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Concussions: Assessment, Treatment, and Management

This educational resource explores the issues and concerns related to traumatic brain injuries (TBIs), specifically concussions. It reviews assessment tools, non-thrust treatment techniques, self-care protocols, and the role of chiropractors in concussion management.

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Concussions: Assessment, Treatment, and Management

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  1. Educational Objectives 1) Review issues and concerns with TBIs. 2) Explore assessment tools for evaluating concussions. 3) Demonstrate non-thrust treatment techniques. 4) Explain self care protocols for TBI management. 5) Discuss the role of Chiropractors and concussions. Acute Concussion Management

  2. blood vessel damage - response to biomechanical or physical injury to brain 1) traumatic brain injury (TBI) with functional or microstructural disturbance 2) severe TBI has macroscopic physical damage and hemorrhage Concussion (latin = to shake violently) - a loss of brain function [cognitive, emotional and physical symptoms] An introduction to sports concussions. Giza CC, Kutcher JS. Continuum (Minneap Minn). 2014 Dec;20(6 Sports Neurology):1545-51. doi: 10.1212/01.CON.0000458975.78766.11. PMID: 25470159 The presence of only one symptom is enough to confirm concussion diagnosis according to the Consensus Statement of the 3rd International Conference on Concussion in Sport.

  3. Concussion Pathophysiology 1) abrupt force causes brain to twist upon itself - axons are twisted, stretched, or severed 2) loss of integrity of cell membranes 3) metabolic energy crisis - ionic flux - indiscriminate release of neurotransmitters - cells attempt to restore ionic homeostasis - axonal transport is dysfunctional or completely impaired [in severe cases, axonal disconnection may occur] noninvasive imaging reveals these changes in patients with mild TBI An introduction to sports concussions. Giza CC, Kutcher JS. Continuum (Minneap Minn). 2014 Dec;20(6 Sports Neurology):1545-51. doi: 10.1212/01.CON.0000458975.78766.11. PMID: 25470159

  4. Diagnosing Acute Concussions (intracranial hemorrhage) - 24 to 48 hours are most crucial to detect severe complications - Increasing headache, vomiting, disorientation, seizures, unequal pupil size and/or deteriorating level of consciousness - AGE: Under 16 and over 60 are at higher risk - Intoxication and NSAIDs increase risk of bleeding - EEG may/may not be normal - Imaging studies can detect lesions and bleeding [fMRI, PET or SPECT scan]

  5. Danger, Will Robinson • Acute Concussion Red Flags [48 hours] • Unable to wake unconscious person • Convulsions, Seizures • Pupil Size Difference • Headaches that get worse and don’t go away • Repeated vomiting • Weakness, numbness or decreased coordination • Slurred speech • Degrading awareness or emotions • Babies/children that won’t eat or be consoled HVLA cervical spinal manipulation is contra-indicated with acute concussion symptoms!

  6. The Pediatric Athlete dangers of mTBI More vulnerable to concussion: 1) structural/functional immaturity 2) less myelination 3) thinner skull bones 4) weaker neck muscles 5) a greater head-to-body ratio Fischer KW, Rose SP. Dynamic growth cycles of brain and cognitive development. In: RW Thatcher, GR Lyon, Rumsey J, Krasnegor N., editors. Developmental Neuroimaging: Mapping the Development of Brain and Behavior. New York, NY: Academic Press;; 1996. pp. 263–279. In. eds. • Functional brain immaturity is: • - present through early adulthood • - continues to mature in cognitive processing • [attention, concentration, learning, memory, reasoning and executive function]

  7. Second-Impact Syndrome (aka malignant cerebral edema) diffuse cerebral swelling with delayed catastrophic deterioration - A primary concern of premature RTP among pediatric athletes Can we manage sport related concussion in children the same as in adults? McCrory P1, Collie A, Anderson V, Davis G. Br J Sports Med. 2004 Oct;38(5):516-9. PMID: 15388528 those who have suffered a prior injury have up to a 5.8 fold increased rate of re‐injury. PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION K May, D Marshall, T Burns, D Popoli, J Polikandriotis. Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255. PMCID: PMC4004129

  8. Second-impact syndrome Occurs within minutes of concussion in athlete still symptomatic from prior brain injury, which can be earlier in same event. Vascular engorgement leads to: - increased intracranial pressure - brain herniation - severe brain damage or death Except for boxing, most cases in literature are adolescents. http://www.cdc.gov/concussion/HeadsUp/clinicians/resource_center/complications_of_concussion.html. Retrieved 2015-12-22

  9. Concussion Evaluation Tools Cognitive Testing - Standardized Assessment of Concussion - Neuro-Psychological Assessments Symptom Evaluation - Graded Checklists Neuro-Imaging Studies Blood Testing Physical Testing - Glasgow Coma Scale - Balance Error Scoring System - Sideline Assessments - Coordination Examination - Vestibulo-Occular Reflex - VideoNystagmography [VNG] Forms -ACE -SCAT3 [child]

  10. What affects the prognosis of TBI? Susceptibility - previous head injuries and coexisting medical conditions - longer loss of consciousness and amnesia indicate longer recovery times Age - 55 and older may take longer to recover Intellect - coping strategies and skills [outlets] Athletics - participation in contact sports Family/social/occupation/financial - substance abuse, depression, poor health and life stressors Surgery - About 1% of mTBI patients seeking treatment need surgery

  11. What affects the prognosis of TBI? Post-concussion syndrome - symptoms may last months, years or become permanent [headaches, dizzy, fatigue, memory, sleep disorders and irritability] Cumulative effects - 3 or more concussions lead to long-term memory loss, depression and a five-fold greater chance of developing Alzheimer’s disease Dementia Pugilistica[punch drunk, NFL] - results in speech problems, memory deficits, tremors, inappropriate behaviors, slowed mental processing and Parkinson’s disease [chronic encephalopathy] Second-impact syndrome [fatal] - Brain swells due to loss of control of blood flow and vessel diameter. - Brain stem herniation can occur within 5 minutes. - Most cases are under 20 years old - 3 times more likely to occur in high school football athletes.

  12. “Concussion are an Epidemic” - CDC - 70 - 90% of head injuries treated are mTBI - yearly hospital treatment rate is 3 per 1000 people [WHO estimates 6 per 1000 people] - Males are twice as likely as females - CDC estimates 300,000 sports-related concussions yearly [10% lose consciousness] - football and boxing are the most common [boxer’s goal is a knock-out] "Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury". Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. (2004). Journal of Rehabilitation Medicine36 (Supplement 43): 28–60. doi:10.1080/16501960410023732.PMID 15083870.

  13. Concussion Symptoms: [may be present in various combinations] Cognitive = confusion*, concentration, slowed thinking, recall/amnesia {frontal lobe} Emotional = irritable*, anger/violent, depression, sadness, anxious/nervous, highly emotion state {temporal lobe} Physical = headache*, nausea, vomiting, balance, light/noise sensitive, vision changes, fatigue Sleep = excessive, difficulty Cranial nerve damage

  14. Concussion Signs sports injury, falls, assaults, auto accidents Any loss of consciousness? If yes, how long? __ minutes Blank or vacant look? Balance or motor incoordination? (stumbles, slow / labored movements, etc.) Disorientation or confusion? (inability to respond appropriately to questions) Loss of memory? If yes, how long? __ minutes Before or after the injury? Visible head/facial injury? BASE Signs of Concussions Balance errors - stand on one leg Awareness - confusion Symptoms - headache, nausea, dizzy Eyes - pupil size, focus, lights

  15. The significance of loss of consciousness (LOC) - LOC has not been noted as a measure of injury severity. - Duration of LOC is a predictor of outcome. - Prolonged LOC (>1 minute duration) may modify management. It was found that the presence of loss of consciousness and post-traumatic vomiting ≥ 2 episodes are factors associated with positive CT scan. Reducing head computed tomography after mild traumatic brain injury: Screening value of clinical findings and S100B protein levels. Asadollahi S, Heidari K, Taghizadeh M, Seidabadi AM, Jamshidian M, Vafaee A, Manoochehri M, Shojaee AH, Hatamabadi HR. Brain Inj. 2015 Dec 15:1-7. [Epub ahead of print] PMID:26671496

  16. Neuro-Imaging Studies Computerized Tomography - more widely available, faster, less expensive - surgical clips, metallic fragments, cardiac monitors/pacemakers cannot receive an MRI - no claustrophobic issues - a moderate- to high-radiation SPECT - gives a 3D image of the brain - requires a gamma emitting isotope - measures changes in blood flow MRI - is generally superior - gives higher detail in soft tissues - measures brain activity by detecting associated changes in blood flow Diffuser Tension [DTI] - measures restricted diffusion of water in tissue - follow neural tracts [tractography] - helps define diffuse brain injuries

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