A Multispecialty Approach to Concussion

Transcription

1 A Multispecialty Approach to Concussion Ryan J. Lynch, DO, MSEd Section Head of Neurology - Summa Barberton Hospital Co-director NNA Brain Injury Program 1

2 Disclosure I have no company affiliations at this time. 2

3 Lecture Disclaimer A majority of the information and statistics for this lecture were taken from the CDC s website: - This is a very good, free, and up to date source for concussion/tbi resources Another good site is: This is the site for the sports test you take before and after a concussion 3

4 Course Objectives At the end of this course, one should be able to: Identify, manage, and treat concussions using a multispecialty approach Start and manage your own concussion clinic effectively Have an understanding of the guidelines for returning to work after a concussion Have an understanding of the current or new guidelines for return to play after athletic concussions 4

5 What is a Concussion? From the CDC Website A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth. 5

6 History of Concussion Hippocrates writings: In cerebral concussion, whatever the cause, the patient becomes speechless, falls down immediately, loses their speech, cannot see or hear. (Sports Neuropsychology, 2006, page 21) 1905 NCAA formed to stop football deaths University of Virginia in 1980s UPMC in 1990s 6

7 History of Concussion NFL in the 2000s Lawsuit against NFL claiming they had knowledge of the risk of permanent damage from multiple concussions In the recent past, an NFL player could return to play in a game with a Grade 1 concussion Now players have to wait 48 hours to see if the concussion worsens This lawsuit makes it difficult to find info on how we used to treat concussions Chronic Traumatic Encephalopathy 7

8 Concussion Statistics Each year an estimated 1.7 million TBIrelated deaths, hospitalizations, and ER visits occur in the US This data translates to 52,000 deaths and 275,000 hospitalizations. In addition, nearly 80%, million people are treated and released from an emergency department. From: 8

9 Concussion Statistics The majority of TBIs that occur each year are diagnosed as mild TBIs (mtbi). mtbis are concussions In fact, a study found that about 75% of TBIs that occur each year are concussions or other forms of mtbi. While a mtbi is usually not life-threatening, this injury can have serious and long-term impact on a person s cognitive, physical and psychological function. From: 9

10 Symptoms of concussion usually fall into four categories: Cognitive/Memory Physical Emotional/Mood Sleep These 4 categories are what most of the major concussion centers and studies break patients' symptoms into 10

11 Cognitive/Memory Loss Difficulty thinking clearly Feeling slowed down Difficulty concentrating Difficulty remembering new information Word finding difficulty Short term memory loss 11

12 Physical Headache Fuzzy or blurry vision Nausea or vomiting (acute) Dizziness Sensitivity to noise or light Balance problems Feeling tired, having no energy 12

13 Emotional/Mood Irritability/Decreased Patience Sadness Nervousness or anxiety Emotionally labile Depression PTSD Psychosis 13

14 Sleep Sleeping more than usual Sleep less than usual Trouble falling asleep Nightmares REM Sleep disorders Narcolepsy Excessive daytime sleepiness Snoring/OSA 14

15 Missed Category - Vision Under physical, the CDC mentions fuzzy or blurry vision. The assumption of blurred vision is in fact a convergence problem This leads to poor reading comprehension, poor reading endurance, poor vision, worsening headaches and vertigo, more concussions, etc 15

16 Missed Category - Vision The brain handles the what in vision and the where is handled by the peripheral nervous system and it s this system that s damaged in a concussion, when it comes to vision problems The where is damaged in concussion, makes it extremely hard to track moving targets, read, drive, watch TV, etc 16

17 Missed Category - Vision Typically, this type of vision loss/damage is assessed by a specialized optometrist, a neurooptometrist, who is trained in evaluation, treatment, and rehabilitation of the visual system, after a brain injury A patient with visual problems following a concussion should be referred to one of these specialized optometrists (neuro-optometric rehabilitation association) 17

18 Concussion These signs and symptoms can occur immediately or may take minutes, hours, days, weeks, and even months to show up All concussions and TBIs need to be evaluated by a physician trained in dealing with them Trainers and coaches need to notify parents of concussions so the patients can see the appropriate physicians 18

19 CDC Guidelines that may indicate a For Adults: Bleed and trip to ER Headache that gets worse and does not go away. Weakness, numbness or decreased coordination. Repeated vomiting or nausea. Slurred speech. 19

20 CDC Guidelines to Seeking Immediate Attention in the ER Drowsiness or cannot be awakened. Anisocoria (One pupil larger than the other) Convulsions or seizures. Cannot recognize people or places. Confusion, restlessness, or agitation. Exhibits unusual behavior. Loss of consciousness (a brief loss of consciousness should be taken seriously and the person should be carefully monitored). 20

21 CDC Guidelines to Seeking Immediate Attention in the ER For Children: Have any of the danger signs for adults listed above. Will not stop crying and cannot be consoled. Will not nurse or eat. 21

22 CDC Action Plan for Sports Concussions 1. Remove the athlete from play. Look for signs and symptoms of a concussion if your athlete has experienced a bump or blow to the head or body. When in doubt, keep the athlete out of play 22

23 CDC Action Plan for Sports Concussions 2. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion. - Do not try to judge the severity of the injury yourself. - Health care professionals have a number of methods that they can use to assess the severity of concussions. 23

24 CDC Action Plan for Sports Concussions As a coach, recording the following information can help health care professionals in assessing the athlete after the injury: Cause of the injury and force of the hit or blow to the head or body Any loss of consciousness (passed out/knocked out) and if so, for how long Any memory loss immediately following the injury Any seizures immediately following the injury Number of previous concussions (if any) 24

25 CDC Action Plan for Sports Concussions 3. Inform the athlete s parents or guardians about the possible concussion and give them the fact sheet on concussion. - Make sure they know that the athlete should be seen by a health care professional experienced in evaluating for concussion. 25

26 CDC Action Plan for Sports Concussions 4. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, determines they are symptom-free and cleared for return to play. - A repeat concussion that occurs before the brain recovers from the first usually within a short period of time (hours, days, or weeks) can slow recovery or increase the likelihood of having long-term problems. - In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. 26

27 AAN Grading of Concussions Grade I - Confusion, symptoms last <15 minutes, no loss of consciousness Grade II - Symptoms last >15 minutes, no loss of consciousness Grade III - Loss of consciousness Grade IIIa - coma lasts seconds Grade IIIb coma lasts minutes 27

28 Diagnosis and Treatment If the patient isn t severe enough to be seen in the ER at onset, usually they are seen by their family doctor or a sports medicine doctor Concussion is a clinical diagnosis, there is no image or test that will tell you the patient had a concussion, although, sometimes we get lucky on tests 28

29 Diagnosis and Treatment Most studies will tell you that 80 to 90% of concussions get better within 3 weeks Those who don t are usually sent to specialists who deal with mtbi The best treatment of any brain injury, especially concussion, is COMPLETE BRAIN REST no school/work, no TV, no reading, no video games, no bright lights, no texting, even exposure to family or stressful situations should be minimized usually for at least 2 weeks 29

30 Diagnosis and Treatment Specialists who treat concussions include: neurologists, neuropsychologists, neurosurgeons, orthopedic surgeons, psychiatrists, sleep specialists, athletic trainers, psychologists, physiatrists, ophthalmologists, neuro-optometrists, physical therapists, occupational therapists, speech therapists, lawyers, etc. 30

31 Neuro-Optometry These optometrists are able to assess and treat the entire visual system following a concussion/tbi The most common visual defect we see is poor convergence with close vision This commonly causes poor reading endurance It will provoke headaches It will cause concussion symptoms to linger It worsens and contributes to concussion induced vertigo

32 Neuro-Optometry After the initial eye exam, most patients will require new glasses Many will need prisms added and/or have the nasal portion of their glasses fogged out Inhibiting nasal vision and adding prism to the glasses temporarily improves the patient's convergence These two additions to their glasses greatly reduce headaches, decrease vertigo, and allow reading to occur again

33 Neuro-Optometry Colored lenses are sometimes used - purples and rose lenses often improve vertigo Shaded tints decrease photophobia and improve headaches Correct glasses can be the difference between returning to work or school vs staying home

34 Neuro-Optometry Visual therapy is also used and can be a big help to the patient Most insurances won t pay for this and it can be very expensive Typically office based but some optometrists offer a computer based rehab that can be done at home which is more convenient and cheaper Some occupational therapists can offer this type of visual therapy

35 Speech/Cognitive Therapy Patients with memory loss, cognitive insults, speech problems and word finding difficulties will need speech therapy You should refer to speech therapy as cognitive therapy because workman s comp doctors will say there s nothing wrong with the patient s speech. They fail to realize that speech therapy is also cognitive therapy. Occupational therapy can also assist with cognitive therapy as well Speech therapists are also great at picking up on malingering patients.

36 Speech/Cognitive Therapy Speech therapy can help patients get back to work or school rapidly They can assist your neuropsychologist with accommodations for work or school

37 Physical Therapy When you write an order for PT, make sure you add concussion or TBI and not just the symptoms of them We primarily use PT for vestibular rehab following a concussion. There are not many PTs that feel comfortable treating vertigo, let alone concussion and TBI PTs also can assist with cervicogenic vertigo, headache treatment, and balance therapy

38 Occupational Therapy OTs can perform cognitive therapy and assist with return to work and school They also perform vision therapy Some can perform driving evaluations and assist with decreasing or driver anxiety when the concussion or TBI was from an MVA

39 Psychiatry If there are any type of emotional or psychiatric changes or problems, we encourage a referral to psychiatry and psychology, especially if there s pre-morbid illness Patients will often resistant on this but if their mood is not under good control, the concussion will not heal We don t recommend starting antidepressants or anxiolytics without expert assistance

40 Psychology We encourage a referral to both psychology and psychiatry for mood disorders following a concussion This is a much quicker and more effective way to treat mood disorders and thus the concussions themselves heal quicker

41 Ophthalmology Obviously we will refer to them for any types of eye trauma, hopefully this has been done before seeing us, but not always They typically will not evaluate for or treat problems with convergence

42 Sports Medicine We have an agreement in our city, that our concussion clinic sees patients who do not resolve after 3 weeks, or who have severe deficits from the onset of the injury In addition, pediatric neurology has given us their blessing too in that they don t want to deal with concussions at all but have agreed to see our severe headaches in their pediatric headache clinic If we find other sports related injuries, we send them to sports med or ortho

43 Neurosurgery/Orthopedics/Trauma Occasionally head trauma patients will need surgical follow up These surgeons can be very helpful in evaluating your patients surgically If nothing else, they can make sure nothing is missed.

44 Physical Medicine and Rehabilitation Physiatry can play a role if you are not comfortable with what therapy can offer your patients. You'll need to find a physiatrist who s comfortable with TBI and concussion They can help guide the therapy for your patient In addition to meds and time, therapy is key to concussion recovery, so physiatry can be a huge help and asset to any program

45 Headache Specialist Sometimes even general neurology can t fix a post concussive headache and we then turn to our headache specialists Typically they can perform nerve blocks and botox injections as well.

46 Sleep Specialist Insomnia and excessive daytime sleepiness are probably the most common sleep problems associated with a concussion Patients can acquire narcolepsy, OSA, snoring and REM sleep disorders following a concussion Obviously, there could have been pre-morbid disease that was undiagnosed and/or the concussion made it worse, but our sleep specialist believes that a TBI can induce these disorders

47 Pain Specialist For very severe headaches and pain, a pain specialist is needed

48 Athletic Trainers These are our soldiers on the field It helps to meet with the hospital system or organization that supplies the trainers in your area, to open lines of communication They can be a big asset to your program because they know your patients well They can perform exertional testing on your patients in order to assist with return to play decisions

49 School/Employer/Family Educating them on concussion and TBI can really be a big help in the recovery process for your patient Obviously, you have to get permission from the patient or guardian when talking the above entities, but when you are all on the same page, it s better for the patient Sometimes you need to be careful what you tell the employers, especially when dealing with workman s comp

50 Lawyers In the case of concussion from a work injury or MVA, lawyers can truly be an asset Trying to get necessary treatments and testing you ordered paid for can take a lot of effort when dealing with workman s comp or auto insurance. A lawyer can make that happen and save you time. They are often familiar with services you may not be aware of, that can help your patient further

51 ImPact Testing ImPact testing is by far the most commonly used test for screening of a concussion Ideally the patient will have a baseline test before the injury This can identify an unreported concussion There are many limitations to this test, including age the first version tested down to age 11 but they are currently working on one for lower ages Other concussion tests include the SCAT, MACE, and ANAM 51

52 Diagnosis and Treatment In our program, we typically see patients who haven t gotten better after 3 weeks with lingering symptoms or ones whose symptoms have worsened The patient schedules with both a neurologist and a neuropsychologist An ImPact test is scheduled 52

53 Diagnosis and Treatment We often find patients who weren't treated aggressively for their symptoms The first symptom we typically address is the headache, which is often problematic since the onset of the concussion 53

54 Diagnosis and Treatment Typical tests we order include: Brain imaging is not indicated unless they have focal deficits or worsening headaches (acute or chronic injury) AAN Guidelines suggest a CT Head or Brain MRI for headaches lasting longer than 1 week EEG for memory loss and staring spells ImPact testing Neuropsychological testing Vestibular testing with full rotational chair 54

55 Guidelines for Return to Play When returning a patient to a sport, the patient has to be symptom free at rest AND with full exertion!!!! A patient who returns to play while they still have symptoms has an increased risk for more concussions, worsening symptoms, and even death from double impact syndrome, stroke and permanent disability are possible too!!!! 55

56 Guidelines for Return to Work Unfortunately, there are no standardized or official return to work guidelines We rely on our neuropsychologists and our therapists to assist in determining return to work guidelines The patient will need to supply a detailed job description You'll need to know what the patient can safely and effectively do, both cognitively and physically, depending on the job Typically you have the patient take time off, then slowly transition back to full time employment. 56

57 Guidelines for Return to Work Communication is a huge factor here Patients can make complete recoveries between visits, don't tell you, and employers may call your office wondering why you haven't released them to work The goal is not to set them up for failure Some patients have insisted on starting back early and ended up getting fired or injured By working closely with your team, the patient, and the patient's employer, you can generally get them back to work easily and safely 57

58 Diagnosis and Treatment After a head injury, don't assume no symptoms = no concussion Tell the patient you may have suffered a concussion and document it As soon as you document no concussion, it's hard for the patient to get benefits from payers Remember, it may take minutes, hours, weeks, and even months before symptoms show up 58

59 Post-Concussive Headaches Headaches (HAs) may be the keystone symptom HAs are usually the most debilitating problem after a concussion and the most under treated symptom We find that if you treat the HA quickly and aggressively, the rest of the symptoms tend to resolve faster If there s a post-concussive visual problem too, this often needs to be addressed as well or the HAs will never improve 59

60 HA Treatment Most commonly used HA meds for concussion: Valproic Acid 250 mg BID Amitriptyline 10 mg QHS Topiramate Titration > 25 mg QHS x 1 week to dose of 75 mg QHS, but may need more Propranolol LA 80 mg QHS Gabapentin 100 mg TID Naproxen OTC as directed on bottle 60

61 Vertigo Treatment Initially the patient needs to be seen by PT for full vestibular rehab, gait/balance training, and Epley Maneuvers PT will want the patient off all dizzy meds Meclizine 12.5 mg to 25 mg TID to QID Promethazine 12.5 mg to 25 mg TID Lorazepam 0.5 mg BID to TID Ginger tablets Sea Sickness Bands 61

62 Cognitive Enhancement The patient should be seeing ST or OT for cognitive therapy Amantadine 100 mg QD to BID Rivastigmine patch 4.6 mg QD Donepezil 5 mg QD Memantine 5 mg BID 62

63 Psych Disorders After Concussion Psychological disorders presenting after a concussion are much more difficult to treat Instead of trying to treat these ourselves, we get psychiatry and/or psychology on board quickly 63

64 Diagnosis and Treatment Concussions take a long time to heal despite perceptions that they are trivial parts of life There is no magic bullet or pill that will heal one over night Please make sure all of your athletes are getting ImPact testing at baseline, before the injury, at school or their doctor s office, and test during and after the season 64

65 Post-Concussion Syndrome Some patients suffer subsequent concussions, making symptoms linger or become permanent. This is known as post-concussion syndrome. This can also occur when the first concussion is so severe that the symptoms never resolve Insufficient brain rest is the most common cause for this 65

66 Symptoms of Post-Concussion Chronic headaches Fatigue Sleep difficulties Syndrome Personality changes (e.g. increased irritability, emotionality) Sensitivity to light or noise Dizziness when standing quickly Deficits in short-term memory, problem solving and general academic functioning 66

67 Prognosis Most patients will make a complete recovery Patients with multiple concussions usually take longer to heal, have more symptoms, the symptoms are more severe, and may have permanent damage 67

68 Final Thoughts Patients who exhibit concussion symptoms but deny or don't remember a concussion, may have had a concussion ImPact test them or get neuropsychological testing to pick up on subtle concussion deficits The whole purpose of baseline ImPact testing and testing throughout the season, is to pick up on small or unreported concussions 68

69 Any Questions? 69