Understanding Brain Concussion: Facts Assessment and Intervention


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  • It can seem that this is a new problem, or one that no one paid attention to until recent things have turned it into a health care epidemic. Not the case. We have been dealing with concussion for a long time. Recent trends have highlighted
  • Some estimate that there are 3.8 million concussions each year – very difficult to clarify how many because so many never are seen in emergency departments and/or are not reported to anyone. So, does that mean that most are trivial, quick to recover, and something we should not worry about? Too simplistic to think of it that way.
  • There are at least 5-6 definitions of concussion from well-respected groups, which overlap substantially but not entirely. It may seem like it should be easy to define this, but unlike defining more severe levels of TBI, a definition of concussion or MTBI is somewhat elusive.
  • Notice that this definition is applied if any of the four features are shown
  • These points apply to MTBI – not moderate and severe TBI.
  • Return to a slide from earlier – showing many of the symptoms associated with concussion. One part of clinical challenge is that common symptoms associated with concussion may be found in other disorders/conditions as well.
  • Significant base rate of symptoms in other conditions that may co-occur with MTBI or in some cases there may be misattribution of symptoms to possible MTBI
  • Working very closely with Children’s National Medical Center
  • Understanding Brain Concussion: Facts Assessment and Intervention

    1. 1. Understanding Brain Concussion: Facts, Assessment, and Intervention <ul><li>William Garmoe, Ph.D., ABPP-CN </li></ul><ul><li>National Rehabilitation Hospital </li></ul><ul><li>Investigator, NRH Neurosciences Research Center </li></ul><ul><li>Assistant Professor, Clinical Neurology, </li></ul><ul><li>Georgetown University Medical School </li></ul><ul><li>October 2011 </li></ul>
    2. 2. Conflicts of Interest <ul><li>No financial or other conflicts of interest related to this presentation </li></ul>
    3. 3. Objectives <ul><li>Review epidemiology and definitions of Concussion </li></ul><ul><li>Review appropriate assessment techniques </li></ul><ul><li>Review guidelines for return to work, school, and athletic play </li></ul><ul><li>Describe the NRH-Medstar Concussion Program </li></ul>
    4. 4. Case Example <ul><li>16 year-old female presented six days following injury from head-to-head collision with opponent while trying to head the ball. </li></ul><ul><ul><li>No loss of consciousness </li></ul></ul><ul><ul><li>No initial gross confusion </li></ul></ul><ul><ul><li>On sideline trainer concluded no concussion </li></ul></ul><ul><ul><li>During halftime started to feel dizzy and slowed </li></ul></ul><ul><ul><li>Concealed symptoms in order to be allowed to play second half </li></ul></ul><ul><ul><li>That evening, dizziness, nausea, bad headache, feeling slowed down </li></ul></ul><ul><ul><li>At time of presentation, still having headaches, feeling a bit less focused, exhausted when tries to study for more than 30 minutes </li></ul></ul><ul><ul><li>Described as mildly more irritable by parents </li></ul></ul>
    5. 5. Case Example <ul><li>34 yea-old male presented two weeks after bicycle accident. Fell off bike when lost traction on riding path. </li></ul><ul><ul><li>Estimated 1-2 minute loss of consciousness </li></ul></ul><ul><ul><li>Seen in emergency department </li></ul></ul><ul><ul><ul><li>Negative neurologic exam apart from mild disorientation and slowed thinking </li></ul></ul></ul><ul><ul><ul><li>Head CT showed no positive findings </li></ul></ul></ul><ul><ul><ul><li>Neck pain and headaches treated with medications </li></ul></ul></ul><ul><ul><ul><li>Told to take 2-3 days off and will be fine </li></ul></ul></ul><ul><ul><li>At time of evaluation was complaining of: </li></ul></ul><ul><ul><ul><li>Forgetfulness and reduced concentration </li></ul></ul></ul><ul><ul><ul><li>Irritability in loud/busy settings </li></ul></ul></ul><ul><ul><ul><li>Photophobia </li></ul></ul></ul><ul><ul><ul><li>Headaches and reduced stamina </li></ul></ul></ul><ul><ul><ul><li>Balance problems </li></ul></ul></ul>
    6. 6. Case Example <ul><li>48 year-old individual presents two years following un-witnessed fall at work. Self-report included: </li></ul><ul><ul><li>Estimated loss of consciousness of 15 minutes </li></ul></ul><ul><ul><li>Immediate onset of poor memory, balance problems, and marked pain in head, neck, and radiating to arms, all of which have continued based on self-report </li></ul></ul><ul><ul><li>Has not returned to work </li></ul></ul><ul><ul><li>Still reporting marked cognitive impairments. Brought reports from websites and treatment professionals diagnosing marked brain damage and recommending rehabilitation and possibly disability application </li></ul></ul><ul><ul><li>Feeling depressed, anxious, and angry </li></ul></ul><ul><ul><li>Has seen multiple medical providers </li></ul></ul><ul><ul><li>Feels poorly understood and mistreated by employer and insurance companies. </li></ul></ul>
    7. 7. Concussion is Not New
    8. 8. Concussion in the Public Square <ul><li>Factors Influencing Our View of Concussion </li></ul><ul><ul><li>Military Conflict </li></ul></ul><ul><ul><li>Concerns in Youth Sports </li></ul></ul><ul><ul><li>Emergence of Concerns About Long-Term Effects in Professional Athletes </li></ul></ul><ul><ul><ul><li>CTE </li></ul></ul></ul><ul><ul><li>Increased Focus By Health Care Providers </li></ul></ul>
    9. 9. Concussion in the Public Square <ul><li>Emerging Trends in Concussion </li></ul><ul><ul><li>Legislation governing management of sports concussion </li></ul></ul><ul><ul><li>Increasing numbers of concussion programs </li></ul></ul><ul><ul><li>Pre-screening of youth, amateur, and professional athletes </li></ul></ul><ul><ul><li>Protocols governing return to play </li></ul></ul><ul><ul><li>Enormous increase in research dollars </li></ul></ul><ul><ul><li>Great misunderstanding about concussion in internet, media accounts, etc. </li></ul></ul>
    10. 10. <ul><li>www.youtube.com/watch?v=KqQwFmW6Sac </li></ul>
    11. 11. Epidemiology of Traumatic Brain Injury (TBI) Centers for Disease Control (CDC) www.cdc.gov <ul><li>In the United States each year: </li></ul><ul><ul><li>1.7 million individuals sustain a TBI </li></ul></ul><ul><ul><li>275,000 need hospitalization </li></ul></ul><ul><ul><li>52,000 of these injuries are fatal </li></ul></ul><ul><ul><li>80% (approximately 1.3 million) are MTBI/Concussion </li></ul></ul><ul><li>Leading Causes of TBI </li></ul><ul><ul><li>Falls (35.2%) </li></ul></ul><ul><ul><li>Motor Vehicle Accidents (16.5%) </li></ul></ul><ul><ul><li>Other types of blow to head (19%) </li></ul></ul><ul><ul><li>Assaults (10%) </li></ul></ul><ul><ul><li>Unknown/Other (21%) </li></ul></ul>
    12. 12. TBI Causes: From CDC - NCIPC
    13. 13. What is a Concussion? <ul><li>Sources of Definitions/Criteria </li></ul><ul><ul><li>CDC </li></ul></ul><ul><ul><li>ACRM </li></ul></ul><ul><ul><li>WHO </li></ul></ul><ul><ul><li>DVBIC </li></ul></ul><ul><ul><li>Vienna and Prague Statements (CSIG) </li></ul></ul><ul><ul><li>AAN </li></ul></ul>
    14. 14. ACRM - BSIG <ul><li>MTBI involves “a traumatically induced physiological disruption of brain function, manifested by at least one of the following” </li></ul><ul><ul><li>Any period of loss of consciousness (LOC) </li></ul></ul><ul><ul><li>Any amnesia for events immediately prior to or following the accident/event </li></ul></ul><ul><ul><li>Any alteration in mental status at time of the accident/event (e.g., dazed, confused, etc.) </li></ul></ul><ul><ul><li>Focal neurologic signs may or may not be present </li></ul></ul><ul><li>LOC less than 30 minutes </li></ul><ul><li>GCS 13-15 within 30 minutes </li></ul><ul><li>PTA less than 24 hours </li></ul>
    15. 15. CDC Mild TBI Work Group Definitions Subgroup (2003) <ul><li>Occurrence of injury to head resulting from blunt trauma or acceleration/deceleration (1 or more of following): </li></ul><ul><ul><li>Observed or self-reported transient confusion, disorientation, or impaired consciousness. </li></ul></ul><ul><ul><li>Observed or self-reported dysfunction of memory around time of injury. </li></ul></ul><ul><ul><li>Observed signs of neurological/neuropsychological dysfunction. </li></ul></ul><ul><li>LOC < 30 min. </li></ul><ul><li>PTA < 24 hrs. </li></ul><ul><li>No penetrating craniocerebral injury. </li></ul>
    16. 16. DVBIC: Acute Management of Mild TBI in Military Operational Setting <ul><li>“ Mild TBI in military operational settings is defined as an injury to the brain resulting from an external force and/or acceleration/deceleration mechanism from an event such as a blast, fall, direct impact, or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms . . . “ </li></ul><ul><li>(from DVBIC 3 rd Annual TBI Military Training Conference </li></ul><ul><li>and DVBIC Clinical Practice Guidelines) </li></ul>
    17. 17. MTBI/Concussion Severity Grading <ul><li>American Academy of Neurology (AAN) (1997) </li></ul><ul><li>Grade 1: </li></ul><ul><ul><li>Transient confusion </li></ul></ul><ul><ul><li>No LOC </li></ul></ul><ul><ul><li>Symptoms resolve within 15 minutes </li></ul></ul><ul><li>Grade 2: </li></ul><ul><ul><li>Transient confusion </li></ul></ul><ul><ul><li>No LOC </li></ul></ul><ul><ul><li>Symptoms last longer than 15 minutes </li></ul></ul><ul><li>Grade 3: </li></ul><ul><ul><li>Any LOC present </li></ul></ul><ul><li>Prague Statement (2004) </li></ul><ul><li>Simple Concussion: Concussion that resolves without complication over 7-10 days </li></ul><ul><li>Complex Concussion: Persistent symptoms, specific complications, LOC of >1 minute, or prolonged cognitive impairments. </li></ul><ul><li>Multiple/Repeat concussions classified as complex </li></ul>
    18. 18. MTBI/Concussion and LOC <ul><li>Historically, MTBI was defined in terms of a short period of loss of Consciousness </li></ul><ul><li>Current diagnostic approach: </li></ul><ul><ul><li>LOC is not a necessary element of concussion </li></ul></ul><ul><li>In large percentage of concussions, possibly the majority, there is no LOC . </li></ul><ul><li>Retrograde and anterograde amnesia are also typically brief </li></ul>
    19. 19. MTBI/Concussion Severity Grading <ul><li>Williams et al. (1990) </li></ul><ul><li>Distinguished ‘Mild’ from ‘Complicated-Mild’ TBI on basis of presence of positive findings on neuro-imaging. </li></ul><ul><li>Patients with MTBI presentation but also positive neuro-imaging findings (‘Complicated-Mild’) have outcomes more similar to moderate TBI. </li></ul>
    20. 20. Symptoms Following Concussion <ul><li>Cognitive </li></ul><ul><ul><li>Dazed </li></ul></ul><ul><ul><li>Poor Concentration </li></ul></ul><ul><ul><li>Impaired Memory </li></ul></ul><ul><ul><li>Confusion/Disorientation </li></ul></ul><ul><ul><li>Slowed Thinking </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Changes in mood </li></ul></ul></ul><ul><ul><ul><li>Anxious </li></ul></ul></ul><ul><li>Somatic </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Dizziness/imbalance </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Photo/phonophobia </li></ul></ul><ul><ul><li>Other visual problems </li></ul></ul><ul><ul><li>Sleep Related </li></ul></ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul><ul><ul><ul><li>Sleep dysfunction </li></ul></ul></ul>
    21. 21. Loss of Consciousness (LOC) and Post-Traumatic Amnesia (PTA) <ul><li>Loss of Consciousness (LOC) of <1 minute not strongly related to outcome </li></ul><ul><li>LOC of >1 minute – not clear how closely related to outocme </li></ul><ul><li>Post-Traumatic Amnesia (PTA) duration quickly loses utility in predicting outcome </li></ul><ul><li>Consideration of mental status changes at time of injury may be more salient </li></ul>
    22. 22. Physical/Mechanical Force Variable <ul><li>Many studies are examining minimum biomechanical threshold that will cause MTBI; rotational versus translational force may mediate this threshold </li></ul><ul><li>MTBI can occur in the absence of LOC and a direct blow to the head </li></ul><ul><li>What about symptoms in absence of LOC or altered mental status at time of injury? </li></ul>
    23. 23. Pathophysiology of MTBI <ul><li>MTBI initiates a progressive neuro-metabolic cascade that involves ionic shifts, altered brain metabolism, and disrupted neuronal connectivity and neurotransmission </li></ul><ul><li>The reversal of this cascade likely takes days to weeks following onset of injury </li></ul><ul><li>Time course of recovery from the neuro-metabolic cascade seems to correlate with natural history of symptoms and recovery, though there is some disagreement about this </li></ul><ul><li>Newer neuro-imaging methods appear to be showing greater sensitivity to identifying damage, but clinical utility of these approaches is still being established </li></ul>
    24. 24. Neuro-metabolic Cascade of MTBI <ul><li>MTBI initiates a neuro-metabolic cascade that involves ionic shifts, altered brain metabolism, and disrupted neuronal connectivity and neurotransmission </li></ul>
    25. 25. Symptoms Following Concussion: How Specific? <ul><li>Cognitive </li></ul><ul><ul><li>Dazed </li></ul></ul><ul><ul><li>Poor Concentration </li></ul></ul><ul><ul><li>Impaired Memory </li></ul></ul><ul><ul><li>Confusion/Disorientation </li></ul></ul><ul><ul><li>Slowed Thinking </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Changes in mood </li></ul></ul></ul><ul><ul><ul><li>Anxious </li></ul></ul></ul><ul><li>Somatic </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Dizziness/imbalance </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Photo/phonophobia </li></ul></ul><ul><ul><li>Other visual problems </li></ul></ul><ul><ul><li>Sleep Related </li></ul></ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul><ul><ul><ul><li>Sleep dysfunction </li></ul></ul></ul>
    26. 26. Symptoms Following Concussion: How Specific? <ul><li>DSM-IV Symptoms of Depression Include </li></ul><ul><ul><li>Sleep Disturbance </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Motor Slowing </li></ul></ul><ul><ul><li>Poor Concentration </li></ul></ul><ul><ul><li>Slowed Thinking </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><li>Iverson & McCracken (1997) </li></ul><ul><li>Individuals with chronic pain and no TBI </li></ul><ul><ul><li>Majority of patients reported disturbed sleep, fatigue, and irritability </li></ul></ul><ul><ul><li>29% forgetfulness </li></ul></ul><ul><ul><li>18% difficulty maintaining attention </li></ul></ul><ul><ul><li>16.5% difficulty with concentration or thinking </li></ul></ul><ul><ul><li>80.6% endorsed 3+ symptoms from Cat C of DSM-IV </li></ul></ul>
    27. 27. Recovery and Treatment
    28. 28. Natural Course of Recovery <ul><li>“ . . . a single, uncomplicated MTBI is a transient neurologic event followed by relatively rapid and spontaneous recovery . . .” </li></ul><ul><ul><ul><li>McCrea, 2008 </li></ul></ul></ul><ul><li>By far the prototypic recovery pattern is rapid or gradual symptom resolution over a period of days or weeks </li></ul><ul><li>By 3 months post-injury, neuropsychological measures typically show no residual impairment </li></ul><ul><li>Most individuals return to normal social, occupational, and recreational functioning within several weeks </li></ul>
    29. 29. Natural Course of Recovery <ul><li>Clinical lore suggests that 15% remain symptomatic over longer period, sometimes chronically </li></ul><ul><li>Some suggest that the 15% figure is an over-estimation due to misinterpretation of data – that the actual percentage is much lower </li></ul><ul><li>Following a single, uncomplicated concussion, persistent symptoms and poor functional outcome often associated with “non-injury” related variables </li></ul>
    30. 30. Complicated Course of Recovery <ul><li>Misdiagnosed injury: TBI more severe than initially identified </li></ul><ul><li>Collateral injuries (musculoskeletal, vestibular) with symptoms that mimic or overlap MTBI </li></ul><ul><li>Comorbidities such as depression, anxiety, substance abuse </li></ul><ul><li>Recurrent MTBI </li></ul><ul><li>Second-Impact Syndrome </li></ul><ul><li>Post-Concussive Syndrome </li></ul>
    31. 31. Recurrent MTBI <ul><li>Recurrent MTBI appears to be associated with more significant post-injury deficits, prolonged recovery time, and higher risk for lasting neurologic and psychiatric disturbance </li></ul><ul><ul><li>Some question whether this applies to repeat concussion following fully resolved prior event </li></ul></ul><ul><li>Increases risk for subsequent concussion </li></ul><ul><li>Not all studies show an added effect of repeat MTBI </li></ul><ul><li>Current research examining potential long-term effects of repeat concussion </li></ul><ul><ul><li>CTE </li></ul></ul><ul><ul><li>Possible higher risk for other dementias </li></ul></ul>
    32. 33. Post-Concussion Syndrome (PCS) <ul><li>Good Reasons Not to Use PCS </li></ul><ul><ul><li>Significant differences in criteria between ICD-10 and DSM-IV </li></ul></ul><ul><ul><li>Used in variable ways </li></ul></ul><ul><ul><ul><li>DSM-IV and ICD-10 refer to persistent symptoms </li></ul></ul></ul><ul><ul><ul><li>Emergency departments may use the label in discharge instructions following concussion </li></ul></ul></ul><ul><ul><li>Nonspecificity of symptoms </li></ul></ul><ul><ul><ul><li>Symptom pattern can apply to many conditions </li></ul></ul></ul>
    33. 34. ICD-10 and DSM-IV Criteria <ul><li>DSM-IV Research Criteria </li></ul><ul><li>History of head trauma with significant cerebral concussion </li></ul><ul><li>NP evidence of attention or memory problems </li></ul><ul><li>3+ symptoms persisting past 3 months </li></ul><ul><li>Symptoms follow head injury or worsen after head injury </li></ul><ul><li>Significant disturbance in social/occupational functioning or decline from previous levels </li></ul><ul><li>Not accounted for by other mental disorder </li></ul><ul><li>ICD-10 (310.2) </li></ul><ul><li>History of head trauma with LOC precedes symptoms by 4 weeks </li></ul><ul><li>Symptoms in 3+ categories </li></ul><ul><ul><li>Headache, dizziness, … </li></ul></ul><ul><ul><li>Irritability, depression … </li></ul></ul><ul><ul><li>Concentration, memory … without NP evidence </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul><ul><ul><li>Reduced alcohol tolerance </li></ul></ul><ul><ul><li>Preoccupation with above Symptoms </li></ul></ul>
    34. 35. Nonspecificity of PCS Symptoms
    35. 36. Supporting Optimal Recovery from MTBI
    36. 37. Concussion: Immediate Medical Response <ul><li>Medical care should be sought immediately after a concussion: </li></ul><ul><li>The person usually should be taken to an emergency room or urgent care center </li></ul><ul><li>The medical team will do an evaluation and may get a CT scan of the brain to be sure the injury is not worse than a concussion </li></ul><ul><li>Most people with concussion do not need to stay in the hospital </li></ul><ul><li>The medical team will treat symptoms, possibly prescribe pain medication, and refer the person to a physician or a concussion treatment center </li></ul><ul><li>During athletic events, the person may be evaluated by a certified athletic trainer or coach, who will help determine what should be done next </li></ul><ul><li>If for any reason the person does not go to a hospital or urgent care center, he/she should call his/her physician as soon as possible </li></ul>
    37. 38. Monitoring Early Recovery <ul><li>In the days following concussion, if any of the following occur, a medical emergency may be happening that requires immediate attention: </li></ul><ul><ul><li>Onset of a severe headache that is the worst pain imaginable </li></ul></ul><ul><ul><li>Rapidly falling into a deep sleep from which the person cannot be wakened </li></ul></ul><ul><ul><li>Sudden problems with falling </li></ul></ul><ul><ul><li>New numbness or weakness on one side of the body </li></ul></ul><ul><ul><li>Onset of severe confusion much worse than following the concussion </li></ul></ul><ul><ul><li>Severe vomiting </li></ul></ul><ul><ul><li>Seizures </li></ul></ul>
    38. 39. Support Natural Course of Recovery <ul><li>The best treatment for the first several days or weeks following concussion is to rest the brain and body: </li></ul><ul><ul><li>For the first few days it is best to minimize the amount of time reading, watching television, spending time on-line, texting, etc. It is not good to do absolutely nothing, but rather keep activity very low. </li></ul></ul><ul><ul><li>Keep mental, physical, and emotional stress low </li></ul></ul><ul><ul><li>Take time off work and school </li></ul></ul><ul><ul><li>Take time off from exercise/physical exertion </li></ul></ul><ul><ul><li>Sleep as much as necessary </li></ul></ul><ul><ul><li>Take in adequate liquids and food </li></ul></ul><ul><ul><li>Avoid all alcohol </li></ul></ul><ul><ul><li>Remind yourself that you will get better with time </li></ul></ul>
    39. 40. Support Natural Course of Recovery <ul><li>Gradual return to activities: </li></ul><ul><ul><li>Start off slowly returning to mental activity, physical activity, work, and sports/exercise </li></ul></ul><ul><ul><li>If symptoms get worse when activity increases, it is a sign to back off and go more slowly </li></ul></ul><ul><ul><li>Take frequent breaks as you increase your activity level. Take breaks even if you are feeling good, because this will help prevent symptoms from coming back </li></ul></ul><ul><ul><li>Students/Athletes: Follow ACE Guidelines </li></ul></ul>
    40. 41. Support Natural Course of Recovery <ul><li>Factors that may slow down or interfere with recovery can include: </li></ul><ul><ul><li>Pre-existing medical conditions such as headaches, tinnitus (constant ringing in the ear), chronic pain, ADD/ADHD, or other neurologic conditions </li></ul></ul><ul><ul><li>A prior history of concussions </li></ul></ul><ul><ul><li>Other physical injuries from the event that cause lasting pain </li></ul></ul><ul><ul><li>Pre-existing psychological conditions such as depression, anxiety, PTSD, alcohol or other drug abuse </li></ul></ul><ul><ul><li>A strong sense of emotional trauma about the event that caused the concussion that does not go away </li></ul></ul><ul><ul><li>Ongoing legal or insurance issues related to the concussion </li></ul></ul>
    41. 42. <ul><li>How Long Does Recovery Take? </li></ul><ul><ul><li>. . . As Long As It Takes </li></ul></ul><ul><ul><li>(taken from E. Diebert, MD) </li></ul></ul>
    42. 43. Medstar-NRH Concussion Program
    43. 44. <ul><li>  </li></ul><ul><li>Recovering from Brain Concussion: </li></ul><ul><li>Information and Practical Suggestions </li></ul><ul><li>  </li></ul><ul><li>National Rehabilitation Hospital Concussion Clinic </li></ul><ul><li>And </li></ul><ul><li>Medstar Sports Health </li></ul>
    44. 45. Children’s National Medical Center (CNMC) Washington, DC
    45. 46. Rationale for Concussion Program <ul><li>Concussion a significant public health issue </li></ul><ul><li>Concussion is often under-recognized and under-appreciated </li></ul><ul><li>Return to work, school, athletics prematurely can exacerbate symptoms </li></ul><ul><li>In very rare circumstances, premature return to athletics may result in SIP </li></ul><ul><li>Early intervention can lead to better outcome </li></ul><ul><li>Few athletes turn pro, but all turn adult </li></ul><ul><li>Inoculate against PCS </li></ul><ul><li>Legislation increasingly mandates expert evaluation and clearance following concussion </li></ul>
    46. 47. Education and Baseline Assessment <ul><li>Medstar and Children’s National Medical Center efforts: </li></ul><ul><ul><li>public education about concussion to schools, athletic clubs (professional, amateur, and recreational) </li></ul></ul><ul><ul><li>Baseline screening for athletic teams using ImPACT </li></ul></ul><ul><ul><li>Training to Athletic Trainers and Coaches </li></ul></ul><ul><ul><li>Research to further understanding of MTBI </li></ul></ul><ul><ul><li>Advocacy on public policy matters </li></ul></ul>
    47. 48. Concussion Management Protocol <ul><li>Referrals </li></ul><ul><ul><li>Emergency departments </li></ul></ul><ul><ul><li>Primary care physicians </li></ul></ul><ul><ul><li>Self-referrals </li></ul></ul><ul><ul><li>Coaches and trainers </li></ul></ul><ul><ul><li>Case Managers/Care Coordinators </li></ul></ul><ul><ul><li>Occupational Health Clinics/Programs </li></ul></ul>
    48. 49. NRH Concussion Management Protocol <ul><li>Referrals scheduled to be seen within seven days </li></ul><ul><li>Initial Assessment: </li></ul><ul><ul><li>Brain Injury Physician Evaluation </li></ul></ul><ul><ul><ul><li>Neurologic exam </li></ul></ul></ul><ul><ul><ul><li>Symptom review </li></ul></ul></ul><ul><ul><ul><li>Balance assessment using the Balance Error Scoring System (BESS) </li></ul></ul></ul><ul><ul><li>Neuropsychology Evaluation </li></ul></ul><ul><ul><ul><li>Detailed clinical interview </li></ul></ul></ul><ul><ul><ul><li>Neuropsychological Screening – depending on referral </li></ul></ul></ul><ul><ul><ul><li>ImPACT – depending on type of referral </li></ul></ul></ul>
    49. 50. NRH Concussion Management Protocol <ul><li>Initial Interventions </li></ul><ul><ul><li>Education about concussion </li></ul></ul><ul><ul><ul><li>Provide in-person feedback and information </li></ul></ul></ul><ul><ul><ul><li>NRH Concussion Booklet, ACE, SCORE, etc. </li></ul></ul></ul><ul><ul><li>Recommendations for return to school, athletics, work, etc. </li></ul></ul><ul><ul><li>Treatment of symptoms on as-needed basis </li></ul></ul><ul><ul><li>Schedule follow-up depending on symptom presentation </li></ul></ul><ul><ul><ul><li>Rapid recovering patients – may not need follow-up appointment </li></ul></ul></ul><ul><ul><ul><li>Slow-recovering or unusual symptoms – follow-up appointment scheduled </li></ul></ul></ul>
    50. 51. NRH Concussion Management Protocol <ul><li>Guiding Principles of Early Treatment: </li></ul><ul><ul><li>Lots of rest </li></ul></ul><ul><ul><li>Gradual return to daily activities </li></ul></ul><ul><ul><li>Activities that provoke active symptoms, back off </li></ul></ul><ul><ul><li>Treat symptoms on a prn basis </li></ul></ul><ul><ul><li>Create a positive expectation for recovery </li></ul></ul>
    51. 52. NRH Concussion Management Protocol <ul><li>Return to Play Following Sports Concussion </li></ul><ul><ul><li>Legislation in DC, Maryland, Virginia, many other states mandate formal clearance by trained health care professionals </li></ul></ul><ul><ul><li>Athlete should be asymptomatic for: </li></ul></ul><ul><ul><ul><li>Subjective complaints </li></ul></ul></ul><ul><ul><ul><li>Neuropsychological assessment </li></ul></ul></ul><ul><ul><ul><ul><li>Screening battery and/or ImPACT if baselined </li></ul></ul></ul></ul><ul><ul><ul><li>No symptoms at physical rest, in normal activities, and under exertion </li></ul></ul></ul><ul><ul><ul><li>Protocols exist for gradual return to exercise, formal drills, team-practices, and games </li></ul></ul></ul>
    52. 53. NRH Concussion Management Protocol <ul><li>Exceptions to Usual Protocol </li></ul><ul><ul><li>Recurrent concussion </li></ul></ul><ul><ul><li>Evidence of more severe TBI </li></ul></ul><ul><ul><li>Greater than two months post-concussion </li></ul></ul><ul><ul><li>Patients referred with PCS </li></ul></ul><ul><ul><li>Known history of major potential complicating factors (e.g., prominent psychiatric or substance abuse history, </li></ul></ul>