2017 Concussion - Policy, Research and Clinical Care...Coaches and Athletes toward Concussions...

2017 Concussion - Policy,

Research and Clinical CareJim Chesnutt, M.D.

OHSU Sports Medicine

OHSU Concussion Program

Orthopaedics & Rehabilitation

and Family Medicine

OR Governor’s Task Force TBI

OCAMP

Recognize: Remove: Refer : Return

Concussion: Objectives

• Learn and apply current guidelines for concussion

diagnosis and management

• Develop strategies to help our patients recover

from a concussion

• Become Familiar with Return to Learn strategies

• Describe Rehabilitation roles and protocols

• Highlight recent research and collaborations

I have no conflicts of interest.

OHSU Concussion Center

The NW’s most comprehensive, multidisciplinary

concussion care center

• Cutting edge research and clinical care

– Concussion rehab and clinical outcomes

– Sensory Integration: balance & auditory processing

– Chronic traumatic encephalopathy(CTE)-tau protein

– Informatics and clinical guidelines

Yearly TBI Scientific Symposium- research to rehab

Partnerships- academics, community and industry

OHSU TBI/ PTSD ConsortiumDr. Jim Chesnutt, SM, Orthopaedics & Rehab, FM

Dr. George Keepers, Chair of Psychiatry

Dr Nathan Selden, Vice chair Neurosurgery

• Over 150 clinicians and researchers

• Research on basic science pathophys &

imaging

• Clinical research: trauma, balance, education

• Multidisciplinary teams, inpt, outpt, outreach

• VA Collaboration, auditory processing, neuro

trauma, PTSD, research, rehab protocols

• Medical Informatics, EBM, policy

OHSU Concussion Management

• Pre-season Impact baseline testing

– Can do whole team or individuals

• Athletic trainers on- field and in injury clinic

• Post –concussion evaluations

– Physician and ATC evaluations & Impact testing

• Concussion Rehabilitation Team

– PT, Vestibular/ENT, SLP/ cognitive,OT/vision

• Severe/Chronic: Neuropsych, Neuro, NSurg

Sport Concussion Support Group (student/family)

Interdisciplinary approach: OHSU Model

ATC Sports

Med

On the

field

Comprehensive Neurological

Rehab Team

OT

PT

SLP

3 wks

Vision Therapist

Neuro optometrist

School coordinator

Neuropsychologist

ED

Outside referral

(MD, PT, DC, other)

Concussions: The Problem

• We now realize concussions occur more often than previously thought

• Young athletes are at risk for serious short-term and long-term problems

• There is much variation in the knowledge of Health Care Providers managing concussed athletes

• New and emerging technologies will lead to a continuing evolution of care

Concussions:

The Oregon PlanState-wide concussion

management program

involving all high schools

• Establish state-wide

physician network

• Uniform evaluation and

management protocol

• Consultation service for

coaches, athletes, parents,

and physicians

• ImPACT baseline suggested

for contact and collision

sport athletes

Oregon Concussion Awareness and

Management Program (OCAMP)

Multi-disciplinary group across the state:

Educators, Physicians, Neuropsychologists,

Certified athletic trainers, Rehab Therapists

Brain Injury Association of Oregon

Athletic Directors(OADA),

Center for Brain Injury Research and Teaching

Representatives from OSAA , OR Dept of Ed.

Concussions: The Oregon Plan

Portland: OHSUDr Chesnutt/King/Wilhelm

Eugene: Slocum

Dr. Mick Koester

Ann Glang PhD

Li-Shan Chou PhD

Bend: The Center-

St Charles Hosp.

Dr. Sondra Marshall

Dr. Viviane Ugalde

Regional OCAMP Concussion Centers

^^

^^

^^

^^

^^

^^

^^

^^

^^

^

Each helps “oversee” programs at the “satellite” sites and

help local doctors/trainers care for their own athletes

*

**

Max’s Law: Sports Concussion

(SB 348- April 2009, 1st one passed!)

Max Condradt is an OR brain- injured athlete

hurt in football.

• No return-to- play the same day as

concussion

• Medical release needed to return to play

• Yearly coach concussion education required– Free for coach : www.osaa.org/healthandsafety/concussion.asp

• Effective: July 2009

http://www.osaa.org/healthandsafety/concussion.asp

Max’s Law: The 4 R’s

1. RECOGNIZE:

– all coaches must receive annual training in recognizing

the symptoms of concussion.

2. REMOVE:

– no same day return to play

3. REFER :

– must be evaluated by a properly trained medical

professional.

4. RETURN :

– all symptoms resolved, graded return to play over

about one wk and a medical release has been obtained

Zachery Lystedt Law Washington HB 1824 5-14-2009

• Youth athletes who are suspected of sustaining a concussion or head

injury be removed from play. "When in doubt, sit them out"

• School districts to work with the Washington Interscholastic Activities

Association (WIAA) to develop information and policies on educating

coaches, youth athletes and parents about the nature and risk of

concussion, including the dangers of returning to practice or

competition after a concussion or head injury.

• All student athletes and their parents/guardians sign an information

sheet about concussion and head injury prior to the youth athlete's

initiating practice at the start of each season.

• Youth athletes who have been removed from play receive written

medical clearance prior to returning to play from a licensed health-care

provider trained in the evaluation and management of concussion.

New 2013 Oregon Bill

Concussions in Club sportsJenna Sneva, ski racer, >12 concussions

Jenna’s Law

Clinical Concussion Care

• Sideline Evaluation:

– SAC, SCAT, Impact, ??

• Home Management

• Clinic Eval

• Clinic follow- up care

• Rehab and speciality care

What is a Concussion?

• A concussion is a mild

traumatic brain injury that

interferes with normal function

of the brain

• Evolving knowledge- “dings”

and “bell ringers” are brain

injuries- no such thing as a mild

concussion

• Loss of consciousness is not

common in concussion(<90%)

Concussion Mechanics/ Biology• Aceleration/ Deceleration

• Linear/ rotational

• Neurometabolic energy crisis

• Decreased cerebral blood flow, glucose

• Abnormalities Glutamate, K, Na, Ca, etc

• Endocrine, neurochemical abnormalities

• Neuron injury and Axon shearing

• Prefrontal motor cortex, corpus collosum

and central processing network

Concussion Symptoms• Symptoms are variable for each individual in

terms of type, intensity and duration:

• Symptoms: (eg, headache, foggy or emotional) l

• Physical signs (eg, loss of consciousness, amnesia,

neurological deficit)

• Balance impairment (eg, gait unsteadiness)

• Behavioural changes (eg, irritability)

• Cognitive impairment (eg, slowed reaction times)

• Sleep/wake disturbance (eg, somnolence,

drowsiness) McCory et al. BJSM. Berlin 2016.

Symptoms

• Headache 75%

• Blurred vision 75%

• Dizziness 60%

• Nausea 54%

• Memory/ confusion 40-60%

• Double vision 11%

• Noise sensitivity 4%

• Light sensitivity 4%

• Loss of consciousness 5-10%Carney, Ghajar et al 2014

New Definitionevidence- based systematic review

1.) a change in brain function;

2.) following a force to the head( +/- hit)

-a potentially concussive event;

3). may (or may not) be accompanied by

temporary LOC;

4.) identified in awake individuals; and

5.) includes measures of neurologic and

cognitive dysfunction. (Carney, Ghajar et al., 2014.)

Concussion -consistent and

prevalent diagnostic indicators

1.) observed and documented disorientation or

confusion immediately after the event;

2.) impaired balance within 1 day after injury;

3.) slower reaction time within 2 days after

injury; and /or

4.) impaired verbal learning and memory within

two days after injury. (Carney,Gjahar, et al.,

2014.)

Interdisciplinary Approach: Concussion Symptoms

Adapted from Collins MW et al; Knee Surg Sports Traumatol Arthosc 2014

Concussion

Anxiety/

Mood

Ocular

Cognitive

Migraine

Cervical

Vestibular

Auditory

Autonomic

Football Injury Data ( RIO)

Concussions 2005/06-2015/16

After eight consecutive years of

increasing concussion rates,

Football concussion rates

decreased from 2012/13 to

2014/15, but increased again in

2015/16

– 4.7 per 10,000 AE 2005/06

– 9.1 per 10,000 AE 2011/12

– 10.8 per 10,000 AE 2012/13

– 10.1 per 10,000 AE 2014/15

– 10.5 per 10,000 AE in 2015/16

Newer Data High School RIO 2015-6

Injury rate per 10,000 player exposures competition

• Boy’s Football-- 10.5

• Girls’ soccer 9.2

• Girls’ lacrosse 8.6

• Boys’ Ice Hockey – 7.6

• Boys’ Wrestling – 5.5

• Girls’ basketball 5.5

• Boys’ Lacrosse – 5.0

• Boys’ Soccer – 4.2

• Girls’ field hockey 4.1

• Boys’ basketball 3.9

Soccer-Football and Concussion

• Estimate 270 million players world wide

• 27 mil in N America

• 40 % concussions for arm/ elbow to head

• 60% contact related to headers but not

headers themselves

• Female more ground contact

• Heading may be related to brain injury

– Usually at least 1000yr worse if over 1800?

Signs on the Field

• Appears dazed

• Confused about play

• Moves clumsily

• Answers question slowly

• Personality/behavior change

• Forgets plays prior to hit

– **Retrograde amnesia**

• Forgets plays after hit

– Anterograde amnesia

• Loses Consciousness

The Knowledge and Decision Making

Behaviors of NCAA Division I Soccer

Coaches and Athletes toward Concussions Jessica Tsao, Jacqueline D. Van Hoomissen and Terence G. Favero

• NCAA Division I soccer coaches (n=40) and athletes (n=66)

Rosenbaum Concussion Knowledge and Attitudes

• coaches and athletes demonstrated moderate to strong knowledge but

deficits in the areas concerning concussion diagnosis and severity.

• athletes exhibited statistically significantly more unsafe attitudes

than coaches regarding concussion management during games and

practices (p < 0.002). Many athletes indicated a willingness to play

• with a concussion

• This study highlights the need for intentional concussion education that

moves beyond identification of concussion and begins to change the

attitudes of athletes towards playing while concussed.

Later Signs of Concussion(Post-Concussion Syndrome)

❖Decreased Processing Speed

❖Short-Term Memory Impairment

❖Concentration Deficit

❖Irritability/Depression

❖Fatigue/Sleep Disturbance

❖General Feeling of “Fogginess”

❖Academic Difficulties

Assessment and Management

• When to go to ER

– Difficult to arouse or

awaken or walk

– Ongoing nausea and

vomiting

– Worsening headache

– Changes in vision

– Unequal pupils

– Severe Confusion or

disorientation

Second Impact Syndrome

• Injury before recovery from the previous

head injury

• May cause brain swelling from loss of

normal control of brain blood flow

– Rare but deadly, more common in teenagers

• Prevention is the key…….

– Do not return to play too early

Head Injury Data in the ED

A five ED study in Canada of 10,000 patients

Clin J Sport Med 2001;11:77–81. ED pts with non-Sport/Recreation-related

injury were most commonly involved in

• falls (38.5%)

• vehicle-related injury (31.3%)

• victims of intentional injury (11.4%)

• LOC 40%

• Cycling and playground > “sports”

CT ?

MRI ?

fMRI?

DTI?90% normal

The Canadian Head CT rule 100% sensitive abnormalities that need neurosurgery.

Major Criteria:1

• 1.)GCS < 15 at 2 hours post-injury; 2.)Suspected open or

depressed skull fracture; 3.) Any sign of basilar skull

fracture; 4.) Blood in the middle ear( hemotympanum), or

around eyes (raccoon eyes) or back of head( Battle’s sign)

or cerebral spinal fluid drainage from the nose/ ears);

5.)vomiting (≥ 2 episodes); 6.) Age ≥ 65.

Minor Criteria: 2

• 1.)Retrograde Amnesia to the Event ≥ 30 minutes;

2.)"Dangerous" Mechanism; 3.)Pedestrian struck by motor

vehicle; 4.)Occupant ejected from motor vehicle; 4.)Fall

from > 3 feet or > 5 stairs. (Stiell et al. 2001).

Brain Imaging in Acute TBI

• The decision rule-predicting positive CT

– 100% sensitive ( picks up all problems)

– 46% specific ( picks up more unrelated

problems)

– 13 % positive if meet criteria

– All negative if no criteria

Concussions: New Science

• Research indicates that HS athletes with

less than 15 min of on- field symptoms

exhibit deficits on formal neuropsychologic

testing and re- emergence of active

symptoms, lasting up to one week post-

injury.

• Symptoms often return with exertion

• Suggests we are returning athletes too early

New Concussion Science• Baseline neuropsych testing of Pro Athletes

in NFL, NHL, Baseball and other sports

• Higher incidence ( 3X) of depression if >3

concussions in Pro athletes in some studies

• Risk of premature dementia

• Possible brain damage

– Brain lesion : tau protein deposition

– Similarities to Alzheimer's/Parkinson’s

– Higher risk if certain genes (APO E -4)

– CTE chronic traumatic encephalopathy

AAN 2013 Concussion Guidelinehttp://www.neurology.org/content/80/24/2250.full.pdf+html

New Guidelines published in 2013!

Sport Concussion Assessment Tool

( SCAT)

Sport Concussion Assessment Tool (SCAT)

The SCAT Card

(Sport Concussion Assessment Tool)

Athlete Information

What is a concussion? A concussion is a disturbance in the function of the brain caused by a direct or indirect force to the head. It results in a variety of symptoms (like those listed below) and may,

or may not, involve memory problems or loss of consciousness.

How do you feel? You should score yourself on the following symptoms, based on how you feel now.

What should I do? Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation.

Signs to watch for: Problems could arise over the first 24-48 hours. You should not be left alone and must go to a hospital at once if you:

· Have a headache that gets worse · Are very drowsy or can’t be awakened (woken up) · Can’t recognize people or places

· Have repeated vomiting · Behave unusually or seem confused; are very irritable · Have seizures (arms and legs jerk uncontrollably)

· Have weak or numb arms or legs · Are unsteady on your feet; have slurred speech

Remember, it is better to be safe. Consult your doctor after a

suspected concussion. What can I expect?

Concussion typically results in the rapid onset of short-lived impairment that resolves spontaneously over time. You can expect that you will be told to rest until you are fully recovered (that means

resting your body and your mind). Then, your doctor will likely advise that you go through a gradual increase in exercise over several days (or longer) before returning to sport.

This tool represents a standardized method of evaluating people after concussion in sport. This Tool

has been produced as part of the Summary and Agreement Statement of the Second International Symposium on Concussion in Sport, Prague 2004

For more information see the “Summary and Agreement Statement of the Second International

Symposium on Concussion in Sport” in the April, 2005 edition of the Clinical Journal of Sport Medicine (vol 15), British Journal of Sports Medicine (vol 39),

Neurosurgery (vol 59) and the Physician and Sportsmedicine (vol 33). This tool may be copied for distribution to teams, groups and organizations. ©2005 Concussion in Sport Group

Post Concussion Symptom Scale

None Moderate Severe

Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6

Balance problems or dizzy 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Vision problems 0 1 2 3 4 5 6

Hearing problems / ringing 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Feeling “dinged” or “dazed” 0 1 2 3 4 5 6

Confusion 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like "in a fog" 0 1 2 3 4 5 6

Drowsiness 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 More emotional than usual 0 1 2 3 4 5 6

Irritability 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6

(follow up symptoms only)

Sadness 0 1 2 3 4 5 6 Nervous or Anxious 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6

Sleeping more than usual 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Other: _______________ 0 1 2 3 4 5 6

Post Concussion Symptoms Ask the athlete to score themselves based on how

they feel now. It is recognized that a low score may be normal for some athletes, but clinical judgment should be exercised to determine if a change in

symptoms has occurred following the suspected concussion event.

It should be recognized that the reporting of symptoms may not be entirely reliable. This may be due to the effects of a concussion or because the

athlete’s passionate desire to return to competition outweighs their natural inclination to give an honest response.

If possible, ask someone who knows the athlete well about changes in affect, personality, behavior, etc.

Remember, concussion should be suspected in the presence of ANY ONE or more of the following:

· Symptoms (such as headache), or · Signs (such as loss of consciousness), or · Memory problems

Any athlete with a suspected concussion should be monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle.

Sports concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several

common features that incorporate clinical, pathological and biomechanical injury constructs that may be utilized in defining the nature of a concussive

head injury include: 1. Concussion may be caused either by a direct blow

to the head, face, neck or elsewhere on the body

with an 'impulsive' force transmitted to the head. 2. Concussion typically results in the rapid onset of

short-lived impairment of neurological function that

resolves spontaneously. 3. Concussion may result in neuropathological

changes but the acute clinical symptoms largely

reflect a functional disturbance rather than structural injury.

4. Concussion results in a graded set of clinical

syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential

course. 5. Concussion is typically associated with grossly

normal structural neuroimaging studies.

The Goal of Appropriate

Treatment

• Minimize the duration of symptoms

• Return to play as soon as safely

possible

• Avoid entirely the risk of second impact

syndrome

• Minimize the rate of chronic post

concussion syndrome

Concussion Guidelines

1. No Same Day Return to Play

2. Return to Play Recommendations

*approximately one week out*

Symptoms fully resolved

-and-

Complete a structured, graded exertion protocol over approximately 5-7 days without symptoms

Quick Recommendations

• Stay home from school for at about 2 days

until significant improvement

• Use tylenol for the first 3 days post injury

• Some nausea/vomiting is common and OK

• No need to awaken all night if stable at 2-4 hrs

post concussion

• Light exercise is OK and maybe beneficial

• Avoid screen time, extreme noise + light

“Rest or not to rest?”

• Recognize role of relative rest:avoid

“cocoon” or “black box” theories

• “best evidence suggests complete rest

exceeding 3 days is probably not helpful” – Silverberg. J Head Trauma Rehab. 2013

• Encourage return to some activity

– mood disorders/social isolation

• Avoiding contact sports

– Decreased reaction speed

– Brain more vulnerable to injury , 2nd impact45

Recovery from concussion

• 80% of concussion recover well if managed

actively in the first 2 weeks.

• Average recovery time for youth with

concussion is about 3 weeks

• Imaging is not usually helpful ( mostly done

in first 48 hrs if decline mental status

increased HA or neurologic deficit)

• Avoid screen time, extreme noise + light

Concussion prognostic Factors

• Athlete pre-injury characteristics:

– Previous concussions

– Migraine ( personal and family)

– Vestibular or occular issues

– ADD or learning issues

– Genetics ( apoE 4)

– Age/ gender

• Am J Sports Med 399110:2311-2318

suggesting slower recovery

Concussion Prognostic Factors

suggesting slower recovery

• Post concussion symptoms:

– Early dizziness/ imbalance( 7x risk >21 days)

– Nausea and Vomiting

– Diff concentrating and fogginess

– Photo/ phonosensitivity

– Early intervention seems to impact recovery

Am J Sports Med 399110:2311-2318

Neuropsychologic testing:

ImPact/ Axon Testing

:• Standardized, computerized, validated

– Memory, attention. processing speed

• Documents subtle impairments

• 60-70% correlation with symptoms

• Worse at 48hrs and recovers 1-4 weeks

• 94.6% sensitive and 97.3% specific

– Schatz,Sandel Am J Sports Med 41(2);321-326.

2012

Verbal

Memory

Visual

Memory

50

55

60

65

70

75

80

85

90

95

100

Symptomatic Asymptomatic Control

N=215, MANOVA p<.000000 (Lovell et al., 2004)

Testing reveals

cognitive deficits

in asymptomatic

athletes within 4

days post-concussion

Unique Contribution Of Neurocognitive

Testing To Concussion Management

Balance screening after concussion

• Balance assessment recommendations in 2009

• Now required for NCAA sports

• BESS (modified) is used as simplier, easier

• count errors - can be variable

• Sensitivity 34%–64% to detect mTBI

• ↑ in scores with exertion or fatigue (~20 min)

• ↑ in scores if ankle instability

• Balance reportedly resolves after 3-5 days But may be due to insensitive testing

**Need better balance tests- goal to find

more sensitive test that can be easily done

Many investigators trying objectify balance better.

(Zurich 2008; McCrory 2009, Guskiewicz 2001, Finnoff 2009, King 2013, Giza 2013)

Instrumenting the BESS could best classify chronic concussion vs healthy

(Mancini et al., 2012, King et al 2013)

King LA, Horak FB, Mancini, Pierce D, Priest KC, Chesnutt JC, Sullivan P,

Chapman JC. Instrumenting the Balance Error Scoring System for use with patients

reporting persistent balance problems after mild traumatic brain injury. Arch Phys

Med Rehabil. 2013 Nov 4.

Recovery of postural control after a concussion King LA1, Horak FB1, Chesnutt J2 & Chapman JC 3,4

1Department of Neurology, Oregon Health & Science University, Portland, OR, USA

2Department of Sports Medicine, Oregon Health & Science University, Portland, OR, USA 3War Related Illness and Injury Study Center (WRIISC-DC), Washington, DC Veterans, Affairs Medical Center

4Department of Neurology, Georgetown University School of Medicine, Washington, DC

RESULTS CONCLUSIONS BACKGROUND & OBJECTIVE The IBESS revealed differences (p= 0.047) in balance between

acutely concussed (2 days post-injury) and control athletes. The

non-instrumented BESS showed no group difference (p= 0.063).

Acutely (Day 2), our case group was divided between those with

normal (54%) and abnormal (45%) balance. Sub-acutely, at 9

days post injury, 40% remained abnormal, decreasing to 20% at

16 days and 1 person at day 23.

Of note, at day 5, 80% of the athletes with abnormal balance had

returned to baseline cognitive efficiency (ImPACT score) and

were returned to play.

ACKNOWLEDGEMENTS

This project was supported by the Oregon Clinical and

Translational Research Institute (OCTRI), grant number

(KL2TR000152) from the National Center for Advancing

Translational Sciences (NCATS) at the National Institutes of

Health (NIH). The content is solely the responsibility of the

authors and does not necessarily represent the official views

of the NIH. We want to acknowledge the Oregon Clinical

Translational Research Institute of OHSU for the use of their

facilities and staff, grant support 1 UL1 RR024140 01. The

project was also supported by NIH R24HD065703 from the

National Center for Medical Rehabilitation Research at the

Eunice Kennedy Shriver National Institute of Child Health &

Human Development and the Center for Translation of

Rehabilitation Engineering Advances and Technology

(TREAT). This project was partially supported by the

Foundation for Physical Therapy.

! Balance deficits, common after concussion, are rarely factored

into clinical decision-making due to a lack of sensitive, objective

measures.

! Having recently found balance deficits in a chronic mTBI sample

with persistent symptoms, the purpose of the current study was

to characterize balance deficits in the acute and post-acute

period after concussion.

The study was conducted at Oregon Health & Science University and

Portland State University. Subjects: 11 athletes with a mean age of 20

(±1) with a recent history of concussion (case group) and 17 age-

matched control athletes with no history of concussion (control group).

METHODS & DESIGN

Testing Protocol: Each participant

was serially tested over 3wks post-

concussion using the Instrumented

Balance Error Scoring System

( IBESS) . Pos tu ra l sway was

automatically quantified both in AP

and ML directions using one Opal

accelerometer. APDM software was

used to calculate the Root Mean

Square (RMS) around the mean

position, a metric representing sway

dispersion (RMS=APacc2+MLacc2).

Non-Instrumented BESS scores were

compared with instrumented

(IBESS).

Fig 3. Eleven athletes tested serially for sway measures during the IBESS. Gray

area represents ± 1 SD from the mean (solid black line) from the 17 age-

matched control athletes with no history of concussion.

CONFLICT OF INTEREST

OHSU and Dr. Horak have a significant financial interest in

APDM, a company that may have a commercial interest in

the results of this research and technology. This potential

institutional and individual conflict has been reviewed and

managed by OHSU.

Figure 2. Bland-Altman plot for

evaluating the agreement among

two measurements taken for the

control group.

Figure 1. Postural Sway during

Instrumented BESS in the Anterior-

Posterior (AP) and Medio-Lateral

(ML direction.

! In acute and post-acute periods after concussion, cases

had measurable balance deficits, not detected on clinical

balance exams (non-instrumented BESS).

! Inertial sensors, objective and portable, may help to

identify incomplete recovery post-concussion.

! These findings have implications for the military since

balance problems post-TBI may impact the functioning of

military personnel in and outside of combat.

Return to play

Also – balance tends to worsen after

return to play as suggested in our data

and data from Howell at Univ Oregon*

3.8 x increase in ortho injuries in 90 days

post concussion RTP 2013

*King et al, 2014

*Howell D. MS, Osternig L. Chou L. 2015 .

*

Dynamic balance during walking

Gait variability larger after concussionworse with dual task

Return to Play considerations• All symptoms need to resolve

– This includes HA, especially

– Follow symptom log

• Neurocognitive scores usually normalize after

symptoms resolve

• If symptoms recur with exercise, school, work

or play: remove from activity/ modify RTP plan

Concussions: Return to PlayA Step-wise symptom limited program

1. Rest until asymptomatic ( Recovery: physical,mental )

2. Light aerobic exercise ( HR: 70% max, jog, exercise bike)

3. Sport- specific exercise( Add movement: No head impact)

4. Non-contact training drills (Exercise intensity,Coordination and cognitive load: add wt lifting, passing, plays )

5. Full contact training (After medical clearance: Restore confidence and asess functional skills by coach/ ATC)

6. Return to competition( game play)

Each stage is 24 hrs or longer, lower stage if symptoms recur

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Return to Academic Plan

1. RECOGNIZE:

Concussion management team identifies student’s concussion and informs teachers

2. REMOVE/REST:

Students remain home for 2 days or more with physical and cognitive rest

3. REFER :

Students suspected of sustaining a concussion must be evaluated and

cleared by a properly trained medical professional.

4. RETURN :

Develop return to academic plan with educational accommodations with

modified environment and work load. Consider freezing grades early and be

flexible with transitions. Back to school before athletics!

Returning to Learning Following a ConcussionMark E. Halstead, Karen McAvoy, Cynthia D. Devore, Rebecca Carl, Kelsey

Logan and Michael Lee,

Council on Sports Medicine and Fitness, and Council on School Health

Pediatrics; originally published online October 27, 2013;

1. Students with a concussion may need academic

adjustments in school to helpminimize a worsening of

symptoms.

2. Given that most concussions resolve within 3 weeks

of the injury, adjustments may often be made in the

individual classroom setting without formal written

plans, such as a 504 plan or IEP.

Returning to Learning Following a

Concussion

3. Students with symptoms lasting longer than 3 to 4

weeks may benefit from a more detailed assessment by

a concussion specialist (licensed physician, such as a

pediatrician, neurologist, primary care sports medicine

specialist, or neurosurgeon with expanded knowledge

and experience in pediatric concussion management)

and recommendations specific to the educational

environment. Considerations should be given to

developing a 504 plan or, subsequently, but unlikely, an

IEP, in the student with a lengthy recovery.

Returning to Learning Following a

Concussion

.4. A team approach consisting of the medical

team, the school team, and the family team to

assist the student in his or her return to learning

is ideal.

5. Students should be performing at their

academic “baseline” before returning to

sports, full physical activity, or other

extracurricular activities following a concussion

CBIRT- www.ocamp.org Return to Learn

Post-Concussion Academic Accommodation Protocol

Most students who sustain a concussion return to pre-injury functioning within 3–4 weeks of their injury.

However, symptoms will linger beyond this time in approximately 10–20% of concussions. When this

happens, the school team must continue academic adjustments and physical restrictions for a longer time.

Symptoms might continue for weeks or even months. It is best practice for a school district to have a

system in place by which a student can be evaluated for additional services (e.g., Section 504 plan, special

education).

A school-wide academic accommodation protocol for students with concussions or brain injuries can be

effectively implemented in most schools using the following progression.

1. Tier 1: The majority of students with a concussion will respond positively to a well-orchestrated system of cognitive reduction, physical rest, simple classroom adjustments to the existing classroom curriculum, and slight environmental changes to support physical and cognitive rest. At Tier 1, the Concussion Management Team (CMT) can collect data on symptoms to monitor progress and make modifications as needed.

2. Tier 2: The 10–20% of students who experience symptoms beyond the typical 3–4 week recovery

period can be systematically moved on to Tier 2 for Targeted Intervention. At Tier 2, a more formalized academic plan might be required for the student (Health Plan, RTI Plan, or Section 504 Plan). The objective of Tier 2 is to expand and strengthen academic accommodations to effect greater recovery from the concussion.

3. Tier 3: The 1–5% of students who do not adequately respond to concussion management efforts at

Tiers 1 and 2 experience severe, long-term neurocognitive and physical effects for weeks or months. Students who do not benefit from management attempts at Tiers 1 or 2 would be advanced to the most intensive level of assessment and intervention provided at Tier 3. At this level, modification of curriculum and protection under IDEA, including an IEP, may be necessary.

•Multi-Disciplinary Teams

•Common Classroom Adjustments

•Slight Environmental Modifications

•Recover Quickly

80-90% of Students with Brain Injuries

Tier 1•Targeted Group Interventions

•Formalized Intervention Plans (504 Plan)

•Academic Accommodations

•Environmental Modifications

•Recover Within 3-4 Weeks

5-10%Tier 2

•Individual Student Interventions

•Significant Environmental Modifications

•Curricular Modifications

•Special Education/IDEA

•Extended Recovery Time

1-5%Tier 3

http://www.ocamp.org

Purpose of Care Plan: Guide recovery , Educate, Manage

exertional and school activity

Educational resources: State TBI Teams

Develop concussion education programs and return to

academic programs, and assist with 504 plans if needed.

Call : 541-346-0597 or Email: www.ocamp.org

http://www.ocamp.org

Return to School

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The Effectiveness of a Web-Based Resource in Improving Post-concussion Management in High

Schools. Glang AE, Koester MC, Chesnutt JC, Gioia GA, McAvoy K, Marshall S, Gau JM, Journal of

Adolescent Health , Volume 56, Issue 1 , 91 – 97, Jan 2015.


USA FOOTBALL- Heads Up program

Video on OSAA website- www.osaa.org

• OSAA- Concussion guidelines and return to learn info from CBIRT/ OCAMP

• www.osaa.org/health-safety

CDC Concussion Tool Kit

• Videos and Educational/ media programswww.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm

http://www.osaa.org

http://www.osaa.org/health-safety

http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm


Concussion

OT

Patient

Medical

provider

PT

Neuro-

psych/psyc

hology

School/

WorkFamily

SLP

Interdisciplinary approach: OHSU Model

ATC Sports

Med

On the

field

Comprehensive Neurological

Rehab Team

OT

SLP

PT

3 wks

Vision Therapist

School coordinator

Neuropsychologist

ED

OHSU Concussion Rehab TeamA. Speech -language pathologist: for evaluation and treatment to

address cognitive and executive function issues

B. Physical therapy: for vestibular therapy and neck and associated

orthopaedic issues and exercise testing and prescription.

C. Occupational Therapy: for visual and functional therapy.

D. Concussion Coping Clinic and Support Group

This is on the 1st floor of OHSU Center for Health and Healing.

Please call 503-494-3151 to schedule an appointment but this will likely

need to be approved by your insurance

OHSU Concussion Team

Sports Medicine DoctorsJim Chesnutt, M.D. .

Ryan Petering, M.D.

Melissa Novak D.O.

Rachel Bengtzen M.D.

Doug McKeag, M.D.

Physical/ Vestibular Therapy Jennifer Wilhelm, PT, DPT,NCS

Jeff Schlimgen, PT, MSPT,NCS

Marvin Smith, PT, DPT

Kitty Leelaamornvichet, PT, DPT

Sarah McCollister, P.T.,DPT

Jyndia Schaible, PT, D.P.T.

Amy Woods, PT, DPT

Margaret McReynolds, P.T., M.S.ED

Neuropsychology

Sara Walker, PhD

Muriel Lezak, PhD

Leeza Maron, PhD

Bonnie Nagel, PhD

Trevor Hall, PhD

James Carson, PhD

Occupatioanl / Visual TherapyRosane Yee , O.T.R./L.,

Anne Marie Banasky, OTR/L

Speech/ Cognitive Therapy

Michal Rubin, MS, CCC-SLP

Haley Landau, MS, CCC-SLP

Peds Therapy Group- Doernbecher

Multiple excellent providers/ specialties

Certified Athletic Trainers

Ryan Rockwood, ATC-R

Orthopeadics / Spine

Family Medicine

Neurology Peds/ Adult

Neurosurgery

Psychiatry

Anesthesia/ Pain Center

ENT/ vestibular

Ophthalmology

Emergency Med

Trauma

Internal Medicine

Pediatrics

Radiology


Adapted from Collins MW et al; Knee Surg Sports Traumatol Arthosc 2014

Concussion

Anxiety/

Mood

Ocular

Cognitive

Migraine

Cervical

Vestibular

Auditory

Autonomic

Concussion Subtypes

Concussion

Anxiety/

Mood

Ocular

Cognitive

Migraine

Cervical

Modifier

Vestibular

Auditory

Autonomic

Sleep- Modifier

Clinical testing/ Data Collection

• Careful individualized clinical assessment

and tracking from time of injury• SCAT3

• Neuropsychological Testing ( Impact, Axon, or

partial or full- RBANDS,

• Anxiety/Mood -PHQ-9, GAS, Sleep scales

• Interdisciplinary Team- OT, PT, SLP

VOMS- see protocol below

BESS or other postural data

Stress Testing

? Imaging

Physical Therapy and concussion management

• Address musculoskeletal problems: headache and neck pain

• Balance and coordination exercises including dual task activities

• Gaze Stabilization, VOR, balance master/SOT

• Exercise tolerance- stress testing, prescription

• Step wise return to play

• Education– Diagnosis, prognosis and timeline

• Reassurance of favorable prognosis

– Symptom management

– Assist with proper referrals

Aerobic Exercise Prescription

• Target heart rate determined by symptom

threshold– Symptoms increase by 3 on 0-10 scale

– Rating of perceived exertion > 16/20 or “very hard”

• Target heart rate = 80-90% heart rate of

symptom threshold

• 20 minutes 5-6 times per week

• Progress target heart rate every 2 weeks 5-10

beats per minute

• Goal: 85-90% of age predicted max heart rate

for 20 minutes for several days.

Aerobic Exercise: Balke Protcol/

Buffalo Concussion Treadmill test protocol

• Provocative exercise test: help to determine if ready for RTP

– Protocol:

• Measure HR, symptoms and RPE at rest and at each minute

• Treadmill: 3.2-3.6 mph, 0% incline

• Increase 1% incline each minute

• After reaching 15%: increase 0.4 mph each minute

• Stop if

– Increase > 3 points of symptoms

– Reaches RPE 19/20

– High inter-rater reliability (95%) and sensitivity (99%)

Leddy JJ et al, Clin J Sport Med. 2011

Leddy JJ et al, Curr Sports Med Rep. 2013

Occupational Therapy and Concussion Management

• Visual deficits

– Reaction time

– Scanning

– Eye movement skills

– Accommodation

– Convergence

– Slowly integrate

visual activities (age

appropriate)

– Ciuffreda et al

Optometry 2007

60% of patients with mTBI have

various oculomotor deficits

90% of visually-symptomatic

mTBI had some form of

oculomotor dysfunction

• Behavior: Self regulation

• Pacing

• School/work

accommodations for vision

Vestibular – Ocular Motor Screening (VOMS)

• 64 concussed people with mean age of 13.9 y/o and

mean time since concussion of 5.5 days

• Six ocular motor and vestibular tests with symptom

rating of 0-10 along with convergence distance

Visual deficits: Vestibular Ocular Reflex (VOR)

• Dynamic visual acuity

(DVA)

– Stand 20’ from Snellen

chart

– Head moved at 2 Hz

(horizontal and vertical)

– (+) if > 2 lines

– Vestibular: Sensitivity

94.5%; Specificity 95.2%

Schubert et al Phys Ther. 2004

Peterson MD J Head Trauma Rehabil 2010

Speech Language Pathology and

Concussion Management

• Memory

• Speed of processing

• Word finding

• Attention

• Executive function

– Planning,

– Problem solving

– Organization

• Social cognition

• School interventions

Initial evaluation: 5/3/16

• SCAT: 75

– 5 points:

✓Don’t feel right

✓Feeling dinged/dazed

✓Feeling slowed down

✓Feeling in a fog

✓Fatigue/low energy

✓Trouble falling asleep

• Headache: 4-5/10

– B temples, frontal

• Dizziness Handicap

Inventory: 40/100

– Physical: 8/28

– Emotional: 18/36

– Functional: 14/36

Initial evaluation: 5/3/16

• BESS: 6/60

• Dynamic visual acuity:

– 2 lines horizontal, 1 line vertical (dizzy)

• Treadmill testHR Headache Dizziness RPE

Rest 83 6/10 7/10

3.3 mph, 0% x 1 min 103 6/10 6/10 2/10

3.3 mph, 2% x 2 min 111 7/10 7/10 2/10

3.3 mph, 3% x 3 min 114 8/10 7/10 3/10

Concussion Medication

Management• Fish oil and tylenol early, NSAID after 72 hrs

• Amitriptyline/ Nortrityline 10 mg pills. Take10-50mg ( 1-5

pills) at night at bedtime for Headache/ sleep.

• Inderal 20-80 mg bid

• Topimax: 25-50 mg BID start 25 HS, increase q3-7

• Trazodone- 25-100 hs, Temazepam, Klonopin, hydroxizine

• Melatonin 0.5-6 mg 1-2 hrs before sleep

• Antidpressants , Amantadine 50-100 mg BID.

• Migraine meds- excedrine, aleve, triptan, feverfew, butterbur

• Natural HA meds- , riboflavin, Mg, co-enzyme Q10

Summary• Must improve early identification & diagnosis

• Coach, athlete, parent, Correction officer, medical

education

• Careful individualized clinical assessment and

tracking from time of injury• SCAT3

• Neuropsychological Testing ( Impact, Axon, or full)

• Interdisciplinary Team- OT, PT, SLP

• Implement active treatment in home & school

school accommodations, 504 plan, OCAMP.org

Max’s Law Implementation Guide- download

• Free coaches education: You too can take this…

www.osaa.org/healthandsafety/concussion.asp

http://www.osaa.org/healthandsafety/concussion.asp

Resources

• www.ohsusportsmedicine.com

• CDC “Heads Up”: www.cdc.gov/concussion/

• Oregon Concussion Awareness and Management Program:

www.ocamp.org

• Center on Brain Injury Research and Training: www.cbirt.org

• Brain 101: http://brain101.orcasinc.com

• Neuro-Optometric Rehabilitation Association (NORA):

www.nora.cc

• Brain Injury Association of Oregon: www.biaoregon.org/

• Brain Injury Association of Washington:

www.braininjurywa.org/

http://www.ohsusportsmedicine.com/

http://www.cdc.gov/concussion/

http://www.ocamp.org/

http://www.cbirt.org/


http://www.nora.cc/

http://www.biaoregon.org/

Sports Concussion ManagementContact our sports medicine team for questions:

Jim Chesnutt, M.D. [email protected]

Ryan Petering, M.D. [email protected]

Melissa Novak, D.O. [email protected]

Rachel Bengtzen, M.D. [email protected]

Doug McKeag, M.D. [email protected]

www.ohsusportsmedicine.com or 503-494-4000

mailto:[email protected]





http://www.ohsusportsmedicine.com

2017 Concussion - Policy, Research and Clinical Care...Coaches and Athletes toward Concussions...

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