Best Practice in Assessment and Management of Mild Traumatic Brain Injury Mark Bayley, MD FRCPC Associate Professor, Univ. of Toronto
JD Teacher Slipped and fell on the ice in playground No clear LOC but dazed 5 minutes later responding verbally Complaining of headache Sent to ER-Negative CT scan
Objectives: By the end of this session, participants will be able to: Describe the basic pathophysiology of mtbi Discuss current concepts in return to activity and work in patients recovering from mtbi Develop an approach for effective assessment and management of patients/workers with mtbi 3
Objective 1.- Describe the basic pathophysiology of concussion
General Definition mtbi Mild Traumatic Brain injury and Concussion are terms used interchangably to denote the acute neurophysiological effects of blunt impact or other mechanical energy applied to the head, such as from sudden acceleration, deceleration or rotational forces. The trauma does not have to be directly to the head, and can be due to a whiplash effect on the brain from a blow elsewhere on the body Immediate and temporary alteration of mental functioning due to trauma Giza CC, Hovda DA. The neurometabolic cascade of concussion. Journal of Athletic Training. 2001;36(3):228-235. 5
Definitions of MTBI/ Concussion American Congress of Rehab Medicine (1998) consensus definition: A traumatically induced physiologic disruption of brain function, as manifested by at least one of the following
ACRM definition of MTBI (1) Any period of loss of consciousness; (2) Any loss of memory for events immediately before or after the accident; (3) Any alteration in mental state at the time of the accident; (4) Focal neurologic deficit that may or may not be transient but where the severity does not exceed the following: (1) Loss of consciousness of ~ 30 minutes or less; (2) An initial Glasgow Coma Scale (GCS) of 13-15 after 30 minutes; and (3) Post traumatic amnesia (PTA) of no more than 24 hours duration. (cf. Duff et al, 2002)
What is mtbi? Exact mechanism unknown Rotational acceleration more important than linear acceleration the jiggle of the brain within the skull causes concussion Axonal injury may occur Probably, the first concussion is a biochemical injury NOT DUE TO Bleeding NOT DUE TO Tearing or Bruising of the brain
12 J Athl Train. 2001 Jul-Sep; 36(3): 228 235.
The Concussion Spectrum of Conditions Acute Concussion Second Impact Syndrome Post Concussion Syndrome Chronic Traumatic Encephalopathy (CTE)
Brain Injury as a Continuum Important to understand that the terms Mild, Moderate and Severe are arbitrary divisions. While some generalities may be made Brain Injury is a continuum from the most negligible to the most profound Every case is unique and requires an individualized approach
http://dvbic.dcoe.mil/resources Grading systems have been devised; however, no truly evidencebased system. 15
Diffuse Axonal Injury May result in symptoms of: slowed thinking Attention and concentration, Balance impairment 16
Focal injury Frontal Lobes Difficulties with working memory, problem solving, Irritability behaviour & executive function Temporal lobe injury.. Impaired memory and difficulties with word finding 17
Red Flags High Number of Symptoms Early Psychological Symptoms Prolonged post traumatic amnesia Memory problems Pre-existing history concussion of psychiatric issues Brief episode of hypotension? Biomarkers? Neuroimaging factors 18
OBJECTIVE 2: Discuss current concepts in return to activity and work in patients recovering from mtbi 19
Question; Complete rest is not recommended for more than: A.1 day B.2 Days C.3 days D.7 Days E.14 days 20
Updated Guidelines for the Management of Concussion/ Mild Traumatic Brain Injury and Persistent Symptoms www.concussionsontario.org
Grading Scheme Levels of Evidence To achieve consistency among the recommendations, the level of evidence for each recommendation was assigned according to the following scheme: Levels of Evidence A At least one randomized control trial, meta-analysis or systematic review B At least one cohort comparison, case studies or other type of experimental study C Expert opinion, experience of a consensus panel.
Sections (Second Edition): 1. Diagnosis/Assessment of Concussion/ mtbi 2. Management of Concussion/ mtbi 3. Sports-Related Concussion/ mtbi 4. General Recommendations Regarding Diagnosis/ Assessment of Persistent Symptoms 5. General Recommendations Regarding Management of Persistent Symptoms 6. Post-Traumatic Headache 7. Persistent Sleep/Wake Disturbances 8. Persistent Mental Health Disorders 9. Persistent Cognitive Difficulties 10. Persistent Vision & Vestibular (Balance/Dizziness) Disorders 11. Persistent Fatigue 12. Return-To-Activity Considerations 1. General Recommendations Regarding Rest & Return-to-Activity 2. Return-to-Work Considerations 3. Return-to-School (Post-Secondary) Considerations
Return-to-Activity after MTBI Historical approach Patients who sustain an MTBI should rest until they are no longer experiencing postconcussion symptoms. At that point, a graded resumption of activities can begin. 24
Benefit of rest? Vigorous exercise within first 2 weeks following injury may delay recovery Theoretical risk based on animal models Rats permitted to use a running wheel initial 2 wks worse neuromolecular (brain derived neurotrophic factor and synapsin I) and behavioural (maze test) outcomes. Randomized trial 6 days rest followed by graded resumption vs graded resumption alone: somewhat lower visual analogue scale ratings on 14/16 post concussive symptoms at 2 weeks, no difference at 6 months. Griesbach et al. Voluntary exercise following traumatic brain injury: brain derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004;125:129 139. de Kruijk et al. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002;73:167 172. 25
Benefit of rest? However, theoretical risk of non-vigorous activity (cognitive, physical) in initial few weeks does not appear have evidentiary basis (e.g. Zurich Guidelines do not have citation to support) 26
Rest should not be assumed to be good; consider like any other treatment; needs to be evaluated with randomized controlled trials. 39 trials of bed rest for 15 different conditions (total patients 5777). 24 trials on bed rest following medical procedure: no outcomes improved, eight worsened (lumbar puncture, spinal anaesthesia, radiculography, cardiac catheterisation). 15 trials on bed rest as treatment: no outcomes improved, nine worsened (acute low back pain, labour, proteinuric hypertension during pregnancy, myocardial infarction, and acute infectious hepatitis). 27
Benefit of activity after MTBI? Willer et al. Management of concussion and postconcussion syndrome. Curr Treat Options Neurol. 2006;8:415 426. Leddy et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20:21 27. Leddy et al. Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med. 2011;21:89 94. Baker et al. Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabil Res Pract. 2012;2012:705309.
Graded resumption of regular preinjury activities (with the exception of competitive sports) as tolerated within the first few days to weeks postinjury, regardless of symptomatic status, is more likely to speed up than delay recovery. Multiple randomized clinical trials of early intervention including guided activation component found benefit. In one study, starting this process on day after injury temporarily exacerbated symptoms but achieved the same long-term outcome as delaying it by a few days. Delaying graded resumption of regular preinjury activities beyond a month may worsen outcome. 29
Summary Return-to-Activity 1) Change in thinking regarding activity vs. rest after MTBI; realization that previously believed benefits of rest were assumed rather than evidence based. 2) Considerable evidence inactivity worsens and exercise improves outcomes for other medical conditions & evidence accruing over past decade supports progressive activity including exercise has a positive impact on outcomes. 3) Not recommended to base resumption of activity on need to be asymptomatic because defining asymptomatic status is challenging and physical and/or mental exertion may temporarily exacerbate postconcussion symptoms at any stage of recovery with no clear long-term neuropathological or functional consequences. 4) Important to note that a minority of patients remain symptomatic for months to years. Ongoing inactivity almost certainly more detrimental than therapeutic in chronic stage. 30
Recommendations for Activity Resumption following mtbi 31
Objective 3 Develop an approach for effective assessment and management of patients/workers with mtbi
The Vicious Cycle of Post- Concussion Syndrome Injury Decreased Attention Physical Symptoms Cognitive Symptoms Anxiety Muscle tension.
Changes to the 2 nd Edition Available at www.concussionsontario.org More Resources (e.g., educational brochures, tools, etc.) Formally vetted by the expert consensus members and external reviewers prior to inclusion in the final guideline Algorithms for all Sections Improved Usability Hyperlinks in the electronic PDF version Video links to assessment demonstrations Complete version (with methodology) vs. Clinical version (without methodology) available Sections offered as separate modules
Case Example JD Management of Symptoms Headache Sleep Mood Cognition Balance/ Dizziness Return to Driving??
Case Example Headache JD has headache that is exacerbated by concentration and exercise Migraine Headache
Case Example Management of Symptoms Identification Headache Sleep Mood Cognition Balance/ Dizziness Return to Work
Case Example Sleep Difficulty with initiating sleep
Managing Mood Symptoms
Behavioural changes/irritability Recommend Serotonin Reuptake Inhibitors- for Episodic Behavioural or Emotional Dyscontrol following TBI. Specifically, Sertraline (25-200 mg/day) and Paroxetine (20 mg/day) have been reported to be effective( ABIKUS 2007 and NGWG) A small dose of sertraline 25 mg is added and the irritability improves well. 51
Case Example Management of Symptoms Identification Headache Sleep Mood Cognition Balance/Dizziness and Vision Return to Driving
Case Example Cognition Referred for neuropsychological assessment Difficulty with concentration and reading Cognitive/mental fatigue
Case Example Management of Symptoms Identification Headache Sleep Mood Cognition Balance/Dizziness and Vision Return to Work
Case Example Balance/Dizziness and Vision Benign Positional Vertigo Dix Hall Pike Maneuver positive Treated with closed particle reduction Dizziness and balance impairment Difficulty walking on uneven terrain/ hiking Referred for Vestibular Rehabilitation Physiotherapy Balance Exercises
Case Example Management of Symptoms Identification Headache Sleep Mood Cognition Balance/ Dizziness
Case Example Post Injury Mood and sleep clearly improved Balance improved Headaches very intermittentand no longer promoted by exertion Cognition - neuropsychological testing Demonstrated relative deficits in information processing speed Decreased divided attention Return to Driving??
Conclusions The exact mechanism of mtbi is not known but likely is combination of biochemical + axonal injury Prolonged rest longer than 3 days likley results in worse outcomes and activitye as tolerated after 3 days likely best approach The ONF guidelines for management of symptoms for MTBI provide an evidence based approach to most common symptoms after mtbi 61
Resources: www.concussionsontario.ca www.onf.org www.abiebr.ca Incog guidelines Journal of Head Trauma Rehab July/Aug 2014 Q & A Period
Some Other TBI resources
ERABI: A Research Synthesis Evidence-Based Review of Moderate to Severe Acquired Brain Injury (ERABI) Freely accessible online review (www.abiebr.com) Joint project involving researchers in three centers 10 th edition in process of being completed The aim of the ERABI is to: Be an up-to-date review of the current evidence in ABI rehabilitation Provide a comprehensive and accessible review to facilitate bestpractices Provide specific conclusions based on evidence that could be used by clinicians to help direct the care of ABI patients at the bedside and at home.
Ontario Neurotrauma Foundation and Partner Projects INESSS-ONF Partnership (www.onf.org) Inter-provincial partnership to jointly produce and implement a CPG for rehabilitation for adults who have sustained moderate to severe traumatic brain injury (MS-TBI) The importance of active stakeholder engagement through guideline creation and implementation
Ackowledgements Expert Consensus Group Robert Brison, Queen s University Carol Cancelliere, Toronto Western Research Institute, University Health Network Angela Colantonio, University of Toronto, Toronto Rehabilitation Institute Victor Coronado, Center for Disease Control and Prevention (CDC) Nora Cullen, Toronto Rehabilitation Institute, University Health Network Lisa Fischer, Western University Anne Forrest, mtbi Survivor Bryan Garber, National Defence, Government of Canada Jonathan Gladstone, University of Toronto Wayne Gordon, Mount Sinai School of Medicine Robin Green, Toronto Rehabilitation Institute, University Health Network Grant Iverson, University of British Columbia Corinne Kagan, Ontario Neurotrauma Foundation Vicki Kristman, Lakehead University Andrea Laborde, Royal Hobart Hospital (Australia)