1 of 34

Concussion Management

Josh Hansen, MD SMCAQ

2 of 34

Disclosure

I have no financial disclosures.

3 of 34

Objectives

  • Concussion management isn’t all that bad

​

4 of 34

Nate Bargatze. 2021, The Greatest Average American.

5 of 34

Concussions are not just, or even predominantly, sports injuries

6 of 34

Just living life, man, you know? Stuff happens to your head. What are you going to do?”

“3 concussions… None from sports..

-Nate Bargatze

7 of 34

The Numbers

  • Estimated 1.7 million TBI emergency room visits annually
  • ~75% of TBIs are mild = Concussion
  • Including clinic/AT/PT visits and concussions not seeking care, that number may be as high as 3.8 million per year
  • Leading Causes of TBI:
    • 35% - Falls
    • 17% - MVA
    • 17% - Blunt Impact (struck by or against a moving or stationary object)
    • 10% - Assaults

​

Ferry B, DeCastro A. Concussion. https://www.ncbi.nlm.nih.gov/books/NBK537017/?report=classic

8 of 34

Centers for Disease Control and Prevention (CDC). CDC grand rounds: reducing severe traumatic brain injury in the United States. MMWR Morb Mortal Wkly Rep. 2013 Jul 12;62(27):549-52. PMID: 23842444; PMCID: PMC4604943.

9 of 34

10 of 34

What is a concussion

  • Traumatically induced transient disturbance of brain function
  • Caused by linear/rotational forces on the brain
  • Results in complex cascade of vascular, ionic, and metabolic dysfunction
    • Axonal injury
    • Energy imbalance
    • Neuro-inflammation
  • Causing a constellation of symptoms

​

Shrey DW, Griesbach GS, Giza CC. The pathophysiology of concussions in youth. Phys Med Rehabil Clin N Am. 2011 Nov;22(4):577-602, vii. doi: 10.1016/j.pmr.2011.08.002. Epub 2011 Sep 25. PMID: 22050937; PMCID: PMC3211100.

11 of 34

Chandran A, Kerr ZY, Roby PR, Nedimyer AK, Arakkal A, Pierpoint LA, Zuckerman SL. Concussion Symptom Characteristics and Resolution in 20 United States High School Sports, 2013/14-2017/18 Academic Years. Neurosurgery. 2020 Sep 1;87(3):573-583. doi: 10.1093/neuros/nyaa091. PMID: 32294184; PMCID: PMC8133332.

12 of 34

Diagnosis

Sport Concussion Office Assessment Tool 6 (SCOAT6). British Journal of Sports Medicine 2023;57:651-667.

Child SCOAT6. British Journal of Sports Medicine 2023;57:672-688.

13 of 34

Setting Up Expectations

14 of 34

Setting Up Expectations

Several patient factors can help predict a prolonged recovery

  • Previous concussion ~ 2-5.8 times increased risk of another concussion
  • Amount/Severity/Duration of previous concussions are predictors of recovery time
  • Young and Older age may be associated with prolonged recovery
  • Female sex
  • Mood Disorders ~ Can also make diagnosis and recovery symptoms hard to track
  • ADD/ADHD and learning disabilities
  • Migraine headaches ~ Is it a concussion or post traumatic migraine syndrome?
  • Non sports concussions ~ prolonged? Additional psychosocial impacts?

Harmon, Kimberly G. MD1; Drezner, Jonathan MD1; Gammons, Matthew MD2; Guskiewicz, Kevin ATC, PhD3; Halstead, Mark MD4; Herring, Stan MD1; Kutcher, Jeff MD5; Pana, Andrea MD6; Putukian, Margot MD7; Roberts, William MD8. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clinical Journal of Sport Medicine 23(1):p 1-18, January 2013. | DOI: 10.1097/JSM.0b013e31827f5f93

15 of 34

What to avoid during recovery

  • No more hits to head
  • Avoid the waves of symptoms
  • Screens?
    • Limitations: subject self reporting both symptoms and screen time. No way to blind the subjects. Small sample, single center study.
    • Screen rest early on may help with recovery

16 of 34

17 of 34

18 of 34

19 of 34

20 of 34

21 of 34

Light to Moderate Aerobic Exercise works, but when should we start?

22 of 34

23 of 34

The Buffalo Concussion Treadmill Test

  • Establish the sub-symptomatic exercise thresh-hold
  • To help establish a safe level of exercise for treatment of concussion
  • To help differentiate between concussion and other possible diagnoses for concussive symptoms (e.g. cervicogenic post-traumatic disorder)
  • To identify physiological variables associated with exacerbation of symptoms, and the patient’s level of recovery
  • Assist in treatment protocols

​

​

​

24 of 34

https://cdn-links.lww.com/permalink/jsm/a/jsm_2020_01_28_haider_19-313_sdc1.pdf

25 of 34

Concussion Treatment is SIMPLE

  • Early light to moderate aerobic exercise
  • Start sometime after 24 hours, as long as symptoms 7/10 or less
  • 20 minutes per day
  • Physical therapy can run the BCTT
  • Or just have them go on a brisk 20 minute walk

​

​

​

​

26 of 34

Headaches/Neck Pain

  • Acetaminophen, NSAIDS
  • Nighttime sleep (only short naps)
  • Sunglasses, blue light lenses
  • Cervical PT/massage, dry needling
  • Trigger point injections
  • Abortive medications: (cautious w/polypharmacy)
    • Amitriptyline 10-50mg QHS
    • Nortryptyline 10-50mg QHS
    • Propranolol 20-50mg BID
    • Topiramate 25-100mg QD

Otherwise, Symptom Management

Vestibulo-Ocular

  • Antihistamines
  • Zofran
  • Vestibular Therapy

27 of 34

Cognitive

  • Speech Language/Cognitive Therapy
  • Sudoko, Crosswords, Word Search
  • Maybe Omega Fatty Acid?
  • No good evidence for amantadine or stimulants

Otherwise, Symptom Management

28 of 34

Future Research

  • Hyperbaric oxygen therapy
  • Sensory deprivation float therapy
  • Vagus nerve stimulation
  • Transcranial magnetic stimulation
  • Neurofeedback therapy
  • Cognitive behavioral therapy
  • Virtual reality rehabilitation
  • Lab marker diagnostics

29 of 34

My Basic Practice

30 of 34

31 of 34

VOMS Testing

  • Smooth pursuit
  • Horizontal and vertical saccades
  • Convergence
  • Horizontal and vertical vestibular-ocular reflex test
  • Visual motion sensitivity test

https://www.physio-pedia.com/Vestibular_Oculomotor_Motor_Screening_%28VOMS%29_Assessment

32 of 34

33 of 34

My Basic Practice

  • Get history and symptom score
  • Neuro eval, VOMS and mBESS testing.
  • Set expectation
  • Prescribe daily symptom limited aerobic exercise
  • Avoid symptom exacerbating activities
  • No screens at least first 48 hours. Then add in work/school screens.
  • DON’T HIT HEAD AGAIN!
  • Possibly cervical and vestibular physical therapy referral
  • Follow up every 2 weeks, further along can be spaced out to 4 weeks
  • Think about starting specific treatments for significant symptoms lasting >2 weeks

​

34 of 34

Thank you!