Interventions in the Management of Concussions

1. Interventions in the Management of Concussions Anne Felicia Ambrose M.D., M.S., FABPMR Medical Director , Traumatic Brain Injury Program Icahn School of Medicine at Mount Sinai New York, NY Department of Emergency Medicine

2. Approach to the Management of Concussion • Pre-Injury • Create and Implement legal safeguard at state, national, Sporting Body level • Changes to the Game-Rules of Play • Protective equipment; • Pre-injury assessments • Injury • Assessments-On the sidelines, ED, Doctor’s Office- Screening, Imaging • Post Injury Interventions • Rest • Return to Play Protocol • Physical and Occupational Therapy • Cognitive and Behavioral Assessments and Therapy • Vision Therapy • Vestibular Therapy • Drug Therapy • Retirement Department of Rehabilitation Medicine

3. Features of sport-related concussion

4. Basic Principles-Post Injury Interventions • Rest-Physical and cognitive rest until asymptomatic • Graded program of exertion • Additional Evaluations and Interventions • Medical clearance • Return to play. Department of Rehabilitation Medicine

5. Rest-Physical and Cognitive • Collegiate and High School students athletes who RTP on the same day have poorer outcomes Neuropsychological deficits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms.. • Malignant brain edema syndrome-seen rarely, but almost exclusively in young athletes • Second Impact Syndrome • Young (<18) elite athlete should be treated more conservatively even though the resources may be the same as an older professional athlete Department of Rehabilitation Medicine

6. Fatigue and Sleep • Incidence • Clinical features • Associative factors -Pain, Pain meds, Females, Depression, Anxiety, time from injury • Association with cognition-slower in attentional tasks • Sleep disturbances -Drowsiness. Trouble falling asleep, Insomnia, Hypersomnia • Treatment

7. Headaches Investigation CT scans be helpful in ruling out serious bleeding injuries, but cannot diagnose a concussion or headache. Treatment • Rest, Avoid second concussion especially in first 10 days • Medications a. No medicine that clearly alleviates post concussive headache. b. Regular headache medications may help. c. Preventive medications if not resolved within a month. (SE-increase fatigue, weight, or memory, confusion) especially in athletes with long playing history, prior +/- recent concussions, Apo E

8. Cognitive Impairment • Incidence • Clinical Features- Slowed reaction times, Difficulty concentratingand remembering, Confusion, Feeling in a fog or dazed • Cognitive Restructuring Form of brief psychological counseling that consists of education, reassurance, and reattribution of symptoms • Cognitive And Behavioral Assessments and Remediations

9. Visual Deficits Department of Rehabilitation Medicine

10. Approach to Common Vision Deficits Following TBI Department of Rehabilitation Medicine

11. Approach to Common Vision Deficits Following TBI

12. Nausea/Dizziness/Vertigo/Loss of Balance Causes of dizziness, Impaired balance or vertigo • Benign paroxysmal positional vertigo (BPPV), • Labyrinthine concussion, • Perilymphatic fistula (PLF), • Post-traumatic Meniere Syndrome (hydrops), • Temporal bone fracture, • Cervical (cervicogenic) vertigo, • Epileptic vertigo, • Migraine associated vertigo and ocular motor abnormalities. Department of Rehabilitation Medicine

13. Symptoms of Post-concussive Vestibular And Balance Dysfunction • Dizziness (55–78%), • Impaired Balance (43–56%), • Blurred Vision Or Diplopia (49%) (Lovell, 2009). Department of Rehabilitation Medicine

14. Approach to Treatment of Vestibular Dysfunction • Rest • Evaluation if symptoms persist >2 weeks • Medications-avoid meclizine, Aspirin • Assessments • Detailed historyof concussion occurred, • Initial presenting symptoms, • New or existing medications, • Prior history of concussions, or any past imaging or treatment. • Clinical diagnostic tools are used to determine the severity of the symptoms to identify potential structural lesions. • Balance Error Scoring System (BESS) test, • computerized dynamic posturography (CDP) which includes balance tests, the Sensory Organization Test, and visual tracking technologies (Lovell, 2009)

17. Pharmacological therapy in sports concussion • Role of pharmacological approach • Management of specific prolonged symptoms (e.g. sleep disturbance, anxiety etc..). • Modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. • An important consideration in RTP is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion. • Where antidepressant therapy may be commenced during the management of a concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician. Department of Rehabilitation Medicine

18. Retirement • Professional athletes with a history of multiple concussions and subjective persistent neurobehavioral impairments • Counseling. about the risk factors for developing permanent or lasting neurobehavioral or cognitive impairments and should recommend retirement from the contact sport to minimize risk for and severity of chronic neurobehavioral impairments Department of Rehabilitation Medicine

19. Play Safe Program at Mount Sinai

20. anne.ambrose@mssm.edu Department of Rehabilitation Medicine