Evaluation and Management of

Concussion

Evaluation and Management of

Concussion

C. S. Nasin, MDTeam Physician

University of Rhode Island

EvaluationEvaluation

“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?

“It’s just a ding…right?”“It’s just a ding…right?”

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

CT Head AlgorithmsCT Head AlgorithmsSensitivity 100%Specificity 51%

Sensitivity 100%Specificity 13%

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

Neuropsychiatric TestingNeuropsychiatric Testing

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”

TreatmentTreatment

REST!!

Not only limited to contact sport activity

•No heavy exertion

•No resistance training

Physical Rest

Cognitive RestCognitive Rest

A major challenge in a college setting!

•Education of the college community

•Communication with Disability Services and the Dean’s office.

Pharmacologic Treatment

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