Sachin Mehta, MD,FAAPMR, BIM

RHI Brain Injury and Resource Facilitation Conference

10/9/19

MANAGEMENT OF

CONCUSSIONS/MILD TBI

&PCS

Speakers Bureau:

Allergan

Avanir

DISCLOSURES

Understand the physical, cognitive, and emotional signs/symptoms of a mild traumatic brain injury/concussion

Identify appropriate management strategies to maximize outcomes in those who have suffered a mild TBI/concussion/post-concussion syndrome

Appreciate the rehabilitation process and resources available to facilitate return-to-work, return-to-school, and return-to-play

OBJECTIVES

18yo female HS cheerleader has a headache, dizziness,

nausea/vomiting, and trouble sleeping 1 day after getting

kicked in the head. + loss of consciousness < 1 minute

History: 2 prior cheerleading-related concussions in the past

year, 2 concussions at 13yo and 15yo, migraines,

anxiety/depression

Diagnosis: another new concussion

WHAT WOULD YOU DO?

A. Refer to Sports Medicine

B. “Cocoon Therapy” for 7 -10 days or until symptoms-free

C. Refer to a Physiatrist or Physical Medicine and

Rehabilitation (PM&R)

D. Order Brain Imaging (Head CT or MRI Brain)

E. Refer to Neurology

F. Something else

WHAT WOULD YOU DO?

TBI INTRODUCTION

Sources: Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample for emergency department visits; HCUP’s

Nationwide Inpatient Sample for hospitalizations; CDC’s National Vital Statistics System for deaths.

TBI INTRODUCTION

Source: Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample

5.3 million (100,000/year) have TBI -related

disabilities (2% of population)

90% of disabilities related to mild

TBI’s/concussions (GCS > 13)

Economic Impact: $9.2 Billion in lifetime medical costs ($4.2 million/survivor)

$51.2 Billion in productivity losses

TBI INTRODUCTION

mTBI Glasgow Coma Scale of

13-15

Loss of consciousness < 30 minutes

Post-traumatic amnesia < 24 hours

Concussion A type of mTBI

A Clinical Syndrome

MILD TBI VS CONCUSSION

About 75% of concussion/ mild TBIs are non-sports related

3.8 to 5 MILLION sports -related concussions annually 80-95% recover in 7-14 days

Non-sports related concussions Most recover in 3 months 33% may have prolonged symptoms (PCS or PPCS)

20% of high school athletes experience a concussion yearly

15-41% of concussed athletes in U.S. high schools returned to play too soon, including up to 16% that returned to play the SAME DAY! (AAN)

CONCUSSION INTRODUCTION

• IC 20-34-7-4– If a student athlete is suspected of sustaining a concussion:

• Immediately remove from play

• IC 20-34-7-5 – The student athlete may not return to play until:

• The student athlete is evaluated and receives written clearance to return -to-play by a licensed health care provider trained in head injuries

• More than 24 hours must have passed since the student athlete was removed from play.

• IN Senate Bi l l 234– The completion of a certified player safety education course is required for a head

coach or assistant coach of any interscholastic sport.

– Certification must be obtained every 2 years

– Changed requirement from coaches of 9 th-12th grade to 5 th-12th grade

INDIANA CONCUSSION LEGISLATION

A traumatic brain injury:– Caused by a direct blow to the head or an impact transmitted to

the head.

– Rapid onset of short-lived neurologic impairment resolves

spontaneously over minutes to hours.

– Causes a functional injury rather than a structural injury

– Usually does not involve loss of consciousness.

– Signs/symptoms cannot be explained by other causes

CONCUSSION- DEFINITION

Consensus Statement on Concussion in Sport-Berlin October 2016)

Football

Wrestling

Soccer - girls

Soccer – boys

Girls basketball – 3 times higher incidence than boys basketball

Overall, females are 2-3 times more likely to get a concussion

than males

Children and teens are more likely to get a concussion and take

longer to recover than adults.

SPORTS WITH HIGHEST INCIDENCE OF

CONCUSSIONS

Primary Injury

Shifting of the brain

Results in contusions

or bruising of the brain

MILD TBI/CONCUSSIONS:

HOW DO THEY OCCUR?

MILD TBI/CONCUSSIONS:

HOW DO THEY OCCUR?

Focal damage and dif fuse damage to nerves

Effects tend to be broad (dif fuse)

SECONDARY INJURY: DIFFUSE AXONAL INJURY

Leading cause of morbidity (cognitive, behavioral, and arousal

deficits) in TBI

Occurs during acceleration/deceleration events (like care

accidents) exposing the brain to stretch and torque

forces pathophysiologic process lasting days nerve

swelling and detachment

CT/MRI often "normal."

SECONDARY INJURY: DIFFUSE AXONAL INJURY

Physical Symptoms

HA, N/V, Balance Problems

Emotional Symptoms

Irritability, Emotional lability,

Sadness, Nervousness

Sleep Dysfunction

Drowsiness, insomnia

Cognitive Symptoms

Memory, Concentration, “Foggy,”

Slow processing speed

CONCUSSION SYMPTOMS

INITIAL MEDICAL ASSESSMENT

Ellis M. et al. Front. Neurol., 20 December 2018

Deteriorating mental status

Focal neurological findings

GCS< 15 after 2 hours

Suspected Skull Fracture

>2 Vomiting episodes

> 30min Pre-traumatic amnesia

Bleeding risk

Intoxication

WHEN TO ORDER IMAGING

SCAT 5

Sideline video review

Thorough H&P

Vision screens show promise for concussion diagnosis

Neurocognitive Testing can increase diagnosis accuracy

CONCUSSION “SIDELINE” OR OFFICE

ASSESSMENT

ImPACT is the most widely used neurocognitive concussion screening tool

Used by the NFL, NHL, MLB, NCAA, WWE, MLS, NASCAR, most high schools, and most military units

Takes approximately 30 minutes to complete

Validity checks are included

Assessments: Verbal memory, Visual memory, Visual motor speed, Reaction time, Impulse control, Symptom score

COMPUTER-ADMINISTERED COGNITIVE

ASSESSMENT

Early diagnosis

Removal from practice/game

Rule out more serious brain injury

Neuropsychological testing (ImPACT)

Prevent long-term cumulative and chronic sequelae- PCS, 2nd Impact Syndrome, CTE

MANAGEMENT OF CONCUSSIONS

Relative Rest the Brain! Individualized relative modification/restriction of BOTH physical

and cognitive activities such as exercise, rigorous classes, homework, videogames—and even driving!

Only 24-48 hours of rest is recommended!!

Until 2013, recommendation was for rest until symptom-free

Followed by gradual increase in physical/cognitive activity without worsening symptoms

Avoid vigorous exertion

MANAGEMENT OF CONCUSSIONS

Consensus Statement on Concussion in Sport-Berlin October 2016)

Physical therapists/ATCs wil l use the Balke or Modified Balke method af ter concussion

Increase intensity on a treadmill or recumbent bike unti l concussion symptoms increase- this max HR is noted

Patients instructed to exercise 20 -30 minutes daily at 80% of this max HR without symptom exacerbation

Balke protocol exercise program can improve cognitive per formance, promote neuronal recovery, improve sleep, increase cerebral blood flow, and improve mood

Can also help dif ferentiate concussion from other symptoms that can present similarly

BUFFALO CONCUSSION TREADMILL TEST

The BCTT has been demonstrated to be valid and reliable ( L ed d y et

a l . , 2 011)

The BCTT has been shown to be safe for use both in PCS as well as acute concussion ( C o r d in g l y et a l . , 2 016 ; L ed d y et a l . , 2 017)

Daily low intensity, sub-symptom threshold aerobic exercise has been demonstrated to be safe during concussion recovery and may even improve recovery time ( C o r d in g ly et a l . , 2 016; M a er len d er et a l . ,

2 016; L ed d y et a l . , 2 017 ; M yc h a s iu k et a l . , 2 016 ; Ku row sk i et a l . , 2 016)

**Evidence suggests aerobic activity speeds up recovery ( L e d d y e t

a l . , 2 0 1 9 ) * *

BUFFALO CONCUSSION TREADMILL TEST

Sports-related concussions

80-95% recover in 7-30 days

Younger, healthier, more motivated

May anticipate “blow” to the head

Non sports-related concussions

Most recover in 3 months

33% may have persistent symptoms

Can be associated with mild, moderate, or severe TBI

POST-CONCUSSION SYNDROME

ICD-10 Criteria:

A. History of head trauma preceding symptom onset

by a maximum of 4 weeks.

B. Symptoms in 3 or more of the following symptom

categories: Headache, dizziness, fatigue

Irritability

Concentration difficulties, memory difficulty

Insomnia

Reduced alcohol, stress, or emotional tolerance

POST-CONCUSSION SYNDROME DIAGNOSIS

History of previous concussions

Female sex

History of mood disorder

History of cognitive dysfunction (ex: ADHD)

Age – younger the athlete, longer the recovery

History of migraine headaches

History of seizures

Involvement in litigation

** Severity is not a risk factor!

RISK FACTORS FOR PCS

Depression

Somatization

Chronic Fatigue/Pain

Whiplash injury

Balance Deficits/Vertigo

Visual-spatial deficits

Combination of above

Secondary Gain/Malingering

DIFFERENTIAL DIAGNOSES

All patients with mTBI are different

Persistent mTBI symptoms require individualizedevaluation and treatment

Treatment should be focused on symptomatic and functional improvement

WHEN TO SEEK TREATMENT

Initial treatment- Rest can be counter-productive

Education, education, education!!

Gradual increase in physical and mental activity!!

A comprehensive mild TBI/Post -Concussion Multi -disciplinary Outpatient Rehabilitation Program is an ideal environment to treat those with PCS/mild TBI Rehabilitation specialists trained to treat mild TBI/PCS

Expertise to address all signs/symptoms

Individualized approach

TREATMENT/REHABILITATION OF PCS

MULTI-DISCIPLINARY ASSESSMENT/TREATMENT OF MILD TBI

The treatment team should include:

Patient

Family

Clinical neuropsychologist

PM&R Physician

Nursing rehab specialist

Physical therapist

Occupational therapist

Speech therapist

Case manager/social worker

Consultants: Neuro-

optometry, ENT, Psychiatry, Neurology

Referrals: Yoga, Tai -Chi,

QEEG/Biofeedback

TREATMENT/REHABILITATION TEAM

Medical management by a board-certified

physiatrist with certification in Brain-Injury

Medicine

Coordinates treatment team

Can provide medical management

Can consult specialists as needed

Can oversee return-to-play; return-to-work; return-

to-school with follow-up appointments as needed

PHYSIATRY/REHABILITATION

SPECIALISTS

Insomnia Educate regarding sleep hygiene

Medications: Trazodone, TCAs, mirtazapine

Melatonin, valerian root: OTC

Avoid diphenhydramine, benzodiazepines, zolpidem

Headaches- usually multi -factorial Migraines

Tension

Occipital neuralgia

Myofascial cervical pain

Treat with medications, injections

Attention/Concentration Deficits Amantadine, methylphenidate,

Ar(modafanil)

Memory Deficits Donepezil, CDP-choline

Emotional Labil i ty/Depression/PBA SSRIs, SNRIs, TCAs, anti -epileptic

agents

MEDICAL MANAGEMENT

Comprehensive neuropsychological assessment by a neuropsychologist specializing in brain injury

Counseling, emotional support, and education regarding recovery from brain injury for patients and families

Cognitive behavioral therapy/neurofeedback Identifies and changes patterns of patient’s thoughts and

behaviors to help with coping

Availability to communicate directly with employer/educational staff for work/school accommodations

NEUROPSYCHOLOGY

Return to play Graduated return to school Return to driving Graduated return to work Prevention of long-term sequelae

Second Impact Syndrome (SIS) Slower recovery from future neurologic injuries Permanent neurocognitive impairment Neurodegenerative disease- Chronic Traumatic

Encephalopathy (CTE) Depression

GOALS OF REHABILITATION

Graduated return to play protocol

Progress from one stage tothe next only if athlete is asymptomatic

Each step should take 24 hours

Should be off all medications

RETURNING TO PLAY

All 50 states have “Return-to-play” legislation

RETURNING TO PLAY

Less than 20 states have “Return-to-Learn” legislation

Similar accommodations can be made for vocational activities

RETURNING TO SCHOOL

• Fur ther research on res idua l e f fec ts and seque lae o f concuss ion , mu l t ip le concuss ions , mul t ip le sub -concuss ive h i t s

• Improved on - f ie ld he lmet -based o r o ther sensory sys tems f o r d iagnos is o f concuss ions

• Comprehens ive S ide l ine /Of f ice V is ion Assessments

• Advanced Neuro - imag ing f o r d iagnos is and p rognos is o f m i ld TB I

• Se lec t ive f l u id (b lood , sa l i va , sp ine f l u id ) b iomarkers to assess seve r i t y o f concuss ion and p red ic t du ra t ion o f recovery

• Genet i c t es t ing to p red ic t r i sk o f i n i t ia l concuss ion , r i sk o f p ro longed recovery , and CTE r i sk

• Vi r tua l rea l i t y /Te le -hea l th to improve rehab i l i t a t ion access to a th le tes where appropr ia te med ica l a t ten t ion may no t ex is t

• Concuss ion Assessment , Research , and Educa t ion (CARE) Consor t ium

FUTURE OF CONCUSSION

DIAGNOSIS/TREATMENT

Mild TBIs and Concussions can cause a constellation of physical, emotional, sleep, and cognitive symptoms- almost always with negative brain imaging

An active, individualized, multi -disciplinary rehabilitation approach can target the main causes of mild TBI, concussions, and PCS

This multi -modal rehabilitation process can facil itate functional recover, including return -to-work, return-to-play, return-to-school for those with mild TBI

SUMMARY

Thank you!

Sachin Mehta, MD

FPN Rehabilitation Specialists

sachin.mehta@franciscanalliance.org

317-528-2693

QUESTIONS??