New Insights in Concussion Management

Jim Chesnutt, M.D.OHSU Sports Medicine

OHSU Concussion ProgramOrthopaedics & Rehabilitation

and Family MedicineOCAMP

Recognize: Remove: Refer : Return

Concussion: Objectives

• Learn about state laws regarding concussion recognition and management

• Learn and apply current guidelines for concussion management and rehabilitation

• Develop strategies to help our patients recover from a concussion

• Highlight recent research and collaborations I have no conflicts of interest.

Clinical Concussion Care

• Sideline Evaluation:– SAC, SCAT, Impact, ??

• Home Eval• ED Eval• 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(<10%)

Concussion: Helmet to helmet hit

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• Bleeding is unusual

Concussion• Symptoms are variable for each individual

in terms of type, intensity and duration• Classified into four main areas:

– physical ( HA, dizzy)– emotional ( agitated, quiet, depressed), – cognitive ( memory, processing)– sleep (falling and/or staying asleep)

• Cumulative impairment can occur• 3x more likely to get a second concussion

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.)

Dynamic Model of Concussion

Newer Data High School RIO 2012Injury rate per 10,000 player exposures competition• Football 22.9• Boys’ ice hockey 14.6• Boys’ lacrosse 10.4• Girls’ soccer 9.2• Girls’ lacrosse 8.6• Girls’ basketball 5.5• Boys’ soccer 5.3• Boys’ wrestling 4.8• Girls’ field hockey 4.1• Boys’ basketball 3.9

Concussions• Estimated 3 mil sports-

related head injuries in US athletes yearly

• 9% of all sports injuries• 700-2000? head-injuries

in Oregon HS athletes based on OSAA participation #s

• Pros: lower incidence possibly 10x lower

Soccer-Football and Concussion

• Estimate 270 million players world wide• 27 mil in N America• 60% concussions- contact related to headers

but not headers themselves• 40% - arm/ elbow to head• Female more ground contact• Heading may be related to brain injury

– Some NP changes if 1000yr > if over 1800?

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 Plan

State-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 TherapistsBrain Injury Association of OregonAthletic Directors(OADA), Center for Brain Injury Research and TeachingRepresentatives from OSAA , OR Dept of Ed.

Concussions: The Oregon Plan

Portland: OHSUDr Chesnutt/King/Wilhelm

Eugene: SlocumDr. Mick Koester

Bend: The Center-St Charles Hosp.Dr. Sondra MarshallDr. Viviane Ugalde

Regional OCAMP Concussion Centers

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Each helps “oversee” programs at the “satellite” sites and help local doctors/trainers care for their own athletes

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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

Max's Law - Sports Concussion SB 348

Left to right: David Kracke, Max Conradt, Governor Ted Kulongoski, Tootie Smith, Sherry Stock

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 play3. 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

New 2013 Oregon Bill Concussions in Club sports

Jenna Sneva, ski racer, >12 concussionsJenna’s Law

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

?Technologic

cure?

New Guidelines published in 2013!

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

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 EDA 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

Brain Imaging in Acute TBI• The Canadian Head CT decision rule-

for 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

– Therefore can limit scanning safely!

Sport Concussion Assessment Tool ( SCAT)

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/ work for at least 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

Concussion recovery: How long does it take?

n = 134 male football athletes

Collins et al; Neurosurgery 2006

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 Factorssuggesting 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 recoveryAm J Sports Med 399110:2311-2318

Return to Play considerations• All symptoms need to resolve

– This includes HA in acute phase ( 3 months) – Follow symptom log

• Neurocognitive scores usually normalize after symptoms resolve

• Start return to play protocol• If symptoms recur with exercise, school, work

or play: remove from activity/ modify RTP plan

Balance screening after concussion

• Balance assessment recommendations in 2009

• BESS (modified) is used • (subjectively counting errors)

• 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- developed at OHSU

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

Wearable sensors to instrument clinical balance and gait testing

to improve objective assessment after concussion.

Laurie King, PhD, PTJim Chesnutt, M.D.

Oregon Health & Science University Dept. of Neurology and Sports Medicine

Instrument the BESS using an inertial sensor

Inertial sensors: similar to force plate -Portable-Automatic analysis

New portable, wearable and wireless technology

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.

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 walkingGait variability larger after concussion

worse with dual task

Conclusions

• Approximately half of acutely concussed athletes had abnormal balance and a subset returned to play before normal balance was restored

• In acutely concussed athletes, instrumented mBESS was more sensitive than clinical mBESS

• Gait may be most impaired under dual task and using variability measures.

• Balance appears to worsen after RTP

AcknowledgementsFunding:• NIH; Research reported in this publication was supported by the Eunice

Kennedy Shriver National Institute Of Child Health & Human Development of the National Institutes of Health under Award Number R21HD080398.

• 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). CTSA grant number(UL1TR000128)

• Medical Research Foundation of OregonCollaborators:• Laurie King, PhD, DPT• Jim Chesnutt MD, Department of Sports Medicine, OHSU• Martina Mancini, PhD Department of Neurology, OHSU• Fay Horak PhD, PT, Department of Neurology, OHSU• Chapman JC PsyD (Dept of Neurology, Washington, DC VAMC)

Participating Universities: Portland State University, Lewis and Clark Univ,George Fox University, Pacific University, Concordia

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

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

Testing revealscognitive deficitsin asymptomaticathletes within 4 days post-concussion

Unique Contribution Of Neurocognitive Testing To Concussion Management

Impact testing in computer labRyan Rockwood, ATC

Module 1: Word Discrimination

Module 2: Design Memory

Module 3: X's and O’s

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

Return to Academic Plan1. 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!

Heads Up: CDC Concussion Tool Kit• Coaches Guide• Athlete and parent Packets• Videos and Educational programs• Media informationwww.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm

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/

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

Partnerships- academics, community and industry

OCAMP

Brain Injury Rehabilitation Center (BIRC)

Stanford

OHSU TBI- PTSD Research to Rehabilitation Scientific Symposium

School of MedicineResearch Roadmap

Collaboration Advancement Award

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

Dr. George Keepers, Chair of PsychiatryDr 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

SLP

PT

3 wks

Vision Therapist

School coordinator

Neuropsychologist

ED

OHSU Concussion Rehab TeamA. Physical Therapy: for vestibular therapy and neck and

associated orthopaedic issues and exercise prescription and therapy.

B. Speech –language Pathologist: for evaluation and treatment to address cognitive and executive function issues

C. Occupational Therapy: for visual and functional therapy.

D. Concussion Coping Clinic and Support GroupThis 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 TeamSports Medicine Doctors

Jim Chesnutt, M.D. Charles Webb, D.O. 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,NCSMarvin Smith, PT, DPT Kitty Leelaamornvichet, PT, DPTSarah McCollister, P.T.,DPTJyndia Schaible, PT, D.P.T.Amy Woods, PT, DPTMargaret McReynolds, P.T., M.S.ED

NeuropsychologySara Walker, PhDMuriel Lezak, PhDLeeza Maron, PhDBonnie Nagel, PhDTrevor Hall, PhDSue Gritzner, PhD

Occupatioanl / Visual TherapyRosane Yee , O.T.R./L., Anne Marie Banasky, OTR/L

Speech/ Cognitive TherapyMichal Rubin, MS, CCC-SLPHaley Landau, MS, CCC-SLP

Certified Athletic TrainersRyan Rockwood, Juliet Baker,

Orthopeadics / SpineFamily MedicineNeurology Peds/ AdultNeurosurgeryPsychiatryAnesthesia/ Pain CenterENT/ vestibularOphthalmologyEmergency MedTraumaInternal MedicinePediatricsRadiology

Interdisciplinary Approach: Concussion Symptoms

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

Concussion

Anxiety/Mood

Ocular

Cognitive

Migraine

Cervical

VestibularAuditory

Autonomic

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• Step wise return to play• Education

– Diagnosis, prognosis and timeline• Reassurance of favorable prognosis

– Symptom management– Assist with proper referrals

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

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. 2004Peterson 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

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)

• Innovations in researchimprove evaluation & treatment • Implement active treatment in home & school

school accommodations, 504 plan, OCAMP.orgMax’s Law Implementation Guide- download

• Free coaches education: You too can take this… www.osaa.org/healthandsafety/concussion.asp

Concussion Final thoughts…Even helmets won’t prevent concussions!

Sports Concussion ManagementContact our sports medicine team for questions:

Jim Chesnutt, M.D. chesnutt@ohsu.eduCharles Webb, D.O. webbch@ohsu.eduRyan Petering, M.D. petering@ohsu.eduMelissa Novak, D.O. novakm@ohsu.edu

Rachel Bengtzen, M.D. bengtzen@ohsu.edu Doug McKeag, M.D. mckeag@ohsu.edu

www.ohsusportsmedicine.com or 503-494-4000