the current state of concussion care: moving … › › resource › resmgr › 2018...the current...

The Current State of Concussion Care:

Moving Away from Rest

Tamara C. Valovich McLeod, PhD, ATC, FNATAJohn P. Wood, D.O., Endowed Chair for Sports Medicine

Professor and Director, Athletic Training ProgramsResearch Professor, School of Osteopathic Medicine in Arizona

Disclosures• I have no disclosures related to this

presentation

Objectives1. Discuss the current status of sideline and

office-based concussion assessment. 2. Debate the merits of an active approach

to treating concussion. 3. Describe the necessary collaborative

approach needed to manage concussion. 4. Discuss the current best practice

recommendations for returning a patient to physical activity, sport, and school.

Lumba Brown, 2018

Berlin Consensus Statement11 Rs

• Recognize• Remove• Re-evaluate• Rest• Rehabilitation• Refer

• Recover• Return to sport• Reconsider• Residual Effects• Risk reduction

McCrory et al, Br J Sport Med. 2017

Sideline and Office-Based Assessment

Berlin On-Field Screen• Rapid screen• Clear on-field signs

– LOC– Ataxia– Tonic posturing– Post-traumatic seizure

Immediate Diagnosis of Concussion

Patricios, 2017

SCAT5 Immediate / On-Field Assessment

McCrory, 2017

Immediate Referral• Deteriorating level of consciousness (LOC)• Loss of or fluctuating LOC• Increased confusion• Inability to recognize people and places• Increased irritability• Worsening headache• Repeated vomiting• Extremity numbness• Signs of skull fracture• Focal findings on neuro exam• Seizure• GCS <13 Anderson & Schnebel, 2016;

Hyden & Petty, 2016

Recognize: Sideline ScreenRapid screening for a suspected SRC, rather than the definitive diagnosis

Clear on-field signs of SRC (should immediately be removed• LOC, tonic posturing, balance impairments

Suspected SRC following a significant head impact or with symptoms can proceed to sideline screening using appropriate assessment tools

More thorough diagnostic evaluation, which should be performed in a distraction-free environment


Berlin Sideline Screen

• Symptom reporting and interview• Verbal cognitive evaluation (eg. SAC)

– Maddocks questions, SAC– Not meant to replace formal cognitive testing

• Balance evaluation (BESS, Tandem gait)• Serial Assessments• Clinical examination


Video Signs for ConcussionNational Rugby

LeagueAustralian Football

LeagueNational Hockey

LeagueClutch or shake head Clutching head / face Clutching of headSlow to get up Slow to get up Slow to get upWobbly legs Incoordination Motor incoordination /

balance problemsBlank / vacant stare Blank / vacant look Blank / vacant stareUnresponsiveness Loss of responsiveness Suspected LOCPost-impact seizure Impact seizure Disorientation

Facial injury Visible facial injury with any of above

No protective actionGardner, 2017 Davis, 2016 Hutchison, 2014

Echemendia, 2017

Davis & Makdissi, 2016

SCAT-5• On-field

assessment• Office assessment

– Symptoms– Cognition– Neurological

screen• Take home

instructions

Child SCAT-5• Ages 5-12• Standardized tool

for administration by HCPs– On-field– Symptoms– Cognition– Neurological– Balance

• Take home instructions

Re-evaluate: Follow-Up Exam


Medical assessment• Comprehensive history and detailed neurological examination including

a thorough assessment of mental status, cognitive functioning, sleep/ wake disturbance, ocular function, vestibular function, gait and balance

Determination of the clinical status of the patient• Has been improvement or deterioration since the time of injury • May involve seeking additional information from those close to patient

Determination of need for emergent imaging• Red flags for intracranial bleed

Follow-Up Evaluations

Concussion AssessmentClinical Exam

Symptoms

Vestibular -Ocular

Postural Control

Mental Status

Neurocognitive

Vestibular Ocular Motor Screening (VOMS)

Systematic method to evaluate oculomotor function

– Ages 9-40– Abnormal findings or provocation of

symptoms may indicate dysfunction and result in referral

– Equipment• Tape measures• Metronome• Target with 14 point font

Mucha, AJSM, 2014

Smooth pursuits Horizontal Saccades Vertical Saccades

Convergence

Horizontal VOR(Also complete Vertical VOR)

Visual Motion Sensitivity

Mucha, AJSM, 2014

King-Devick Test

• Evaluates visual tracking and saccadic eye movements

• Initially used for reading and dyslexia

• Sideline post-concussion showed significant worsening from BL: 46.9 vs. 37.0 s, P = 0.009 (Galetta, 2011)

www.kingdevicktest.com

Vestibulo-Ocular Exam• VOMS predictive of delayed recovery (Anzalone,

2016)– Symptom provocation– Clinical abnormality

• Smooth pursuits, saccades, VOR• VOMS feasible in pediatric ED (Corwin, 2018)

• Eye tracking abnormalities correlated with symptoms (Bin Zahid, 2018)

– Convergence and accommodative abnormalities associated with concussion

Balance Assessment

• Heel to opposite knee• Finger to nose• Romberg test• Computerized posturography (SOT, CTSIB)• Clinical balance tests (BESS, SEBT)• Functional balance tests (TUG, Gait)

– Tandem gait– Instrumented gait– Timed up and go

Difficult to quantify and use in serial assessments

Mental Status Tests• SCAT5• Mini-mental status examination• Acute Concussion Examination (ACE)• Appropriate in first 48-72 hours• Sensitivity decreases significantly after 72

hours

Neurocognitive Tests• Pencil and paper or computerized• Baseline testing not felt to be required as a

mandatory aspect of every assessment – May be helpful or add useful information to the

overall interpretation of these tests– Provides an educational opportunity for the

healthcare provider to discuss the significance of concussion

• Post-injury neurocognitive testing is not required for all athletes – If used should be performed by a trained and

accredited neuropsychologist


Physiologic Measures• Advanced neuroimaging • Fluid biomarkers

– Confusion with FDA approval of biomarker for ICH

• Genetic testing • Important research tools• Level of evidence for clinical assessment

is LOW– Require further validation to determine clinical

utilityMcCrory et al, Br J Sport Med. 2017

Active Treatment Approaches

REST

Physical Rest

Cognitive Rest

Rest Activity

Activity or Rest?

No school or exercise activity

School activity only

School activity and light activity at home

School and sports practice

School and sports gamesMajerske, JAT, 2008

Berlin Recommendations• Brief period (24–48 hours) of complete rest

– Gradually and progressively more active – Staying below their cognitive and physical

symptom• Rehabilitation needs to include cognitive and

school activities• Return to Sport should occur after

– Brief rest, symptom limited activity, off medications, full return to school

• Need to address academics– Successfully return to school first, then sport!

Schneider, 2017; McCrory, 2017; Davis, 2017

CDC Pediatric Recommendations

• Health care professionals should counsel patients to observe more restrictive physical and cognitive activity during the first several days after mTBI in children (moderate; level B)

• Following these first several days, health care professionals should counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression (moderate; level B)

• After the successful resumption of a gradual schedule of activity, health care professionals should offer an active rehabilitation program of progressive reintroduction of noncontact aerobic activity that does not exacerbate symptoms, with close monitoring of symptom expression (high; level B)

Lumba Brown, 2018

TreatmentIntervention that occurs between injury and RTPMay include interventions done after RTP

Return to PlayProgression from medical clearance to return to sport and full, unrestricted play

Post-Concussion Management

Acute management

• Remove• Immediate referral /

red flags

Sub-symptom treatment/rehabilitation

• Based on symptom presentation

• As tolerated

Return to activity progression

• Testing to return to sport

• Functional progression

Protection Phase

Deficit Management

Phase

Return to Sport Phase

Lundblad, 2017

Premise for Treatment• “Rest”

– Avoidance of exacerbating activities• No need to shut down areas that do not

exacerbate symptoms– Able to tolerate light aerobic exercise without

increasing symptoms?– Able to read without increasing symptoms?– Able to attend school without increasing

symptoms?

Improved cognitive

function after TBI

Symptom resolution

Mood improvement

Improved neuroplasticity,

cortical connectivity &

activation

Improved regulation of

cerebral blood flow

Exercise as an Intervention

Crane, 2012, Majerske 2008, Gomez-Pinella, 2011; Maerlender, 2015; Ahlskog, 2011; Colcombe, 2004; Lautenschlager, 2008

Early Exercise Interventions

Physical

• Maintain fitness• Physiological

benefits of exercise• Rehabilitation of

affected systems

Psychological

• Improved compliance

• Remove isolation• Reduction in

anxiety• Psychological

benefits of exercise

Clinical Pathways

• Can we predict patient outcomes?• Can we determine the best treatments for

each patient based on initial clinical presentation?

Clinical Pathways

Risk Factors

• Prior concussions

• Migraine• LD/ADHD• Sex• Age• Medical hx

Concussion

• Immediate clinical presentation

Clinical Trajectories

• Vestibular• Ocular• Cognitive• Migraine• Anxiety /

Mood• Cervical

Treatment Pathways

• Cognitive rest• Physical rest• Vestibular

rehabilitation• Medications• Cognitive-

speech therapy

• Early exercise• Manual

therapy

Collins, 2013

PPE Acute Exam

Mood / Anxiety

Nutrition

Sleep Academic Adjustments

Vestibular Therapy

Oculomotor Rehabilitation

Exercise Cervicogenic/ Migraine

Sleep• Address sleep issues first

– Systems regarding arousal, alertness, attention and sleep are vulnerable after TBI (Ponsford, 2012)

– Perceived sleep disturbance related to greater symptom burden and lower neurocognitive scores (Kostyun, 2014)

• Good sleep hygiene– Aim for similar sleep/wake times each day– Quiet, dark environment– Avoid visual stimulation from electronics

Targeted Treatments•Difficulty concentrating, overall fatigue, decreased energy levels•Reduce cognitive and physical demands•Regulate sleep, stress, diet, and mild exercise (1 short walk/day)

Cognitive/Fatigue

•Dizziness, fogginess, nausea, anxiety, overstimulation by complex environments

•Brought on with rapid head or body movements•Vestibular rehabilitation

Vestibular

•Localized, frontal-based headaches, fatigue, distractibility, difficulty with vision, pressure behind eyes, trouble focusing

•Consult with neuro-optometrist, vestibular therapist•Rehabilitation with vision therapy specialist

Ocular Motor

Collins, 2013

Targeted Treatments• Overall increase in anxiety, perhaps with sleep disturbance

and vestibular issues• Treat vestibular issues• Begin physical exertion protocols and regulate sleep

Anxiety/Mood

• Moderate to severe headache with nausea and photosensitivity or phonosensitivity, often exaggerated by physical activity and stress

• Pharmacologic intervention

Post-traumatic Migraine

• Headache and neck pain• ROM, manual cervical and thoracic mobilization, posture

education, biofeedback, soft tissue mobilizationCervical

Collins, 2013

Mood Disturbances• Concussion can result in anxiety, depression,

emotional disturbances (Ponsford, 2012; Hutchison, 2009; Mainwaring, 2004; Kontos, 2012)

• Treatment – Referral to psychologist, psychiatrist, cognitive

rehab– Cognitive Behavior Intervention (Hodgson, 2005)

– Mood stabilizing medications– Structured environment (Collins, 2014)

• Understand stress of removing from social (sport) • Allow some time with teammates• Active treatments may reduce stress

HeadachesCervicogenic• Hemicranial pain referred

to the head by bony of soft tissue structures of the neck (Biondi, 2005)

• Treatment (Page, 2011)

– Postural correction– Manual therapy– Modalities– Exercise therapy– Breathing patterns

Migraine• Pre-existing condition

may be exacerbated• Migraine presentation can

occur after concussion• Can be caused by related

vestibular dysfunction• Treatment

– Medications– Vestibular rehabilitation

Indications for Vestibular Therapy

• Atypical Recovery– Not back to baseline on balance assessment

by 10 days post-concussion– Impaired dynamic visual acuity tests– Dizziness– Motion provoked dizziness– Nausea– Blurred vision with head movement– Motion sensitivity

Kevi Ames, PT, DPT

Indications for Vestibular Rehabilitation

• Symptoms– Vertigo (especially when lying in bed)– Dizziness/ imbalance

• No improvement over one week or is persistent beyond two weeks

• Balance impairments– Strong Romberg (after one week)– BESS

• ↑ BL after 1 wk or > 10 errors per set, > 30 total after 1 wk• + Dix Hallpike

– +/- improvement or resolution with Epley maneuver• Patients generally like the active nature of

participating in their recoveryJavier Cardenas, MD

Vestibular Rehabilitation After Concussion

Intervention

• Gaze stabilization (X1)• Standing balance• Walking with balance

challenges• Canilith repositioning

Outcomes

• ↓ Dizziness rating• ↑ Activities-specific balance

confidence scale• ↓ DHI• ↑ Dynamic gait index• ↑ Functional gait

assessment• ↓ TUG• ↑ SOT (all conditions)

Alsalaheen, JNPT, 2010

Buffalo Concussion Treadmill Test

• Assists with differential diagnosis (Leddy, 2013)

– Patients with concussion stop at submaximal level

– If able to exercise to exhaustion without replicating symptoms then symptoms not due to physiologic concussion

• Cervical injury• Vestibular / ocular dysfunction• Post-traumatic headache or migraine

Exercise Interventions

Treatment

Supervised

Documented

ProgressedMultifaceted

Planned

• Type of exercise• Duration• RPE• HR• BP• Symptoms

• Initially do not stimulate visual field, vestibular

• Progress to add stimuli

• Avoid stimulating brain activities that are correlated to symptoms

• Aerobic• Coordination• Visualization• Motivation• Education

Berlin Recommendations: Treatment

• Specific treatments based on clinical examination findings and symptoms

• Individualized symptom-limited aerobic exercise programs – Patients with persistent post-concussive symptoms

associated with autonomic instability or physical deconditioning

• Targeted physical therapy – Patients with cervical spine or vestibular dysfunction

• Collaborative approach including cognitive behavioral therapy – Persistent mood or behavioral issues.


Berlin Recommendations: Persistent Symptoms

• Beyond expected time frames (ie, >10–14 days in adults and >4 weeks in children)

• Multimodal clinical assessment – Needed to identify specific primary and

secondary pathologies that may be contributing to persisting post-traumatic symptoms

• Treatment should be individualized – Target-specific medical, physical and

psychosocial factors identified


Treatment Case Examples

Adolescent Soccer Athlete

• Symptom Reports– Dizziness with

movement– Balance problems– Headache– Mild nausea– Photosensitivity

• Past Medical History– 3 prior concussions

• Clinical Exam Findings– Symptom provocation

with VOMS testing– Balance deficits

• Clinical Profile1. Vestibular2. Post-traumatic migraine

Adolescent Soccer Athlete• Treatment plan

– Vestibular rehabilitation• Home exercises

– Sleep regulation– Proper hydration and nutrition– Light physical activity– Academic adjustments

Collegiate Volleyball Athlete

• Symptom Reports– Trouble focusing– Fatigue– Irritability– Fogginess– Anxiety

• Past Medical History– 1 concussion previous

season– Unresolved

• Clinical Exam Findings– NCT scores normal– Mild symptom

provocation with VOMS– Increase symptoms with

exertion testing

• Clinical Profile1. Anxiety/Mood2. Post-traumatic migraine3. Vestibular

Collegiate Volleyball Athlete• Treatment plan

– Physical activity as tolerated, ideally with friends

– Referral to psychologist• Cognitive behavioral therapy

– Sleep regulation– Appropriate hydration and nutrition– Vestibular rehabilitation

• Home exercises

Collaborative Approach to Concussion Care and Best

Practices for Return to Activity

Treatment Team• Athletic Trainer• Sports medicine provider• Primary care providers• Sport Physical Therapist• Vestibular Therapist• Physician Assistant• Nurse Practitioner• Neurologist• Neurosurgeon• Neuropsychologist• Occupational Therapist• School Nurse

• Speech & Language Pathologist

• Physical Medicine & Rehabilitation physician

• Ocular Therapist• Behavior Optometrist• Psychologist• PsychiatristAdjunct Team MembersCoach, Teacher, Academic Counselor, Family

Team Team Members RolesFamily Patient, parents, guardians, relatives,

peers, teammates, family friendsImpose restMonitor and track symptoms at home including emotional and sleep-related symptoms dailyCommunicate with school teams

Medical Primary care provider, team physician, emergency department, concussion specialist, neuropsychologist, other medical referrals

Rule out more serious injuryEvaluate patient periodicallyCoordinate information from other teamsEncourage physical and cognitive rest

School Academic

School nurse, school counselor, teachers, school psychologist, social worker, school administrator, school physician, school occupational or physical therapist

Reduce cognitive loadMeet with patient to create academic adjustmentsWatch, monitor, and track academic and emotional issues

School Physical Activity

Athletic trainer, school nurse, coach, physical education teacher, school physician, playground supervisor

Watch, monitor, and track physical symptomsAthletic trainer should do daily follow-up examinationsEnsure no physical activity

Williams & Valovich McLeod, Quick Consult: Concussion, 2015

Concussion Management Team at HS Level

School System Preparation

Establish state and local school policies

and procedures

Educate school personnel about mild traumatic brain injury

Implementation of school-based concussion

management action plans

Medical System Preparation

Training resources for medical providers

Communication plan with school personnel

Gioia, 2016

School Support Infrastructure

Defining and training an interdisciplinary school concussion management team

Professional development of the school and medical communities with respect to

concussion management in the school

Identification, assessment, and progressmonitoring protocols

Availability of a flexible set of intervention strategies to accommodate the student’s

recovery needs

Systematized protocols for activecommunication among medical, school, and

family team membersGioia, 2016

Concussion & Academic OutcomesNegative

• Cumulative GPA significantly lower in youth with 2+ concussions & recent concussion (Moser, 2005)

• Higher academic dysfunction scores 1 week after concussion compared to extremity injured (Wasserman, 2016)

• Symptomatic students had increased level of concern for impact of concussion on academic performance and more school related problems (Ransom, 2015)

• Vision symptoms, hearing difficulty, and concentration difficulty were significantly associated with academic difficulty (Swanson, 2016)

• 79% of ATs managed patient who experienced a decrease in school and academic performance following concussion (Williams, 2015)

None• Concussion did not alter academic outcomes when using end of year

GPA (Russell, 2016)

Universal Level (Tier 1)• Temporary• Academic adjustments

Targeted Level (Tier 2)• Longer term• Academic accommodations

Intensive Level (Tier 3)• Permanent • Academic modifications

McAvoy, 2018

Universal Level (Tier 1)

• Students receive – Quick and early screening– Academic adjustments promptly

and liberally– Academic supports that can be

adjusted frequently (hourly, daily, weekly) by the general education teacher

• Individualized Health Plan (IHP) – Tailor-made plan for students

whose healthcare needs affect or have the potential to affect the student’s safe and optimal school attendance and academic performance

• 70 % of students with a concussion recover within 4 wks– RTL plan needs to be immediate

and applied in general education• General education teachers

– Trained to front-load academic supports within the first 4 weeks

– Fade academic supports as the concussion symptoms subside

• IHP may be an ideal mechanism for use in the RTL process for students who have sustained a concussion

McAvoy, 2018

Targeted Level (Tier 2)• Students may receive

– academic supports in a more customized fashion

– academic supports for a longer period of time

• 504 Plan– Most common Tier 2 support– Federal civil rights law– May be considered if a medical

condition, substantially limits at least one of the major life activities

• Thinking, concentrating, reading, or learning

• Academic supports provided in a 504 Plan would be referred to as academic accommodations

• Protracted recovery – Beyond 1 month– 504 Plan may prove to be an

ideal mechanism for use in the RTL process for

– Symptoms that are severe or persistent

– More customized or longer educational need

McAvoy, 2018

Intensive Level (Tier 3)

• Student unable to receive benefit from general education

• Specialized instruction, placement, or programming

• Academic supports provided on an IEP may include academic modification of the curriculum

• Uncommon – Concussions are often

short-term transient injuries

– Rarely result in a significant disability

• If IEP is warranted– Primary exceptionality

category would be TBI

McAvoy, 2018

Return to School Strategy

McCrory, 2017

Daily activities at home that do not give the child symptoms

School activities

Return to school part-time

Return to school full time

In the Way Way Past

Grade First concussion Subsequent concussions

I 15 minutes 1 week

II 1 week 2 weeks, withphysician approval

IIIa (unconsciousfor seconds) 1 month 6 month, with

physician approval

IIIb (unconsciousfor minutes) 6 months 1 year, with

physician approval

Colorado Medical Society guidelines for return to play

Based on LOC and amnesia

Cookbook approach and does not take into account individual clinical presentation.

Return to Play Today• Prohibited same day return

– NFL– NCAA– NFHS– AIA– Most state laws

• Individualized• Follows treatment/rehabilitation plan


Acute management


red flags



• As tolerated




Return to Activity Criteria

School• Full return to classroom

without accommodations

Symptoms• No symptoms at rest• Minimal symptoms that do

not increase with activity• Off medications

Progression• Transition from

treatment/rehabilitation to gradated stepwise RTA protocol


Acute management


red flags



• As tolerated




Meet RTA Criteria

Return to Sport• Graduated stepwise rehabilitation strategy• Brief period of rest (24-48 hr)• Symptom limited activity (Stage 1)

– Staying below physical and cognitive symptom threshold

– Symptom resolution indicator for moving to next stage• Proceed if able to meet criteria without recurrence

of symptoms• Can include results of adjunct assessments in

decision-making– Neurocognitive– Balance– Oculomotor

McCrory, 2017

McCrory et al, 2017

~24 hours between each stage

Berlin ProgressionRehabilitation/Treatment

Inclusive RTP Progression

Step 2: Light Exercise

AerobicBalance - staticVOR - seatedVision – stable head

Step 3: Sport-Specific Exercise

Aerobic - moderateBalance – dynamic & dual taskingVOR – stand-walk-jogVision – dynamic and add dual tasking

Step 4: Non-contact Practice

Aerobic – sport-specific, strengthening, plyometricsVOR – high speed head movement, sport-specificVision – high demand, sport-specific

Step 5: Full contact Px

Aerobic – BCTTAdjunct testing • Cognitive• Balance• Vestibular• Oculomotor

Step 6

Full return to competition

Take Home Points• Concussion best practices are rapidly

evolving• Emphasis on oculomotor examination is

helpful in diagnosis and prognosis• Active treatment approaches are

recommended• Referral to appropriate medical

professionals for treatment is key• Return to activity should follow a stepwise

progression

Community Health Center BAKPAC ProjectDr. Joy LewisDr. Cailee Welch BaconMs. Kate WhelihanDr. Aaron AllgoodDr. Isaac NavarroDr. Tamara Valovich McLeod

ATSU Concussion Program | Athletic Training

www.atsuconcussion.comTamara C. Valovich McLeod, PhD, ATC, FNATA

[email protected] | 480-219-6035

www.atpbrn.org

the current state of concussion care: moving … › › resource › resmgr › 2018...the current...

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