POST CONCUSSION SYNDROMEJose Posas III, MD

3/15/19

Ochsner Regional Neuroscience Symposium

DISCLOSURES

• I have no financial disclosures

GOALS & OBJECTIVES

• To be able to discuss the signs and symptoms of concussion in chronic phases

• To be able to discuss the reasons why patients fall outside of the majority and linger with injuries

• To be able to make the appropriate referrals

• To be able to discuss the consensus from Berlin

DEFINITION

• Giza et al 2013 - Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness.

• 7-14 days 90%

• Broshek et al 2015 – Post Concussion Syndrome … It’s complicated, swipe left

• Weeks/months/years 10%?

CAVEATS

• Population – Langlois et al 2006 – 3.8 million Americans

• Comorbidities

• Assumption of truth

• Allow the exam and tests to prove or disprove this idea

SYMPTOMS

• Cognitive

• Emotional

• Anxiety/Depression/Irritability/Mood

• Sleep/Energy

• Fatigue

• Physical

• Vestibular/Ocular/Cervical/Migraine

SIGNS

COGNITIVE

Tang-Schomer et al 2012Mckee et al 2009

Long termYears? Decades?

Shorter term?

EMOTIONALDavis et al 2017Fralick et al 2016

SLEEP/ENERGYOyegbile et al 2017

Gender differences Minen et al 2016

Linked to comorbid sleep/psych, post traumatic headache

PHYSICAL Schwedt et al 2017

MRI changes

WHY?

VESTIBULOPATHY

CONVERGENCE INSUFFICIENCY

WHIPLASH• Mercer & Bogduk 2001

HEADACHEMinen et al 2016

OCCIPITAL NEURALGIA

COGNITIVE IMPAIRMENT

EMOTIONAL LABILITY

MANAGEMENT

REHAB

PHARMACOLOGIC

INTERVENTIONAL

OCHSNER CONCUSSION MANAGEMENT PROGRAM

• Sports Medicine

• PM&R

• Brain Injury Medicine

• Sports Neurology

• Neuropsychology

• Vestibular Rehab

• Oculomotor Rehab

• Cognitive Rehab

• Vestibular ENT

• Audiology

• Neuro-ophthalmology

• Psychiatry

• Psychology

• Pain Management

• Neurosurgery

• Ortho Spine

BERLINSeptember 2016

April 2017

IMAGING/BIOMARKERS/HBOT

Hawkins et al 2017Crawford et al 2017

Harch et al 2017

THANK YOU

REFERENCES

• 1: Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R. Summary of ev idence-based guideline update: ev aluation and management of concussion in sports: report of the Guideline Dev elopment Subcommittee of the American Academy of Neurology. Neurology. 2013 Jun 11;80(24):2250-7. doi:10.1212/WNL.0b013e31828d57dd. Epub 2013 Mar 18. Rev iew. PubMed PMID: 23508730;PubMed Central PMCID: PMC3721093.

• 2: Broshek DK, De Marco AP, Freeman JR. A rev iew of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228-37.doi: 10.3109/02699052.2014.974674. Epub 2014 Nov 10. Rev iew. PubMed PMID:25383595.

• 3: Langlois JA, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: a brief ov erv iew. Journal of Head Trauma Rehabilitation. 2006;21(5):375-8

• 4:Tang-Schomer MD, Johnson VE, Baas PW, Stewart W, Smith DH. Partial interruption of axonal transport due to microtubule breakage accounts for the formation of periodic v aricosities after traumatic axonal injury. Exp Neurol. 2012 Jan;233(1):364-72. doi: 10.1016/j.expneurol.2011.10.030. Epub 2011 Nov 4. PubMed PMID: 22079153; PubMed Central PMCID: PMC3979336.

• 5: McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gav ett BE, Budson AE, Santini VE, Lee HS, Kubilus CA, Stern RA. Chronic traumatic encephalopathy in athletes: progressiv e tauopathy after repetitiv e head injury. J Neuropathol Exp Neurol. 2009 Jul;68(7):709-35. doi: 10.1097/NEN.0b013e3181a9d503. Rev iew. PubMed PMID: 19535999; PubMed Central PMCID: PMC2945234.

• 6: Dav is GA, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097506SCAT5

• 7: Oyegbile TO, Delasobera BE, Zecav ati N. Gender differences in sleep symptoms after repeat concussions. Sleep Med. 2017 Dec;40:110-115. doi: 10.1016/j.sleep.2017.09.026. Epub 2017 Oct 12. PubMed PMID: 29221773.

• 8: Minen MT, Boubour A, Walia H, Barr W. Post-Concussiv e Syndrome: a Focus on Post-Traumatic Headache and Related Cognitiv e, Psychiatric, and Sleep Issues. Curr Neurol Neurosci Rep. 2016 Nov ;16(11):100. Rev iew. PubMed PMID: 27709555.

• 9: Schwedt TJ, Chong CD, Peplinski J, Ross K, Berisha V. Persistent post-traumatic headache v s. migraine: an MRI study demonstrating differences in brain structure. J Headache Pain. 2017 Aug 22;18(1):87. doi: 10.1186/s10194-017-0796-0. PubMed PMID: 28831776; PubMed Central PMCID: PMC5567584.

• 10: Mercer SR, Bogduk N. Joints of the cerv ical v ertebral column. J Orthop Sports Phys Ther. 2001 Apr;31(4):174-82; discussion 183. PubMed PMID: 11324871.

• 11: Hawkins JR, Gonzalez KE, Heumann KJ. The Effectiv eness of Hyperbaric Oxygen Therapy as a Treatment for Postconcussion Symptoms. J Sport Rehabil. 2017 May;26(3):290-294. doi: 10.1123/jsr.2015-0087. Epub 2016 Nov 11. PubMed PMID: 27834587.

• 12: Crawford C, Teo L, Yang E, Isbister C, Berry K. Is Hyperbaric Oxygen TherapyEffectiv e for Traumatic Brain Injury? A Rapid Ev idence Assessment of the Literature and Recommendations for the Field. J Head Trauma Rehabil. 2017 May/Jun;32(3):E27-E37. doi: 10.1097/HTR.0000000000000256. Rev iew. PubMed PMID: 27603765; PubMed Central PMCID: PMC5426690.