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Updates in Concussion Medicine For Healthcare Professionals

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Concussion in the pediatric athlete is fought with difficult decision trees, pressure from parents and coaches, and potential for serious harm and even death if mismanaged. Jordan G. Roberts, PA-C discusses an overview of what's new in this rapidly evolving field at the AAPA national meeting in May 2018.

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Updates in Concussion Medicine For Healthcare Professionals

  1. 1. Pearls & Pitfalls in Sports-Related Concussion Jordan G. Roberts, PA-C @ModernMedEd AAPA National Conference 2018 New Orleans
  2. 2. Disclosures None
  3. 3. 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
  4. 4. 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
  5. 5. 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 Associations With 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
  6. 6. 1. Discuss the initial evaluation of the student athlete with a suspected sports-related concussion (SRC) in the primary care setting Objectives 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
  7. 7. Definition
  8. 8. 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.
  9. 9. Pathophysiology (wait don’t leave…)
  10. 10. Mechanism of injury ● Rotational ● Acceleration-deceleration ➔Neurometabolic cascade Pathophysiology Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D, Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.
  11. 11. 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.
  12. 12. Diagnosis
  13. 13. ➔History ➔Physical Examination Can’t we just order a bunch of tests and skip the H&P? Diagnosis
  14. 14. What Tools Do You Need?
  15. 15. ➔Symptom Scale ➔Something to assess: ◆ Vestibular-ocular function ◆ Balance ◆ Cognitive function What Tools Do You Need?
  16. 16. History
  17. 17. 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
  18. 18. Tool #1: The Symptom Scale
  19. 19. Graded checklist of symptoms ➔ Used to monitor course & recovery Several 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.
  20. 20. Concussion Symptom Scale Available for download at ModernMedEd.com/conference
  21. 21. Examination
  22. 22. ● 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
  23. 23. Tool #2: The VOMS
  24. 24. A Brief Vestibular/Ocular Motor Screening (VOMS) Available for download at ModernMedEd.com/conference 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.
  25. 25. Red Flags
  26. 26. ● Loss of consciousness ● Multiple episodes of vomiting ● Neck pain with motor dysfunction or radiculopathy ● Neurologic deficits (weakness, anisocoria, GCS<13) Red Flags
  27. 27. Workup
  28. 28. To scan or not to scan? CT or MRI? With or Without Contrast? 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.
  29. 29. 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
  30. 30. Neurocognitive Assessment ➔ ImPACT, C3 Logix Vestibular-Ocular Function ➔ King-Devick, VOMS Balance ➔ SWAY, BESS Other Diagnostic Tools
  31. 31. Management
  32. 32. ‘Relative’ rest ➔Mushroom theory of strict rest When 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.
  33. 33. Return to... Management
  34. 34. MOST important part of recovery process Stages Step 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
  35. 35. Supporting a Student During Return-to-Learn
  36. 36. Be aware of symptom triggers ➔Lights ➔Noise ➔Activity Threshold? Support During Return-to-Learn
  37. 37. Photophobia ➔Classrooms ➔Sporting events ➔Electronics Support During Return-to-Learn
  38. 38. Phonophobia ➔Band/music class ➔Loud classrooms ➔Sporting events Support During Return-to-Learn
  39. 39. Tinted lenses ●Red or orange: media/screens 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
  40. 40. 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
  41. 41. Encourage art & creativity ➔Avoid inactivity (aka boredom)! Support During Return-to-Learn
  42. 42. Return-To-Play
  43. 43. 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.
  44. 44. 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 Protocol Day 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.
  45. 45. 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.
  46. 46. 1. Concussions are unique, complex brain injuries 4 Take-Home Lessons For Practice 2. The presentation & course can be extremely variable 3. Sorry, you can’t rely on lab tests or imaging to diagnose 4. Focus on the Return-to-Learn, even if the athlete is focused on the Return-to-Play
  47. 47. ModernMedEd.com Jordan@ModernMedEd.com @ModernMedEd To download references, handouts, and other bonus materials, visit: https://ModernMedEd.com/conference Thank You

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