Concussion PDF - Curtin University 17/05/2020

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17/05/2020 COMMONWEALTH OF AUSTRALIA Copyright Regulation 1969 WARNING This material has been copied and communicated to you by or on behalf of Curtin University of Technology pursuant to Part VB of the Copyright Act 1968 (the Act) The material in this communication may be subject to copyright under the Act. Any further copying or communication of this material by you may be the subject of copyright protection under the Act. The pictures used in this lecture are only intended to be used as pictures and NOT the associated website or information attached to them Do not remove this notice 1 Concussion 2 1 17/05/2020 Todays Topics What is concussion? Discuss sport‐related concussion Explain the pathophysiology of concussion What are the most serious signs of concussion? What are the common symptoms of concussion? Understand testing for concussion Describe post concussion syndrome Discuss subconcussion and chronic traumatic encephalopathy (CTE) 3 Traumatic Brain Injury An injury to the brain caused by trauma • Hypoxic/Anoxic brain injury occurs when the brain is starved of oxygen e.g. near drowning, after cardiac arrest • Contusion is a bruise of the brain tissue Coup and contrecoup injuries https://www.dolmanlaw.com/coup‐contrecoup‐brain‐injuries/ 4 2 17/05/2020 Traumatic Brain Injury • Penetrating brain injuries occur when something pierces through the skull. • A concussion is a mild traumatic brain injury caused by biomechanical forces 5 Concussion – mild traumatic brain injury • Injury to the brain caused by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Even a sudden movement of the head can cause concussion. • Results in the rapid onset of short‐lived impairment of neurological function that (usually) resolves spontaneously. • 80% of traumatic brain injuries are concussion • 90% of concussions do not seek medical treatment 6 3 17/05/2020 Sports related concussion • ≈20% of concussions are sport related (Langlos et al., 2006) • When considering sports with similar rules, women athletes are more likely to get concussed and have a more severe symptoms https://www.pinkconcussions.com/brain‐injury https://qbi.uq.edu.au/concussion/what‐is‐concussion 7 Sports related concussion Sports with the highest concussion rates are • • • • • motor sports (181 per 100,000 participants), equestrian (130 per 100,000 participants), Australian rules football (80 per 100,000 participants), all codes of rugby (50 per 100,000 participants), roller sports (45 per 100,000 participants). https://www.sportaus.gov.au/__data/assets/pdf_file/0005/683501/February_2019_‐_Concussion_Position_Statement_AC.pdf 8 4 17/05/2020 Pathophysiology of concussion • Neuronal cell membrane disruption and axonal stretching causes a cascade of events: • Axon membrane potential disrupted so dysregulation of the flow of ions across the membrane (potassium out and calcium in) • Hard working sodium/potassium pumps (attempting to fix the ionic imbalance) and lower blood flow depletes cell energy • Increase in excitatory transmitters (glutamate) cause excess calcium into the neuronal cell body interrupting energy generation • Leads to a general decrease in neuronal activity • Lasts at least 2‐3 days • No short‐term evidence of structural changes to the brain 2 minute neuroscience ‐ concussion 9 Signs of serious concussion Reflect generalised disturbance to brain function Obvious signs of concussion loss of consciousness, • an obvious sign, but you don’t have to lose consciousness to have a concussion • loss of consciousness is reported in 10%–20% of cases (Helps et al., 2008) • Loss of consciousness brainfacts.org 10 5 17/05/2020 Signs of serious concussion Reflect generalised disturbance to brain function tonic posturing (the fencing response), tonic posturing ‐ fencing pose 1 tonic posturing ‐ fencing pose 2 • temporary brainstem dysfunction balance disturbance and ataxia • ataxia ‐ watch number 9 in black • cerebellar sign pdfs.semanticscholar.org 11 Sport Concussion Assessment Tool (SCAT 5) – 22 common symptoms • headache • ‘don’t feel right’ • ‘pressure in the head’ • difficulty concentrating • neck pain • difficulty remembering • nausea or vomiting • fatigue or low energy • dizziness • confusion • • • • • • • • • • • • blurred vision drowsiness balance problems sensitivity to light more emotional sensitivity to noise irritability feeling slowed down sadness feeling like ‘in a fog’ nervous or anxious trouble falling asleep (if applicable) Not all symptoms are seen in every person 12 6 17/05/2020 Concussion Recognition Tool Designed for everyone to use on field CRT ‐ AFL https://bjsm.bmj.com/content/51/11/872 13 Clinical and/or sideline assessments • Gold standard at present ‐ Sport Concussion Assessment Tool (SCAT 5) • The SCAT5 is a standardized tool for evaluating concussions designed for use by physicians and licensed healthcare professionals. The SCAT5 cannot be performed correctly in less than 10 minutes • For children aged 12 years or younger, please use the Child SCAT5 • Pre‐season SCAT5 baseline testing can be useful for interpreting post‐ injury test scores, but is not required for that purpose SCAT 5 For your interest only ‐ not compulsory viewing https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports‐2017‐097506SCAT5.full.pdf 14 7 17/05/2020 Balance test • The BESS test is part of the SCAT 5 BESS test Additional domains that may add to the clinical utility of the SCAT tool include clinical reaction time, gait/balance assessment, and oculomotor screening https://www.ncbi.nlm.nih.gov/pubmed/28446453 15 Vestibular/ocular‐motor • Photophobia and blurred vision, abnormalities of specific eye movements, such as saccades, vestibulo‐ocular reflex, smooth pursuit, convergence, or accommodation deficits. • More than half of the brain's pathways are dedicated to vision and eye movement control, therefore often affected • Vestibular/Ocular‐Motor Screening (VOMS) 16 8 17/05/2020 Reaction time tests The patient has their hand around, but not touching, a rubber puck at the bottom of the stick, then the tester drops the stick, and the patient catches it on the way down. The distance down the puck they have caught it reflects their reaction time https://www.physio‐pedia.com/Concussion_Assessment 17 Concussion • 80% of people • symptoms of a concussion should resolve in 7‐10 days • Children and adolescents often take longer • 20% take longer or don’t recover 4 types of symptoms • Post concussion syndrome • Cognitive – memory • some people it lasts 3 – 6 months attention focus • Some people continue to deteriorate • Sleep – too much then too • Can be a downward spiral of • neuronal metabolism disruption • reduced cellular energy • Increased swelling reducing blood flow • reduced oxygen to neurons little • Mood – anxious, irritable, depressed • Physical – headache, dizzy, sensitive to light and noise post concussion syndrome 18 9 17/05/2020 Risk factors for poorer recovery • one or more past concussions is associated with having more physical, cognitive and emotional symptoms • severity of the initial symptoms in the first day, or initial few days, after injury • migraine headaches or depression • child/adolescent ‐ up to 30% of children and adolescents remain symptomatic 1 month after injury (Zemek et al., 2016) • female https://qbi.uq.edu.au/concussion/concussion‐in‐children 19 Treatment • 1‐2 days of both cognitive and physical rest • Following this, patients should be encouraged to gradually increase activity (Schneider et al., 2018) • Some evidence that sub‐symptom threshold aerobic exercise in the first week might improve symptoms and improve recovery (Leddy et al., 2018) https://completeconcussions.com/2019/10/01/what‐to‐do‐after‐concussion‐rest‐or‐exercise/ 20 10 17/05/2020 Subconcussive impacts • Enough force to injure axonal or neuronal integrity, but not result in clinical symptoms (at the time of injury). • Soccer heading and sub‐concussion? • Leads to Chronic Traumatic Encephalopathy ? https://www.bbc.com/future/article/20200131‐why‐women‐are‐more‐at‐risk‐ from‐concussion 21 Chronic Traumatic Encephalopathy (CTE) What is CTE? • Long term “brain damage” • “emerging evidence that some retired athletes have mild cognitive impairment, neuroimaging abnormalities and differences in brain metabolism disproportionate to their age” (Manley et al., 2017) • Autopsy cases of former athletes have revealed diverse forms of neuropathology • Thought to be the accumulation of exposure to head acceleration events (HAEs), even in the absence of a diagnosis of concussion • Alzheimer’s disease/ dementia, Parkinson’s disease and motor neuron disease • Prominence with retired American football athletes (NFL) $$$ CTE Muhammad Ali 22 11 17/05/2020 Summary What is concussion? Discuss sport‐related concussion Explain the pathophysiology of concussion What are the most serious signs of concussion? What are the common symptoms of concussion? Understand testing for concussion Describe post concussion syndrome Discuss subconcussion and chronic traumatic encephalopathy (CTE) 23 12