internet, Social Media
• State Laws:
– Washington 2009
– Virginia 2010/2011
– Now all 50 States and Washington DC
Lystedt’s Law
• State of Washington
– Zach Lystedt was returned to play by his coach
after 2 injuries in one game
– Second injury produced malignant brain swelling
and permanent brain damage
• Resulted in law requiring evaluation prior to
return to play (2009)
Virginia Law 2010/2011
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1. No member of a school athletic team shall participate in any athletic event or practice the
same day he or she is injured and:
– a. exhibits signs, symptoms or behaviors attributable to a concussion; or
– b. has been diagnosed with a concussion.
2. No member of a school athletic team shall return to participate in an athletic event or
training on the days after he/she experiences a concussion unless all of the following
conditions have been met:
– a. the student no longer exhibits signs, symptoms or behaviors consistent with a
concussion, at rest or with exertion;
– b. the student is asymptomatic during, or following periods of supervised exercise that is
gradually intensifying; and
– c. the student receives a written medical release from a licensed health care provider.
The Zurich Consensus Statement (November 2008) return to play guidelines and the American
Academy of Pediatrics (AAP) Concussion Guidelines (August 2010), are available online to
assist healthcare providers, student athletes and their families, and school divisions, as
needed.
What is Concussion?
• Zurich 2012 - As Defined by “Concussion in
Sport” Group
– Concussion is a brain injury and is defined as a complex
pathophysiological process affecting the brain induced by
biomechanical forces. Several common features that incorporate
clinical, pathologic and biomechanical injury constructs that may be
utilized in defining the nature of a concussive head injury include:
What is Concussion, cont. ?
1. Caused by either a direct blow to the, face, neck, or elsewhere on the
body with an “impulsive force transmitted to the head”.
2. Concussion typically results in rapid onset of short-lived impairment of
neurological function that resolves spontaneously. However in some
cases, symptoms may evolve over a number of minutes to hours.
3. Concussion may result in neuropathological changes, but the acute
clinical symptoms largely reflect a functional disturbance rather than
a structural injury and, as such, no abnormality is seen on standard
structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or
may not involve loss of consciousness. Resolution of the clinical and
cognitive symptoms typically follows a sequential course. However, it
is important to note that in some cases symptoms may be prolonged.
Symptoms
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Headache
“Pressure in Head”
Neck Pain
Nausea/Vomiting
Dizziness
Blurred Vision
Balance
Sensitivity Light
Sensitivity Noise
Feeling Slowed Down
Feeling Like “in a fog”
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(SCAT 3)
“Don’t Feel Right”
Difficulty Concentrating
Difficulty Remembering
Fatigue/Low Energy
Confusion
Drowsiness
Trouble Falling Asleep
More Emotional
Irritability
Sadness
Nervous or Anxious
Common Signs and Symptoms
• SCAT3 Sports Concussion Assessment Tool-3rd Edition
• Child-SCAT3 Sports Concussion Assessment Tool-Children 5-12
Age: A Factor in Recovery
• Younger age - prolonged recovery
– High school athletes had prolonged recovery
times compared to college athletes (Field et al, J.
Pediatrics, 2004)
– High school athletes demonstrated longer lasting
memory deficits compared to college athletes
(Sim et al, J. Neurosurgery, 2008)
– High school athletes had prolonged recovery
times compared to NFL athletes (Pellman, Lovell,
et al, Neurosurgery 2003)
Mild TBI: Gender and Recovery
• Females may be at greater risk compared
to males
– Based on NCAA and high school data, in sports played
by both sexes, females sustained a higher rate of mild
TBI than males (Comstock et al, JAT, 2007)
– Large sample of junior high, high school, and
collegiate soccer athletes, females had longer recover
times than males (Colvin, Lovell et al, AOSSM, 2008)
Effects of Repetitive Injury
• Studies have suggested that repetitive trauma
in athletes is associated with poorer outcomes
– Athletes with 3 or more mild TBI’s are 3 times
more likely to have an additional injury
(Guskiewicz et al, JAMA, 2003)
– Athletes with 3 or more prior mild TBI’s were
more likely to demonstrate markers of concussion
during the period of our study (Collins, Lovell, et
al, Neurosurgery, 2002)
Concussion Management
• Acute Management
– Athletic Trainer and/or Physician
– Rule out more serious intracranial pathologyMental Status Exam and/or Neurologic
Examination (Focal)
• Post Injury Management
– Prevent against Second Impact Syndrome
– Prevent against cumulative effects of injury
– Prevent presence of Post-Concussion Syndrome
Pediatric
Practices
ATC in
Schools
Sports
Medicine
School
Nurses
Primary Care
Physicians
Neurology
Emergency
Department
Neurosurgery
Carilion
Sports
Concussion
Clinic
Trauma
PM&R
Psychiatry
Parents/
Pediatric
Neurology
School
Vestibular/
PT
Psychology
Neurosurgery
Neuroradiography
Behavioral
NeuroOptometr
y
Core Team:
• Neuropsychologist
“Point Guard”
• Physiatrist
medical expertise
• Physical Therapy
vestibular therapy
Support
Personnel:
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Athletic Trainers
Physical Therapists
Guidance Counselors
School Nurses
Parents
Initial Interview
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Reason For Referral
History
Risk Factors
School History
Psychological History
Medical History
Social History
Medications
Treated Now By
Concussion History
• SCAT3
• Dizziness Handicap
Inventory
• Neuropsychological Testing
• Vestibular/Visual-Ocular
Screening
• Education
• Health Behaviors
• Recommendations/
Referrals
Neurocognitive Testing (NCT)
• Cogsport
• Headminders (CRI)
• ANAM- Automated Neuropsychological
Assessment Matrix
• IMPACT- Immediate Post-Concussion
Assessment and Cognitive Testing
• CNS Vital Signs
Vestibular / Ocular Motor Screening (VOMS)
Mucha, Collins et al (2014)
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Smooth Pursuit
Horizontal and Vertical Saccades
Near Point Convergence Distance
Horizontal Vestibular Ocular Reflex (VOR)
Visual Motion Sensitivity (VMS)
Rate: Headache, dizziness, nausea, fogginess
Convergence: ≥5cm
Treatment
• Cognitive Rest-giving your brain a rest
– If symptoms are not too severe you may go to school.
– Phone calls in moderation and soft music may be used for
relaxation.
– Using a computer for school work is acceptable, but you
may need to limit usage if working on computer increases
symptoms.
– Limit or cease use of electronic devices (for example, video
games, TV, texting, internet)
Treatment
• Physical Rest- giving your body a rest
– Take extra naps as needed, no staying up late.
– General physical rest until you have no symptoms
(headache, nausea, attention/memory problems, and
visual problems etc.).
– No activities of physical exertion. This includes no physical
education and no participation in organized sports. The
most important thing is for you not to engage in any
activity that puts you at risk for having another head injury
until you have completely recovered.
Other Interventions
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Sleep
Diet
Hydration
Stress
Exercise
Treatment Process
• After 2 weeks (14-21 days from concussion) difficult patients
who are not improving (dizziness, vestibular problems,
headaches, sleep and attention symptoms) are referred to:
• Physiatrist: Medical Evaluation
• Physical Therapist: Vestibular Evaluation
• Goal= Return to School and Return to Play
Extended Care To Others
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Primary Care Physician
Physical Therapy
Physical Medicine & Rehabilitation
Pediatric Neurology
Family Sports Medicine
Sports Medicine/Orthopedics
Neurosurgery
Neurology
Psychiatry
Athletic Trainers
Massage Therapy
Sports Concussion Specialists- UVA and UNC
Behavioral Neuro-Optometrist
Accommodations
No School
Attend School ½ Time
School Full Time
Homebound Instruction
School Flex-time (Student at
School in a quiet Room)
No tests for Grade until Prepared
No Exams, No standardized Tests
(SATs, ACTs, SOLs etc.)
No Sports or Activities of Physical
Exertion
No Sports Until caught up with
School Work
Testing in a Quiet Room
Extra Time on Tests and Projects
Extra Time For Summer Reading
Requirements
Other Accommodations
(McGrath, 2010)
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Excused Absence from Class
Rest Periods During School Day
Excuse From Specific Tests and Assignments
Accommodations for Light Sensitivity (lights, caps,
visors, or sunglasses
Use of a Reader-Books on tape
Use of a Note Taker
Preferential Seating to Lessen Distraction
Temporary Assistance From Tutor
Graduated Return To Play Protocol
Zurich Concussion In Sport, (2014)
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No Activity
Light Aerobic exercise
Sport-Specific Exercise
Non-Contact Training Drills
Full Contact Practice
Return To Play
Stepwise Progression/Typically 1 Week
Clinical Recovery
• No self (or other) reported symptoms of concussion.
• Performance on neurocognitive testing should be equal to his/her
abilities or within Reliable Change Index of his estimated abilities.
• When above criteria is met the athlete should go through a 5-step
gradual Return To Play Protocol under the supervision of an
athletic trainer or medically-supervised parent that includes Light,
Medium, and Aerobic Exercise. The idea is to increase exertion,
with movement, and finally with controlled contact. When the
athlete goes through each step on subsequent days without
symptoms he is then cleared to return to sports activities.
Typically takes 5-7 days.
Return to Sport
Multiple Concussions/Complex Cases
• Must meet clinical recovery guidelines
– Other factors to consider include:
• Age
• History of ADD, LD, psychological problems etc.
• Grades/performance in school back to pre concussion level
• History- suggesting increased vulnerability to concussion
• Multiple Concussions – and the likely need for retirement from
contact sports
• Does it seemingly take less biomechanical force to cause another
concussion?
Return to Sport
• Does it take longer to recover with each additional
concussion?
• With the occurrence of subsequent concussions do
concussions occur more frequently?
• Does the athlete have persisting functional problems
(headaches, attention/learning problems, increased
emotional issues)
NOTE: In the evaluation and treatment of concussions we are
making advances but there is still more we don't know than what
we know!
Physical Therapy: Evaluation For Vestibular and
Ocular Motor Problems
• Treatment- Static/Dynamic Visual Training and
Home Exercises, Heat /Ultrasound Sound, Soft
Tissue Mobilization
• Return to Function
– School
– Play
– Work
Medical Treatment
• Sleep is always addressed- Sleep Hygiene, and
Medication-Melatonin and Trazodone
• Neck pain, usually muscular, Flexeril then Zanaflex .
Consider PT.
• Dizziness and Neck Pain-refer to PT for Vestibular
Therapy
• Headaches-Type with Appropriate TreatmentMusculoskeletal, Cervicogenic, Rebound, Nerve Injury,
Post-Traumatic Migraine and Fatigue Related Migraine
• Fogginess, Attention/Concentration- Amantadine and
Methylphenidate
Summary
• Heterogeneous Population
• Individualized Plan of Care
• Multidisciplinary Treatment
(Takes a Village)
• Specific Trajectories to Pathways
Collins et. al (2014)
Clinical Trajectories
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Cognitive/Fatigue
Vestibular
Ocular Motor
Post Traumatic Migraine
Cervical
Anxiety/Mood
Collins et. al (2014)
Recent Advances
To Rest or Not to Rest
• Silverberg and Iverson (2013) raised the
question “Is rest after concussion the best
medicine?”
• Prior to 1940’s complete bed rest was
recommended for loss of consciousness of any
duration.
• Zurich Consensus Guidelines (2008)
highlighted rest as the “cornerstone of
concussion management”
• Exact nature and duration of rest period not
definitive. Along a spectrum from complete
bed rest to partial activity.
• Zurich Consensus Statement (2008) until
asymptomatic then institute graded
resumption of activities.
Problems With Rest
• Benefits of rest largely assumed not evidence
based.
• Ongoing inactivity in chronic stage more
detrimental than therapeutic.
Other Medical Problems
• Rest initially recommended for back pain
• Chronic Fatigue Syndrome- rest does not
alleviate chronic fatigue. Thought to
contribute to maintenance.
• Vestibular Disorders- patients avoid activities
that require head movement which limits
adaptation and resolution of symptoms.
• Limited Activity- long thought to be causal
mechanism in depression.
• Anxiety- may be a cause and consequence of
excessive activity.
• Avoidance of feared activities maintaining or
strengthens negative predictions and self
evaluations.
Human Studies
• Gagnon et al (2009) Children slower to recover after
sport concussion. Symptoms greater than 4 weeks.
Participated in a controlled/closely monitored
rehabilitation program.
– Sub-maximal (50-60% maximal capacity) aerobic trainingtreadmill and bicycle
– Light coordination exercises
– Home program
– Visualization
• Results- All children were able to resume their normal
physical activity at end of program. Recovery was
rapid.
Human Studies
• Gagnon et al (2015). A pilot study of active
rehabilitation for adolescents who are slow to
recover from sport-related concussion. 10
athletes. Symptomatic more than 4 weeks.
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Gradual closely monitored light aerobic exercise
Coordination exercises
Mental imagery
Reassurance/normalization of recovery
Stress/anxiety reduction strategies
• Results:
– Significant decrease in symptoms
– Participants reported significant decrease in fatigue
– Cognitive function was significantly improved in visual
motor processing speed.
– Leddy et al (2010) Controlled aerobic exercise
rehabilitation after establishing symptom-free
exercise capacity via treadmill testing has helped
athlete and non-athlete post concussion symptom
patients recover.
Other Evidence
• Thomas et al (2015) Benefits of strict rest after
acute concussion
– Study of 5 days of strict rest vs. control group (1-2
days with gradual return in physical activity)
– Results- recommending strict rest from the ED did
not improve symptom, neurocognitive, and
balance outcomes in youth diagnosed with
concussion. Adolescents recommended strict rest
after injury reported more symptoms over course
of study.
Animal Research
• Griesbach (2004) In study with rats, findings
suggest that premature exercise compromises
compensating responses to the injury. In their
studies, early physiological stimulation through
voluntary exercise reduced the capacity for
neuroplasticity. Rats that exercised 2 weeks after
injury benefited.
• Iverson et al (2012) Animals allowed to exercise
too soon after injury do not show exerciseinduced increases in molecular markers of
neuroplasticity.
Summary
• Silverberg and Iverson (2013) Complete rest
exceeding 3 days is probably not helpful.
Gradual resumption of pre-injury activities
should begin as tolerated (with the exception
of activities that have a high MTBI exposure
risk) and supervised exercise may benefit
patients with persistent symptoms.
Revision of Virginia Law-2015
• Return to Learn- Academic Concussion
Management Plan
• Graduated phases to promote recovery
• Instructional modifications
• Progressive
– Goal: Allowing student athletes to participate in
classroom activities without worsening of
symptoms
– Phases:
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Cognitive/Physical Rest
Light cognitive mental activity
Maximum, moderate, and minimal modifications
Full-time classroom participation
– 504 plan considered if student-athlete is without
significant evidence of improvement at 3-4 weeks
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