Mild Traumatic Brain Injury and its Impact on Patients

1. Mild Traumatic Brain Injury and its Impact on Patients Tiffany Wright PGY-4 5/4/11

3. Objectives • Review mild traumatic brain injury • Discuss immediate and long term sequelae • Discuss neuropsychiatric evaluation and treatment modalities

4. Mild Traumatic Brain Injury • AKA “concussion” • Most widely accepted definition • A physiological disruption of brain function as a result of a traumatic event, that may or may not be transient, but where the severity of injury does not exceed the following: • PTA >24hrs • GCS of 13-15 after the first 30 min • LOC <30 min American Congress of Rehabilitation Medicine

5. Features of Concussion • Vacant stare (befuddled facial expression) • Delayed verbal and motor responses • Confusion and inability to focus attention • Disorientation • Slurred or incoherent speech • Gross observable incoordination (stumbling, inability to walk tandem/straight line) • Emotions out of proportion to circumstances (distraught, crying for no apparent reason) • Memory deficits (repeatedly asking same question; inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes) • Any loss of consciousness (paralytic coma, unresponsiveness to arousal)

6. Symptoms after Concussion • Early (minutes to hours) • − Headache • − Dizziness or vertigo • − Lack of awareness of surroundings • − Nausea or vomiting • Late (days to weeks): • − Persistent low grade headache • − Light-headedness • − Poor attention and concentration • − Memory dysfunction • − Easy fatigability • − Irritability and low frustration tolerance • − Intolerance of bright lights or difficulty focusing vision • − Intolerance of loud noises, sometimes ringing in the ears • − Anxiety and/or depressed mood • − Sleep disturbance

8. Concussion in Sports • Significant research and media attention • More articles since 2000, than all previous years combined • Research directed at protecting athletes, both professional and students

9. Concussion Grades (1-3) Grade 1 1. Transient confusion 2. No loss of consciousness 3. Concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes. Most common yet the most difficult form to recognize. Not rendered unconscious Momentary confusion (e.g., inattention, poor concentration, inability to process information or sequence tasks) or mental status alterations. Having been "dinged" or having their "bell rung." Grade 2 1. Transient confusion 2. No loss of consciousness 3. Concussion symptoms or mental status abnormalities on examination last more than 15 minutes Not rendered unconscious Symptoms or signs of concussion or mental status abnormalities on examination that last longer than 15 minutes Any persistent Grade 2 symptoms (greater than 1 hour) warrant medical observation. Grade 3 • Any loss of consciousness, either brief (seconds) or prolonged (minutes) Usually easy to recognize—the athlete is unconscious for any period of time.

10. Sideline Evaluation

11. Recommendations Grade 1 1. Remove from contest. 2. Examine immediately and q5 min for symptoms (at rest and exertion) 3. May return if clear within 15 minutes 4. A second Grade 1 → elimination that day (return if asymptomatic for one week at rest and with exercise) Grade 2 1. Remove from contest and disallow return that day. 2. Examine on-site frequently 3. Trained person should re-examine the athlete the following day 4. A physician should perform a neurologic examination to clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion. 5. CT or MRI if: HA or other symptoms worsen or persist > 1 week 6. A second Grade 2 → return deferred until for 2 weeks symptom-free at rest and with exertion 7. Abnormality on CT or MRI → terminate the season

12. Recommendations Grade 3 1. Transport if still unconscious or worrisome signs 2. Thorough neuro evaluation emergently, including CT if indicated 3. Hospital admission if any pathology detected, or if mental status remains abnormal 4. If findings normal, the athlete may be sent home with explicit written instructions 5. Neuro status assessment daily until all symptoms have stabilized or resolved 6. Prolonged unconsciousness, persistent mental status alterations, worsening post-concussion symptoms, or abnormalities on neuro exam → urgent neurosurgical eval or trauma center 7. After brief (seconds) Grade 3 , withhold play until asymptomatic for 1 week at rest and with exertion 8. After a prolonged (minutes) Grade 3, withhold play for 2 weeks at rest and with exertion 9. Second Grade 3, withhold play for a minimum of 1 asymptomatic month (physician may extend beyond 1 month, depending on clinical evaluation and other circumstances) 10. CT or MRI if: headache or symptoms worsen or persist longer than 1 week 11. Abnormality on CT or MRI → terminate the season

13. Symptom Assessment: At Rest and During Exertion

14. Consensus Statement on Concussion 2008 • Multiple problems with previous method of assessing concussions • No data to support grading systems • No regard to age when considering return to play • Too much emphasis on loss of consciousness, no emphasis on mild concussive symptoms

15. Consensus Statement on Concussion 2008 • Any pt with any of the following after head trauma should get formal evaluation • Symptoms: • somatic (headache) • cognitive (“feeling like in a fog”) • emotional (lability) • Physical signs: LOC, PTA • Behavioral: Irritability, anxiety • Cognitive impairment: Delayed reaction times • Sleep disturbance: Drowsiness

16. Consensus Statement on Concussion 2008 • All pts with sx suggestive of concussion need on site eval, including c-spine evaluation: • SCAT2 • Symptoms • Physical signs • Cognitive evaluation • Balance exercises • Coordination skills

19. Consensus Statement on Concussion 2008 • Consider current status • Improvement or deterioration • Decide if need for neurologic imaging: • Prolonged alteration in level of consciousness • Focal neurologic deficits • Deterioration

20. Consensus Statement on Concussion 2008 • Do you need functional MRI? • Measures oxygen utilization during various tasks • Activation patterns correlate with symptoms and recovery • Not routine part of assessment at this time • Often used in elite athletes to determine RTP

21. Consensus Statement on Concussion 2008 • Graduated Return to Play 1. Complete rest 2. Light activity to increase HR 3. Sport specific exercise to add movement 4. Non-contact training drills to add cognitive load 5. Full contact practice to regain confidence 6. Return to play Remain at each stage x 24 hrs minimum. If sx develop, return to previous stage.

22. Consensus Statement on Concussion 2008 • Some adult athletes can RTP same day, if cleared based on high level resources (NP testing, etc) • Athletes 18 yrs and younger should not RTP same day, regardless • NP testing can be adjunct to assess readiness to RTP once symptoms resolve

23. Consensus Statement on Concussion 2008 • Modifying factors • Excessively severe or prolonged symptoms • Concussive convulsions • Multiple previous concussions or a recent concussion, or lower concussion threshold • Age • Comorbid conditions (learning disabilities, psychiatric disorders, ADHD)

24. Why is this such a big deal? • Second Impact Syndrome • Rare, but fatal • Occurs when a person receives a second (often insignificant) blow to the head before recovered from concussion • Thought to be due to loss of autoregulation of cerebral arterioles from first injury • Second injury causes increase in cerebral blood flow • Massive cerebral edema • Brain stem herniation

25. Why is this such a big deal? • Cognitive decline from repeated concussions • Often seen in children and adolescents as the developing brain appears more susceptible • Neuropsychiatric testing can be used to guarantee return of cognitive fxn to baseline prior to RTP • Online testing available • Impact • Cogsport • Headminders

26. Case study • 18 year old gifted student with scholarship to Harvard • Two previous concussions, 1/97 and 2/04 • Concussion 12/8/04 • 5 min confusion, no LOC, No amnesia • Family MD next day, no symptoms, cleared • ImPACT (Neuropsychiatric and symptoms combined) testing on 12/9/04, no consult • 80% verbal, 75% visual memory, 27th and 35th percentile • Reaction time 56th percentile

27. Case study • Resumed hockey 12/13/04 • Checked in occiput in 2nd period • No LOC, no symptoms • Played rest of game • Severe headache after game • Vomited and disoriented • Normal CT • Repeat ImPACT testing • 64% verbal, 44% visual, <1st percentile in both • Reaction time 39th percentile • 12/22/04 Recovered only to 42nd, 20th and 70th percentile respectively • Lost scholarship

28. Chronic Traumatic Encephalopathy • Formely called Dementia Pugilistica • Originally described in boxers • Also been seen in NFL players, wrestlers, epileptics, headbangers, and domestic violence victims • Autopsy diagnosis • Clinically: • memory disturbances • behavior and personality changes • Parkinsonism • Speech and gait abnormalities • May be seen in as many as 17% of pts with repetitive concussions

29. Chronic Traumatic Encephalopathy • Pathologic findings • Decreased brain weight • Enlargement of lateral and third ventricles • Thinning of corpus callosum • Tau immunoreactiveneurofibrillary tangles • Tau deposition occurs in a distinct pattern • Due to damage to blood brain barrier and release of local neurotoxins • Unclear what severity of trauma is required to initiate changes

30. Chronic Traumatic Encephalopathy • NFL Chris Henry with CTE on autopsy • Dave Duerson • NFL safety 1983-1993 • Suffered from erratic behavior, impulsivity, mood disturbances • Died of self inflicted GSW to chest • Suicide note requested brain examination • Extensive changes in frontal cortex, amygdala, and hippocampus • >10 concussions, some with LOC

31. Post-Concussive syndrome • Persistence of symptoms beyond 7 days • Up to 40-50% of pts have post concussive symptoms at 1 month • Down to 25% at 1 year • Up to 20% are on disability at 1 year • Incidence significantly lower in athletes than in general population

32. Post Concussive Syndrome • DSM IV criteria • History of concussion • 3 of these 8 sx (fatigue, sleep disturbance, headache, dizziness, irritability, affective disturbance, personality change, apathy) • Symptoms that began or worsened with injury • Interference with social functioning • Exclusion of dementia

33. Post concussive syndrome • Actually a controversial issue • Symptoms are common in a lot of the population • Symptoms overlap with depression, chronic fatigue syndrome, etc • May not be any higher in mTBI pts than pts with orthopedic injuries

34. Post concussive syndrome • Risk factors • Older age • Female gender • Underlying history of drug or alcohol use • Underlying history of psychiatric disorders • mTBI as a result of MVC, fall or assault as compared to sports related injuries

35. Post Concussive Syndrome • Why so much higher in trauma pts than athletes? • Malingering • Litigation • Underlying psych issues/substance abuse issues • Underreporting by athletes • “They have these new [brain] tests we have to take. Before the season, you have to look at 20 pictures and turn the paper over and then try to draw those 20 pictures.  And they do it with words, too.  Twenty words, you flip it over, and try to write those 20 words.  Then, after a concussion, you take the same test and if you do worse than you did on the first test, you can’t play.  So I just try to do badly on the first test.” -Peyton Manning

36. Why is this so important to us? • Despite the interest in sports concussions, most mTBI in adults are the result of falls, MVCs or assault • Our pts are at the highest risk of developing post-concussive symptoms • We are often the only ones evaluating these pts for their head injury

37. Case Study • Healthy 25 yr old horse trainer • To UK after thrown from a horse • Witnessed 7-8 min LOC • Trauma eval: • C7 lateral mass fx • Right 1st rib fx • Right knee contusion • Concussion (normal head CT) • Free fluid in pelvis with no solid organ injury, likely physiologic

39. Case Study • On exam she had a GCS of 15 and complained only of shoulder pain and a headache. • No abdominal pain, nontender abdomen • Remained in a C-collar for C spine fx • Complained of headache, dizziness and nausea • 2 days later, CT repeated due to inability to tolerate po • On HD#5, developed abdominal pain • Taken to OR for diagnostic laparoscopy to rule out bowel injury

40. Case Study • Discharged home several days later, after being cleared by PT. • Symptoms all attributed to concussion. • “Your symptoms will improve. It just takes time.” • Returned to ER a week later • Had fallen at home • Again, reassured • Sx persisted at clinic appt 3 weeks post injury • Referred to Dan Han at KNI for neuropsycheval

41. Case Study • During Neuropsycheval, complained of • Decline in word finding ability • Seizure like activity during the first week • Fatigue • Sleep difficulty • Headaches • Dizziness • Irritability • Anxiety • Nausea

42. Case Study • Given a variety of neuropsych tests • Found to be impaired in the following cognitive measures • Verbal memory- mildly impaired • Reaction time- mildly impaired • Visual motor speed- borderline impaired • Verbal fluency- borderline impaired • Visuospatial construction ability- mildly impaired

43. Case Study • He also noted that she had a considerable amt of anxiety • While results are mildly impaired, they are inconsistent with the degree of symptoms she self reported suggesting compromised insight • Recommendations: • No driving until after repeat testing • Anxiety mgmt • No significant physical activity to risk head injury • EEG to rule out seizure activity • Repeat testing in 4-6 weeks

44. What can we do?? • Some recommend early referral to specialist for rehabilitation • No difference in outcome at 1 year • Statistically significant differences in: • Life satisfaction • Reintegration to society • Health related quality of life • Return to productivity

45. Rehabilitation • Cognitive sx • Speech or OT to learn strategies for managing problems with arousal, executive functioning, attention, memory • Ear plugs or sunglasses • Paper or electronic memory aids • Stimulants for attention or arousal problems

46. Rehabilitation • Psychological sx • Counseling • Relaxation techniques • Sleep hygiene • Education • Support groups • Cognitive behavioral therapy

47. Rehabilitation • Headaches • Depends on cause. Often multifactorial • Physical therapy • Postural retraining • Relaxation techniques • Treatment of underlying anxiety/depression • Trigger point injections • NSAIDS, migraine meds

48. Neuropsych testing • Dan Han (KNI) • Neuropsychologist • Can perform testing only. No treatment ability. • Suggests that all pts with concussion be referred for neuropsychiatric eval • May not be feasible due to large numbers of pts

49. UK Concussion Program

50. What is our role? • Improved discharge education • Studies indicate that sufficient education on what to expect, etc can alleviate anxiety and thus other sx • Referral (neuropsych, PM&R) • All pts who still have symptoms at clinic follow up • ??Offer to all pts- some pts are unaware of their cognitive sx • Risks associated with driving, etc