Concussion: When Return To Play Is Combat Christopher Meyering, DO MAJ MC USA Director Sports Medicine DD Eisenhower Family Medicine Residency Disclaimers The views expressed in this lecture are those of the presenter and do not reflect official policy or position of the Department of the Army, the Department of Defense, or the US Government The naming of specific neuropsychological products does not constitute endorsement of any product Objectives Review and understand the signs and symptoms of concussion Review evaluation tools and treatment prior to return to activity Discuss the complications of concussion Discuss the military implications and guidance for mild traumatic brain injury (mTBI) Case Presentation Case Presentation 28 year old male was performing a clearing mission in a downtown location when an IED exploded at the front of the squad One soldier killed instantly by explosion Our patient was knocked backwards and others reported he was not moving for a “short while” Case Presentation Able to get back to evac point walking with rest of squad Feels “dazed” and dizzy when walking though Recalls starting the clearing operation but not the incident Also complains of some nausea but has not vomited Has few small superficial injuries but otherwise unremarkable Case Presentation You are at the evac point as the Battalion Surgeon You have a senior medic and a junior medic plus your ambulance along with escort units Your Aid Station is 15 minutes away, Level 2 facility is 25 minutes away CASH is 45 minutes away, AirEvac can be present in 10 minutes There is heavy enemy activity in the area WHAT DO YOU WANT TO DO DOC? Evacuate immediately? Watch and wait? Send soldier back out with squad to continue clearing? Definition Concussion or mTBI is a pathophysiological process affecting the brain induced by direct or indirect biomechanical forces Rapid onset of short-lived neurological impairment which usually resolves spontaneously Usually a functional rather than a structural disturbance Wide range of clinical symptoms which may or may not include loss of consciousness (LOC) Herring et al: ACSM Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement. Med Sci Sports Exerc 2005, 39:196-204. Acute Signs and Symptoms Suggestive of Concussion Cognitive Somatic Affective Acute Signs and Symptoms Suggestive of Concussion Cognitive Post-traumatic amnesia (PTA) Retrograde amnesia (RGA) Loss of Consciousness (LOC) Disorientation Delayed verbal and motor responses Excessive drowsiness Acute Signs and Symptoms Suggestive of Concussion Somatic Headache Fatigue Dizziness Nausea/Vomiting Visual disturbances Phonophobia Acute Signs and Symptoms Suggestive of Concussion Affective Emotional lability Irritability Additional Military Considerations mTBI should be suspected for all patients exposed to or involved in a blast, fall, vehicle crash, or direct head impact that lose consciousness, have amnestic event or become dazed or confused Significant association between barotrauma TM perforation and concussion Pyne S. Concussion. 2008 USAFP Annual Meeting Xydakis et al. Tympanic-membrane perforation as a marker of concussive brain injury in Iraq; N Engl J Med 357;8, 2007 Warning Signs Inability to awaken Severe or worsening headaches Persistent vomiting Weakness/ Numbness/ Focal neuro signs Vision difficulty Worsening confusion Persistent or Recurrent seizures Grading Systems Concussion Grading At least 25 described concussion grading systems Most commonly used were the Cantu criteria, American Academy of Neurology parameter and the Colorado Medical Society guidelines Current recommendation for grading is to use an individualized symptom-based concussion management utilizing frequent reassessment Severity determined after symptoms have resolved Concussion Categories Simple Complex Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med Vol 15 (2), 2005, pp48-55. Military No concussion Concussion with LOC Concussion without LOC Concussion Categories Simple Most common Progressive resolution without complication over 7- 10 days No intervention required No advanced neuroimaging or neuropsychological testing needed Typically resumes activity without further problem Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med Vol 15 (2), 2005, pp48-55. Concussion Categories Complex Persistent symptoms (or recurrence with exertion) Specific sequelae such as concussive convulsions, LOC> 1 min, or prolonged cognitive deficits after the injury Repeated concussions Additional evaluation with neuroimaging and neuropsychological testing advised Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med Vol 15 (2), 2005, pp48-55. Management Principles Management Principles Brief LOC (seconds, not minutes) associated with specific early deficits, but does not predict concussion severity and time to recovery RGA, PTA and prolonged confusion are better predictors of severity of mTBI, but should not be used alone Symptom duration guides activity advancement and defines severity Individualize treatment and recovery Case Presentation Our soldier returns to the Aid Station for evaluation on the following day (24 hours) Feels improved with walking around, but still with some dizziness Remembers more of the mission but not immediately prior to the blast WHAT DO YOU WANT TO DO DOC? Continue to monitor at Aid Station? Evacuate to higher level care? Allow to return to duty? Concussion Assessment Tools SAC Developed as a sideline assessment tool Able to differentiate between concussed and nonconcussed at time 0 but not thereafter One-third of patients able to improve their score despite remaining symptomatic Should not be used exclusively to make a diagnosis Putukian M. Repeat Mild Traumatic Brain Injury: How to Adjust Return to Play Guidelines. Current Sports Med Reports. 2006, 5:15-22 SCAT Proposed in the Prague Guidelines Clear supportive data not evident Patient answers questions about multiple symptoms associated with concussion Clinician asks about clinical signs of concussion and evaluates memory and cognition MACE Assesses orientation, immediate memory, concentration, and delayed recall Contains components of the SAC and SCAT Gives guidance to clinician on scoring Max score is 30 Score of 25 or less likely significant Assessment cards available to order at www.dvbic.org or www.pdhealth.mil When and What To Image? Diagnostic Imaging Cervical Spine Symptom based Skull X-ray Not helpful Consider facial bone x-rays if indicated CT Scan or MRI Usually normal for simple concussions Use if clinically suspicious of intracranial hemorrhage Nearest MRI in theater is Kuwait Back To Our Case Problem Case Presentation Our soldier returns to the Aid Station for evaluation on the following day (24 hours) Feels improved with walking around, but still with some dizziness Remembers more of the mission but not immediately prior to the blast What Do You Want To Do Doc? Continue to monitor at Aid Station? Evacuate to higher level care? Allow to return to duty? Current Guidelines Current Guidelines Assess for Red Flags Decreased LOC Seizures Pupil asymmetry Progressive worsening of function Focal neurological dysfunction GCS < 15 If any Red Flags present, evacuate to Level 3 Current Guidelines Assess symptoms of concussion Physical examination with detailed neurological and cognitive evaluations Give MACE exam If concussed begin primary care management Removal from stimulus environment Information sheet to service member Available at www.dvbic.org in PDF file Duty restrictions Physical and Cognitive rest Current Guidelines Can observe at Primary Care level for 7 days Recommend this only if improving Evaluate every 1-3 days Rely on your medics/corpsmen to watch for changes Involve command to ensure soldier is restricted If no symptoms at rest, perform exertion and repeat testing If any signs or symptoms with exertion then still concussed Current Guidelines Serial neurological assessment helps determine the need for more advanced intervention Gradual improvement or worsening may be subtle Oral and written instructions should be given to the patient and a responsible party with focus on worsening symptoms and specific follow-up Need to avoid alcohol Regular diet Headache Management Acetaminophen for the first 48 hours Can switch to NSAID after 48 hours For persistent headaches over 7 days can use nortriptyline or amitriptyline 25 mg qhs but only give a 10 day prescription Avoid narcotics and tramadol Back to the Case Again Case Presentation Our soldier is at the Level 2 facility Still c/o headaches, dizziness and nausea Difficulty focusing on computer screen and having difficulty with sleeping Now What? Additional Testing Neuropsychological (NP) Testing Civilian Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) Headminder CogSport Military Automated Neuropsychological Assessment Metrics (ANAM) Currently using ANAM 4 Neuropsychological Testing Detailed assessment and quantification of cognitive function Evaluates information processing, memory recall, attention and concentration, reaction time, scanning and visual tracking ability, and problem solving abilities Neuropsychological Testing Few studies with published data on sensitivity and specificity Sensitivity of 80% and specificity of 77% for an NP test battery when athletes compared to their own baseline NP test Sensitivity dropped to 75% if preinjury test not available ImPACT sensitivity and specificity has been 81.9% and 89.4% Putukian M. Repeat Mild Traumatic Brain Injury: How to Adjust Return to Play Guidelines. Current Sports Med Reports. 2006, 5:15-22 Military Neurocognitive Assessment Automated Neuropsychological Assessment Metrics (ANAM) Developed by Army, comprised of 30 tests for neuropsychological domains Includes a 15 minute ANAM TBI battery and assesses processing speed, learning, delayed memory, working memory, and spatial memory Computerized system with pre-test, post-test and assessment and treatment algorithms Validity still being evaluated Neuropsychological Testing Concerns with NP testing Stress, fatigue and sleep deprivation result in decreased performance on NP testing Research and commercial interest in testing may skew testing utility and validity Correlation with symptoms of mTBI Can see continued deficits in cognitive function with NP testing after symptoms resolved Neuropsychological Testing Additional concerns Original plan after April 2008 was to test every soldier going to and returning from theater Logistical issues for getting testing done Not available at all levels Evaluation teams used to try and capture all injuries Fellows from WRAMC deploying for short term intervals to collect data Case Presentation Our soldier was evacuated to CSH after 1 week of observation due to persistent symptoms Still complains of headaches, dizziness, difficulty sleeping, and difficulty concentrating on tasks He remembers more, but not all, of the day when his squad member was killed in front of him He keeps having recurrent, intrusive images of those events which affect his ability to function Prolonged Concussion Symptoms Majority of patients with concussion will have complete resolution of symptoms Small percentage have symptoms lasting over 4 weeks Physical Behavioral/Emotional Cognitive Prolonged Concussion Symptoms Physical Symptoms Nausea & Vomiting Headache Vision problems Fatigue Transient neuro Phono/Photosensitivity abnormalities Sleep disturbance Seizures Drowsiness Balance problems Dizziness Prolonged Concussion Symptoms Behavioral/ Emotional Problems controlling emotions Irritability Anxiety Depression Prolonged Concussion Symptoms Cognitive Problems with memory Difficulty concentrating Limitations in functional status Risk Factors for Prolonged Symptoms Pre-existing mental health conditions such as depression, anxiety, or PTSD Co-occurrence of psychiatric disorders Lack of support system History of malingering Current Guidelines for Referral from Level I or II Current Guidelines Confirm TBI screen Review all records Comprehensive exam Neurological Psychological Consider ENT, Ophthalmology and/or balance testing Current Guidelines CT scan if: Positive findings on exam Evidence of trauma above the clavicles Seizure Vomiting Headache Short-term memory deficits Coagulopathy From Jagoda et al 2008. http://www.acep.org/practres.aspx?id=30060 Current Guidelines If negative CT scan continue with treatment trial as previously mentioned Neurocognitive assessment Refer to other available specialists as needed Repeat evaluation every 72 hours up to 14 days If still not improving or still having symptoms with exertion consider evacuation to Level IV Consider MEB if symptoms persist in garrison setting for 6 months Additional Military Implications Need to weigh the relative costs of removal from the unit vs. utilizing an impaired service member Multiple factors can lead to under-diagnosis Ignorance of the diagnosis and its impact Distrust of the medical system by the service member Cheating by memorizing the answers to assessment tools For the Future Working on data capture to ensure continuity of communication and care Working on clarifying the role of automated neurocognitive testing in theater Revising the MACE From DVBIC Consensus Conference Guidelines Recap Red Flags, Evac to Level 3 Concussed service member can remain under Primary Care unless concerning findings or not showing signs of improving Rely on consultants through email@example.com if any concerns Summary Increase awareness of severity of these injuries Go to www.dvbic.org for MACE cards for medics; yourself Need to recognize and begin treatment early Understand when a patient needs additional care Questions?