Concussion Management in Primary Care (Affleck, Ohkubo, Matthew 9/1/2021)

Many thanks to Dr. Monica Ohkubo,  Dr. Ty Affleck, Athletic Trainer Chelsea Matthew, and DNP Surani Kwon for a great interdisciplinary Grand Rounds presentation from the North Coast Concussion Management team on Concussion Management in Primary Care. 

A recording of their presentation is available HERE. 

Driven by increased attention on head injuries over the last decade, the standard of care for sport-related concussions has changed significantly from a general If you feel okay, it's okay, go back in and play mentality to a much more evidence-based stepwise management approach to concussion. 

• In US, there are 1.3-3.8 million concussions annually, close to 300,000  ER visits (2010-2016)
• In football alone, 7.7% NFL players experience concussion (this amounts to only about 130/year), but if 4-6% of high schoolers also experience concussion, this amounts to 1.2 million/year
• People with history of concussion are more likely to have another
• Hx migraine, depression, insomnia cognitive problems, visual abnormalities-->  concussion can unearth or exacerbate these conditions (learning disability can be activated, depression can represent or be exacerbated)
• Many used to believe that most athletes recovered from concussion in 7-10 days with a few stragglers. . .new evidence has found that after 2 weeks less than 1/2 of athletes with concussion have fully recovered

Initial Concussion Care: "You don't know how bad it is until it's over" -Dr. Ohkubo

• You cannot assign a time frame for recovery as soon as the concussion is recognized  (but by state law, it's always at least 7 days)

• NO return to play in same game/practice
• Monitor for deterioration over the first few hours after injury (s/sx bleed)
• Early follow-up with someone trained
• Physical rest
• Mental rest: no phones, no school/shortened school
• Per state law, any high school athlete with a concussion must follow up with physician trained in concussion management for medical clearance

Best practices for Concussion Management

Standardized Concussion Assessment Tool (SCAT5)

The SCAT-5 is a validated tool to use for concussion evaluation. Includes several components: GCS, c-spine evaluation, symptom evaluation, cognitive tests, balance tests, memory, coordination, and 6 step return to play guidelines. The link above will take you to the full 8 page document.

Of note, the symptom evaluation on the SCAT includes  22 symptoms: physical, emotional, mental, sleep. Different areas can be differentially affected

Athletes also can cover up symptoms because they are used to pushing themselves, so pay attention to the individual answers

Eye and Balance Test

Balance testing (BESS): 20 second each feet together hands on the hip eyes closed, non-dominant leg, tandem stance with non dominant foot in the back

Neurocognitive Testing

Gold standard is baseline testing (pre injury) to be able to assess extent of injury if/when it occurs

SRJC and SRCS are doing this for all athletes: Computerized neurocognitive baseline and f/u testing

Athletic Trainers

 Athletic trainers are (board certified, link between healthcare provider and the athlete and parent) important resource to be able to be available to do concussion training/prevention as well as assist with assessment and return to play protocols

• prevention and recognition of injury, referral, treatment rehabilitation
• academic modification
• objective assessment at sideline, retesting
• referrals for physician, mental health support
• facilitation of return to play protocol
• day to day contact with athletes

Treatment and Management of Concussion

1. Cognitive and physical REST is huge. Academic accommodations have to be provided by doctors specific form that physicians need to fill out (e.g. half days at school, extra time on tests, reduced homework load, note taking, not on computer all the time)
2. Diet: appetite changes after concussion (more/less hungry). Eat small things through the day
3. Hydration: nausea, drinking small amount during the day
4. Sleep: sleep patterns can change (more/less than normal, frequent waking). Don't wake a sleeping athlete. Sleep is important in recovery. Naps: not after 3pm
5. Exertion: people recovering both physical and mental, though small sub-symptom exercise can help recovery. 
6. Stress: interpersonal arguments, emotions can change post concussion, crying out of nowhere (not criers), lights/sound noise: bright lights, fluorescent lights, sunglasses (accommodation), loud sounds (e.g. PE class)
7. Do NOT push the symptoms

Return to Play Process (CA state law)

• Anyone diagnosed with concussion, must go through the process that starts with a medical evaluation, and then start 7 day process
• For contact sports, athletes must get a two step medical clearance
• Each step MUST be separated by at least 24 hours
• If symptoms return at any step, stop the activity, let rest for the rest of the day and return to the same step

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Step#1      Rest until asymptomatic

MEDICAL CLEARANCE

Step#2:     Light aerobic activity (walk around track or football field)

Step#3:     Sport specific exercise (running, swimming)

Step#4:     Non contact training drills (shooting, serving, setting)

MEDICAL CLEARANCE

Step#5:     Contact practice

Step#6:     Contact game

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It's important to note that concussion symptoms tend to cluster: "Concussion picks on everyone's weakness". 

Someone may have minimal to no symptoms in one category but profound deficits in another. Directing your attention to where their symptoms are is a key take home. 

• vestibular
• cognitive/fatigue
• ocular
• post-traumatic migraine
• anxiety/mood
• cervical 

Specialists can be helpful depending on the problem: concussion specialist, vestibular rehab, neuro opthamologist, neuropsychologist

Use of neurocognitive tests

Gold standard is to have a baseline and post-test injury test. That way you can compare the two. IF you don't have a baseline, there are standardized scores based on age/educational level that you can use to make your assessment.  

Specifically, the computerized neurocognitive test ImPACT used at SRJC and SRCS (see image below for an example report)

Other tools:

• Vestibular and oculomotor testing (VOMS test)
• A "Home SCAT test": ideally, athletic trainers are supporting the return to play process; however, if there is no athletic trainer to link to care, consider using parent to help athletes get through the process. Have the athlete go through above steps and have parent administer a variation on the SCAT (below)
• Light aerobic exercise (in Dr. Affleck's words, "oxygen") can help speed recovery
• Disrupted sleep? Consider melatonin

Additional References/resources:

CDC: www.cdc.gov/concussion/

UPMC: www.upmcphysicianresources.com

northcoast concussion.org 

CIF physician letter to school: https://cifstate.org/sports-medicine/concussions/CIF_Physician_Letter_to_School_after_Concussion_Visit.pdf