What EVERY Chiropractor can do in 2017

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Spencer Baron, DC, DACBSP®

Current Concepts in Concussion: 

DISCLAIMER

The views and opinions expressed in this presentation

are solely those of the original authors and other

contributors. These views and opinions do not

necessarily represent those of the PFCS staff, and/or

any/all contributors of this program.

DISCLOSURES

DISCLOSURES

DISCLOSURES

Doctors of Chiropractic For Collegiate and Professional Sports

DoC4CAPS

Dr. Spencer Baron

Miami Dolphins (NFL) 1996

Florida Marlins (MLB) 1997

Florida Panthers (NHL) 2003

Secrets of the Game (2009)

Diplomate of the American Chiropractic Board of Sports

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DrBaron@DrSpencerBaron.com

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Protection Identification

Treatment of

Mild Traumatic Brain Injury (mTBI)

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What is “mild” about TBI?

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Constantly evolving ...

• Pathophysiology of Concussion

• Diagnosing a Concussion

• Management of Concussion

• Preventing of Concussion

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Changes in nomenclature

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“Head Symptoms”13

“Sub Concussive Blows”

Biomechanical forces

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Coup vs contra coup

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Coo Coo

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So, what happens to the brain?

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Neuropathologist, Dr. Ann McKee has

identified four stages of the

degenerative process from

Chronic Traumatic Encephalopathy

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Computed Tomography (CT Scan)

SWAN, SWI or VenoBOLD

Functional MRI (fMRI)

Diffusion Tensor Imaging

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Magnetoencephalograph

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High Definition Fiber Tracking (HDFT)

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PET w/ radioisotope

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S100B

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Second impact syndrome

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5 -18 years old

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65% of ER visits

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Why woman fare worse in Concussion

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Diagnosis of Concussion

No two concussion are the same ...37

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Would soccer be safer if young players were not allowed to head

the ball?

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Which produces more concussion?

Concussions come in all types40

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Concussion Guidelines Step 1: Systematic

Review of Prevalent Indicators

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Carney N, Ghajar J, Jagoda A, Neurosurgery. 2014 Sep; 75 Suppl 1:S3-15. doi: 10.

Signs and symptoms

• Neck pain and stiffness,

• Headache

• Shoulder pain

• Dizziness,

• Fatigue, • Jaw Pain

• Arm pain, weakness

• Visual disturbances,

• Ringing in the ears - Tinnitus

• Back pain • Depression

• Anger

• Frustration,

• Anxiety

• Stress

• Drug dependency,

• Post Traumatic Stress

• Sleep disturbance - Insomnia

• Social isolation

• Headache

• Temporary loss of consciousness

• Confusion or feeling as if in a fog

• Amnesia • Dizziness

• Ringing in the ears

• Nausea or vomiting

• Slurred speech

• Fatigue • Concentration and memory

complaints

• Irritability • Sensitivity to light and noise

• Sleep disturbances

• Psychological problems and depression

• Disorders of taste and smell

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Whiplash Concussion

Signs and symptoms

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Whiplash Concussion• Neck pain and stiffness,

• Headache

• Shoulder pain

• Dizziness, • Fatigue,

• Jaw Pain

• Arm pain, weakness

• Visual disturbances,

• Ringing in the ears - Tinnitus • Back pain

• Depression

• Anger

• Frustration,

• Anxiety

• Stress

• Drug dependency,

• Post Traumatic Stress

• Sleep disturbance - Insomnia

• Social isolation

• Headache

• Temporary loss of consciousness

• Confusion or feeling as if in a fog • Amnesia

• Dizziness

• Ringing in the ears

• Nausea or vomiting

• Slurred speech • Fatigue

• Concentration and memory complaints

• Irritability

• Sensitivity to light and noise

• Sleep disturbances

• Psychological problems and depression

• Disorders of taste and smell

Symptoms detailed:SOMATIC

• Headache • Dizziness • Balance disruption • Nausea / Vomiting • Visual disturbance (Photophobia,

blurry / double vision) • Phonophobia

AFFECTIVE

• Emotional lability

• Irritability

• Fatigue

• Anxiety

• Sadness

SLEEP • Sleep more than usual • Sleeping less than usual

COGNITIVE • Confusion • Anterograde amnesia • Retrograde amnesia

• Loss of consciousness

• Disorientation

• Feeling mentally “foggy”

• Vacant stare

• Inability to focus

• Delayed verbal and motor responses

• Slurred / incoherent speech

• Excessive drowsiness

SOMATIC AFFECTIVE SLEEP COGNITIVE

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3 Areas of Action:

•On field exam

•Sideline evaluation

•Removal from play

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On field exam

• Airway, Breathing, Circulation

• Neurological Assessment: Mental Status,

Neurological Deficit, Cervical Spine Status - be

prepared to immobilize and transport

• Determine Initial Disposition: Emergency

transport or Sideline evaluation

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Vestibular Ocular Motor Screening (VOMS)1. Pursuits: H-Test

2. Saccades: Horizontal

3. Saccades: Vertical

4. Gaze Stability: Horizontal

5. Gaze Stability: Vertical

6. Convergence insufficiency

7. Balance Screen

Balance Pad

Sideline evaluation• Perform a more detailed physical examination and history

(including previous concussions)

• Assess for Concussion Symptoms (use Sports Concussion Assessment Tool, aka SCAT 3 - form, preferably for ages 13 and older) MOST important: Pay attention to the Number and Duration of symptoms.

• Cognitive

• Somatic

• Affective symptoms

• Evaluate Orientation, Memory, Concentration and Balance - the athlete should be removed from play if they are exhibiting concussion symptoms or unable to provide memory recall, or having problems with balance.

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King-Devik

Lamar Miller56

Removal from play• No same day play - too much potential for repeat

concussion

• Don’t be pressured

• Monitor the athlete for 1 to 2 hours following the injury. Once again, immediately transport to ER if any signs of deteriorating neurological function.

• Document the injury • Discuss the injury with guardians - (use hand out)

• Review symptoms they should watch for and home

• And at school

• Reinforce Concussion guidelines

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In your office

•Cognition

•Neurology

•Balance

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Best indicators for CT or MRI

★Neurological Exam

★Mechanism of Injury

★Symptom Assessment

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Best indicators for Hospital Admission

• Signs of injury that require monitoring and repeat exams

• Fluctuating or deteriorating neurological, cognitive or symptom evaluation

• Safety of athlete is better served by careful neurological observation than by home observation

• It is unclear if an athlete can be adequately observed at home

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Characteristics of Injury• Ask how it happened - type and

location of force • Document: type and location of force

(rotational force is greatest factor) *Angular acceleration may increase risk factor of concussion from 25% to 80%.

• Loss of consciousness - (very small percentage, approx 10%)

• Areas of concern

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Risk factors affecting recovery

• Concussion history - may be

cumulative

•Number

• Severity

•Time of occurrence

•Mechanisms of prior incidences

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IMPORTANT!

Risk factors affecting recovery

Personal and family history of conditions that may result in protracted or extenuating factors, such as:

• Migraines

• Depression

• Mood disorders

• Anxiety

• Learning disabilities

• Attention Deficit/Hyperactivity Disorder

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What do you think is the first question an athlete or a parent is going to ask?

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“When can I get back in the game?”

How many fingers do I have up?

How many will I have up tomorrow?

Management of Concussion

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Refer to a Specialist if:• Symptoms have not

gone away after 10 to 14 days

• The symptoms worsen

• The patient has a

history of multiple concussions or risk factors for

prolonged recovery

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Returning to School• Cognitive Rest - Avoid mentally

exerting activities that aggravate symptoms. Such as:

• Working on a computer

• Watching television

• Using a cellphone

• Reading

• Playing video games

• Text messaging

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Involve school nurses, teachers and counselors

Signs:

• Increased problems concentrating • Increased problems remembering new

information

• Longer time required to complete tasks

• Increased symptoms (i.e. headache, fatigue) when working

• Greater irritability

• Poorer academic performance

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Involve school nurses, teachers and counselors

Areas to modulate:

• Time off from school

• Shortened day

• Shortened classes, or rest breaks during classes

• Rest breaks during the day

• Allowances for extended time to complete coursework

• Reduced work load

• Un-timed tests

• No significant classroom or standardized testing until symptoms subside

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Do you remember when …

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Imagine if …

Returning to Play

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FIVE STEP PROCESS

• Step 1: Light Aerobic Exercise

• Step 2: Moderate Exercise

• Step 3: Non-contact Exercise

• Step 4: Practice

• Step 5: Play

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Step 1: Light Aerobic Exercise

• Goal: Increase athlete’s heart rate

• Time: 5 to 10 minutes

• Activity: Exercise bike, walking or light jog

• Do not do: Weightlifting, Jumping or Hard Running

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Step 2: Moderate Exercise

• Goal: Limited body and head movement

• Time: Reduced from typical routine

• Activity: Moderate jogging, brief running, moderate intensity stationary biking and moderate intensity weight lifting

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Step 3: Non-contact Exercise

• Goal: More intense, but NON-contact

• Time: Close to typical routine

• Activity: Running, high intensity stationary biking, the player’s regular weightlifting routine and non-contact sports specific drills

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Step 4: Practice

•Goal: Reintegrate into full contact practice

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Step 5: Play

•Goal: Return to full competition

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up to 2x

College

1 year Post Concussion

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15%

NFL

Concussion25%

1st Degree Sprains

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32 - “SAFE” Helmets NHL to Youth

25% UNSAFE 1 - 3 rated 22 - 1 & 2 rated 9 - FAILED

5 max.

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Strict Rest for the

adolescent

No Added Benefit

Potential Treatment

Strategies

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Current and Emerging Rehabilitation for Concussion

91. Norre ME. Cervical vertigo. Diagnostic and semiological problem with special emphasis upon “cervical nystagmus”. Acta Otorhinolaryngol Belg 1987;41(3): 436–52.

92. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: im- plications for assessment and management. J Orthop Sports Phys Ther 2009; 39(5):364–77.

Acute Tx and Prevention strategies

★ Ketogenic diet approach is preferred.

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Diet, ketones, and neurotrauma•Impact Factor: 4.58 •Pre Clinical trials •Ketones during glucose metabolic depression has resulted in age-related neuroprotection

B.Nutritional approaches: — Omegas: DHA, EPA, GLA — Vitamin D

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B.Nutritional approaches

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Blueberries

Water

Red MeatFish

Chicken

B.Nutritional approaches

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Herbs:

Boswellia

Cumin

Bromelain

Which Type of Exercise Is Best for the Brain?

Nokia, M. S., Lensu, S., Ahtiainen, J. P., Johansson, P. P., Koch, L. G., Britton, S. L. and Kainulainen, H. (2016), Physical exercise increases adult hippocampal neurogenesis in male rats provided it is aerobic and sustained. J Physiol. doi:10.1113/JP271552

HBOT and Concussion

J Neurotrauma. 2013 Dec 1; 30(23): 1995–1999., doi: 10.1089/neu.2012.2799, PMCID: PMC3837504, Hyperbaric Oxygen Therapy for Post-Concussion Syndrome: Contradictory Conclusions from a Study Mischaracterized as Sham-Controlled, Paul G. Harch

Prevention strategies

A.Neck strengthening exercises (in all planes)

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J Prim Prev. 2014 Oct;35(5):309-19. doi: 10.1007/s10935-014-0355-2., Neck strength: a protective factor reducing risk for concussion in high school sports., Collins CL1, Fletcher EN, Fields SK, Kluchurosky L, Rohrkemper MK, Comstock RD, Cantu RC.

Br J Sports Med 2013;47:321-326 doi:10.1136/bjsports-2013-092216., What are the most effective risk-reduction strategies in sport concussion, Brian W Benson, Andrew S McIntosh, David Maddocks, Stanley A Herring, Martin Raftery, Jiří Dvořák

Neck Strength101

1 pound 5% decrease

Strength Concussion

Weak Neck

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Prevention strategies

C.Following the rules D.Good sportsmanship E. Correctly wearing the right

protective equipment F. Appropriate techniques G.Protective equipment

★ Fit properly

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AIR

FOAMor GEL

VS

Prevention strategiesC.Following the rules D.Good sportsmanship E. Correctly wearing the right

protective equipment F. Appropriate techniques G.Protective equipment

★ Fit properly ★ Age appropriate ★ Activity appropriate ★ Well maintained ★ Worn consistently

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"After getting hit so hard from behind, the symptoms from the concussion were frustrating. Treatment, along with

Chiropractic, relieved the tension around my neck and head. The ache eased so I could think better and was more

comfortable, and within enough time to pass the tests and lead the team to a win the following weekend."

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Questions?

What did you learn today?