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ConcussionTrainingDay

EvaluationofConcussionandPCS:MedicalPerspective

ProfessorGaryJBrowneMedicalDirector,KidsConcussionService

Children’sHospitalInstituteofSportsMedicineChildren’sHospitalMedicalCentre

Level2,Suite13Appointments- 98450761

Objectives

• UnderstandkeyelementsthatmakeupthePhysicalExamination

• Beawareofthereliabilityoftheseelements

• Adapttheseelementstosuittheclinicalsituation

• Beawareofdifferencesinchildren

Theinitialapproach

NoInjury Concussion Emergency

McCrory,P..October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,WhatistheDefinitionofconcussion?

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ThePhysicalExaminationofConcussion:AParadigmShiftinDiagnosis

• Clinicaltoolsmustbereliableandreadilyadaptable tosuitetheclinicalsituation

• Approachmustbestructured,followingahierarchyofassessment

• Usetasksthatcommonlyprecipitateorexacerbateconcussionsymptoms

• Fallwithintwoclinicaldomains

1. ScreeningExamination

2. FocussedConcussionExamination

ScreeningExamination

Initialevaluation- AssessABC’s(Primarysurvey),Cervicalspine,Consciousness,Mentalstatus(MMSE),Seizures,Focality

EMSresponse- Repeatedvomiting,Severeorprogressiveheadache,Seizure,Abnormalgait,Slurredspeech,Weaknessornumbnessinextremities,Unusualbehavior,skullfracture,AMS,Somethingsnotquiteright

Clinicaldecisionrulesforimaging

Clinicalhistory-Mechanismofinjury(SCAT)ObtainsomeclinicalhistoryfromobserversAssessforconcussionifhead,face,orneckinjuriespresentPriorconcussionhistory—inquireaboutprevioussymptomsofconcussionandnumberofconcussions.

Evaluateforsymptoms (PocketCRT/SCAT)

ScreeningExaminationNeurologicalexam- Neckexam,3’neurologicexam;assesspupillaryreflexes,cranialnerves,motorstrength;performgait/stationtestsforbalance(Romberg),palpateforneckpain

Mentalstatus(SAC/SCAT)Attentionspan(immediatelyrepeatfournumbersforwards;at2minutes,repeatmonthsofyearbackwardsorrepeatfivedigitsforwardsandbackwards)Short-termmemory(threeobjectsat5minutes)Assessforposttraumatic(retrograde)amnesia(PocketCRT)

i.“Whatteamareyouplaying?”ii.“Whatisthescoreofthegame?”iii.“Whatarethecoloursoftheuniformsoftheteamyouareplaying?”

AssessforanterogradeamnesiaAssesslong-termmemory

Secondarysurvey- lacerations,faciomaxillary&othersysteminjury

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FocussedConcussionExamination

Fourpillars

History

Cognitivefunction

VestibularOcularcontrol

Balancecontrol

FocussedConcussionExamination

History

Defineinjurycharacteristics

Mechanismofinjury

Post-injurysymptoms

Definerisk

Co-morbidities

Riskfactors

Symptomevaluation• 22symptoms• Likertscale<5normal• Selfreported

Post-concussionSymptomScoring

Symptomexacerbation• Circumstances• Environment• Activities

Lau.AmJSportsMed.2011.

SymptomBurden-Sensitive96%,Specificity63%

JAMA. 2016

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FocussedConcussionExamination

History

Co-morbidities&RiskfactorsPreviousconcussion,headaches,ADHA,LD,psychiatricconditions,previousspinalinjury,neuro-opthalmologicconditions,otherconditionse.g.epilepsy,neuro-structural

Scopaz.SportsHealth2013

Familyhistory

Pastmedicalhistory

Schoolandsocialfactors

Inserson G,October28th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatarethekeymodifiersforconcussionoutcomes?

FocussedConcussionExamination

Cognitivefunction

Orientation(time,placeorperson)

Concentration(digitalbackwards)

Memory(wordtasks)

Reactiontime

Cognitivefunction

StandardizedAssessmentofConcussion(Sensitivity94%,Specificity91%)

• Orientation• Immediatememory• Concentration• Delayedrecall

MaddockQ’s

Abbreviate-WestmeadPost-TraumaticAmnesiaScoreA-WPTAS Hayter.Appl NeuroPsy:Adult2016

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Cognitiveperformance- Computer

Lau.Neurosurgery.2012;Schatz.AmJSportsMed.2013

McCrea,M.October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatadvancedornoveltestscanassistintheevaluationofconcussion?

Cognitiveperformance- Reactiontime,clinical

Dropsticktest

Sits,dominanthandneutraloverdesk

8recordeddroppingofstick

Recorddistancedropped

RT(ms)=1000x√(2xdistanceincm)/(980cm/s2)

Eckner.BrJSportsMed2014;48:112-118

FocussedConcussionExamination

Mucha AmJSportsMed.2014;McDevvitt InJSpMed2016;Anzalone AmJSportsMed.2016

VestibularOcularcontrol

Visualacuity

Smoothpursuits

EyeSaccades

NearConvergence

Vestibulo-ocularreflex

VisualMotorSensitivity

Sensitivity91.7%,Specificity81.7%

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VisualMotionSensitivity

Horizontal&VerticalVORSensitivityNearPointConvergence

Horizontal&VerticalSaccadesHorizontal&VerticalPursuits

FocussedConcussionExamination

Guskiewicz.Clin SportsMed.2011;ChandrasekharNeuroRehabilitation 2013

Balancecontrol

Station

Singlelegstance

Tandemstance

Tandemgait

Dualtasking

BalanceErrorScoringSystem

BESSSensitivity91%,Specificity64%

m-BESSSensitivity91%,Specificity71%

m-BESS:BalanceErrorScoringSystem• PosturalStabilityonafirmsurface

• 20secondseach

• CounterrorstoscoreEyesopeningMovementHandsoffhips

• Unabletoholdoraminimumof5sec,maximumscore

• Abnormalresponse,≥5duringeachtrial

m-BESSSensitivity95%,Specificity71%

Combiningm-BESS/VOMS-Specificity96%,accuracy94.4%

McDevittInt JSpMed2016

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BalanceExam- Tandemwalking/Dual-tasking

1. Tandemwalking- forward

2. Tandemwalking- backwards

Specificityof91%

OnFieldAssessment

• Ifunconscious,ABCs,C-spine,Seizure,Levelofconsciousness,Focality

• ImportantobservationsUnresponsive,LOCClutchingorshakingheadSlowtogetupVacantstaringorgazeGaitataxiaSeizurelikeactivity

Patricios J,October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatarethecriticalsidelineelementsforadiagnosis?

Sidelineassessment

• Istherelikelytobeastructuralbraininjury?

• Istherelikelytobeaconcussion?SCAT-4

AnyonesymptomoranyonesignshouldresultinimmediateexclusionandwithdrawalfromthegameNonextdayreturnuntilre-evaluated

SCATelements-ObservedsignsSymptomreportingSACelementsOrientationImmediatememoryConcentrationDelayedrecallBalanceNeckassessment

Echemendia R.October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,WhatmeasuresshouldbeaddedtoSCAT?

HighyieldSpontaneousnystagmusVerticaleyediscordanceDynamicvisionRomberg/m-BESSPositionalmaneuversNeckexamination

Fedderman N,October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatdomainsofclinicalfunctionshouldbeassessedpost-injury?

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EmergencyDepartmentAssessment

Excludesignificantinjury- traumaexamination

Neuroimaging

Makeadiagnosisofconcussion

FocusedConcussionExam

Documentneckpain

Commenceashortperiodofrest

Organiseappropriatefollow-up- HEADBUMPS

Primarycare- Subacuteassessment

Ruleoutotherinjuryand/orpotentialsubtlestructuralbraininjury

Confirmthediagnosis,focusedconcussionexam

Definethedeficits,systemsnotpathwayspecific

Tailortreatment

Considerneedforreferraltoaspecialistservice

ne

CardiologyExercisetherapySleepmedicine

NeurologyNeurosurgeryRehabilitation

Complexconcussion/PostConcussionSyndrome

McCrory,P..October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,WhatistheDefinitionofconcussion?Moran,SouthMedJ2015

PsychiatricPsychologicalBehaviouraltherapy

PhysiotherapyPhysicaltherapiesVestibulartherapies

Post-concussionsyndrome

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Orthostatic/Dynamicvitalsigns

OrthostaticHypotensionTachycardiaHeatintolerance

Dynamic,exerciseinducedTachycardiaAutonomicdysfunction

Exerciseintolerance

HelpdifferentiatefromConcussionmimics

ProvocationtestingtoriskstratifypatientsConcussion

InitialAssessment

Subacutephasephysiology

SecondaryAssessment

GradedexercisetestGradedexercisetest

Recovered Targetsymptom

Targetedtherapy

PhysiologicPCD PhysiologicPCD

SubthresholdExerciseProgramRecoveryproceduresMcCrea,M.October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatadvancedornoveltestscanassistintheevaluationofconcussion?

TertiaryImagingincomplexconcussion

Catscansareforfelines.Iwillgiveyourdogapetscan

McCrea,M.October27th 2016- 5th InternationalConsensusConferenceonConcussioninSport,Whatadvancedornoveltestscanassistintheevaluationofconcussion?

• Possibleindicationsforimaging-• SuspicionofICinjury• Dramaticworseningofsymptoms• Prolongedsymptom

• HighqualityMRI,MRA/MRV,DTI• Micro-structuralinjurythatmaysuggestprolongedrecoveryorvascularinjury

• DAI,vascularinjuriesandWMstructure• Problem,highlysensitiveforWMTabnormalities(98%)butnotveryspecific(45%)

• PETscanningfordementia

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Paediatricconcussion- Specialconsiderations

1. Physiologicaldevelopment

2. Impactforcesandprotectiveability

3. Physicalandcognitiverecovery

4. Effectsonschoolandlearning

5. Everydayenvironmentalinfluencesanddemands

6. Potentialforlong-termsequelae

DavisG.28th October28th 2016- 5th InternationalConsensusConferenceonConcussioninSport.Whatisthedifferenceinconcussionmanagementinchildrenascomparedtoadult?

CatastrophicinjurySecondimpact

• SecondImpactSyndrome- geneticbasis/Ca++channelopathy?• CACN1Amutation,potentialforcerebraloedemaafterarelativelyminorbraininjury,familialhemiplegicmigraine

Kors.AnnNeurol2001;49:753-760

CarreraNeurology 1999:53:126;doi:10.1212/WNL.53.1.26:1526-632X

• Athletescarryingaspecificgenotype(CACNA1Ers704326)haveamuchgreaterriskofaprolongedrecoveryfollowingconcussion• Historyofmigraineincreasestheriskofsevereinjuryorprolongedrecovery

McDevitt.AOSSMMarch2016

• Brainimpact,amplifiedinyoungbrains• IncreasedofCa++ andNa+ influxinducedbyglutamate-triggeredoveractivationoftheNMDAreceptors&AQP4mediatedoedema

AtkinsonJ.Mayoclin Proc2000

Integrateuniqueelementsintoassessment

Developmental

Medical

Psychological

Family/Environmental

Academic/School

StandardisedAssessmentofConcussion- >6years

A-WPTAS- >6years

Developmentalconundrum

DavisG.BJSM2014;Grubenhoff.Pediatrics 2010;Tesson etalEmerg MedAustralas 2016

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Multimodalassessment

Developmentallyadaptedassessment

Cognition

Balance

Strength

Agility/Motorskills

Social/Psychological/School

Gioia etal.BrainInjury2015;Reedetal.J.Vis.Exp.,e51892,2014

3CondensedmodelofcareincludingGXT

0.00

0.25

0.50

0.75

1.00

Sens

itivity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.8928

BESSE FIRMSURFACE FOAMSURFACE

1VestibularOcularMotorScreeninginkids

Sensitivity90%Specificity89%

1Ellis.JneurosurgPediatr 2015, 1AnzaloneAmJSportsMed.2016;2KhannaSportsHealth2015;3BrowneetalPediatrics 2016

2M-BESSinKids

WhatcharacteristicsinkidsdetermineRTA?• AdolescentswithheadacheonEDadmission,requiringhospitalisationatEDencounter,atriskpersistentPCS

BabcockJAMAPediatr 2013

• SubacuteGXT(2daysofrest)

BrowneetalPediatrics 2016

• WestmeadsteptestBogg.PedExScience2016

Exercisetolerant- commenceactivity,activerehab,normalrecovery

Exerciseintolerant- facilitatedactivity,progressiverehab,slowrecovery

Extremeexerciseintolerant,extendedrest,facilitatedactivity,rehab,veryslowrecovery

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Takehomemessages

• PEiscentraltotheassessmentofconcussion• toolsweuseneedtobeadaptedtosuittheclinicalsituation

• Complexconcussion• higherlevelofevaluationisoftenneeded,thisbestundertakeninareferralcentrewithappropriateinterdisciplinarysupportsystems

• Childrenaredifferent• Riskcanbemitigatethroughearlydiagnosis,effectivetreatmentandeducation