Concussion Management 2012: Where Are We Now?

Andrew Getzin, MD

Cayuga Medical Center

Ithaca, NY

Challenging Injury• Variability in presentation, can be subtle• No clear marker, no definitive test• Ideal management ?• Track recovery ?• Prevention?• When “is it safe?”• Research Evolving

What is a Concussion?

A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces

McCrory, 3rd international Concusion in Sport, Zurich, Clin J Sport Med 2009

NEJM Case

“Concussion refers to an immediate and transient loss of consciousness accompanied by a brief period of amnesia following a blow to the head”

Ropper and Gorson, NEJM 2007

Loss of Consciousnes

• Brief LOC does not correlate with severity of concussion

• Developed from studies with animal models and more severe head injuries

• Most likely related to subcortical involvement (Reticular Activating System)

Lovell, Clin J Sports Med 1999;8:193

Giza and Hovda, J Athl Training 2001

Pathophysiology

• Alterations in intracellular/extracellular glutamate, potassium, and calcium

• A relative decrease in cerebral blood flow in the setting of an increased requirement for glucose- Mismatch

• Work by Vagnozzi demonstates metabolic period of increased vulnerability

Vagnozzi, Neurosurgery 2005, 2007

Len, MSSE 2011

Second Impact Syndrome?• Abnormal cerebral blood flow that occurs shortly

after an individual sustains a second concussion prior to fully recovering from a previous concussion

• Vascular engorgement leads to massive increase in intracranial pressure and brain herniation

• Usually severe brain damage or death• “The scientific evidence to support this concept

is nonexistent”• Diffuse cerebral swelling (DCS) occurs in

children> adults with a poor outcome

Saunders and Harbaugh, JAMA 1984

McRory, CSMR 2012

High School Football Player Dies

October 2008

Recovery from Concussion• 80-90% of concussions resolve in 7-10

days• Post-concussion syndrome (PCS) is the

term used to describe prolonged or incomplete recovery

• Non-injury factors often play a role in the persistence of symptoms

Exertion Effects

• Symptoms are exacerbated by:• Mental effort• Environmental

stimulation• Emotional stress• Physical activity

Goals of Initial Office Visit• Determine if Individual sustained a

concussion• Protect his/her brain to allow for recovery

• Activity limitation• School work modification

• Potential support with medication for symptoms

• Provide reasonable patient expectations

Signs and Symptoms

Concussion: Team Physician Consensus Statement, MSSE 2011

Risk Factors That May Prolong or Complicate Recovery

Concussion: Team Physician Consensus Statement, MSSE 2011Makdissi, AJSM 2011

Early Concussion Guidelines• Cantu: 1-post traumatic amnesia <30 minutes, 2- LOC <

5 minutes, post traumatic amnesia > 30 minutes, 3- LOC > 5 minutes, post traumatic amnesia > 24 hours

• Colorado Medical Society: 1- no LOC, no post-traumatic amnesia, confusion, 2- no LOC, post-traumatic amnesia, confusion, 3- LOC of any duration

• American Academy of Neurology: 1- no LOC, Confusion symptoms <15 minutes, 2- No LOC, Confusion symptoms >15 minutes, 3- LOC of any duration

PE: Concussion in the Office• Regular physical exam including HEENT,

neck, and neurological exam• 5 Word Recall- immediate and 5 minutes• Months of the year backwards• Digits backwards• Speech• Pronator drift: Rhomberg• Finger-to-nose• Gentle push with their eyes closed

Rx: Concussion in the Office

“The art of medicine consists in amusing the patient while nature cures the disease.” Voltaire

Initial Rx: Concussion in the Office

• Mental and Physical Rest• 92% of repeat in-season concussions

occur within 10 days• Initial medication to support

• Anti-nausea• Headache medication• Sleep medication?

• Schoo/work support

Guskiewicz, JAMA 2003Majerske, J Athl Tra 2008

Follow-up Office Visits

• Is the individual improving?• Obtain information from other sources: family,

teachers, work• Gradual progression back to normalcy• Is it time to intervene?

Additional Rx: Concussion in the office

• Physical & Occupational Therapy• Neck & back problems• Balance (fall prevention)• Vision and Cognition

• Neuropsychological Testing• Additional Medication

• Headache: elavil• Mental Health: SSRI• Stimulant

• Exercise trial

Leddy, Clin J Sport Med 2010

What Information Guides Return to Activity

• Symptoms• Physical Exam

including balance testing

• Cognitive assessment: neuropsychological assessment?

Hutchison, AJSM 2011

What Is Symptom Free?

• Dependent on time and day of measurement, emotional status, attitude, motivation, and honesty

• Postconcussion-like symptoms are prevalent in the non-concussed population

• Perhaps return to baseline symptoms

Alla, Br J Sports Med 2011

Zurich Return to Play Guidelines

• Athlete should not return-to-play in the current game or practice

• Athlete should be monitored for deterioration for 24 hours

• Return-to-play must follow a medically supervised stepwise process

• Athlete must be symptom-free at rest AND after exertion

Zurich Return to Play Progression

• No activity, complete rest• Light aerobic exercise but no resistance

training• Sport specific exercise and progressive

addition of resistance training• Non-contact training drills• Full contact training and scrimmage• Game play

Preparticipation Evaluation: Hx of Previous Concussions

• Mechanism of injury• Length of time for full recovery• Time out of school/work• Special Treatment

Preparticipation Evaluation: BESS

Concussion Prevention

• There are currently no personal protective equipment that prevents concussions including mouth guards and helmets

• Improper fit of equipment may increase risk for concussion

• Rule changes

Thank You