6. TEXT
OBJECTIVES
▸ Case review
▸ Consensus Summaries
▸ Evidence-based updates
▸ Concussion phenotypes (sub-typing)
▸ Updates in targeted subtype management
7. CASE 1
▸13 y/o healthy boy with elbow to head
▸No LOC, some HA and dizziness
▸Assessed and had not ‘red flags’
▸Continues with regular school activities
▸Reports ongoing worsening HA and new Migranes
8. CASE 1— AT 4 WEEKS
▸Sees neurologist and starts on Topimax
▸Normal MRI brain
▸Symptoms continue to progress
▸No longer tolerating sports or exercise
▸Struggling with academics
▸Depressed, hopeless
9. CASE 1 — AT 3 MONTHS
▸Seen at SPARCC at 3 months
▸Ongoing severe:
▸Cognitive deficits
▸Exercise intolerance
▸Cervical dysfunction and migraines
WHAT NOW??
10. :(
MYTHS
▸“Its just a concussion, you’ll be ok in a few days”
▸“No LOC or big hit == no concern”
▸“Normal MRI/CT means you’re good”
▸“Concussions don’t last more than 2 weeks”
▸“Its just your migraines”
▸“Its all in your head, you are just depressed”
11. TEXT
BACKGROUND
▸ Estimated 2-4 million concussions per year
▸ 75-90% of concussions in sports DO NOT
involve loss of consciousness
▸ Females have higher rate than males in same
sports
13. CONCUSSION
Trauma to the brain
Impairment in normal brain function because
due to chemical alteration
Disturbance in the normal pathways in the
neurons
Increased symptoms with daily activities
14.
15. CONCUSSION
TIMELINE
▸ Symptoms resolve in 10-14d (adults)
▸ Longer with adolescents (2-3 wks)
▸ ~30% have prolonged symptoms (PPCS)
▸ > 4 wks should prompt referral
CUMULATIVE EFFECT OF
MULTIPLE CONCUSSIONS?▸ Prolonged recovery
▸ Lower Concussion threshold
18. EMERGENT CT SCAN?
RED FLAGS
▸ Any neurological deficits
▸ History of prolonged LOC (>30 sec)
▸ Deterioration of symptoms
▸ Severe headache (9-10/10)
▸ Persistent Confusion or AMS
▸ Seizure
▸ Suspicion of Skull Fracture
19.
20. TEXT
CONSENSUS SUMMARIES
▸ Avoid routine CTs
Multidisciplinary Functional Testing
▸ Validated tools
Scat5/ImPACT/VOMS
▸ PPCS up to 30%
Refer after 4 weeks
ID PPCS Risk Factors
▸ Avoid absolute rest > 2-3d
Customized RTL
Active Rehab
▸ Rehab > Meds !
Exertional Rehab
Vestibulo-ocular Rehab
Cervical Rehab
21. TEXT
CONSENSUS ON
MANAGEMENT
▸ Research supports multi-disciplinary therapeutic approach and
Early Intervention
Return to learn and cognitive support
Return to play protocol
Vestibulocular Rebab
Cervical Rehab
Graded Exertional Rehab
23. WHAT’S NEW
MODERN EVIDENCE-
BASED CONCEPTS▸ Prolonged symptoms
Variety of PPCS stages
Predictors of PPCS
▸ Earlier Intervention
Better outcomes / time to recovery
▸ Evidence for ongoing injury
Structure vs Function (VOMS / Cog Test)
Macrostructure vs Microstructure
▸ Concussion Sub-typing!
26. TEXT
PREDICTORS OF MORBIDITY
▸ Early Risk factors for prolonged symptoms
Severity of initial symptoms
Migrane type HA (photo/phono)
Dizziness, VOMS +
Psychiatric/Sleep co-morbidity
Delayed Care
Severe Vision Deficits!
27. TEXT
EARLY INTERVENTION
▸Removal from play
▸Immediate frontline Care
▸ASAP Concussion care (SCAT5, VOMS, Cog)
▸Early Rehabilitative Management
Lower Risk of PPCS
Decreased Symptom Burden
Faster Recovery
29. TEXT
EVIDENCE OF PERSISTENT INJURY
▸ Most commonly persistent FUNCTIONAL impairments
Cognitive (ImPACT, NP Testing)
Vestibulo-ocular (Balance, Eye testing)
Neurophysiology (qEEG/Evoked potentials)
Neurometabolic
▸ Micro-structural injury to white matter on DTI
30.
31.
32. TEXT
CO-MORBIDITY VS INJURY
▸There is often overlap
▸Co-morbidities create predispositions to injury and longer recoveries
▸Baseline weakness are more prone to get weaker (compare symptoms to
baseline)
▸Objective testing can help determine persistent injury vs baseline co-morbidity
41. TEXT
SUBTYPE SUMMARIES
▸Migraine and mood most common (VOM)
▸Good inter-rater reliability agreement across profiles….
▸Not as good as ranking them
▸Future of concussion is targeted management for subtypes (not “protocol” for all)
49. References:
1. 5th Consensus Statement on Concussion in Sport. BJSM
April 2017.
2. Mucha, AM etal. A Brief Vestibular/Ocular Motor Screening
(VOMS) Assessmentto Evaluate Concussions: Preliminary
Findings. Investigation performed at the University of
Pittsburgh, Pittsburgh, Pennsylvania, USA. 2014.
3. Pediatric Sport-Related Concussion: A Review of the Clinical
Management of an Oft-Neglected Population. Kirkwood MW,
Yeates KO, Wilson PE. Pediatrics. April 2006; 1359-1371.
