Practical Advice Regarding Concussions

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Practical Advice Regarding Concussions

• F. Clarke Holmes, M.D.
• Director of Sports Medicine
• Georgetown University

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Definition

• A mild traumatic brain injury resulting in a
  constellation of neurologic symptoms
• Typically resulting from a contact injury, but
  can be non-contact

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Concussion Symptoms

• Headache
• Pressure in head
• Neck pain
• Dizziness
• Nausea/vomiting
• Vision problems
• Hearing problems
• Feeling dazed
• Confusion
• Feeling slowed down
• Feeling in a fog

• Drowsiness
• Fatigue/low energy
• More emotional
• Irritability
• Difficulty concentrating
• Difficulty remembering (retrograde or
  anterograde)
• Poor appetite

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Delayed Concussion Symptoms

• Sadness
• Anxiety
• Difficulty sleeping
• Sleeping more than usual
• Sensitivity to light
• Sensitivity to noise
• Poor grades/test scores

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Pathophysiology of MTBI

• Neuronal dysfunction
• Ionic shifts
• Altered metabolism
• Impaired connectivity
• Changes in neurotransmission

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Neurometabolic Cascade Following MTBI
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On the Field Management

• If unconscious, assume concomitant cervical spine
  injury until proven otherwise
• Dont rush to get the athlete off the field, but
  also dont do your entire neuro/mental status
  exam on the field either

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Sideline Management

• Place the athlete in a area where he/she can sit,
  not be bothered by other athletes and coaches and
  can adequately hear your questions
• If a concussion is suspected, notify the coaches
  that the athlete is out until further notice
• Consider giving the athlete a few minutes to
  regain his composure before beginning the barrage
  of questions

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Sideline Management

• After a quick physical exam focused on pupils,
  the cervical spine and gross strength, focus on
  the history and mental portion of the exam
• If there are mental/cognitive deficits, then the
  functional testing (sprints, push-ups, etc.) are
  irrelevant, since the athlete will not be
  returning to the game

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Sideline Management

• Ask about symptoms first
• Orientation to person, general time and place are
  typically intact
• Progress to game-specific questions

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Game-Specific Questions

• What quarter is it?
• What is the score of the game?
• Who scored last?
• Who are we playing?
• Who replaces you when you are out?
• What happened just prior to the injury?
• What is the nickname of our opponent?

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After Initial Questioning

• Give the athlete a few minutes to cool off and
  regain composure
• Observe the athlete from afar- 10-30 feet away
• Look for the blank stare, shaking of the head,
  abnormal body language such as a slumped and less
  aggressive posture

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In-Game Return-to-Play

• Only clear an athlete to return under the
  following conditions
• Initial presentation was mild (no LOC)
• Symptoms completely resolve within only a few
  minutes (less than 5-10)
• All neurological testing is normal
• Sport-specific drills (running, cutting, kicking,
  catching) reveal normal speed and coordination
  and do not cause any symptoms
• You truly believe the athlete is being honest
  with regards to the reporting of his symptoms

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Pearls

• The more insistent (and more irrational) the
  athlete is to return to the game, the more likely
  he suffered a concussion
• Once a concussion has been diagnosed, take and
  hide the athletes helmet/headgear to prevent him
  from returning to the game

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Pearls

• Be wary of the delayed and recurrent symptoms
• Many athletes may seemingly normalize within
  minutes of an injury, but then have a recurrence
  and potential worsening minutes to hours later
• This concept suggests that very rarely should an
  athlete with a suspected concussion return to the
  game on the same day of an injury

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Post-Game

• Always evaluate an athlete with a concussion
  after the game
• Can monitor for improvement or worsening of
  symptoms
• Allows you to educate the athlete regarding the
  implications of a concussion including warning
  signs, follow-up, dos and donts
• May allow for a coach and/or parents to be
  present during an exam or discussion

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Post-Game

• Find out the plans of the athlete for the evening
• Who can monitor him?
• Suggest strict rest
• Supply the athlete and/or roommate/parents with
  contact phone numbers for the physician or ATC
• Schedule follow-up with ATC or MD
• Next day for moderate-severe concussions
• 1-3 days for mild concussions

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Post-Concussion Medication Use

• Discourage all analgesic use in the acute phase
• May mask headache/neck pain symptoms
• NSAIDs may theoretically increase risk of
  intracerebral bleeding
• May cause nausea if, especially if taken on an
  empty stomach

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Treatment

• REST!... is the only know effective treatment for
  a concussion
• Encourage frequent breaks from studying
• Encourage good hydration and regular meals to
  avoid dehydration and hypoglycemic-related
  headaches

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Medications

• Tylenol may be used to treat headache symptoms if
  there is no immediate intent to return-to-play
• Migraine prophylaxis meds are sometimes used for
  post-concussive syndrome related headaches
• i.e., Topamax, amitriptyline

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Explaining the Process to the Athlete

• An athlete will accept his/her initial
  disqualification if you fully explain the
  implications of a concussion
• Risk of prolonged or permanent symptoms such as
  headache, depression, concentration and learning
  difficulties, etc. with a premature return and/or
  a 2nd concussion before full recovery
• 2nd impact syndrome, although rare, can be used
  somewhat as a scare tactic to help athletes
  understand the serious nature of a concussion

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Return-to-Play and Guidelines

• Many guidelines exist, but there has been a shift
  away from use of any specific guideline
• Return-to-play decisions must be individualized
  based on multiple factors
• The risk in return
• Number of previous concussions, especially in the
  last year
• Severity of current concussion
• Age of the patient more conservative approach
  with younger athletes

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Clinical Tools

• Sport Concussion Assessment Tool (SCAT)
• Poor mans neuropsychological test
• SCAT card is a useful tool for sidelines and
  office assessment
• Easy way to track the symptoms of the athlete and
  can used for documentation of subjective recovery

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Neuropsychological Testing

• Many types exist
• ImPACT is one of the more widely used tests
• Baseline testing is imperative
• If baseline testing not available, then
  post-concussion scores can be compared to
  age-matched controls and a percentile generated
• However, usefulness of this type of comparison is
  debated often, missing 1-2 questions can really
  affect ones performance and scores

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Neuropsychological Testing

• When to test and how often
• Controversial
• I think the tests are most useful when the
  athlete is asymptomatic or nearly asymptomatic
• If symptoms still exist, then the athlete will be
  held out irregardless, and thus, the NP test will
  not guide return-to-play
• NP tests may be useful for the symptomatic
  athlete to help determine whether symptoms are
  concussion-related or not
• i.e., post-game headaches without recollection of
  any trauma

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Neuropsychological Testing

• ATC or MDs using these tests should take the test
  themselves to have an appreciation of the type of
  questions and the difficulty involved
• Neuropsychological tests should neither be the
  primary determinant regarding return-to-play, nor
  should they take the place of good clinical
  judgement

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ImPACT

• Constructs a clinical report based on the
  following categories
• Memory composite (verbal)
• Memory composite (visual)
• Visual motor speed composite
• Reaction time composite
• Impulse control composite
• Total symptom score

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The Role of Imaging

• Computed tomography and MRI rarely have a role in
  the diagnosis of simple concussions
• Invariably, they will be normal in concussions
• Consider an immediate CT scan under the following
  conditions
• Prolonged loss of consciousness (gt30 seconds)
• Major neurological deficits, especially motor
  deficits
• Significant lethargy or rapid/progressive
  worsening of symptoms

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The Role of Imaging

• MRI may be slightly more sensitive in detecting
  subtle abnormalities such as petechial
  hemorrhages
• By definition, then the diagnosis has likely
  moved beyond a concussion alone
• No radiation as with a CT scan
• Imaging can be considered if symptoms are
  prolonged (2 weeks) to exclude another etiology
  of the symptoms
• Attempt to avoid imaging simply to appease any
  involved parties

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The Role of Imaging

• PET scans, SPECT scans and functional MRI may be
  on the horizon to assist with concussion
  diagnosis, severity grading and return-to-play

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Concussion Rehab Protocol

• Rest completely until asymptomatic and NP test
  suggests resolution
• Day 1- indoor conditioning
• Eliminates temperature and humidity fluctuations,
  greater risk of dehydration and greater
  peripheral vision activation
• Day 2- outdoor conditioning
• If an outdoor athlete if indoor, increase the
  intensity and duration of the conditioning

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Concussion Rehab Protocol(continued)

• Day 3- individual sport-specific drills
• Day 4- full team practice, non-contact (jersey
  signifying non-contact status)
• Day 5- full participation in practice and
  potentially a game

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Concussion Rehab Protocol

• To advance to the next stage, the athlete has to
  remain asymptomatic
• If symptoms develop, then consider
• Rest for an additional 1-3 days
• Return to the previous stage
• Consider making each stage 2-3 days if returning
  from a more severe concussion or if multiple
  concussions during that season

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Women and Concussions

• Recent research suggests that women may be at
  higher risk for concussions than male
  counterparts that play the same sport
• In high school soccer and basketball athletes,
  women demonstrated a higher risk

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Women and Concussions

• Potential reasons to explain the higher risk
• Men generally have stronger neck muscles,
  potentially adding a higher level of protection
• Risk level may be the same, yet women may report
  concussion symptoms at a higher rate

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Conclusion

• Individualize your approach with each athlete
• Concussion management is not cookie-cutter
  medicine
• Disqualifying an athlete from competing for the
  remainder of the season is difficult, and must be
  individualized and based on multiple factors
• Determine who your concussion experts are
• Who manages the most?
• Many neurologists and neurosurgeons rarely see or
  manage athletes with concussions

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Conclusion

• If in doubt, hold them out
• Doing the right thing will not always be a
  popular decision with the athletes, coaches or
  parents