Pearls & Pitfalls in Sports-Related

Concussion

Jordan Garner-Roberts, PA-CLast Update: AFPPANP 2018 San Antonio

Disclosures

None

Objectives

1.Discuss the initial evaluation of the student athlete with a suspected sports-related concussion (SRC) in the primary care setting

2.Describe techniques for supporting student athletes during Return-to-Learn (RTL) phase of recovery

3.Recognize indications for Return-to-Play (RTP) by weighing risks against benefits of continued participation

Objectives

Background

Background“The Gridiron Crisis”

“President threatens to shut down football”

“Football carries nearly the same risk that a soldier

[assumes] on the battlefield” - New York Times

“The Gridiron Crisis of 1905”

“President Roosevelt threatens to shut down football”

“Football carries nearly the same risk that a soldier

[assumes] on the battlefield” - New York Times, 1894

Houghton Library Blog

Historical Background

https://blogs.harvard.edu/houghton/2013/09/20/myths-debunked-sadly-theodore-roosevelt-never-rode-a-moose/

Definition

Concussion is a traumatic brain injury and is induced by

biomechanical forces

• Rapid onset, transient neurological impairment that resolves spontaneously

• Symptoms evolve over minutes to hours

• Resolution follows a sequential course (but not always)

• May result in neuropathologic changes, but functional > structural disturbance

Definition

McCrory, Paul et al. "Consensus Statement On Concussion In Sport—The 5th International Conference On Concussion In Sport Held In Berlin, October 2016".

British Journal of Sports Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.

Pathophysiology(wait don’t leave…)

Mechanism of injury

● Rotational

● Acceleration-deceleration

➔Neurometabolic cascade

Pathophysiology

Mechanism of injury

● Rotational

● Acceleration-deceleration

➔Neurometabolic cascade

Pathophysiology

LOSS OF CONSCIOUSNESS:

ONLY 10% OF CASES

Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D,

Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.

Diagnosis

➔History➔Physical ExaminationCan’t we just order a bunch of tests and skip the H&P?

Diagnosis

What Tools Do You Need?

➔Symptom Scale➔Something to assess:◆ Vestibular-ocular function

◆ Balance

◆ Cognitive function

What Tools Do You Need?

History

Description of the incident➔Do they remember what happened?

Symptom onset ➔ Immediate v delayed◆ If delayed, activity in the meantime

Any on-field documentation

History

Tool #1: The Symptom Scale

Graded checklist of symptoms➔ Used to monitor course & recoverySeveral iterations; ever-evolving➔ Post Concussion Symptom Scale➔ Graded Symptom Checklist➔ Rivermead Post Concussion Scale

Tool #1: Symptom Scale

Alla S, Sullivan SJ, Hale L, et al. Self-report scales/checklists for the measurement of

concussion symptoms: a systematic review. British Journal of Sports Medicine 2009;43:i3-i12.

Examination

● Balance difficulties/gait abnormalities

● Impaired coordination ➢ Finger-to-nose, Romberg, tandem gait

● Confusion

● Positive vestibular-ocular motor (VOMS) screen

Do Not Ignore the Cervical Spine Examination!

Examination

Red Flags

● Loss of consciousness

● Multiple episodes of vomiting

● Neck pain with motor dysfunction or radiculopathy

● Neurologic deficits (weakness, anisocoria, GCS

Workup

To scan or not to scan?

Imaging

Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of

PECARN, CATCH, and CHALICE Rules for Children with Minor Head Injury: A

prospective cohort study. Annals of emergency medicine. 2014;64(2):145-

152.e5. doi:10.1016/j.annemergmed.2014.01.030.

Brain Trauma Indicator

“FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults”

News Release from FDA.gov

February 14, 2018

Laboratory Investigation

https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm

Neurocognitive Assessment➔ ImPACT, C3 LogixVestibular-Ocular Function ➔ King-Devick, VOMSBalance➔ SWAY, BESS

Other Diagnostic Tools

Management

‘Relative’ rest➔Mushroom theory of strict restWhen can an athlete return to competition?

What exactly is ‘relative’ rest?

Management

Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest

May Not Improve Concussion Recovery Time. The Journal of head trauma

rehabilitation. 2016;31(4):233-241. doi:10.1097/HTR.0000000000000165.

Return to...

Management

MOST important part of recovery process

StagesStep 1: ‘Relative’ rest

Step 2: Modified school schedule

Step 3: Full day of school, no testing

Step 4: Full days, limited testing➔ Mastery Learning Materials

Step 5: Return to full academic load

Can start anywhere on the list, and advance or step back as tolerated

Return-To-Learn

Supporting a Student During Return-to-Learn

Be aware of symptom triggers➔Lights➔Noise➔Activity

Threshold?

Support During Return-to-Learn

Photophobia ➔Classrooms➔Sporting events➔Electronics

Support During Return-to-Learn

Phonophobia ➔Band/music class➔Loud classrooms➔Sporting events

Support During Return-to-Learn

Tinted lenses

● Red or orange: media/screens○“Night Mode”

● Gray: sunlight

Support During Return-to-Learn

Clark J, Hasselfeld K, Bigsby K, Divine J. Colored

Glasses to Mitigate Photophobia Symptoms

Posttraumatic Brain Injury. Journal of Athletic

Training, 2017; DOI: 10.4085/1062-6050-52.4.04

Encourage art & creativity➔Avoid inactivity (aka boredom)!

Return-To-Play

Indications

Contraindications

Return-To-Play

McCrory, Paul et al. "Consensus Statement On Concussion In

Sport—The 5th International Conference On Concussion In Sport Held In Berlin, October 2016". British Journal of Sports

Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.

Supervised progression of activity

● Both intensity and duration ● Should be sport-specific

Goal: safely return to pre-injury activity levels

Look for ANY symptom recurrence

ProtocolDay 1: Light aerobic conditioning

Day 2: Moderate aerobic conditioning

Day 3: Full aerobic conditioning, drills requiring

physical and mental dexterity

Day 4: Non-contact practice

Day 5: Resume normal activity

For extra liability protection: have a form letter sent to school with athlete

- Athlete signs- Parent signs

THEN you provide a letter of clearance

Return-To-Play

McCrory, Paul et al. "Consensus Statement On Concussion In

Sport—The 5th International Conference On Concussion In Sport Held In Berlin, October 2016". British Journal of Sports

Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.

Considerations for Retirement

Return-To-Play

Considerations for Retirement

Return-To-Play

Traumatic structural lesion, especially if craniotomy is required

Prolonged inability to complete RTL or RTP without symptoms returning

Psychiatric outcomes

How many concussions is too many?

Recovery gets ‘harder’ → increasing:○ Frequency of mTBI○ Time to symptomatic recovery○ Severity/number of symptoms

Ellis MJ, Mcdonald PJ, Cordingley D, Mansouri B, Essig M, Ritchie L.

Retirement-from-sport considerations following pediatric sports-related

concussion: case illustrations and institutional approach. Neurosurgical

Focus. 2016;40(4). doi:10.3171/2016.1.focus15600.

Alla S, Sullivan SJ, Hale L, et al. Self-report scales/checklists for the measurement of concussion symptoms: a systematic review.

British Journal of Sports Medicine 2009;43:i3-i12.

Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F. Sports- and Recreation-Related Concussions in US Youth. Pediatrics.

2016;138(1). doi:10.1542/peds.2015-4635.

Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. The

Journal of head trauma rehabilitation. 2016;31(4):233-241. doi:10.1097/HTR.0000000000000165.

Carney N, Ghajar J, Jagoda A et al. Concussion Guidelines Step 1. Neurosurgery. 2014;75:S3-S15. doi:10.1227/neu.0000000000000433.

Clark J, Hasselfeld K, Bigsby K, Divine J. Colored Glasses to Mitigate Photophobia Symptoms Posttraumatic Brain Injury. Journal of Athletic Training, 2017; DOI: 10.4085/1062-6050-52.4.04

Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D, Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.

Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE Rules for Children with Minor Head Injury: A prospective cohort study. Annals of emergency medicine. 2014;64(2):145-152.e5. doi:10.1016/j.annemergmed.2014.01.030.

References

http://bjsm.bmj.com/content/43/Suppl_1/i3.shorthttps://www.ncbi.nlm.nih.gov/pubmed/27325635https://www.ncbi.nlm.nih.gov/pubmed/26394292https://www.ncbi.nlm.nih.gov/pubmed/25006974https://www.ncbi.nlm.nih.gov/pubmed/28650685https://www.ncbi.nlm.nih.gov/books/NBK326721/https://www.ncbi.nlm.nih.gov/pubmed/24635987

Ellis MJ, Mcdonald PJ, Cordingley D, Mansouri B, Essig M, Ritchie L. Retirement-from-sport considerations following pediatric sports-related concussion: case illustrations and institutional approach. Neurosurgical Focus. 2016;40(4). doi:10.3171/2016.1.focus15600.

Press Announcements - FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. U S Food

and Drug Administration Home Page. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm.

Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. Journal of Athletic Training. 2001;36(3):228-235.

Giza CC, Choe MC, Barlow KM. Determining if Rest Is Best After Concussion. JAMA Neurology. May 2018.

doi:10.1001/jamaneurol.2018.0006.

Harrison EA. The First Concussion Crisis: Head Injury and Evidence in Early American Football. American Journal of Public Health. 2014;104(5):822-833. doi:10.2105/AJPH.2013.301840.

Howell DR, O’Brien MJ, Beasley MA, Mannix RC, Meehan WP. Initial somatic symptoms are associated with prolonged symptom duration following concussion in adolescents. Acta paediatrica (Oslo, Norway : 1992). 2016;105(9):e426-e432. doi:10.1111/apa.13486.

LaRoche AA, Nelson LD, Connelly PK, Walter KD, McCrea MA. Sport-Related Concussion Reporting and State Legislative Effects. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2016;26(1):33-39. doi:10.1097/JSM.0000000000000192.

Laskowitz D, Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.

References

http://thejns.org/doi/full/10.3171/2016.1.FOCUS15600https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htmhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC155411/https://jamanetwork.com/journals/jamaneurology/article-abstract/2673725?redirect=truehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987576/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5335869/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4609217/https://www.ncbi.nlm.nih.gov/books/NBK326725/

McCrory, Paul et al. "Consensus Statement On Concussion In Sport—The 5th International Conference On Concussion In Sport Held In Berlin, October 2016". British Journal of Sports Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.

McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004 Jan;14(1):13-7. PubMed PMID: 14712161.

Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American journal of sports medicine. 2014;42(10):2479-2486. doi:10.1177/0363546514543775.

Patel DR, Parachuri V, Shettigar A. Evaluation and management of sport-related concussions in adolescent athletes. Translational Pediatrics. 2017;6(3):121-128. doi:10.21037/tp.2017.03.09.

Prince C, Bruhns ME. Evaluation and Treatment of Mild Traumatic Brain Injury: The Role of Neuropsychology. Brain Sciences. 2017;7(8):105. doi:10.3390/brainsci7080105.

Thomas D, Apps J, Hoffmann R, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. PEDIATRICS. 2015;135(2):213-223. doi:10.1542/peds.2014-0966.

Yorke A, Smith L, Babcock M, Alsalaheen B. Validity and Reliability of the Vestibular/Ocular Motor Screening and AssociationsWith Common Concussion Screening Tools - Nov 11, 2016. Sage Journals. 2017. Available at: http://journals.sagepub.com/doi/full/10.1177/1941738116678411. Accessed February 2, 2017.

References

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699https://www.ncbi.nlm.nih.gov/pubmed/14712161https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209316/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5532189/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575625/http://pediatrics.aappublications.org/content/early/2015/01/01/peds.2014-0966http://journals.sagepub.com/doi/full/10.1177/1941738116678411.

Contact MeModernMedEd.com

Jordan@ModernMedEd.com

@ModernMedEd

To download references, handouts, and other bonus materials, please visit:

https://ModernMedEd.com/conference

Thank You

http://www.modernmeded.comhttps://modernmeded.com/conference