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Evaluation and Management of
Concussion
Evaluation and Management of
Concussion
C. S. Nasin, MDTeam Physician
University of Rhode Island
“Its just a ding….right?”
Lovell MR et al. American Journal of Sports Medicine, Vol. 32, 2004.
• 43 High School football players with grade I AAN concussions
• All cleared within 15 minutes
• Is it safe to return to the competition?
Physical Exam…in the office
Physical Exam…in the office
History: particular attention to Risk Factors (Prior concussions, ADD, migraines, learning disabilities, and co-morbid mental illness)
HEENT: pupils, fundoscopic examNeck: C-spine tendernessNeurologic: Cranial nerves, Motor, DTRs, Rhomberg
*Mental Status exam: 3 word recall, Serial 7’s, “WORLD” backwards
Office Physical Examination
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)
Physical Examination, continued…
“To CT or not to CT…That is the question…”
“To CT or not to CT…That is the question…”
Certainly indicated if:• Focal neurological exam• Progressive symptoms
Neuropsychological TestingNeuropsychological Testing
Used to provide a sensitive index of higher brain functioning by measuring:
• Memory• Attention• Executive function• Speed and flexibility of cognitive processing
Computer Based Neurocognitive 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
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”
Cognitive RestCognitive Rest
A major challenge in a college setting!
•Education of the college community
•Communication with Disability Services and the Dean’s office.
Physical•Headache• Visual• Dizziness• Noise/Light Sensitivity• Nausea
Neuropsychiatric•Emotional• Depressed• Nervous/Irritable
Cognitive•Inattention• Memory deficits• Fatigue•“Fogginess”
Sleep Disturbance
Medical Treatment
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
PhysicalMigraine Prophylaxis-TCAs, β-blockers, CCB, SSRIsVestibular Therapy
NeuropsychiatricSSRIs, Therapy
CognitiveStimulants -Ritalin*, Strattera*-Amantadine*
Sleep Disturbance
Melantonin, Trazadone
Medical Treatment
* Off label use
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
PhysicalMigraine Prophylaxis-TCAs, β-blockers, CCB, SSRIsVestibular Therapy
NeuropsychiatricSSRIs, Therapy
CognitiveStimulants -Ritalin, Strattera*-Amantadine*
Sleep Disturbance
Melantonin, Trazadone
Medical Treatment
* Off label useTCA(i.e. Elavil)
Adapted from Collins M. ImPACT Training Workshop. Providence, RI. 2010
Graded Return to PlayGraded 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 DirectionsFuture 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 (S-100b,
NSE, MBP, GFAP)
SummarySummary
• 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!”
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 2004Lovell 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.
References