active rehabilitation for concussion management · 2018-10-29 · presentation objectives •...
TRANSCRIPT
10/29/2018
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Active Rehabilitation for Concussion Management
Hannah Jepson Slaughter, ARNP, PC‐CPNP
Presentation Objectives
• Review of the pathophysiology of a concussion
• Overview of epidemiology, Iowa law, and best practice standards
• Discuss acute post-injury management
• Highlight the importance of immediate evaluation and symptom management
• Review the latest evidence that support active rehabilitation
• Discuss graduated return to learn and return to play protocols
Defining Concussion
Traumatic brain injury (mTBI) induced by biomechanical forces and a pathophysiological process affecting the brain
• Direct or indirect blow to any part of body
• Acute rapid onset of symptoms due to neurologic impairment
• Neuropathological changes that present primarily as functional disturbances
• Absence of structural lesions on traditional neuroimaging
• Range of symptoms that follow a sequential course
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Pathophysiology
• Linear and rotational forces acting on brain
• Sudden stretching of the neuronal and axonal membranes causes mass disruption of ion channels
• Damage can continue over a matter of days
Signoretti, S. et al, 2011
“Energy Crisis”
Post-concussive Brain Vulnerability
Signoretti et al, 2011
Energy CrisisWindow of Vulnerability
Second Impact
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Epidemiology
• 2005‐2009 more than 2 million outpatient visits and almost 3 million ED visits for mTBI in children
• ED visits and hospitalizations for TBI related events have increased
• 82% of youth concussions diagnosed in primary care setting
• 14‐18 year olds represent about half of children dx with concussion
• Younger children and those with medicaid tend to seek initial care in ED.
TBI in Youth
• Most common causes of ED visits for TBI in youth:
• < 10: playground accidents and falls
• 10-19 years boys: football and biking
• 10-19 years girls: soccer and biking
• 15-24: MVC
CDC 2001‐2009
Marar M, et al 2012
Concussion rates among high school athletes by sport, 2008‐2010 school years
Rate of Occurrence
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Haarbauer‐Krupa et al. 2018
Occurrence by Level of Contact
Contact Limited Contact
No Contact Other
Football Cheerleading Swimming Playing
Soccer Baseball Dancing Gym Class
Basketball Volleyball Swinging Playground
Ice Hokey Bike riding Monkey bars Recess
Lacrosse Softball Track Other
Signs and Symptoms
• Acute
– Headache
– Dizziness
– Nausea
– Vomiting
– Dazed/Stunned
– Confused
– Paresthesia
– Amnesia
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• Post acute
– Balance problems
– Visual problems
– Light sensitivity
– Noise sensitivity
– Emotional changes
– Sleep disturbances
– Cognitive changes
Signs and Symptoms
12Rochefort et al., 2017
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Symptom Resolution
• Adults: 10-14 days
• Children (13-18 years): 4-6 weeks
• Generally have favorable outcome
• 70-80% of times symptoms resolve 1-3 months
• 10-30% of time symptoms > 3 months
• Severity of initial symptoms = longer recovery
• Low level symptoms = quicker recovery
• Physiological dysfunction > clinical measures
Post Concussion Goals
• Healthy child
• Successful return to learn (RTL)
• Safe return to play (RTP)
• Prevention of second injury
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Concussion Challenges
• Recognition difficult
• Post injury physical examination typical
• Recovery road individualized
• Comorbid conditions complicate recovery
• Until recently no clinical practice guidelines
• Lack of expertise in clinical setting
• Lack of RTP protocols
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Iowa Code 280.13C HF 2442
• School sports
• Grades 7-12 only
• Distribution of concussion information to families
• Staff annual education about concussions
(IHSAA and IGHSAU websites )
• Immediate removal from play
• No return to play that day
• Written clearance by LHCP
• EMCP added
• Required adoption of RTL and RTP
• Limited liability for schools who follow RTP protocols.
Best Practice
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Best Practice
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Best Practice
www.iashaa.org
Best Practice
Law
• School sports only
• Grades 7‐12 only
• Annual Concussion information to families
• Staff education
• Immediate removal from play
• No return to play that day
• Written clearance by LHCP
• RTL before RTP
Best Practice
• ALL sports
• ALL ages
• Concussion education in school
• Monitoring and no driving
• LHCP evaluation < 24 hrs
• Concussion protocol activated ASAP
• Multidisciplinary
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CDC Clinical Guidelines
• Diagnosis of mTBI
• no CT
• Identify risk factors to warrant CT
• No routine MRI
• No SPECT
• No X‐ray
• Use age appropriate validated symptom scale
• No use of biomarkers
• Counsel 70‐80% of children no symptoms > 1‐3 months
• Counsel individual trajectory of recovery
• Standard assessment tools should not be exclusively used
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CDC Clinical Guidelines
• Prognosis of mTBI
• Assess premorbid hx as part of sports physicals
• Counsel risks for delayed recovery
• Screen for known risk factors of persistent symptoms
• May use validated prediction rules to provide prognostics
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CDC Clinical Guidelines
• Assessment of mTBI
• A: Use combination of tools to assess recovery of mTBI
• B: Use validated symptoms scales to assess recovery
• C: Cognitive computer testing
• D: Balance testing
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CDC Clinical Guidelines
• RTL of mTBI
• Medical and school based teams to help guide increase in academic activities as tolerated
• RTL to based on severity of symptoms
• Consider long term accommodations (504) for prolonged symptoms
• Collaboration to monitor and adjust RTL
• Refer for neurocognitive testing
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CDC Clinical Guidelines
• Management of mTBI
• Consider head CT with severe headaches or worsening symptoms
• Nonopoid management
• Rebound headache counseling
• Chronic headaches multifactoral
• Vestibular ocular therapy may be beneficial
• Sleep hygiene
• Identify etiology of cognitive dysfunction
• Multidisciplinary evaluation
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Community Resources
• 2016 Berlin Consensus Guidelines released in 2017
• IDPH Concussion management Guidelines for Iowa Schools
• REAP
• CDC Heads Up
• Brain Injury Alliance of Iowa (BIAI)
• Iowa Concussion Consortium (ICC)
• Local specialty concussion clinics
• Sports Medicine
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So Now What!?
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Continuum of Care
Immediate Care
Acute CareFollow‐up
Care
Injury 0‐72 hours > 72 hours
Immediate Care
1. Cervical spine assessment
2. Red Flags
3. Standardized sideline assessment tool
4. Remove from Play
Immediate Care
1. Cervical spine assessment
• Not lucid or fully conscious a SCI should be assumed until proven otherwise.
• Neck pain at rest?
• If NO pain active ROM of neck?
• Can athlete feel and move arms and legs?
• Parasthesia?
• Loss of bowel and/or bladder control?
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Immediate Care
• Red Flags
• Neck pain at rest
• Double vision
• Weakness or tingling (paresthesia) in arms or legs
• Severe or increasing headache
• Seizure or convulsion
• Loss of consciousness
• Deteriorating conscious state
• Vomiting
• Restless, agitation, or combativeness
Immediate Care
3. Assess for signs and symptoms of a concussion
Symptoms and Severity Concentration
Orientation Neurological
Memory Balance
Acute Care
• Follow up with PCP within 24 hours• Recent CDC practice guidelines for HCP
• Physical examination (typically normal)
• Scat 5 (symptom checklist)
• Pursuits, saccades, convergence
• Education
• Hydration
• Nutrition
• Sleep hygiene
• Activate Return to Learn (RTL)
• Activate Return to Play (RTP)33
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Follow Up Care
• Follow up > 72 hours• PCP, Concussion Clinic if available, sports medicine
physician.
• SCAT5 (symptom checklist)
• Returned to school or work
• Ongoing or new symptoms
• Sleeping
• Exacerbating factors
• Alleviating factors
• Re-evaluation of RTL and RTP protocols
• Medication management34
Referrals
Concussion Clinic/ Sports Medicine Multidisciplinary evaluation
Occupational Therapy Vison concerns
Physical Therapy Balance and coordination concerns
Vestibular Therapy Dizziness, tinnitus
Speech Language Therapy Executive functioning and cognitive
Developmental Optometry Nystagmus, overshooting, convergence
Mental Health Depression , anxiety
Neurology Headaches lasting > 6 months
Massage Therapy Cervical pain
Chiropractor Cervical pain
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ChildServe Concussion Clinic
Physician Services
Therapy Services
Vestibular Ocular
Ocular motor
Balance and Coordination
Physical Conditioning
Education
Accommodations
CommunityMultidisciplinary
Team
Return‐to‐academics
Return‐to‐play/activity
Education
Accommodations
Education
Prevention
Collaboration
Support
Physical Exam
Neuro Exam
SCAT 5
ImPACT
Cognitive
Active Rehabilitation
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Evidence for Early Physical Activity
• Howell et al. (2016)• Participants aged 13-18, higher levels of physical activity
after the injury were associated with a shorter symptom duration
• Grool et al. (2016)• Lower rates of Post Concussive Syndrome of those who
completed early physical activity (within 7 days of injury)
• Buckley e. al. (2016)• Non-rest group of college students achieved asymptomatic
status sooner than the rest group
Active Rehabilitation
• Physical Activity Progression
• Light Aerobic activity (walking the dog)
• Impact related aerobic activity (Jogging, running, jumping)
• Head below heart activity (mountain climbers, sit ups)
• Resistance training (weight lifting)
• Sport or activity specific training (strengthening, speed, agility, reaction time)
Active Rehabilitation
• Comprehensive Medical History
• Physical Exam
• Balance and Coordination
• Vestibular/Ocular Motor Testing
• Computerized Neurocognitive Testing
• Cognitive Linguistic Assessment
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Balance
Balance Error Scoring System (BESS)
Vestibular/Ocular Motor Testing
- VOR: Associated with the highest percentage of concussed patients reporting symptom provocation (61%)
- Concussed Patients:
• Total symptom score of ≥2
• NPC ≥5 cm
Headache Dizziness Nausea Fogginess
Baseline Symptoms 0‐10 0‐10 0‐10 0‐10
Smooth pursuits
Saccades‐horizontal
Saccades‐vertical
Convergence
VOR‐horizontal
VOR‐vertical
Visual Motion Sensitivity
Mucha, et al 2014
Vestibular Ocular Motor Screen (VOMS)
Vestibular/Ocular Motor Testing
VOMS video
https://www.youtube.com/watch?v=CJF6kJcFGqE
Abbreviated version
https://www.youtube.com/watch?v=LyxcLTSsF_w
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King Devick
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Visual Scanning Testing
King Devick
• Journal of Neurological studies (Rizzo et al.)
• 2016
• King Devick Objective Measures:
– 25 concussed patients compared to 42 controls
– Concussed patients demonstrated
• Significantly longer reading times
• Significantly longer intersaccadic intervals
• Larger deviation of saccade endpoints from
the center of the numbers
• Greater number of saccades
Rizzo, et al 2016
Vestibular-Ocular Motor Testing
Dynavision
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Computerized Neurocognitive Testing
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)
• Verbal Memory• Visual Memory • Reaction Time• Processing Speed• Impulse Control
Computerized Neurocognitive Testing
Schatz et al, 2012• Athletes 81 symptomatic concussed athletes compared to
non‐concussed controls tested within 3 days of injury
Sensitivity Specificity
91.4% 69.1%
Sensitivity Specificity
94.6% 97.3%
• 37 asymptomatic concussed athlete compared to non‐concussed controls tested within 3 days of injury
Cognitive Linguistic Assessment
• Orientation
• Immediate recall
• Concentration
• Executive functioning
• Short term memory
• Long term memory
• Cognitive strategies to be successful in school or work
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Return-to-Academics
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Return-to-Play/Activity
Post-Concussion Syndrome (PCS)
• Diagnosis• ICD 10 definition: “persistence of a constellation of physical,
cognitive, emotional, and sleep symptoms beyond the usual recovery period”
• No tests available to diagnose
• 3-month duration or more of concussion related symptoms:
DSM (5th ed), 2013, Makdissi et al 2017
Headaches Dizziness
Fatigue Irritability
Difficulty concentrating Impaired memory
Difficulty with mental tasks Difficulty sleeping
Reduced tolerance to stress
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Post-Concussion Syndrome (PCS)
• Risk Factors for PCS
• On field dizziness – 6.3 fold increase in PCS risk (Iverson, 2007)
• Lack of early physical activity (Grool, 2016)
• High initial symptom load (Howell, 2016)
• Female sex (Howell, 2016)
• Premorbid conditions (Asken, 2017)
Previous concussion Headache/migraine history
Learning disability ADHD
Depression Anxiety
How many is too many?
• No evidenced-based guidelines
• Individualized
• Comorbidities
• Modifying factors to consider
• Multiple lifetime concussions
• Structural abnormality on imaging
• Persistent decreased academic or workplace performance
• History of prolonged recovery with past concussions
• Post-concussion syndrome (PCS)
• Student/family priorities
• Realistic expectations
Prevention
• Helmets do NOT prevent concussions
• Safe techniques in practices and games and on playgrounds
• Safe playground equipment
• Enforcement of rules
• Checking in ice hockey
• Heading in soccer
• Preseason baseline testing adopted by schools or with sports physicals
• Health education curriculum
• Community based concussion management
• Creating positive and open culture
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Clinical Community
• Advanced neuroimaging techniques to help demonstrate concussion is associated with changes in the brain structure and function which correlate with symptoms
• Assessment of blood, saliva, CSF biomarkers
• Role of genetics in predicting risk of injury, prolonged recovery, long term neurological health problems, and effects of repetitive head impact exposure
• Research to develop diagnostic criteria for CTE prior to death
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Chronic Traumatic Encephalopathy
• Degenerative brain condition
• 4 stages
• Repetitive brain trauma (concussion or subconcussive)
• Not just associated with football (boxing, military)
• Postmortum diagnosis
• Been around for years (punch drunk, dementia pugilistica)
• Tau protein tangles
• Wide range of symptoms
• Multi-factorial: # of concussions, genetics, alcohol, drugs
• Some may have tangles but don’t present clinically
• Many of professional athletes without CTE
• Keep a positive attitude56
Iowa Community
• Iowa Concussion Consortium (ICC)
• REAP distributed to all schools April 2016
• New legislation for concussion management April 2018
• BIAI
• IDPH Concussion Management
guidelines
• CTE Hope
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Future
• Best practice recommendations required by law
• More specialized training in community
• Trained brain injury HCP on sidelines for all sporting events
• Baseline testing requirements for all students all schools
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Case Study #1
• 16 year old female
• Volleyball concussion
• PID #31
• Concussion #6
• Headaches, occasional dizziness, neck pain
• Med hx: no depression, no anxiety, no trouble sleeping, no migraines, no family history of above, 3 week resolution of previous mTBI
• No medications
• Returned to school with some symptoms, but keeping grades up and has returned to driving
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Case Study #1
• SCAT 5 20/22 30/132
• VOMS mild increase in symptoms
• King Devick some impairment
• Dynavision no impairment
• Balance no impairment
• IMPACT high average functioning
• Stage 5 of RTL
• Stage 2 of RTP
• Active Rehab
• No volleyball rest of season
• Chiropractor 60
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Case Study #2
• 15 year old male
• Football concussion
• PID #17
• Concussion #3
• headaches, dizziness, and sensitivity to noise
• Med hx: ADHD, no depression or anxiety, trouble sleeping, quick recovery of previous mTBIs
• No medications
• Returned to school with some symptoms, but
keeping grades up
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Case Study #2
• SCAT 5 14/22 22/132
• VOMS moderate increase in symptoms
• King Devick some impairment
• Dynavision no impairment
• Balance no impairment
• IMPACT average functioning
• Stage 4 of RTL
• Stage 3 of RTP
• Active Rehab
• No football rest of the season, but baseball
drills, no active batting and no scrimmaging62
Case Study #3
• 18 year old male
• Drag racing concussion with other ICI hospitalized
• PID #14
• Concussion #4
• Reports no symptoms
• Med hx: depression, anxiety, trouble falling asleep, long recovery of other mTBI
• Tylenol and ibuprofen prn
• Graduated from high school works for family mechanic garage, no college plans
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Case Study #3
• SCAT 5 6/22 10/132
• VOMS moderate increase in symptoms
• King Devick moderate impairment
• Dynavision some impairment
• Balance no impairment
• IMPACT low average functioning
• Stage 3 of RTP- long term
• Active Rehab
• No more contact sports including drag racing
ever64
Websites
Berlin consensus statement https://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097699
CDC Heads Up Campaignhttps://www.cdc.gov/HEADSUP
CDC clinical practice guidelineshttps://jamanetwork.com/journals/jamapediatrics/article-abstract/2698456
SCAT 5https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
IDPH Concussion Management Guideline for Schoolshttps://idph.iowa.gov/Portals/1/userfiles/32/Iowa%20Concussion%20Guidelines%202017%20-%20electronic.pdf
REAPhttp://www.iahsaa.org/wp-content/uploads/2016/09/reap-publication-20-pages_092016.pdf
References
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References
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References
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References
19. McAvoy, Karen. (2016) “REAP the benefits of good concussion management.” http://www.iahsaa.org/wp-content/uploads/2016/09/reap-publication-20-pages092016.pdf. HCA HealthONE. Date accessed: 10/16/17.
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22.Rizzo, J. et al. (2016), Rapid number naming in chronic concussion: eye movements in the King–Devick test. Ann Clin Transl Neurol, 3: 801–811. doi:10.1002/acn3.345
References
23. Rochefort, C., Walters-Stewart, C., Aglipay, M. (2017). Balance Markers in Adolescents at 1 Month Postconcussion. The Orthopaedic Journal of Sports Medicine. 5(3), March. DOI: 10.1177/2325967117695507
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