Understanding Brain Concussion: Understanding Brain Concussion: Facts, Assessment, and Facts, Assessment, and

InterventionIntervention

William Garmoe, Ph.D., ABPP-CNWilliam Garmoe, Ph.D., ABPP-CNNational Rehabilitation HospitalNational Rehabilitation HospitalInvestigator, NRH Neurosciences Investigator, NRH Neurosciences

Research CenterResearch CenterAssistant Professor, Clinical Neurology, Assistant Professor, Clinical Neurology, Georgetown University Medical SchoolGeorgetown University Medical School

October 2011October 2011

Conflicts of InterestConflicts of Interest No financial or other conflicts of No financial or other conflicts of

interest related to this presentationinterest related to this presentation

ObjectivesObjectives1.1. Review epidemiology and definitions of Review epidemiology and definitions of

ConcussionConcussion

2.2. Review appropriate assessment techniquesReview appropriate assessment techniques

3.3. Review guidelines for return to work, school, Review guidelines for return to work, school, and athletic playand athletic play

4.4. Describe the NRH-Medstar Concussion ProgramDescribe the NRH-Medstar Concussion Program

Case ExampleCase Example 16 year-old female presented six days following injury 16 year-old female presented six days following injury

from head-to-head collision with opponent while trying from head-to-head collision with opponent while trying to head the ball.to head the ball. No loss of consciousnessNo loss of consciousness No initial gross confusionNo initial gross confusion On sideline trainer concluded no concussionOn sideline trainer concluded no concussion During halftime started to feel dizzy and slowedDuring halftime started to feel dizzy and slowed Concealed symptoms in order to be allowed to play second halfConcealed symptoms in order to be allowed to play second half That evening, dizziness, nausea, bad headache, feeling slowed That evening, dizziness, nausea, bad headache, feeling slowed

downdown At time of presentation, still having headaches, feeling a bit less At time of presentation, still having headaches, feeling a bit less

focused, exhausted when tries to study for more than 30 focused, exhausted when tries to study for more than 30 minutesminutes

Described as mildly more irritable by parentsDescribed as mildly more irritable by parents

Case ExampleCase Example 34 yea-old male presented two weeks after bicycle 34 yea-old male presented two weeks after bicycle

accident. Fell off bike when lost traction on riding path.accident. Fell off bike when lost traction on riding path. Estimated 1-2 minute loss of consciousnessEstimated 1-2 minute loss of consciousness Seen in emergency departmentSeen in emergency department

Negative neurologic exam apart from mild disorientation and Negative neurologic exam apart from mild disorientation and slowed thinkingslowed thinking

Head CT showed no positive findingsHead CT showed no positive findings Neck pain and headaches treated with medicationsNeck pain and headaches treated with medications Told to take 2-3 days off and will be fineTold to take 2-3 days off and will be fine

At time of evaluation was complaining of:At time of evaluation was complaining of: Forgetfulness and reduced concentrationForgetfulness and reduced concentration Irritability in loud/busy settingsIrritability in loud/busy settings PhotophobiaPhotophobia Headaches and reduced staminaHeadaches and reduced stamina Balance problemsBalance problems

Case ExampleCase Example 48 year-old individual presents two years following 48 year-old individual presents two years following

un-witnessed fall at work. Self-report included:un-witnessed fall at work. Self-report included: Estimated loss of consciousness of 15 minutesEstimated loss of consciousness of 15 minutes Immediate onset of poor memory, balance problems, and Immediate onset of poor memory, balance problems, and

marked pain in head, neck, and radiating to arms, all of marked pain in head, neck, and radiating to arms, all of which have continued based on self-reportwhich have continued based on self-report

Has not returned to workHas not returned to work Still reporting marked cognitive impairments. Brought Still reporting marked cognitive impairments. Brought

reports from websites and treatment professionals reports from websites and treatment professionals diagnosing marked brain damage and recommending diagnosing marked brain damage and recommending rehabilitation and possibly disability applicationrehabilitation and possibly disability application

Feeling depressed, anxious, and angryFeeling depressed, anxious, and angry Has seen multiple medical providersHas seen multiple medical providers Feels poorly understood and mistreated by employer and Feels poorly understood and mistreated by employer and

insurance companies. insurance companies.

Concussion is Not NewConcussion is Not New

Concussion in the Public Concussion in the Public SquareSquare

Factors Influencing Our View of Factors Influencing Our View of ConcussionConcussion Military ConflictMilitary Conflict Concerns in Youth SportsConcerns in Youth Sports Emergence of Concerns About Long-Term Emergence of Concerns About Long-Term

Effects in Professional AthletesEffects in Professional Athletes CTECTE

Increased Focus By Health Care ProvidersIncreased Focus By Health Care Providers

Concussion in the Public Concussion in the Public SquareSquare

Emerging Trends in ConcussionEmerging Trends in Concussion Legislation governing management of Legislation governing management of

sports concussionsports concussion Increasing numbers of concussion programsIncreasing numbers of concussion programs Pre-screening of youth, amateur, and Pre-screening of youth, amateur, and

professional athletesprofessional athletes Protocols governing return to playProtocols governing return to play Enormous increase in research dollarsEnormous increase in research dollars Great misunderstanding about Great misunderstanding about

concussion in internet, media concussion in internet, media accounts, etc.accounts, etc.

www.youtube.com/watch?v=KqQwFmW6Sac

Epidemiology of Traumatic Brain Injury Epidemiology of Traumatic Brain Injury (TBI)(TBI)

Centers for Disease Control (CDC)Centers for Disease Control (CDC)www.cdc.gov

In the United States each year:In the United States each year: 1.7 million individuals sustain a TBI1.7 million individuals sustain a TBI 275,000 need hospitalization275,000 need hospitalization 52,000 of these injuries are fatal52,000 of these injuries are fatal 80% (approximately 1.3 million) are MTBI/Concussion80% (approximately 1.3 million) are MTBI/Concussion

Leading Causes of TBILeading Causes of TBI Falls (35.2%)Falls (35.2%) Motor Vehicle Accidents (16.5%)Motor Vehicle Accidents (16.5%) Other types of blow to head (19%)Other types of blow to head (19%) Assaults (10%)Assaults (10%) Unknown/Other (21%)Unknown/Other (21%)

TBI Causes: From CDC - NCIPCTBI Causes: From CDC - NCIPC

What is a Concussion?What is a Concussion? Sources of Definitions/CriteriaSources of Definitions/Criteria

CDCCDC ACRMACRM WHOWHO DVBICDVBIC Vienna and Prague Statements (CSIG)Vienna and Prague Statements (CSIG) AANAAN

ACRM - BSIGACRM - BSIG MTBI involves “a traumatically induced physiological MTBI involves “a traumatically induced physiological

disruption of brain function, manifested by at least disruption of brain function, manifested by at least one of the following”one of the following”1.1. Any period of loss of consciousness (LOC)Any period of loss of consciousness (LOC)2.2. Any amnesia for events immediately prior to or Any amnesia for events immediately prior to or

following the accident/eventfollowing the accident/event3.3. Any alteration in mental status at time of the Any alteration in mental status at time of the

accident/event (e.g., dazed, confused, etc.)accident/event (e.g., dazed, confused, etc.)4.4. Focal neurologic signs may or may not be presentFocal neurologic signs may or may not be present

LOC less than 30 minutes LOC less than 30 minutes GCS 13-15 within 30 minutesGCS 13-15 within 30 minutes PTA less than 24 hours PTA less than 24 hours

CDC Mild TBI Work Group CDC Mild TBI Work Group Definitions Subgroup (2003)Definitions Subgroup (2003)

Occurrence of injury to head resulting from blunt Occurrence of injury to head resulting from blunt trauma or acceleration/deceleration (1 or more of trauma or acceleration/deceleration (1 or more of following):following): Observed or self-reported transient confusion, Observed or self-reported transient confusion,

disorientation, or impaired consciousness.disorientation, or impaired consciousness. Observed or self-reported dysfunction of memory Observed or self-reported dysfunction of memory

around time of injury.around time of injury. Observed signs of neurological/neuropsychological Observed signs of neurological/neuropsychological

dysfunction.dysfunction. LOC < 30 min.LOC < 30 min. PTA < 24 hrs.PTA < 24 hrs. No penetrating craniocerebral injury.No penetrating craniocerebral injury.

DVBIC: Acute Management of Mild TBI DVBIC: Acute Management of Mild TBI in Military Operational Settingin Military Operational Setting

““Mild TBI in military operational settings is defined Mild TBI in military operational settings is defined as an injury to the brain resulting from an as an injury to the brain resulting from an external force and/or acceleration/deceleration external force and/or acceleration/deceleration mechanism from an event such as a blast, fall, mechanism from an event such as a blast, fall, direct impact, or motor vehicle accident which direct impact, or motor vehicle accident which causes an alteration in mental status typically causes an alteration in mental status typically resulting in the temporally related onset of resulting in the temporally related onset of symptoms . . . “symptoms . . . “

(from DVBIC 3(from DVBIC 3rdrd Annual TBI Military Training Conference Annual TBI Military Training Conference and DVBIC Clinical Practice Guidelines)and DVBIC Clinical Practice Guidelines)

MTBI/Concussion Severity GradingMTBI/Concussion Severity Grading American Academy of American Academy of

Neurology (AAN) (1997)Neurology (AAN) (1997) Grade 1: Grade 1:

Transient confusion Transient confusion No LOCNo LOC Symptoms resolve Symptoms resolve withinwithin 15 15

minutesminutes Grade 2: Grade 2:

Transient confusionTransient confusion No LOCNo LOC Symptoms last Symptoms last longerlonger than than

15 minutes15 minutes Grade 3: Grade 3:

Any LOC presentAny LOC present

Prague Statement Prague Statement (2004)(2004)

Simple Concussion: Simple Concussion: Concussion that resolves Concussion that resolves without complication over without complication over 7-10 days7-10 days

Complex Concussion: Complex Concussion: Persistent symptoms, Persistent symptoms, specific complications, LOC specific complications, LOC of >1 minute, or prolonged of >1 minute, or prolonged cognitive impairments.cognitive impairments.

Multiple/Repeat concussions Multiple/Repeat concussions classified as complexclassified as complex

MTBI/Concussion and LOCMTBI/Concussion and LOC Historically, MTBI was defined in terms of a Historically, MTBI was defined in terms of a

short period of loss of Consciousnessshort period of loss of Consciousness Current diagnostic approach:Current diagnostic approach:

LOC is not a necessary element of concussionLOC is not a necessary element of concussion

In large percentage of concussions, possibly In large percentage of concussions, possibly the majority, the majority, there is no LOCthere is no LOC..

Retrograde and anterograde amnesia are Retrograde and anterograde amnesia are also typically briefalso typically brief

MTBI/Concussion Severity GradingMTBI/Concussion Severity Grading

Williams et al. (1990)Williams et al. (1990) Distinguished ‘Mild’ from ‘Complicated-Mild’ Distinguished ‘Mild’ from ‘Complicated-Mild’

TBI on basis of presence of positive findings TBI on basis of presence of positive findings on neuro-imaging.on neuro-imaging.

Patients with MTBI presentation but also Patients with MTBI presentation but also positive neuro-imaging findings positive neuro-imaging findings (‘Complicated-Mild’) have outcomes more (‘Complicated-Mild’) have outcomes more similar to moderate TBI.similar to moderate TBI.

Symptoms Following ConcussionSymptoms Following Concussion CognitiveCognitive

DazedDazed Poor ConcentrationPoor Concentration Impaired MemoryImpaired Memory Confusion/Confusion/

DisorientationDisorientation Slowed ThinkingSlowed Thinking

• EmotionalEmotional IrritabilityIrritability Changes in moodChanges in mood AnxiousAnxious

SomaticSomatic HeadacheHeadache Dizziness/imbalanceDizziness/imbalance Nausea/vomitingNausea/vomiting Photo/phonophobiaPhoto/phonophobia Other visual problemsOther visual problems

• Sleep RelatedSleep Related FatigueFatigue Sleep dysfunctionSleep dysfunction

Loss of Consciousness (LOC) and Loss of Consciousness (LOC) and Post-Traumatic Amnesia (PTA)Post-Traumatic Amnesia (PTA)

Loss of Consciousness (LOC) of <1 minute not Loss of Consciousness (LOC) of <1 minute not strongly related to outcomestrongly related to outcome

LOC of >1 minute – not clear how closely related LOC of >1 minute – not clear how closely related to outocmeto outocme

Post-Traumatic Amnesia (PTA) duration quickly Post-Traumatic Amnesia (PTA) duration quickly loses utility in predicting outcomeloses utility in predicting outcome

Consideration of mental status changes at time of Consideration of mental status changes at time of injury may be more salientinjury may be more salient

Physical/Mechanical Force VariablePhysical/Mechanical Force Variable

Many studies are examining minimum Many studies are examining minimum biomechanical threshold that will cause MTBI; biomechanical threshold that will cause MTBI; rotational versus translational force may mediate rotational versus translational force may mediate this thresholdthis threshold

MTBI can occur in the absence of LOC and a MTBI can occur in the absence of LOC and a direct blow to the headdirect blow to the head

What about symptoms in absence of LOC or What about symptoms in absence of LOC or altered mental status at time of injury?altered mental status at time of injury?

Pathophysiology of MTBIPathophysiology of MTBI

MTBI initiates a progressive neuro-metabolic cascade that MTBI initiates a progressive neuro-metabolic cascade that involves ionic shifts, altered brain metabolism, and involves ionic shifts, altered brain metabolism, and disrupted neuronal connectivity and neurotransmissiondisrupted neuronal connectivity and neurotransmission

The reversal of this cascade likely takes days to weeks The reversal of this cascade likely takes days to weeks following onset of injuryfollowing onset of injury

Time course of recovery from the neuro-metabolic Time course of recovery from the neuro-metabolic cascade seems to correlate with natural history of cascade seems to correlate with natural history of symptoms and recovery, though there is some symptoms and recovery, though there is some disagreement about thisdisagreement about this

Newer neuro-imaging methods appear to be showing Newer neuro-imaging methods appear to be showing greater sensitivity to identifying damage, but clinical greater sensitivity to identifying damage, but clinical utility of these approaches is still being establishedutility of these approaches is still being established

Neuro-metabolic Neuro-metabolic Cascade of MTBICascade of MTBI

MTBI initiates a MTBI initiates a neuro-metabolic neuro-metabolic cascade that involves cascade that involves ionic shifts, altered ionic shifts, altered brain metabolism, brain metabolism, and disrupted and disrupted neuronal connectivity neuronal connectivity and and neurotransmissionneurotransmission

Symptoms Following Concussion: Symptoms Following Concussion: How Specific?How Specific?

CognitiveCognitive DazedDazed Poor ConcentrationPoor Concentration Impaired MemoryImpaired Memory Confusion/Confusion/

DisorientationDisorientation Slowed ThinkingSlowed Thinking

• EmotionalEmotional IrritabilityIrritability Changes in moodChanges in mood AnxiousAnxious

SomaticSomatic HeadacheHeadache Dizziness/imbalanceDizziness/imbalance Nausea/vomitingNausea/vomiting Photo/phonophobiaPhoto/phonophobia Other visual problemsOther visual problems

• Sleep RelatedSleep Related FatigueFatigue Sleep dysfunctionSleep dysfunction

Symptoms Following Concussion: Symptoms Following Concussion: How Specific?How Specific?

DSM-IV Symptoms of DSM-IV Symptoms of Depression IncludeDepression Include Sleep Sleep

DisturbanceDisturbance FatigueFatigue Motor SlowingMotor Slowing Poor Poor

ConcentrationConcentration Slowed ThinkingSlowed Thinking IrritabilityIrritability

Iverson & McCracken Iverson & McCracken (1997)(1997)

Individuals with chronic pain and no Individuals with chronic pain and no TBITBI Majority of patients reported Majority of patients reported

disturbed sleep, fatigue, and disturbed sleep, fatigue, and irritabilityirritability

29% forgetfulness29% forgetfulness 18% difficulty maintaining 18% difficulty maintaining

attentionattention 16.5% difficulty with 16.5% difficulty with

concentration or thinkingconcentration or thinking 80.6% endorsed 3+ symptoms 80.6% endorsed 3+ symptoms

from Cat C of DSM-IVfrom Cat C of DSM-IV

Recovery and TreatmentRecovery and Treatment

Natural Course of RecoveryNatural Course of Recovery “ “ . . . a single, uncomplicated MTBI is a transient . . . a single, uncomplicated MTBI is a transient

neurologic event followed by relatively rapid and neurologic event followed by relatively rapid and spontaneous recovery . . .”spontaneous recovery . . .”

McCrea, 2008McCrea, 2008

By far the prototypic recovery pattern is rapid or By far the prototypic recovery pattern is rapid or gradual symptom resolution over a period of days or gradual symptom resolution over a period of days or weeksweeks

By 3 months post-injury, neuropsychological measures By 3 months post-injury, neuropsychological measures typically show no residual impairmenttypically show no residual impairment

Most individuals return to normal social, occupational, Most individuals return to normal social, occupational, and recreational functioning within several weeksand recreational functioning within several weeks

Natural Course of RecoveryNatural Course of Recovery

Clinical lore suggests that 15% remain symptomatic Clinical lore suggests that 15% remain symptomatic over longer period, sometimes chronicallyover longer period, sometimes chronically

Some suggest that the 15% figure is an over-Some suggest that the 15% figure is an over-estimation due to misinterpretation of data – that estimation due to misinterpretation of data – that the actual percentage is much lowerthe actual percentage is much lower

Following a single, uncomplicated concussion, Following a single, uncomplicated concussion, persistent symptoms and poor functional outcome persistent symptoms and poor functional outcome often associated with “non-injury” related variablesoften associated with “non-injury” related variables

Complicated Course of RecoveryComplicated Course of Recovery Misdiagnosed injury: TBI more severe than initially Misdiagnosed injury: TBI more severe than initially

identifiedidentified

Collateral injuries (musculoskeletal, vestibular) with Collateral injuries (musculoskeletal, vestibular) with symptoms that mimic or overlap MTBIsymptoms that mimic or overlap MTBI

Comorbidities such as depression, anxiety, substance Comorbidities such as depression, anxiety, substance abuseabuse

Recurrent MTBIRecurrent MTBI

Second-Impact SyndromeSecond-Impact Syndrome

Post-Concussive SyndromePost-Concussive Syndrome

Recurrent MTBIRecurrent MTBI Recurrent MTBI appears to be associated with more Recurrent MTBI appears to be associated with more

significant post-injury deficits, prolonged recovery significant post-injury deficits, prolonged recovery time, and higher risk for lasting neurologic and time, and higher risk for lasting neurologic and psychiatric disturbancepsychiatric disturbance Some question whether this applies to repeat Some question whether this applies to repeat

concussion following fully resolved prior eventconcussion following fully resolved prior event Increases risk for subsequent concussionIncreases risk for subsequent concussion Not all studies show an added effect of repeat MTBINot all studies show an added effect of repeat MTBI Current research examining potential long-term Current research examining potential long-term

effects of repeat concussioneffects of repeat concussion CTECTE Possible higher risk for other dementiasPossible higher risk for other dementias

Post-Concussion Syndrome (PCS)Post-Concussion Syndrome (PCS)

Good Reasons Not to Use PCSGood Reasons Not to Use PCS Significant differences in criteria between Significant differences in criteria between

ICD-10 and DSM-IVICD-10 and DSM-IV Used in variable waysUsed in variable ways

DSM-IV and ICD-10 refer to persistent symptomsDSM-IV and ICD-10 refer to persistent symptoms Emergency departments may use the label in Emergency departments may use the label in

discharge instructions following concussiondischarge instructions following concussion Nonspecificity of symptomsNonspecificity of symptoms

Symptom pattern can apply to many conditionsSymptom pattern can apply to many conditions

ICD-10 and DSM-IV CriteriaICD-10 and DSM-IV Criteria

DSM-IV Research CriteriaDSM-IV Research Criteria History of head trauma with History of head trauma with

significant cerebral concussion significant cerebral concussion NP evidence of attention or NP evidence of attention or

memory problemsmemory problems 3+ symptoms persisting past 3 3+ symptoms persisting past 3

monthsmonths Symptoms follow head injury or Symptoms follow head injury or

worsen after head injuryworsen after head injury Significant disturbance in Significant disturbance in

social/occupational functioning social/occupational functioning or decline from previous levelsor decline from previous levels

Not accounted for by other Not accounted for by other mental disordermental disorder

ICD-10 (310.2)ICD-10 (310.2) History of head trauma with History of head trauma with

LOC precedes symptoms by 4 LOC precedes symptoms by 4 weeksweeks

Symptoms in 3+ categoriesSymptoms in 3+ categories Headache, dizziness, …Headache, dizziness, … Irritability, depression …Irritability, depression … Concentration, memory … Concentration, memory …

without NP evidence without NP evidence InsomniaInsomnia Reduced alcohol toleranceReduced alcohol tolerance Preoccupation with above Preoccupation with above

SymptomsSymptoms

Nonspecificity of PCS SymptomsNonspecificity of PCS Symptoms

Supporting Optimal Supporting Optimal Recovery from MTBIRecovery from MTBI

Concussion: Immediate Medical Concussion: Immediate Medical ResponseResponse

Medical care should be sought immediately after a concussion:Medical care should be sought immediately after a concussion: The person usually should be taken to an emergency room or urgent The person usually should be taken to an emergency room or urgent

care centercare center The medical team will do an evaluation and may get a CT scan of the 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 concussionbrain to be sure the injury is not worse than a concussion Most people with concussion do not need to stay in the hospitalMost people with concussion do not need to stay in the hospital The medical team will treat symptoms, possibly prescribe pain The medical team will treat symptoms, possibly prescribe pain

medication, and refer the person to a physician or a concussion medication, and refer the person to a physician or a concussion treatment centertreatment center

During athletic events, the person may be evaluated by a certified During athletic events, the person may be evaluated by a certified athletic trainer or coach, who will help determine what should be done athletic trainer or coach, who will help determine what should be done nextnext

If for any reason the person does not go to a hospital or urgent care 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 possiblecenter, he/she should call his/her physician as soon as possible

Monitoring Early RecoveryMonitoring Early Recovery In the days following concussion, if any of the In the days following concussion, if any of the

following occur, a medical emergency may be following occur, a medical emergency may be happening that requires immediate attention:happening that requires immediate attention: Onset of a severe headache that is the worst pain imaginableOnset of a severe headache that is the worst pain imaginable Rapidly falling into a deep sleep from which the person Rapidly falling into a deep sleep from which the person

cannot be wakenedcannot be wakened Sudden problems with fallingSudden problems with falling New numbness or weakness on one side of the bodyNew numbness or weakness on one side of the body Onset of severe confusion much worse than following the Onset of severe confusion much worse than following the

concussionconcussion Severe vomitingSevere vomiting SeizuresSeizures

Support Natural Course of Support Natural Course of RecoveryRecovery

The best treatment for the first several days or weeks The best treatment for the first several days or weeks following concussion is to rest the brain and body: following concussion is to rest the brain and body: For the first few days it is best to minimize the amount of time For the first few days it is best to minimize the amount of time

reading, watching television, spending time on-line, texting, etc. reading, watching television, spending time on-line, texting, etc. It is not good to do absolutely nothing, but rather keep activity It is not good to do absolutely nothing, but rather keep activity very low.very low.

Keep mental, physical, and emotional stress lowKeep mental, physical, and emotional stress low Take time off work and schoolTake time off work and school Take time off from exercise/physical exertion Take time off from exercise/physical exertion Sleep as much as necessarySleep as much as necessary Take in adequate liquids and foodTake in adequate liquids and food Avoid all alcoholAvoid all alcohol Remind yourself that you will get better with timeRemind yourself that you will get better with time

Support Natural Course of Support Natural Course of RecoveryRecovery

Gradual return to activities:Gradual return to activities: Start off slowly returning to mental activity, physical Start off slowly returning to mental activity, physical

activity, work, and sports/exerciseactivity, work, and sports/exercise If symptoms get worse when activity If symptoms get worse when activity

increases, it is a sign to back off and go more increases, it is a sign to back off and go more slowlyslowly

Take frequent breaks as you increase your activity Take frequent breaks as you increase your activity level. Take breaks even if you are feeling good, level. Take breaks even if you are feeling good, because this will help prevent symptoms from because this will help prevent symptoms from coming backcoming back

Students/Athletes: Follow ACE GuidelinesStudents/Athletes: Follow ACE Guidelines

Support Natural Course of Support Natural Course of RecoveryRecovery

Factors that may slow down or interfere with recovery Factors that may slow down or interfere with recovery can include:can include: Pre-existing medical conditions such as headaches, tinnitus Pre-existing medical conditions such as headaches, tinnitus

(constant ringing in the ear), chronic pain, ADD/ADHD, or (constant ringing in the ear), chronic pain, ADD/ADHD, or other neurologic conditionsother neurologic conditions

A prior history of concussionsA prior history of concussions Other physical injuries from the event that cause lasting painOther physical injuries from the event that cause lasting pain Pre-existing psychological conditions such as depression, Pre-existing psychological conditions such as depression,

anxiety, PTSD, alcohol or other drug abuseanxiety, PTSD, alcohol or other drug abuse A strong sense of emotional trauma about the event that A strong sense of emotional trauma about the event that

caused the concussion that does not go awaycaused the concussion that does not go away Ongoing legal or insurance issues related to the concussionOngoing legal or insurance issues related to the concussion

How Long Does Recovery Take?How Long Does Recovery Take?

. . . As Long As It Takes. . . As Long As It Takes

(taken from E. Diebert, MD)(taken from E. Diebert, MD)

Medstar-NRH Concussion Medstar-NRH Concussion ProgramProgram

   Recovering from Brain Recovering from Brain

Concussion: Concussion: Information and Practical Information and Practical

SuggestionsSuggestions   

National Rehabilitation National Rehabilitation Hospital Concussion ClinicHospital Concussion Clinic

And And Medstar Sports HealthMedstar Sports Health

Children’s National Medical Center Children’s National Medical Center (CNMC)(CNMC)

Washington, DCWashington, DC

Rationale for Concussion ProgramRationale for Concussion Program Concussion a significant public health issueConcussion a significant public health issue Concussion is often under-recognized and under-Concussion is often under-recognized and under-

appreciatedappreciated Return to work, school, athletics prematurely can Return to work, school, athletics prematurely can

exacerbate symptomsexacerbate symptoms In very rare circumstances, premature return to In very rare circumstances, premature return to

athletics may result in SIPathletics may result in SIP Early intervention can lead to better outcomeEarly intervention can lead to better outcome Few athletes turn pro, but all turn adultFew athletes turn pro, but all turn adult Inoculate against PCSInoculate against PCS Legislation increasingly mandates expert evaluation Legislation increasingly mandates expert evaluation

and clearance following concussionand clearance following concussion

Education and Baseline Education and Baseline AssessmentAssessment

Medstar and Children’s National Medical Medstar and Children’s National Medical Center efforts:Center efforts: public education about concussion to schools, public education about concussion to schools,

athletic clubs (professional, amateur, and athletic clubs (professional, amateur, and recreational)recreational)

Baseline screening for athletic teams using Baseline screening for athletic teams using ImPACTImPACT

Training to Athletic Trainers and CoachesTraining to Athletic Trainers and Coaches Research to further understanding of MTBIResearch to further understanding of MTBI Advocacy on public policy mattersAdvocacy on public policy matters

Concussion Management ProtocolConcussion Management Protocol ReferralsReferrals

Emergency departmentsEmergency departments Primary care physiciansPrimary care physicians Self-referralsSelf-referrals Coaches and trainersCoaches and trainers Case Managers/Care CoordinatorsCase Managers/Care Coordinators Occupational Health Clinics/ProgramsOccupational Health Clinics/Programs

NRH Concussion Management NRH Concussion Management ProtocolProtocol

Referrals scheduled to be seen within Referrals scheduled to be seen within seven daysseven days

Initial Assessment:Initial Assessment: Brain Injury Physician EvaluationBrain Injury Physician Evaluation

Neurologic examNeurologic exam Symptom reviewSymptom review Balance assessment using the Balance Error Scoring Balance assessment using the Balance Error Scoring

System (BESS)System (BESS) Neuropsychology EvaluationNeuropsychology Evaluation

Detailed clinical interviewDetailed clinical interview Neuropsychological Screening – depending on Neuropsychological Screening – depending on

referralreferral ImPACT – depending on type of referralImPACT – depending on type of referral

NRH Concussion Management NRH Concussion Management ProtocolProtocol Initial InterventionsInitial Interventions

Education about concussionEducation about concussion Provide in-person feedback and informationProvide in-person feedback and information NRH Concussion Booklet, ACE, SCORE, etc.NRH Concussion Booklet, ACE, SCORE, etc.

Recommendations for return to school, Recommendations for return to school, athletics, work, etc.athletics, work, etc.

Treatment of symptoms on as-needed basisTreatment of symptoms on as-needed basis Schedule follow-up depending on symptom Schedule follow-up depending on symptom

presentationpresentation Rapid recovering patients – may not need follow-up Rapid recovering patients – may not need follow-up

appointmentappointment Slow-recovering or unusual symptoms – follow-up Slow-recovering or unusual symptoms – follow-up

appointment scheduledappointment scheduled

NRH Concussion Management NRH Concussion Management ProtocolProtocol

Guiding Principles of Early Treatment:Guiding Principles of Early Treatment: Lots of restLots of rest Gradual return to daily activitiesGradual return to daily activities Activities that provoke active symptoms, Activities that provoke active symptoms,

back offback off Treat symptoms on a prn basisTreat symptoms on a prn basis Create a positive expectation for recoveryCreate a positive expectation for recovery

NRH Concussion Management ProtocolNRH Concussion Management Protocol Return to Play Following Sports Return to Play Following Sports

ConcussionConcussion Legislation in DC, Maryland, Virginia, many Legislation in DC, Maryland, Virginia, many

other states mandate formal clearance by other states mandate formal clearance by trained health care professionalstrained health care professionals

Athlete should be asymptomatic for:Athlete should be asymptomatic for: Subjective complaintsSubjective complaints Neuropsychological assessmentNeuropsychological assessment

Screening battery and/or ImPACT if baselinedScreening battery and/or ImPACT if baselined No symptoms at physical rest, in normal No symptoms at physical rest, in normal

activities, and under exertionactivities, and under exertion Protocols exist for gradual return to exercise, Protocols exist for gradual return to exercise,

formal drills, team-practices, and gamesformal drills, team-practices, and games

NRH Concussion Management ProtocolNRH Concussion Management Protocol

Exceptions to Usual ProtocolExceptions to Usual Protocol Recurrent concussionRecurrent concussion Evidence of more severe TBIEvidence of more severe TBI Greater than two months post-concussionGreater than two months post-concussion Patients referred with PCSPatients referred with PCS Known history of major potential Known history of major potential

complicating factors (e.g., prominent complicating factors (e.g., prominent psychiatric or substance abuse history, psychiatric or substance abuse history,