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Midwest Orthopaedics at Rush Concussion Assessment & Management

Elizabeth M. Pieroth, PsyD, ABPP, MPH July 23, 2021 Director of the Concussion Program MOR/Rush Disclosures for Dr. Pieroth:

Consult to (no personal income derived): Bears Rockford IceHogs Chicago Fire National Womens Soccer League

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 2 Disclosures for Dr. Pieroth:

Volunteer consultation to: Brain Injury Association of Board of Directors National Advisory Board, US Football Heads Up Football Committee US Soccer Sports Medicine Research, Education & Advisory Panel Amateur Hockey Association of IL Safety Committee NFL Head, Neck and Spine Committee NFL Co-Director Neuropsychology Consultant Program

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 3 Objectives: Review: 1. Brief review of Pathophysiology 2. Initial Assessment 3. Initial Recommendations 4. Treatment Course 5. Treatment for Persistent Symptoms (PPCS) 6. Repetitive Concussions/ Retirement Issues

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 4 Pathophysiology

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 5 Recognition Data from the NFL, NHL and NRL (rugby) demonstrate the value of using observable signs. • Gait ataxia/motor incoordination • Vacant stare • Unresponsiveness/lying motionless • No protective action • Getting up slowly and clutching the head were not useful

(Davis et al, 2019; Garnder et al, 2017; Echemendia et al, 2018, Echemendia et al, 2016)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 6 Initial Evaluation (on the sideline) • Most of the time there is a clear mechanism of injury, but not always. • Always assess (even briefly) an athlete with a significant contact. • Athletic trainers are particularly helpful here, as they know the athlete's normal behavior/personality. • Serial assessments for athletes to monitor delayed onset of symptoms.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 7 Signs and Symptoms Signs (observable by others) Symptoms (reported by athlete) • Appears stunned/dazed • Headache or "pressure" in head • Confused about assignment • Nausea or vomiting • Forgets an instruction • Balance problems or dizziness • Can't recall events before or after • Double or blurred vision contact • Sensitivity to light or noise • Moves clumsily • Ringing in the ears • Answer questions slowly • Feelings hazy, foggy, slowed • Loses consciousness • Feels confused • Shows mood, behavior or • Unable to concentration or personality changes reporting memory problems SCAT Testing

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 9 SCAT5 Immediate/On-Field Assessment​ Office/Off-Field Assessment​ 1. Red flags​ 1. Athlete background​ 2. Observable signs​ 2. Symptom evaluation​ 3. Maddocks questions​ 3. Cognitive screening​ 4. GCS​ 4. Neurologic screen​ 5. Cervical spine assessment​ 5. Delayed recall​ 6. Decision​

Midwest Orthopaedics at Rush | 7/22/2021 10 When to use Child SCAT5 Ages 5-12

Differences from SCAT5 1. No Maddocks questions 2. Adds parent report of signs/symptoms 3. No orientation questions

, MPHElizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 11 No-Go Symptoms

• Loss of consciousness • Impact seizure • Tonic posturing ("fencing position") • Amnesia • Confusion • Gross motor instability

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 12 Concussion "danger signs" (CDC guidelines)

• One pupil larger than the other. • Drowsiness or inability to wake up. • A headache that gets worse and does not go away. • Slurred speech, weakness, numbness, or decreased coordination. • Repeated vomiting or nausea, convulsions or seizures • Unusual behavior, increased confusion, restlessness, or agitation. • Loss of consciousness. Even a brief loss of consciousness should be taken seriously.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 13 Initial Evaluation (if not seen acutely):*

1. Mechanism of injury 2. Initial symptoms 3. Symptom-onset

*Three biggest mistakes in concussion assessment made here

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 14 Why look at mechanism of injury?

A concussion requires contact to the head or forceful movement of the head significant enough to cause injury.

But… • We don’t have a threshold for the force required • We don’t have a clear understanding of what contributes to injury

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 15 Why look at initial symptoms?

1. Helps with differential diagnosis

2. Helps us determine which patients may have a prolonged recovery (Martinez et al, 2020)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 16 Why look at time of symptom onset?

Could the symptoms be caused by something else?

* If the symptoms start days later, it is likely not a concussion.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 17 What else can cause concussion-like symptoms?

• Dehydration • Cervical strain • Chest/abdominal trauma • Weight cutting • Anxiety/psychological reaction to stressors or to the trauma itself • Migraine (exercise-induced or traumatically-induced) • Sinus infections/colds • Life!

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 18 Concussion signs/symptoms are common in the general public

Non-patients: Visual problems 40% Balance 14% Temper outbursts 30% Headaches 58% Dizziness/vertigo 22% Anxiety 60% Light sensitivity 30% Word finding 47% Depression 33% Poor concentration 35% Forgetful 47%

(Paniak et al, 2002)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 19 Concussion signs/symptoms are common in certain populations

• 31,958 high school athletes • 19% of boys and 28% of girls reported a symptom burden consistent with an ICD-10 diagnosis of Post-concussion syndrome • Students with preexisting conditions even more likely: 21-47% boys, 33-72% girls • Prior psychiatric condition was the strongest predictor followed by history of migraine and ADHD

(Iverson, 2015)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 20 Concussion signs/symptoms are common in certain populations

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 21 Treatment Recommendations/Follow-up Care

• Set expectation of recovery from the very start* • Discuss expected recovery times (1-3 weeks in most people, can be 4 weeks in children) • Do NOT overprescribe rest • Monitor their symptoms for possible causes of persistent symptoms • Refer to concussion specialist if not recovering within expected time-frame or other complicating factors Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 22 What are the recommendations for an acute injury?

Symptom-Management (Did you notice I didn’t say rest?!?!)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 23 Elizabeth M. Pieroth, PsyD, ABPP, MPH Rush University Medical Center | 7/22/2021 24 Concussion In Sport Group

“There is insufficient evidence that prescribing complete rest achieves these objectives. After a brief period of rest during the acute phase (24-48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation…. The exact amount and duration of rest is not yet well defined in the literature and requires further study.” (McCrory et al, 2017)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 25 Physical Activity after Concussion is OK!

Physical activity after concussion did not cause an increase in length of recovery. In fact, higher levels of activity were associated with shorter symptom duration. (Howell et al., 2016)

Subsymptom threshold aerobic exercise within the first week of concussion “speeds recovery and may reduce the incidence of delayed recovery." (Leddy et al, 2018; Baker et al, 2020)

It's safe and effective in pediatric patients as well (Del Rossi et al, 2020)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Rush University Medical Center | 7/22/2021 26 Inactivity after concussion may make symptoms worse

Patients who did not engage in early physical activity had: • longer symptom duration • greater odds of post-injury headache • greater symptoms at initial clinical evaluation. (Howell et al, 2020)

Patient placed on extended rest showed no benefit and reported more symptoms (Thomas et al, 2015).

Elizabeth M. Pieroth, PsyD, ABPP, MPH Rush University Medical Center | 7/22/2021 27 Subsymptom Aerobic Exercise

***“Practical Management: Prescribing Subsymptom Threshold Aerobic Exercise for Sport-Related Concussion in the Outpatient Setting” (Bezherano et al, 2020) https://www.ncbi.nlm.nih.gov/pubmed/32058454

“Exercise intolerance, which is defined as the inability to exercise near to age- appropriate maximum HR due to exacerbation of concussion-related symptoms, is considered to be a clinical manifestation of autonomic physiological dysfunction after SRC and in some cases of PPCS.”

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 28 How do we assess recovery?

1. Asymptomatic with and without exertion 2. Balance and ocular examination is normal 3. Cognitive functioning has returned to normal

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 29 What is true recovery?

One study looked at a of physiological measures Functional MRI Diffusion Tension Imaging (DTI) Magnetic Resonance Spectroscopy (MRS) Cerebral blood flow Electrophysiology Heart rate Exercise tolerance Fluid biomarkers Transcranial Magnetic Stimulation (Kamins et al, 2017)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 30 Cognitive Testing

• Computerized testing is NOT a diagnostic tool. • Cognitive testing is an important component of return-to-play decisions but should NOT be used in isolation. • Standardization of the test administration and strict control of the testing environment (e.g., noise level, distractions) are vital to the validity of the test results (both baseline & post-injury). • Cognitive test scores should ONLY be interpreted by those with the proper training and experience.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 31 Post-Concussion Syndrome (PCS)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 32 Do these symptoms really meet the criteria for a syndrome?

A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 33 Persistent Post-Concussion Symptoms (PPCS)

The focus is on the symptoms, not the concussion.

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 34 Does it really make a difference what we call it?

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 35 What are the causes of persistent symptoms?

“The Big 6” 1. Cervical 2. Vestibular 3. Ocular-motor 4. Migraine 5. Autonomic Dysfunction 6. Psychological factors

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 36 Other Factors to Consider:

• Pain • Anxiety/depression* • Sleep disturbances* • Medication side effects • Malingering • Factitious Disorder • Somatoform Disorder • Attributional bias

Elizabeth M. Pieroth, PsyD, ABPP, MPH Rush University Medical Center | 7/22/2021 37 What are the "red flags" to suggest retirement?

1. Increased vulnerability 2. Longer recovery times 3. Persistent symptoms 4. Number of concussions *

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 38 When is "enough, enough"?

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 39 Retirement

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 40 Retirement (Esopenko et al, 2021)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 41 Retirement

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 42 The Role of the Concussion Specialist

There is consistent evidence that the earlier a concussion patient is evaluated by a concussion specialist, the sooner they recovery. (Desai et al, 2019; Kontos et al, 2020)

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 43 Thank you!

Elizabeth M. Pieroth, PsyD, ABPP, MPH [email protected]

Twitter @DrEPieroth

Elizabeth M. Pieroth, PsyD, ABPP, MPH Midwest Orthopaedics at Rush | 7/22/2021 44