Concussion in Sports in New York Kristine Campagna, DO Latham Medical Group Assistant Team Physician, UAlbany Faculty, AMC Primary Care Sports Med Fellowship 28 Years of Innovation Quality Compassion Concussion in Sports in New York • Objectives – Case presentation to highlight some common issues – Review of NYS legislation – Discussion of best practice models – Insights from most recent international consensus statement Concussion in Sports in New York • Common issues – Field side care, who do we send to the ER? – 1st office follow-up, return to school decision? • Limitations? • Medications? • Equipment? – Deciding return to play • Evaluation & testing • Stepwise/graded protocol Concussion in Sports in New York • Case Presentation – July 2012 – 16 y/o female soccer player sustained head-to-head contact with opponent during tournament game on a Friday. Brief headache/dizziness, but no LOC/amnesia. Continued to play. – Sat. game, knocked over landing initially on buttocks, then head hit ground. Symptoms recurred. No LOC. Got up and continued. – That night, nausea and fatigue. – Sun. challenged for aerial ball and again knocked over, this time head hits ground 1st. Immediate dizziness, photophobia. Took time to get up, coach came onto field and took her off. Concussion in Sports in New York • After this 3rd impact, she had persisting headache and neck stiffness symptoms. • Despite that, was allowed to resume play after 10 minutes and completed game without further incident. • Tournament athletic trainer did evaluate and noted her balance was abnormal. • Presented to her PCP Mon AM, persisting headache and vomited x2 including episode while at PCP office. Referred to Emergency Dept. at AMC. • Past Medical History: extremity fracture(s), no previous head injury. • Meds/Allergies: Ibuprofen prn, NKDA. • Family/Social: High school soccer athlete, no neurological FH. • ROS: Headache, neck stiff, N/V, dizziness, fatigue/sleeping a lot. • Conclusions : Sport-related concussions can be difficult to diagnose. Concussion produces an evolving constellation of somatic, cognitive and neurobehavioral symptoms that are typically most severe during the earliest acute post-injury period (i.e. within the first 24–48 h) and diminish over a matter of several days to weeks in the majority of athletes. Athletes suspected of concussion should be removed from play and evaluated thoroughly. Sports Concussion Assessment Tool • • • Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT3, which incorporates the Maddocks’ questions and the Standardized Assessment of Concussion (SAC). Concussion in Sports in New York • Physical Exam: – BP 106/68, HR 68, RR 16, Temp 98.5, Weight 123lb. – Generally looked well, alert & oriented x3, affect normal. No bruising or discharge nose/ears. – Cranial nerves: EOMI, no nystagmus/diplopia, visual fields intact, fundi no papilledema, VII-XII symmetrical. – UE: no ulnar drift, normal finger-nose, dysdiadochokinesis, power/sensation/DTR’s symm. & normal. – LE: power/sensation/DTR’s symm. & normal, Romberg negative, struggled to walk heel-to-toe, unable to maintain tandem stance with hands on hips and eyes closed. – Neck: FROM, mild TTP right side paraspinal musculature. • Serial examination best conducted using same format as initial field side asst, e.g. SCAT3 Concussion in Sports in New York • Imaging – CT Scan was done in Emergency Dept. • Assessment/Plan – Concussion – Discharged from ED, for follow-up with PCP or Sports Medicine Concussion in Sports in New York • Seen by Sports Medicine 4d later – History and physical exam repeated; still reporting headache, and balance still abnormal on exam – Too symptomatic for computerized neuropsych testing at this time – Recommended rest from physical and cognitive activity (was out of school on vacation, limited computer/phone & TV) – Suggested f/u in 1 week CONCLUSIONS: • current evidence evaluating the effect of rest and treatment following a sport-related concussion is sparse • initial period of rest may be of benefit • long-term outcome of rest, and the optimal amount and type of rest? • low-level exercise may be of benefit • optimal timing post-injury currently unknown • rehabilitative techniques in individuals with clinical findings suggesting cervical spine or vestibular dysfunction may facilitate recovery • need for high-level studies evaluating the effects of ; – – – – resting period pharmacological interventions rehabilitative techniques exercise for individuals who are slow to recover Concussion in Sports in New York • Sports Med F/U 10d post-injury – Persisting intermittent headaches, less intense, total Sx score 21 – Dizzy with sit-to-stand, BP 88/54 – Improved balance, able to heel-toe walk and could perform tandem stance/hands on hips and eyes closed for 15 secs w/o mistake – Computerized neuropsych test: (ACCURATE BUT VERY SLOW) • memory composite verbal of 91 (66%ile) • memory composite visual 85 (86%ile) • visual motor speed composite of 24.67 (<1%ile) • reaction time composite of 0.86 (1%ile) • impulse control composite of 3 • cognitive efficiency index of 0.34 Computerized NPT (ImPACT, CogSport, etc) Concussion in Sports in New York • 10d F/U Assessment: – Still symptomatic from concussion which is typical for high school athlete < 2 weeks from injury* – Exam improved – Initial NPT shows deficits with a slow processing speed and reaction time – Persisting neck pain needs assessed further • Recommended: – Continue to rest until asymptomatic – X-ray C-spine, Physical Therapy * Conclusions: • Cases of concussion in sport where clinical recovery falls outside the expected window (i.e. 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. • Important components of management, after the initial period of physical and cognitive rest, include associated therapies such as cognitive, vestibular, physical and psychological therapy, assessment for other causes of prolonged symptoms and consideration of a graded exercise program at a level that does not exacerbate symptoms. Concussion in Sports in New York • Sports Med F/U 1 month after injury – Headaches resolving, recur with light aerobic activity. Some photophobia still. Sx score 13. Doing PT for neck. – Normal exam – Computer NPT: • • • • • • memory verbal 90 (61%ile) same memory visual 75 (54%ile) lower visual motor speed 29.58 (2%ile) better but still low reaction time 0.66 (11%ile) better but still slow impulse control 3 cognitive efficiency index of 0.45 Concussion in Sports in New York • 1 month Post-Injury Assessment: – Patient is improving, but still symptomatic from concussion with deficits persisting on NPT • Recommendations: – May continue aerobic activity if remains symptom free only, may progress to more vigorous activity (e.g. strength/conditioning or sprints), if tolerated can advance to skills practices – Must remain non-contact Concussion in Sports in New York • RTP protocol – Advance each day – 5-7 days to complete – Needs supervision Concussion in Sports in New York • Treatment Plan: – Contacted School Physician & Athletic Trainer a high school soccer pre-season about to begin – Pharmacological management of headaches not considered as was improving (despite relatively prolonged course) Concussion in Sports in New York • Sports Med F/U 6 weeks post-injury – Bumped head on car while getting out 4d prior, relatively innocuous at time, but since then symptoms have escalated. – Attempted more vigorous activity under supervision of school athletic trainer and felt a lot worse. – Exam remains normal, except unable to balance in tandem stance >10 seconds (deterioration) Concussion in Sports in New York • 6 Weeks Post-Injury Assessment: – Second head injury while still recovering from 1st • Treatment Plan: – Concern how will perform academically going into senior year; initiated 504 plan and provided recommendations to school regarding limitations and accommodations. – High school had an established return to school protocol which was initiated, initially stayed at home with tutoring x 2 weeks. Concussion in Sports in New York • Further treatment plan: – No anticipated return to soccer fall season – After normal EKG, started Amitriptyline to decrease headache intensity – Started Amantadine to help concentration Concussion in Sports in New York • Headache prophylaxis similar to migraine headache management Concussion in Sports in New York • Sports Med F/U 9 Weeks Post-Injury – Headache recurs after 1 hour of home tutoring, does continue despite this to complete 2 hours/day. Photophobia mild. – Exam normal, including balance. – NPT: • • • • • memory verbal 81 (32%ile) memory visual 72 (47%ile) visual motor speed 31.5 (12%ile) reaction time 0.69 (7%ile) cognitive efficiency index 0.3 Concussion in Sports in New York • 9 Week Assessment: – Persisting postconcussive syndrome with symptoms and neuropsych deficits • Recommendations: – Increased Amitriptyline up to 40mg QHS – Projected return to school by end of month Concussion in Sports in New York • Could we have predicted this prolonged course? Concussion in Sports in New York • Sports Med F/U 3 Months Post-Injury – Headaches and photophobia improved further – Successful in return to school, now just about caught up academically – Still on meds, but dad feels she is ‘back to normal’ – NPT really unchanged: • • • • • verbal memory81 (32%) visual memory 72 (47%) visual motor speed 31 (8%) reaction time 0.65 (12%) cognitive efficiency index of 0.26 Concussion in Sports in New York • 3 Month Post-Injury Assessment: – Concussion July 2013, now with persisting postconcussive syndrome 3 months later. • Recommendations: – Returned to school successful – Instructed to consider return to activity under guidance of school athletic trainer – Continue meds Concussion in Sports in New York • Sports Med F/U 4 Months Post-Injury – Symptom score still 15, but feels better. – Exam normal – NPT: • • • • • • verbal memory 76 (15%ile) same visual memory 79 (66%ile) same visual motor speed 39.05 (45%ile) much better reaction time 0.55 (57%ile) much better impulse control 6 cognitive efficiency index 0.28 Concussion in Sports in New York • 4 month Assessment/Recommendations: – Improved processing speed and reaction time, ready for escalation in exercise intensity Concussion in Sports in New York • Sports Med F/U 6 Months Post-Injury – Weaned off meds – Tolerating 20-30 mins of aerobic activity daily – Grades for this school year affected, difficulty focusing and concentrating persisted. – NPT: Concussion in Sports in New York • 6 Month Assessment & Recommendations: – Verbal memory deficit remains, suggesting permanency – Reaction time and processing speed approaching normal – Referred for formal neuropsychological evaluation Concussion in Sports in New York • Brief computerized cognitive evaluation tools are the mainstay of these assessments worldwide, given the logistical limitation in accessing trained neuropsychologists; however, it should be noted that these are not substitutes for formal neuropsychological assessment. Concussion in Sports in New York • Conclusions: – Concussions are often difficult to diagnose – Management initially still centers around rest – There is no magic solution to getting kids better – Individualized plan rather than set protocol – It takes time to counsel and advise athletes and parents, coaches and schools – Communication is the principal management tool – If in doubt, sit them out… Concussion Education Written material is key – http://archpedi.jamane twork.com/article.aspx? articleid=1148388 – http://www.cdc.gov/co ncussion/sports/index.h tml – http://www.nysphsaa.o rg/safetyresearch Special thanks to Dr Hamish Kerr Questions?