#58: Concussion, traumatic brain injury, and post-concussive syndrome

September 18, 2017 | By Matthew Watto, MD

Get a-HEAD of concussions (aka traumatic brain injuries) with tools, tips, and tricks from The Concussion Guy, Dr. Evan Ratner, Medical Director of Gridiron Heroes. Learn to recognize concussion/traumatic brain injury, what questions to ask, physical exam maneuvers, and how to counsel patients and families on safe return-to-learn/play.

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Case from Kashlak Memorial: 29F with no significant PMH presents to primary care office less than 24 hours after she accidentally struck her head on the metal of her car door. She experienced temporary altered consciousness lasting about one hour along with a headache. No nausea, vomiting, speech, or vision changes. She rested at home last night, but didn’t feel up to reading, or watching TV. She drove herself to your office today.

Clinical Pearls:

1. Concussion: “External force to the head followed by alteration in brain function”8. Traumatic brain injury (TBI) is often used interchangeably, but TBI usually more severe. Both are serious injuries with symptoms that need to be monitored until resolution (see Table 1 for WHO criteria). Classifying as mild or severe is unhelpful.
2. Eye movements: Test extraocular eye movements. Look for horizontal, or vertical nystagmus. Test accommodation (ability to converge eyes and constrict pupils to focus on object in front of nose) and look for divergence of one eye. Hold thumb at arm’s length and rotate back and forth at waist at 90 degree interval keeping focus on thumb and maintaining balance.
3. Balance: Test Romberg for proprioception. First, patient stands and balances w/eyes open, then w/eyes closed. Next, give gentle pushes. Modified Romberg = patients stands on foam rubber and balances. Can also try standing on one foot. Test heel-to-toe walk, and tandem gait w/eyes open, then w/eyes closed.
4. Reaction time: Lightly, throw your pen to the patient, and ask them to catch it.
5. Neurocognitive testing: Most helpful if baseline test available. Return to play when post-concussive exam returns to baseline. Wait until score plateaus if no baseline available.
6. Imaging: Sick people look sick. Young healthy people usually have very concerning history and physical. In older, sicker folks the imaging threshold is lower. CT scan is gold standard given ability to detect subdural/epidural hematoma, and skull fracture. Use the Canadian CT head rule.
7. Canadian CT head rule: Perform CT if any of these present: GCS ≤15 at 2 hours postinjury; open, depressed, or basilar skull fracture; more than one episode of vomiting; or age ≥65 years old.
8. Post-concussive syndrome (PCS): Prolonged symptoms of concussion/TBI. Four domains: Cognitive, somatic, sleep-arousal, and mood symptoms (see Table 2).
9. Nonpharmacologic management: Consider cognitive behavioral therapy for mood/affective symptoms, vestibular rehab for dizziness/balance, and controlled aerobic exercise for global symptoms. Massage, acupuncture, and chiropractic therapy are under investigation.
10. Medication management: Early tx w/as needed antiemetics for nausea, and analgesic pain relievers for headache. Consider use of antidepressants for mood symptoms, amantadine for poor concentration, and impaired cognition (low quality evidence for all mentioned therapies).  
11. Urban legend = You can’t sleep after a concussion: False! Brain rest is key and sleep should be encouraged, unless patient has need for urgent neurosurgical intervention. Don’t let patients sleep if they have RED FLAGS! E.g. evidence of skull fracture, severely altered consciousness, vomiting (multiple episodes), seizure, high force/energy mechanism of injury, or focal neurologic deficits.
12. Second impact syndrome: Rare, but real phenomenon with brain herniation and death from even minor impact following an initial concussion that has not yet fully healed. Patients are very susceptible to even low force/energy impacts. Guidelines recommend minimum 7-10 day return-to-play.
13. Return-to-learn (or work): Walking and light activity okay immediately if tolerated. No driving for 24 hours and avoid all screens for 48-72 hours post-injury. Return to school once able to concentrate and tolerate light and sound. Provide note to teacher (boss) allowing modified environment, extra time for testing, shortened days, breaks as needed, etc. Restrictions should remain until symptom free.
14. Return-to-play: Must fully return-to-learn first! Advance intensity every 24 hours for 5-6 days. Steps: 1) Light aerobic activity 2)moderate activity 3) heavy (non-contact) activity 4) full contact practice 5) competitive play. Go back one step if sx occur.   
15. Recurrent concussions: Athletes are more susceptible to future concussions after a first concussion. Season is over after two concussions. Consider stopping a given sport after three concussions. Don’t avoid this difficult conversation!

Goal: Listeners will develop a basic approach to the diagnosis and management of concussions, and provide counseling to patients and families.

Learning objectives:
After listening to this episode listeners will…

1. Define concussion, and traumatic brain injury
2. Define post-concussive syndrome
3. Utilize available tools to diagnose concussion
4. Counsel patients/families on concussion management
5. Manage patient and family expectations following concussion
6. Recognize and manage post-concussive syndrome
7. Counsel patients and athletes on the return-to learn and return-to-play protocol

Disclosures:
Dr. Ratner reports no relevant financial disclosures. He uses the ImPACT Assessment tool, but receives no financial benefit by recommending this product.

Time Stamps
00:00 Intro
02:33 Listener feedback
05:35 Picks of the week
12:15 Getting to know our guest
19:41 Defining and classifying concussion
23:00 What questions to ask your patient
26:34 Physical exam for patient with concussion
28:50 Use of neurocognitive testing in concussion
30:45 Specifics of testing eye movements and balance
35:00 Who needs imaging?
41:51 Recap of what we’ve learned so far
43:40 Can you let someone with a concussion go to sleep?
47:08 Return-to-learn protocol
50:30 Return-to-play protocol
52:30 Post-concussive syndrome
53:55 Medications for post-concussive symptoms
58:58 Second impact syndrome
64:40 Counseling the patient with multiple concussions
67:08 Take home points
69:09 The Curbsiders recap their favorite teaching points
71:30 Outro

Links from the show:

1. NY Times article “You’ll never be famous…and that’s okay” by Emily Esfahani Smith
2. YouTube video Millennials in the workplace by Simon Sinek
3. TED Radio Hour (Podcast) – Rethinking School
4. Atypical (TV show) on Netflix
5. Zero Belly Cookbook (book) by David Zinczenko
6. Killing series e.g. Killing Kennedy (books) by Bill O’Reilly
7. Scrubs (TV show) available with Hulu subscription
8. Mayer, AR. The spectrum of mild traumatic brain injury: A review. Neurology 2017
9. Spouse, RA et al. Sport-related concussion: How best to help young athletes. J Fam Practice 2016
10. Postconcussive Syndrome Following Sports-related Concussion: A Treatment Overview for Primary Care Physicians. Southern Med J 2015
11. Brain Injury Basics | HEADS UP | CDC Info for teachers and parents