Concussion Management 2012: Where Are We Now? Andrew Getzin, MD Cayuga Medical Center Ithaca, NY.
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Transcript of Concussion Management 2012: Where Are We Now? Andrew Getzin, MD Cayuga Medical Center Ithaca, NY.
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Concussion Management 2012: Where Are We Now?
Andrew Getzin, MD
Cayuga Medical Center
Ithaca, NY
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Challenging Injury• Variability in presentation, can be subtle• No clear marker, no definitive test• Ideal management ?• Track recovery ?• Prevention?• When “is it safe?”• Research Evolving
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What is a Concussion?
A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces
McCrory, 3rd international Concusion in Sport, Zurich, Clin J Sport Med 2009
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NEJM Case
“Concussion refers to an immediate and transient loss of consciousness accompanied by a brief period of amnesia following a blow to the head”
Ropper and Gorson, NEJM 2007
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Loss of Consciousnes
• Brief LOC does not correlate with severity of concussion
• Developed from studies with animal models and more severe head injuries
• Most likely related to subcortical involvement (Reticular Activating System)
Lovell, Clin J Sports Med 1999;8:193
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Giza and Hovda, J Athl Training 2001
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Pathophysiology
• Alterations in intracellular/extracellular glutamate, potassium, and calcium
• A relative decrease in cerebral blood flow in the setting of an increased requirement for glucose- Mismatch
• Work by Vagnozzi demonstates metabolic period of increased vulnerability
Vagnozzi, Neurosurgery 2005, 2007
Len, MSSE 2011
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Second Impact Syndrome?• Abnormal cerebral blood flow that occurs shortly
after an individual sustains a second concussion prior to fully recovering from a previous concussion
• Vascular engorgement leads to massive increase in intracranial pressure and brain herniation
• Usually severe brain damage or death• “The scientific evidence to support this concept
is nonexistent”• Diffuse cerebral swelling (DCS) occurs in
children> adults with a poor outcome
Saunders and Harbaugh, JAMA 1984
McRory, CSMR 2012
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High School Football Player Dies
October 2008
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Recovery from Concussion• 80-90% of concussions resolve in 7-10
days• Post-concussion syndrome (PCS) is the
term used to describe prolonged or incomplete recovery
• Non-injury factors often play a role in the persistence of symptoms
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Exertion Effects
• Symptoms are exacerbated by:• Mental effort• Environmental
stimulation• Emotional stress• Physical activity
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Goals of Initial Office Visit• Determine if Individual sustained a
concussion• Protect his/her brain to allow for recovery
• Activity limitation• School work modification
• Potential support with medication for symptoms
• Provide reasonable patient expectations
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Signs and Symptoms
Concussion: Team Physician Consensus Statement, MSSE 2011
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Risk Factors That May Prolong or Complicate Recovery
Concussion: Team Physician Consensus Statement, MSSE 2011Makdissi, AJSM 2011
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Early Concussion Guidelines• Cantu: 1-post traumatic amnesia <30 minutes, 2- LOC <
5 minutes, post traumatic amnesia > 30 minutes, 3- LOC > 5 minutes, post traumatic amnesia > 24 hours
• Colorado Medical Society: 1- no LOC, no post-traumatic amnesia, confusion, 2- no LOC, post-traumatic amnesia, confusion, 3- LOC of any duration
• American Academy of Neurology: 1- no LOC, Confusion symptoms <15 minutes, 2- No LOC, Confusion symptoms >15 minutes, 3- LOC of any duration
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PE: Concussion in the Office• Regular physical exam including HEENT,
neck, and neurological exam• 5 Word Recall- immediate and 5 minutes• Months of the year backwards• Digits backwards• Speech• Pronator drift: Rhomberg• Finger-to-nose• Gentle push with their eyes closed
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Rx: Concussion in the Office
“The art of medicine consists in amusing the patient while nature cures the disease.” Voltaire
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Initial Rx: Concussion in the Office
• Mental and Physical Rest• 92% of repeat in-season concussions
occur within 10 days• Initial medication to support
• Anti-nausea• Headache medication• Sleep medication?
• Schoo/work support
Guskiewicz, JAMA 2003Majerske, J Athl Tra 2008
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Follow-up Office Visits
• Is the individual improving?• Obtain information from other sources: family,
teachers, work• Gradual progression back to normalcy• Is it time to intervene?
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Additional Rx: Concussion in the office
• Physical & Occupational Therapy• Neck & back problems• Balance (fall prevention)• Vision and Cognition
• Neuropsychological Testing• Additional Medication
• Headache: elavil• Mental Health: SSRI• Stimulant
• Exercise trial
Leddy, Clin J Sport Med 2010
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What Information Guides Return to Activity
• Symptoms• Physical Exam
including balance testing
• Cognitive assessment: neuropsychological assessment?
Hutchison, AJSM 2011
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What Is Symptom Free?
• Dependent on time and day of measurement, emotional status, attitude, motivation, and honesty
• Postconcussion-like symptoms are prevalent in the non-concussed population
• Perhaps return to baseline symptoms
Alla, Br J Sports Med 2011
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Zurich Return to Play Guidelines
• Athlete should not return-to-play in the current game or practice
• Athlete should be monitored for deterioration for 24 hours
• Return-to-play must follow a medically supervised stepwise process
• Athlete must be symptom-free at rest AND after exertion
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Zurich Return to Play Progression
• No activity, complete rest• Light aerobic exercise but no resistance
training• Sport specific exercise and progressive
addition of resistance training• Non-contact training drills• Full contact training and scrimmage• Game play
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Preparticipation Evaluation: Hx of Previous Concussions
• Mechanism of injury• Length of time for full recovery• Time out of school/work• Special Treatment
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Preparticipation Evaluation: BESS
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Concussion Prevention
• There are currently no personal protective equipment that prevents concussions including mouth guards and helmets
• Improper fit of equipment may increase risk for concussion
• Rule changes
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Thank You