Download Approach to the Management of Concussion

Interventions in the
Management of
Concussions
Anne Felicia Ambrose M.D., M.S., FABPMR
Medical Director , Traumatic Brain Injury Program
Icahn School of Medicine at Mount Sinai
New York, NY
Department of Emergency Medicine
Approach to the Management of Concussion
1. Pre-Injury
1. Create and Implement legal safeguard at state, national, Sporting
Body level
2. Changes to the Game-Rules of Play
3. Protective equipment;
4. Pre-injury assessments
2. Injury
1. Assessments-On the sidelines, ED, Doctor’s Office- Screening,
Imaging
3. Post Injury Interventions
1.
2.
3.
4.
5.
6.
7.
8.
Rest
Return to Play Protocol
Physical and Occupational Therapy
Cognitive and Behavioral Assessments and Therapy
Vision Therapy
Vestibular Therapy
Drug Therapy
Retirement
Features of sport-related concussion
SYMPTOMS/ PH
YSICAL SIGNS
SLEEP
DISTURBANCES
COGNITIVE
IMPAIRMENT
EMOTIONAL/
BEHAVIOURAL
CHANGES
Loss of
consciousness He
adache Nausea/V
omiting Dizzines
s Loss of
balance/poor
coordination
Visual
disturbances Phot
ophobia
Amnesia Decreas
ed playing ability
Drowsiness Trou
ble falling
asleep Sleeping
more than
usual Sleeping
less than usual
Slowed reaction
times Difficulty
concentrating Dif
ficulty
remembering Co
nfusion Feeling
in a fog Feeling
dazed
Irritability Emoti
onal
lability Sadness
Anxiety Inapprop
riate emotions
Basic Principles-Post Injury Interventions
1. Rest-Physical and cognitive rest until
asymptomatic
2. Graded program of exertion
3. Additional Evaluations and Interventions
4. Medical clearance
5. Return to play.
Department of Rehabilitation Medicine
Rest-Physical and Cognitive
1. Collegiate and High School students athletes who RTP on
the same day have poorer outcomes
Neuropsychological deficits post-injury that may not be evident on the
sidelines and are more likely to have delayed onset of symptoms..
2. Malignant brain edema syndrome-seen rarely, but almost
exclusively in young athletes
3. Second Impact Syndrome
4. Young (<18) elite athlete should be treated more
conservatively even though the resources may be the same
as an older professional athlete
Fatigue and Sleep
1. Incidence
2. Clinical features
3. Associative factors
-Pain, Pain meds, Females, Depression, Anxiety, time from injury
4. Association with cognition-slower in attentional tasks
5. Sleep disturbances
-Drowsiness. Trouble falling asleep, Insomnia, Hypersomnia
6. Treatment
Headaches
Investigation
CT scans be helpful in ruling out serious bleeding injuries, but cannot
diagnose a concussion or headache.
Treatment
1.
Rest, Avoid second concussion especially in first 10 days
2.
Medications
a. No medicine that clearly alleviates post concussive headache.
b. Regular headache medications may help.
c. Preventive medications if not resolved within a month. (SE-increase fatigue,
weight, or memory, confusion) especially in athletes with long playing history, prior
+/- recent concussions, Apo E
Cognitive Impairment
1. Incidence
2. Clinical FeaturesSlowed reaction times, Difficulty concentrating and remembering,
Confusion, Feeling in a fog or dazed
3. Cognitive Restructuring
Form of brief psychological counseling that consists of
education, reassurance, and reattribution of symptoms
4. Cognitive And Behavioral Assessments and Remediations
Visual Deficits
Approach to Common Vision
Deficits Following TBI
Deficit
Primary Associated Symptom:
Treatment
Accommodation
Constant/intermittent blur
Lenses, restorative accommodation
training
Tear Film
Integrity
Distorted clarity/gritty sensation,
which varies with blinking
Eye drops
Versional
Ocular Motility
Slower, less accurate reading
/difficulty sustaining gaze, shifting
gaze, or tracking targets
Basic scanning and searching
exercises
Typoscopic approach
Constant/intermittent eyestrain /
Vergence Ocular diplopia eliminated with monocular
Motility
occlusion
Fusional prism,;Varying degrees of
occlusion ; Vergence stabilizing
exercises
Approach to Common Vision Deficits
Following TBI
Deficit
Primary Associated Symptom:
Treatment
VisualVestibular
Interaction
Disequilibrium exacerbated in
multiply, visually-stimulating
environments
Adaptive exercises using graded
provocations.correct accommodation
Light-Dark
Adaptation
Elevated light sensitivity
Tinted lenses
Visual Field
Integrity
Missing a portion of vision
Yoked or spotted prisms, mirrors,
and field expanding lenses ,scanning
strategies and compensatory/
adaptation approaches
Visual
processing
Slower speed/impaired visual
memory and visual-spatial
processing
Adaptive and restorative exercises
Nausea/Dizziness/Vertigo/Loss of
Balance
Causes of dizziness, Impaired balance or vertigo
1. Benign paroxysmal positional vertigo (BPPV),
2. Labyrinthine concussion,
3. Perilymphatic fistula (PLF),
4. Post-traumatic Meniere Syndrome (hydrops),
5. Temporal bone fracture,
6. Cervical (cervicogenic) vertigo,
7. Epileptic vertigo,
8. Migraine associated vertigo and ocular motor
abnormalities.
Symptoms of Post-concussive Vestibular And
Balance Dysfunction
1. Dizziness (55–78%),
2. Impaired Balance (43–56%),
3. Blurred Vision Or Diplopia (49%)
(Lovell, 2009).
Approach to Treatment of Vestibular Dysfunction
1. Rest
2. Evaluation if symptoms persist >2 weeks
3. Medications-avoid meclizine, Aspirin
4. Assessments
1.
2.
3.
4.
5.
Detailed history of concussion occurred,
Initial presenting symptoms,
New or existing medications,
Prior history of concussions, or any past imaging or treatment.
Clinical diagnostic tools are used to determine the severity of the symptoms
to identify potential structural lesions.
1.
2.
Balance Error Scoring System (BESS) test,
computerized dynamic posturography (CDP) which includes balance tests, the
Sensory Organization Test, and visual tracking technologies
(Lovell, 2009)
Type and purpose
Theoretical description
Example
Canalith repositioning
maneuver
(Curative for BPPV)
Diagnostic and therapeutic
Repetitive head movements
maneuvers simple and effective for
BPPV
Habituation
(For impaired motion
sensitivity)
Provocation of stimuli induces
symptoms; enhances vestibular
compensation; requires repetition;
intensity of exercise proportional
to severity of symptoms
Head position or movement
inducing
dizziness or vertigo
Adaptation
(For impairments in
convergence)
Enhancement of intact vestibular
circuits to compensate for loss of
function within same system; Use
of retinal slip during head
movement
(verticle or horizontal)
Instructed to move head while
maintaining focus on moving
(VOR1) or stationary
(VOR2) target. Degree of
difficulty of exercise
increased progressively
Type and purpose Theoretical
description
Example
Substitution
(For major
vestibular
impairment)
Exercises that facilitate preprogrammed eye
movements to scan field and detect target
in order to prompt head and neck
movements to override vestibular-ocular
reflex
Replacement of
deficient vestibular
system by
enhancement of ocular
systems
Balance exercises Positional Exercises
(To enhance
supportive balance
systems)
Proprioceptive
Neuromuscular
Facilitation
Static balance
= alternating visual and somatosensory input,
with change of support base-> Wide vs Narrow
Aerobic exercise
(To strengthen
balance via
muscle
conditioning)
Progressive walking exercise with increase
time and intensity. Advance gradually to
sustained aerobic activity.
Promotes
strengthening of
muscle groups to help
improve balance
reaction time
Dynamic balance
= higher level of challenge. Head turning while
walking; quick head turn (right or left) while
walking; incorporating task while walking->
tossing an object or cognitive task while walking
Pharmacological therapy in sports
concussion
1.
Role of pharmacological approach
1. Management of specific prolonged symptoms (e.g. sleep disturbance,
anxiety etc..).
2. Modify the underlying pathophysiology of the condition with the aim of
shortening the duration of the concussion symptoms.
2.
An important consideration in RTP is that concussed athletes should not
only be symptom free but also should not be taking any pharmacological
agents/medications that may mask or modify the symptoms of
concussion.
3.
Where antidepressant therapy may be commenced during the
management of a concussion, the decision to return to play while still on
such medication must be considered carefully by the treating clinician.
Retirement
1. Professional athletes with a history of multiple
concussions and subjective persistent neurobehavioral
impairments
2. Counseling. about the risk factors for developing
permanent or lasting neurobehavioral or cognitive
impairments and should recommend retirement from
the contact sport to minimize risk for and severity of
chronic neurobehavioral impairments
Play Safe Program at Mount Sinai
Athletic Coaches, School Nurses, Parents
Emergency Departments, Pediatricians, Sports Doctors
PLAY SAFE PROGRAM
Physical /Occupational/Vision/Vestibular therapy
Neurology/Neurosurgery/Orthopedics/ENT/Ophthalmology
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