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Concussion to Consequence: Managing Sport-Related Concussion On & Off the FieldOvid Webcast--October 18, 2011Ovid Webcast--October 18, 2011

Today’s Host

Anne Dabrow Woods MSN, RN, CRNP, ANP-BC

Chief Nurse, Lippincott Williams & Wilkins and Ovid Technologies

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American Medical Society for Sports Medicine

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the resources that health professionals worldwide rely on every day

Today’s Speakers

Margot Putukian, MD, FACSMDirector of Athletic Medicine, Head Team Physician, Princeton University

Associate Professor, Robert Wood Johnson UMDNJ

Past-President, American Medical Society for Sports Medicine

NFL, Head, Neck & Spine Committee

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John D. Corrigan, PhDProfessor, Ohio State UniversityDepartment of Physical Medicine and Rehabilitation

Editor-in-Chief of the Journal of Head Trauma Rehabilitation

Acute Concussion Identification & Management

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Margot Putukian, MD., FACSM

Director of Athletic Medicine, Head Team Physician, Princeton University

Associate Professor, Robert Wood Johnson UMDNJ

Past-President, American Medical Society for Sports Medicine


Concussion Challenges

• Elusive injury

• Variability in presentation, can be subtle

• No clear marker, no

definitive test

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definitive test

• Ideal management ?

• Track recovery ?

• Prevention?

• When “is it safe?”

• Research Evolving

Definition of Concussion Concussion in Sport, “Zurich Guidelines” McCrory et al, Clin J Sport Med. 19(3):185-200, May 2009

• Pathophysiological process affecting the brain

caused by direct or indirect biomechanical forces

• Common features:

– Rapid onset of usually short-lived neurological

impairment, typically resolves spontaneously

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impairment, typically resolves spontaneously

– Clinical symptoms that reflect a functional

disturbance rather than structural injury

– Range of symptoms that may or may not involve

loss of consciousness (<10%)

• Standard neuroimaging is usually normal

Recognition of Injury

• Recognition of injury not always easy;

– Symptoms are not specific to concussive injury

– Presentation may be delayed for several hours-days

• High index of suspicion

• Differential diagnosis; trauma-induced

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• Differential diagnosis; trauma-induced

migraine, skull fracture, bleed or

other more serious

brain injury

• Standardized approach

Concussion; Signs & Symptoms

Table 2: Selected acute & delayed signs & symptoms suggestive of concussion

Cognitive Somatic Affective SleepDisturbances

Confusion

Anterograde amnesia

Retrograde amnesia

Loss of consciousness

Headache

Dizziness

Balance

disruption

Emotional

lability

Irritability

Fatigue

Trouble falling

asleep

Sleeping more

than usual

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Loss of consciousness

Disorientation

Feeling “in a fog”,

“zoned out”

Vacant stare

Inability to focus

Delayed verbal &

motor responses

Slurred/incoherent

speech

Excessive drowsiness

disruption

Nausea/vomiting

Visual

disturbances

(photophobia,

blurry/double

vision)

Phonophobia

Fatigue

Anxiety

Sadness

than usual

Sleeping less

than usual

Team Physician Consensus Conference,

Herring et al, in press, 2011

Pre-Season Assessment

• Concussion plan for “high risk” sports

• EDUCATION

• Identify modifiers; known to prolong or

complicate recovery

• Baseline evaluation; symptoms, neurological

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• Baseline evaluation; symptoms, neurological

exam including cognitive and balance exam

• Emergency protocols & procedures Identify facility that is trauma center w/ neurosurgical capabilities

Pre-Season Planning; EDUCATION

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Modifiers (Team Physician Consensus Statement, Herring et al, in press)

TABLE 1. RISK FACTORS THAT MAY PROLONG OR

COMPLICATE RECOVERY FROM CONCUSSION

FACTORS MODIFIER

Concussion Hx Total number, proximity, severity (duration)

Symptoms Total #, severity (intensity and especially duration)

Signs Prolonged LOC (>1 min)

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Signs Prolonged LOC (>1 min)

Susceptibility Concussions occurring with lower impact magnitude

and/or requiring longer recovery.

Age Youth & adolescent athletes may recover more slowly

Pre-existing

conditions

Migraine, depression, anxiety/panic attacks, attention

deficit hyperactivity disorder (ADHD), learning

disabilities (LD)

Baseline Form; Concussion History & Other Modifiers (NFL Sideline Concussion Assessment Tool; www.nflhealthandsafety.com)

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Sideline / On Field Assessment

• Recognition and evaluation of athlete with

concussion is essential role of medical

staff covering practice/games

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• No same day return to play for athlete

suspected of or diagnosed with

concussion, even if symptoms resolve as

athletic event evolves

Sideline Evaluation• ABC’s (airway, breathing, circulation)

• Neurologic & mental status

• Rule out c-spine, skull

fracture, intracranial bleed

• Spine board & transport to

appropriate facility if (+)

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appropriate facility if (+)

• Remove from play; close

observation

• Detailed history &

concussion evaluation

None Moderate Severe

Headache 0 1 2 3 4 5 6“Pressure in head” 0 1 2 3 4 5 6Neck Pain 0 1 2 3 4 5 6Nausea or vomiting 0 1 2 3 4 5 6Dizziness 0 1 2 3 4 5 6Blurred vision 0 1 2 3 4 5 6Balance problems 0 1 2 3 4 5 6Sensitivity to light 0 1 2 3 4 5 6Sensitivity to noise 0 1 2 3 4 5 6Feeling slowed down 0 1 2 3 4 5 6

Symptom ChecklistSideline Concussion

Assessment Tool 2; Clin J of Sport Med. 20(4):332, July 2010.

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Feeling slowed down 0 1 2 3 4 5 6Feeling like "in a fog“ 0 1 2 3 4 5 6“Don’t feel right” 0 1 2 3 4 5 6Difficulty concentrating 0 1 2 3 4 5 6Difficulty remembering 0 1 2 3 4 5 6Fatigue or low energy 0 1 2 3 4 5 6Confusion 0 1 2 3 4 5 6Drowsiness 0 1 2 3 4 5 6Trouble falling asleep 0 1 2 3 4 5 6(if applicable)More emotional 0 1 2 3 4 5 6Irritability 0 1 2 3 4 5 6Sadness 0 1 2 3 4 5 6Nervous or Anxious 0 1 2 3 4 5 6

Sideline Evaluation SCAT2, Clin J Sport Med. 20(4):332, July 2010

• Is the athlete acting differently?

• Was there loss of consciousness?, If so, for

how long?

• Was there problems with balance or unsteadiness?

• Orientation Questions:

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• Orientation Questions:– What month is it?

– What’s the date?

– What day is it?

– What year is it?

– What time is it, (within an hour) ?

Sideline EvaluationSCAT2, Clin J of Sport Med. 20(4):332, July 2010

• Modified Maddocks;– What venue?

– What ½ is it?,

– Who just scored?,

– Who did we play last week?

– Did we win?

• Cognitive Evaluation

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• Cognitive Evaluation– 5 word recall, 3 trials

– Months backwards

– Digit Span Backwards

– Delayed recall

• Balance Evaluation BESS

• Finger to nose X 5

Sideline EvaluationModified BESS (Guskiewicz) in SCAT2, Clin J of Sport Med. 20(4):332, July 2010

• Eyes Closed, hands on hips

• Error scoring

• 3 Stances; 20 sec each

– Double leg stance

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– Double leg stance

– Single leg stance; stand

on non-dominant leg

– Tandem stance; non-

dominant foot in back

When to Refer to the ERSCAT2, Clin J of Sport Med. 20(4):332, July 2010

• Prolonged disturbance of conscious state

• Focal neurological deficit

• Worsening symptoms

• Lethargy / drowsiness

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• Significant or worsening headache

• Nausea / vomiting

• Seizures

• These are the indications for CT / MRI to exclude skull fracture or bleed

Disposition

• Athlete should be improving & monitored

• If any deterioration, consider transport

for emergency evaluation / exclude

more serious brain injury

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more serious brain injury

• Post Injury Care; if stable and able to go

home under care of responsible adult

Post Injury Care

• Physical & Cognitive rest

• Plan for follow up care

• Home care information;

– When to go to ER

– Avoid aspirin, NSAIDs, alcohol

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– Avoid aspirin, NSAIDs, alcohol

– No exertion / lifting

– Avoid cognitive work

• Consider Neuropsychological

testing

• May need to make school/work accommodations

• Determine severity of injury once all

symptoms have cleared, neurologic

exam (including cognitive evaluation,

and balance normal)

Severity of Injury

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and balance normal)

• Nature, burden, duration of symptoms

may be more indicative of severity

Severity of Injury;

• Memory problems, persistent confusion

associated with concussions that take

longer for recovery Collins CJSM ’03, Erlanger ’03

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• Headache lasting > 60 hrs, self report of

“fatigue/fogginess”, or > 4 symptoms

associated with delayed RTP Makdissi AJSM ‘10

• Many factors to consider in NP testing

• Provides reliable assessment &

quantification of brain functioning by

examining brain - behavior relationships

Neuropsychological (NP) Testing

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• Many factors to consider in NP testing

• Not uncommon to see deficits in cognitive

function by NP testing persist after

symptoms have abated… opposite also true

Collins AJSM ’03, Collins CJSM ’03, Echemendia ’01, Lovell ’03, McCrory ’05, Broglio ’07, VanKampen ’06,

Echemendia NAN 10/21/08

Neuropsychological Testing

Types of tests

• Computerized

• Paper / pencil

• Hybrid

Measure broad range of cognitive function:

• Speed of information processing

• Memory recall

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• Memory recall

• Attention & concentration

• Reaction Time

• Scanning & visual tracking ability

• Problem solving abilities

Use of Neuropsychological Testing

• Contribution to management & RTP

• Protocols for using NP as part of

“concussion plan” is evolving

• One “tool in the toolbox”

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• One “tool in the toolbox”

• Cannot be used on own to make or rule

out diagnosis or “clear” athlete

• Neuropsychologists are in the best

position to interpret tests

Take Home; Return to Play

• Return to Play (RTP) decision challenging

• Consider Modifiers;

• Individualized progression

– Symptom free at rest

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– Symptom free at rest

& w/ exertion

– Normal neurological exam (including cognitive and balance evaluation)

– Gradual progression w/ incremental increase• Physical demands & risk for contact

Age as Modifier• Recovery appears to take longer in the

young athlete

• Maturing brain may

be at particular risk

• Second Impact

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• Second Impact

Syndrome reported

primarily in athletes < 18

• Education of athletes & parents

particularly important in young

Concussion Management Clin J Sport Med. 20(4):332, July 2010

• Physical & cognitive rest until sx resolve

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Individualized progression depending on modifiers

*** Rate of progression individualized. Don’t speed up in kids

Prevention?

• Mouthguards / Helmets?

• Rule Changes / Changing the “culture of the game”

• Neck strengthening / conditioning

• Education

• NFL as role model;

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• NFL as role model; – Significant change in rules; no same day RTP, defenseless

players, hits to head, $$ penalties

– Education

– Standardized sideline evaluation

– Ongoing research efforts

– Long term / cumulative effects of head trauma

Future Directions

• Role of new neuroimaging techniques, genetics?

• Risk factors & modifiers?– Why do some athletes seem to be at greater risk for injury

and/or take longer to recover?

• Role of Neuropsychological testing; ideal protocol?

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• Role of Neuropsychological testing; ideal protocol?

• Depression & suicide?

• Gender effect?

• Rehabilitation?

• Ideal tools for assessment and tracking recovery?

• MORE RESEARCH NECESSARY

Additional Resources

• “Zurich Guidelines”; McCrory et al, Clin J Sport Med. 19(3):2009

• SCAT2: Clin J Sport Med. 20(4):332, July 2010

• Team Physician Consensus Statement, Herring et al, in

press, Med Sci Sports Exerc

• http://www.amssm.org/ Find a Doc, Statement on

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• http://www.amssm.org/ Find a Doc, Statement on

Concussion in Athletes in review

• http://www.cdc.gov/concussion/sports/

• www.nflhealthandsafety.com

• http://www.aan.com/go/practice/concussion

Lifetime Risks of Concussions

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John D. Corrigan, PhDProfessorDepartment of Physical Medicine and RehabilitationOhio State University

What are the long-term consequences?

• The concussion has cleared.

• The athlete’s sport has relatively greater risk for concussion.

• You are asked, “should this athlete

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• You are asked, “should this athlete

risk a subsequent concussion?”

What do we know?

Zurich guidelines Consensus Statement on Concussion in Sport, 3rd

International Conference, McCrory et al., Clin J Sport Med 2009 19(3).

• “Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value.” (p. 189)

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Zurich guidelines Consensus Statement on Concussion in Sport, 3rd

International Conference, McCrory et al., Clin J Sport Med 2009 19(3).

• “Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value.” (p. 189)

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• “The consensus panel agreed that a range of modifying factors may influence the investigation and management of concussion and in some cases may predict the potential for prolonged or persistent symptoms.” (p. 189)

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What’s new?

1. Emerging data on delayed consequences of traumatic brain injury, including mild TBI

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What’s new?

1. Emerging data on delayed consequences of traumatic brain injury, including mild TBI

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2. Emerging data on factors other than severity that increase thelikelihood of long-termconsequences

2009 Institute of Medicine Report

Gulf War and Health

Volume 7:

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Long-Term Consequences of

Traumatic Brain Injury

Consequences of TBI Persisting or Developing Six or More Months Post-injury

• Seizures• Ocular- & visual-motor disturbances

• Cognitive deficits• Post-concussive

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• Post-concussive symptoms

• Depression• Aggression• Suicide• Unemployment• Social isolation

Consequences of TBI Persisting or Developing Six or More Months Post-injury



• Psychosis• Premature death• Progressive dementia

• Parkinsonism

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• Parkinsonism• Diabetes insipidus• Endocrine dysfunction

• Hypopituitarism• Growth hormone insufficiency

Consequences of TBI Emerging orRe-Emerging Later in Life




• Parkinsonism

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Consequences of Mild TBI




• Parkinsonism

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Findings published in 2011

• Widespread Tau and Amyloid-Beta Pathology Many Years After a Single TBI in Humans––Johnson, Stewart and Smith Brain Pathology, in press

• Brain Injury May More Than Double Dementia Risk in Older Veterans––Yaffe et al. Alzheimer’s Association International Conference 2011

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International Conference 2011

• TBI Increases Risk of Parkinson's Disease––Hutson et al., Journal of Neurotrauma 2011

• Traumatic Brain Injury Is a Risk Factor for Schizophrenia––Molloy et al, Schizophrenia Bulletin 2011

• TBI Linked with Tenfold Increase in Stroke Risk––Chen, Kang & Lin Stroke 2011

#2 New Findings about Lifetime History of TBI

• Moderate and severe TBI’s are not the only ones that leave residual consequences.

• Not just TBI’s resulting in loss of consciousness

• New findings suggesting:

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• New findings suggesting:

– Repeated, mild TBI’s

– Mild TBI’s early in life

Repeated Mild TBI’s

• “Multiple mild” TBI’s observed in athletes, members of the armed services exposed to blasts, victims of child abuse, victims of intimate partner

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child abuse, victims of intimate partner violence, and substance abusers

• Concerns regarding subconcussive blows among athletes, as well as service members exposed to blasts

Early developmental TBI’s

• Clients in substance abuse treatment have higher incidence of childhood TBI’s than general public.

• Prisoners have high prevalence of early childhood TBI’s.

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TBI’s.

Early developmental TBI’s

• Clients in substance abuse treatment have higher incidence of childhood TBI’s than general public.

• Prisoners have high prevalence of early childhood TBI’s.

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TBI’s.

• General public with TBI’s before age 15 more likely disabled in adulthood.

• Birth cohorts show early TBI’s predispose to later behavioral problems.

Christchurch Health & Development Study

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A Major Missing Piece of Information

How does a temporary disruption of brain function become permanent damage?

• Metabolic?

• Genetic or epigenetic?

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• Functional (i.e., electrical/neurochemical)?

• Structural?

Does the “spacing” between blows make

a difference?

“When can an athlete risk a subsequent concussion?”

• For now, must be answered on an athlete-by-athlete basis.

• History of altered consciousness without loss of consciousness less risky than concussions with loss of consciousness.

• No guidance for how much loss of consciousness is

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• No guidance for how much loss of consciousness is inconsequential when evaluating previous TBI’s.

• Reason for concern about experiencing a subsequent TBI while still healing from a previous, and cannot rule-out the risk of subconcussive blows.

• Reason for concern about childhood TBI’s even if mild.

Stay in-touch with this topic

� Visit the AMSSM website www.amssm.org

� Find the latest coverage in The Journal of Head Trauma Rehabilitation www.headtraumarehab.com

� Try OvidMD for free in Oct 2011 by signing up at www.ovid.com . OvidMD is a clinical tool for clinicians that provides quick answers to clinical questions based on relevant current full-text content from Ovid and UpToDate™ .

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