Concussion Care in College Health

Expanding Knowledge and New Perspectives

Peter C. Doyle MD

Concussion-what is it?• A mild traumatic brain injury with no significant

findings on currently available neuroimaging devices (CT, MRI). Sudden impacts with rotational acceleration of the head are a common cause.

• An injury of neuronal tracts and mitochondria that disrupts the normal sodium-potassium-calcium channels responsible for transmission of nerve impulses.

• This damage is on an axonal level and takes ATP energy to repair.

What is happening at the level of the axon? Worst case:

What happens most often.

Axonal repair.

• A healthy brain uses 25% of our energy output on a daily basis.

• The injured brain requires many more calories to effect repairs

• This increased energy need is thought to account for a large part of the profound fatigue often felt after concussion.

Diagnosis of Concussion

• Usually by history of the injury or by direct observation of the event.

• Easy dx with high energy impacts ( high speed collision in contact sports, fall from bicycle, hit by boom on the sailing team etc.)

• Harder diagnosis with minor injuries ( I stood up fast bumped my head on a shelf, a tennis ball hit me on the head etc.)

Disposition of the concussion Patient if you are the initial evaluator!

• When in doubt, send them out! Beware of:• High energy injury – MVA, bike etc.• Shoulders, clavicles, wrists, knees may mean

concussion too!• Any Loss of Consciousness• Any neuro deficits• A History or suspicion of intoxication• Worsening symptoms

Disposition of the concussion patient sent to you from the ED or another

clinician.

• Exactly the same as above!• Re-evaluate!• Trust yourself!• Be most cautious during the first three days!

Why I like the CDC’s “Mild TBI Pocket Guide”

• It reminds me to look out for intoxication!• Ask about medications - especially

anticoagulants• Look for physical evidence of trauma above

the clavicle• Don’t forget age!• A dangerous mechanism is defined as ejection

from a motor vehicle, a pedestrian struck, and a fall from a height > 3 feet or 5 steps

Remember the Red Flags!• Neck pain or tenderness• Double vision• Weakness or tingling/burning in arms or legs• Severe or increasing headache• Seizure or convulsion• Loss of consciousness• Deteriorating conscious state• Vomiting• Increasingly restless, agitated or combative

The Good News

• Symptoms will get better• Most minor concussions require no special

care – 70-80% will resolve on their own.• Treatment is available for the bad ones.• Research is continually producing useful hints

about prognosis and therapy.

The Bad News.• There is tremendous fear and anxiety associated

with this illness.• No real consensus on management.• Wide variability in terms of symptoms.• Wide variability in terms of recovery times.• Little correlation between level of initial injury

and development of post concussive syndrome!• Outcomes can be substantially affected by

various pre-existing conditions.

Pre-existing conditions to be aware of:

• Motion sickness• Migraine headaches• ADD ADHD Learning disabilities• Depression• Anxiety• Insomnia• Convergence Insufficiency

Evaluation and Management of Concussion

• Once severe injury is ruled out, think in terms of identifying major symptoms.

• Objective symptoms - ocular, vestibular and cervical.

• More subjective symptoms – cognitive, fatigue, anxiety/mood, post traumatic headache.

Look at the whole patient.• Think of the 6 common symptom pattern model:- Vestibular- Ocular- Cognitive/Fatigue- Anxiety/Mood- Post Traumatic Migraine- Cervical/Neck Pain• Most concussions will exhibit more than one pattern- Possible 7th pattern - neuroendocrine

Cervicalgia – neck pain

• Assess for gross defects (limited ROM, acute vertebral tenderness to palpation, acute muscle spasms).

• Treat with nsaids, initial ice for 10 minutes TID and after 2 – 3 days, alternating heat and ice.

• Gentle stretching as tolerated.• Refer to Chiropractic, Ortho or PT if the

student is willing to go.

Vestibular and Oculomotor deficits are highly prevalent

following concussion.

Convergence insufficiency identifies athletes at Risk of prolonged recovery from Sports

related concussion.Am J Sports Med. 2017 Aug;45(10):2388-2393. doi: 10.1177/0363546517705640. Epub 2017 May 16

Prevalence of Ocular Deficits - Overview

• In the Normal Population• Convergence Insufficiency – 5%• Accommodation Insufficiency– 6%• Abnormal Eye Movements – age-related• After Concussion/mTBI• Convergence Insufficiency – 30%-45%• Accommodation Insufficiency – 20%-50%• Abnormal Eye Movements – 20%-40%

Ask about pre-existing Ocular conditions

• Convergence insufficiency• Phorias/Lazy Eye• History of poor depth perception• History of poor eye-hand coordination• Prior eye surgery or therapy• Abnormalities of binocular vision

Management of Ocular deficits

• If new CI, AI, loss of binocular vision, blurry vision or severe intolerance to light are present, consider prompt referral to a Optometrist familiar with post concussion ocular therapy

• Ocular deficits can be highly disconcerting and will drive other symptoms such as headache and dizziness very quickly.

Ocular evaluation - VOMs

Visual Motion Sensitivity test.

• The test that most commonly provokes symptoms in my experience.

• The vestibular ocular reflex is also commonly provocative

• Use the VOMs to identify injury, practicing all provocative tests for a few minutes once or twice a day can become effective therapy.

• Look for laterality of injury.• Refer slow responders to OT promptly.

Ocular therapy and management of symptoms

• If gross ocular deficits are detected, why wait to begin treatment?

• For C.I. pencil push-ups or a Brock String.• Practice suppressing VMS, OKN and VOR – start slow

and increase speed as patient improves.• Practice accommodation for A. I.• Practice saccades, smooth pursuits, mazes are great!• Consider sunglasses, tints for screens, cut outs to

focus on one paragraph at a time.

Does vision therapy work?• Vision Therapy/ Rehabilitation was recommended for

82.5% of patients• Convergence Insufficiency• Successful outcome: 83%• Improved: 15%• Accommodative Insufficiency• Successful outcome: 33%• Improved: 67%• Saccadic Dysfunction• Successful outcome: 71%• Improved: 2%

Scheimann et al. CHOP 2018

Vestibular Evaluation and Management

• Tandem gait testing and Single leg stance are most often positive. Look for laterality.

• Testing with eyes open and closed – watch for falls with tandem gait! Dual task is more sensitive.

• Finger to nose test is rarely useful for me.• Once again, use deficits to guide therapy. Consider

practicing one legged stance on firm floor and progress to foam pad etc. Practice bad side 3x more often than good side.

• Simple exercises are available on YouTube – See Leslie Montgomery Concussion

Practical Experience Time!

• VOMs• Balance• These exercises will improve symptoms.• They will give patients a sense of control.• They will provide a metric of improvement.• They can give us a sense of when to send for

specialty care.

Documenting oculomotor and vestibular tests

Formal BESS and VOMS testing takes time. I use a 3 level scale.

1. Feels normal2. Doesn’t feel right3. Feels way wrong/ I’m going to barf!

Trust what your patients are telling you. They will know what doesn’t feel right!

Cognitive Evaluation and Management of Cognitive

Complaints

• Symptoms are almost always very alarming in our population!

• Currently a very subjective evaluation -most people can do serial 7’s etc.

• Symptoms are worse with screen time, busy environments, background noise and motion.

• Best treated with stimulus control, sleep, and early exercise. Avoid alcohol!!!

• Restart cognitive effort after 1-2 days. Try 10-30 minutes once or twice a day to start. If unable to study in the morning try again in the afternoon. Advance as you would exercise.

• It is ok to pretreat with acetaminophen or ibuprofen to control headache pain.

Main drivers of cognitive symptoms?

• Initially in 1-3 days - ? Spreading mitochondrial dysfunction and energy deficit due to calcium influx etc.

• Short term – energy deficit plus ocular/vestibular injury patterns

• Pain and headache.• Mid to longer term – ocular injury plus

insomnia, circadian rhythm disruptions.

Medications for cognitive therapy.

• Manage environments first – meds alone are a bad idea.

• Amantadine 100mg PO BID ?• Sleep aids if necessary.• Supplements – more on this later.• Stimulants verrry rarely.• Generally left to concussion clinics and used

for patients with post concussion symptoms.

Cognitive Management continued.• Exercise should be delayed by 1-2 days then begun at low

level in a safe way – stationary bikes are excellent. • Exercise is now associated with better outcomes and is

clearly indicated for Post Concussion Syndrome (Leddy 2016)

• Exert to a low symptom level – HA pain of 3-4 is acceptable. It’s ok to use nsaids to pretreat.

• If patient does well you can advance level of exertion rapidly.

• Expect 2 steps forward, one step back. Go to more complex exercise when full in-line exertion is tolerated

Reinforce good learning techniques.

• Start a learning session with a technique to control the stress response:

- Mindfulness meditation- Somatic muscle relaxation- Positive reminiscence- Interact with a friendly dog • Use study sprints – set intervals with a reward for

completion, start with 10 or 20 minutes. • Mix subjects to avoid overload.• Never cram!

Manage bad environments.

Recommend good environments.

Post traumatic migraine/headache.

• Migraine tendency can be unmasked by concussion• It is often part of the fatigue, insomnia and brain fog

picture. This pain can be debilitating.• Consider early use of medication if the HA is keeping

students from class. • Try to determine the precipitants: Is the headache

coming from vestibular causes (dizziness/balance/vision) or is it classic migraine?

• Is there a musculoskeletal component? Is HA pain radiating up from the neck? Use chiropractic and physical therapy.

• Be sure to r/o other causes like sinus pressure/sinus HA

• Reinforce sleep, 7-9 hours only, short or no naps!

Headache treatment.

• Start with regular meals and good hydration - 80oz of water per day!

• Use nsaids first-line but if not effective, consider Amitriptyline/Nortriptyline as they are good prophylactic agents and can help with sleep.

• If you have a patient with dizziness related HA, consider Klonopin for its vestibular suppression and as a sleep aid. Be sure to send for vestibular therapy at PT

• Triptans are ok, be careful with caffeine containing meds to avoid sleep disturbances. Gabapentin may work.

• Reinforce regular bedtimes and keep naps to 20 minutes if at all. Strictly avoid alcohol!

Mood/Anxiety• Always use education and reassurance. 2 steps forward and 1

back is still a step forward! Be positive!• Avoid isolation, do not let patients remain in a dark room!• Start exercise after 1-3 days, even if a gentle walk is all that is

tolerated. Advance this quickly if no or minimal symptoms.• Encourage increased contact with pre-existing BH providers

and refer promptly.• Consider meds: Vistaril, brief klonopin, SSRI’s if necessary.• Reinforce sleep hygiene! Strictly avoid alcohol and drugs!

Concussion care – diet and supplements.

• A controversial subject – no one agent has been shown to be helpful. Studies are pending but many clinicians are starting to recommend various products.

• Several studies of sTBI have shown benefit from various supplements/diets.

• The brain gets 25% of our energy intake ordinarily, the concussed brain needs more.

• A good diet prior to concussion is a sign of a good prognosis.

General Dietary Advice from Spaulding Rehab.

• Mediterranean type diets are best.• Avoid sweets, refined flours, soda, high fructose corn

syrup, even honey• Choose whole grains, beans, legumes, sweet

potatoes, bright colored fruits and leafy greens. Eat the rainbow!

• Surprise! saturated fat from dairy is ok but pass on the red meat and pork.

• Avoid trans – fats, coconut oil, palm oil, Oreos

More diet…

• Mono and polyunsaturated fats are good.- Monos - Nuts, olives, avocadoes, pulverized flax seeds- Polys – fish oil – omega 3’s are anti-inflammatory, omega 6 is

pro-inflammatory

• Protein is necessary!- It’s a mood stabilizer- It helps with cognition and memory- It helps balance blood sugar (fiber does this too)• Fish really is brain food! Salmon, tuna, mackerel are best!

More on Supplements

• Students like them. They can give a sense of control.

• Lots of clinicians are recommending them.• Low risk of harm. Many use them already.• Animal studies show some benefit,

particularly if given before injury!• Downside – cost, risk of overuse or imparting

a sense of lower risk of concussion.

What are they supposed to do?

• The purpose of most supplements are to manage the TBI cascade that ends in Axon loss:Inflammation-Excess glutamate-oxidative stress.

• Some are used by neurologists to manage headache/migraine.

Which Supplements are Popular?

• Omega 3 fish oil, keep it less than 3 gms/day• Magnesium to attenuate oxidative stress from excess

glutamate.• Vitamin D3 2000 - 4000iu/day• Tumeric/Curcumin• B-complex especially folate• Coenzyme Q10• Resveratrol?• Creatine?

What should you recommend?

• Check with experts you know.• Avoid mega doses.• Consider interactions.• Stay up on the scientific and popular

literature.• Fish oil omega 3, B complex, Magnesium and

Vitamin D3 are very low risk.

Coming Technology

• Video Eye Tracking – does VOMs testing but can pick up subtle deficits/patterns

• Vestibulography – a more objective measure of gait and balance injuries

• Vocal pattern testing for concussion• Diagnosis and therapy combination

equipment.• Blood testing for various concussion markers.

Resources

• UPMC Physician Resources Concussion Series• Boston Children’s Hospital Sports Medicine• Children’s Hospital of Philadelphia• Spaulding Rehabilitation Dieticians• Drs. Grant Iverson, William Meehan, Robert

Cantu, Rebekah Mannix, Michael Hoffer and many others.

• 20th Special Forces Group