Jack is a 36?yo Asian pacific male who comes to your clinic with a complaint of Low Back Pain (6 of 10). It began 2 days ago after he lifted a heavy box at work. He denies previous inst

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Managing concussion in primary care The incidence of concussion is increasing in children and adults, as is the demand for clinicians who can diagnose and treat both patient groups.

Concussions, considered a type of mild trau­ matic brain injury (TBI), are increasing in incidence in both adult and pediatric

populations.1,2 Concussions can occur as the result of motor vehicle accidents, falls, occupational accidents, recreational accidents, and assaults. The Centers for Disease Control and Prevention (CDC) estimates that between 1.6 and 3.8 mil­ lion concussive injuries related to sports occur in the United States annually.3 As the number of emergency department visits for concussion- related injuries increases, so does the demand for primary care providers competent in the evalua­ tion and management of concussions during both the initial presentation and clinical follow-up.

The 4th International Conference on Concussion in Sport, held in 2012, agreed upon the fol­ lowing definition of concussion: “an injury involving a complex pathophysiological process affecting the brain, induced by traumatic bio­ mechanical forces.”4 A concussive head injury can be characterized by the following features: (1) It originates with a direct blow to the head or to another part of the body with transmis­ sion of an “impulsive” force to the head; (2) the rapid onset of transient neurologic impairment follows spontaneously; (3) the symptoms largely reflect a functional disturbance rather than a structural injury, with no abnormality seen on standard structural neuroimaging studies; (4) variable clinical symptoms may not include loss of consciousness; and (5) symptom resolution typically follows a sequential course but may be prolonged in a small percentage of cases.4

B e t w e e n 1 .6 a n d 3 . 8

m i l l i o n s p o r t s – r e l a t e d

2 4 THE CLIN ICAL ADVISOR • SEPTEMBER 2016 • w w w . C l i n i c a l A d v i s o r . c o m

C lin ic a l p re s e n ta t io n Because concussion remains a clinical diagnosis, recognition of the typical symptoms and signs (Table 1) is fundamental to initiating management promptly. The hallmark symptoms that a patient typically describes are confusion and amnesia, occasion­ ally with but often without loss of consciousness.5 Symptoms may manifest immediately after the head injury or appear several minutes later/’ The victim usually retains a memory of the traumatic event, but loss of recollection of the events before (retrograde amnesia) and after (anterograde amnesia) the head trauma is frequent. Other early symptoms of concussion include headache, dizziness (vertigo or imbalance), and nausea with or without vomiting.6 Throughout the next several hours or days, the patient may experience cognitive and mood disturbances, photophobia, hyperacusis, or sleep disturbances.7

It is important to note that in many cases, a concussion is not associated with any pertinent examination findings. However, some typical signs may be the following: vacant stare, inability to focus, disorientation, slurred speech, memory deficits, gross observable incoordination, and delayed verbal expression/’ Lastly, posttraumatic seizures typically occur in fewer than 5% o f concussion injuries and are more commonly seen in patients w ith severe TBI.8 In the typical clinical course, a concussion resolves w ithin a short period (7-10 days).4

D iag n o s is It is im portant that any patient in whom a concussion or a m ild TBI is suspected be medically evaluated immediately, whether in a physician’s office or hospital emergency depart­ m ent or on the sideline o f an athletic event. Evaluation of an acute injury should include a comprehensive history, determ ination o f the mechanism o f injury, mental status testing, and a detailed neurologic assessment. “R ed flag” signs and symptoms, such as prolonged loss o f consciousness, persistent alterations in mental status, and abnormal findings on a neurologic examination, should prompt urgent neuro­ im aging and possible neurosurgical consultation.9

Numerous standardized diagnostic tools have been developed to aid in the recognition of concussions and to provide guidance regarding athletes’ return to play. These include the Standardized Assessment oi Concussion (SAC), Postconcussion Symptom Scale and Graded Symptom Scale Checklist, Sport Concussion Assessment Tool 3 (SCAT3), Westmead Posttraumatic Amnesia Scale (WPTAS), and Immediate Postconcussion Assessment and Cognitive Testing (ImPACT), to name a few.10 A child SCAT3 has also been developed to assess concussion in patients aged 5 to 12 years. It is believed that children report concussion symp­ toms differently, so an assessment tool with an age-appropriate

T A B L E I . Signs and s y m p to m s o f co n cussion"

Category Sign o r sym ptom

Physical • Headache • Nausea • Vomiting • Balance problems • Dizziness • Visual problems

• Fatigue • Photophobia • Phonophobia • Numbness/tingling • Feeling dazed • Feeling stunned

Cognitive • Feeling mentally "foggy" • Feeling slowed down • Difficulty concentrating • Difficulty remembering • Forgetfulness of recent

information

• Confusion about recent events • Answering questions slowly • Repeating questions

Emotional • Irritability • Sadness • Anxiety

• Increased emotional lability • Nervousness

Sleep-related • Drowsiness • Difficulty falling asleep

• Sleeping more or less than usual

symptom checklist is required.4 These tools are useful in the sideline assessment of athletes who have potential concussion injuries as well as in the office setting, with serial monitoring used to determine the resolution o f symptoms.11

The findings on conventional im aging are almost always normal because concussions are typically a functional and not a structural problem. However, if neuroimaging is being considered, brain computed tomography (CT) is typically the test o f choice initially, especially for an acute injury. Magnetic resonance imaging should be considered for patients with persistent symptoms who are at risk for posttraumatic complications, such as headaches, vertigo, seizures, and postconcussion syndrome.12 Neuropsychological testing has been shown to be a useful adjunct, providing clinical value regarding cognitive function. However, testing is best per­ formed and the results interpreted by a neuropsychologist, although there are currently no agreed-upon recommenda­ tions for the universal use o f neuropsychological testing.4-11

M a n a g e m e n t Most patients w ith a concussive head injury can be managed safely in the outpatient setting. Observation with a responsible caregiver is recommended in the first 24 hours after an injury because o f the slight risk for an intracranial complication.13 Admission to the hospital is typically recommended for patients with any of the following: (1) Glasgow Com a Scale score <15, (2) abnormal findings on C T scan, (3) seizures, and (4) abnormal bleeding parameters due to an underlying disorder

w w w .C lin ica lA d v is o r.c o m • THE CLIN ICAL ADVISOR • SEPTEMBER 2 0 16 25

M A N A G IN G C O N C U S S IO N IN PRIMARY CARE

A m ore conservative re tu rn -to -p lay protocol has been proposed fo r children and adolescents th a t includes extended periods w ith o u t sym ptom s.

or oral anticoagulation.14 A patient with an uncomplicated concussion is typically educated about the need for physical and cognitive rest for at least 24 hours. Certainly, this period can be longer if the patient remains symptomatic or the severity o f the symptoms warrants continued rest. Cognitive rest is especially important in children and adolescents and should include abstaining from activities such as playing video games, watching television, working on a computer, using tablets and smart phones, listening to loud music, reading, and engaging in mental exercises requiring focus and concentration in the academic setting.15 This period should be followed by a gradual return to work, school, or physical activity, depending on the patient.4 Again, it is important to note that the majority o f patients with concussion-related injuries typically recover spontaneously over several days.

Return to play. Because a significant number of concussion- related injuries occur within the sporting arena, many providers seek guidelines on when to counsel athletes, parents, and coaches about returning to competition. Most experts concur that no athlete should return to play on the day that a concussive injury occurred. This minimizes the risk for complications resulting from a repeated head injury. Moreover, research indicates that athletes at the collegiate and high school level are more likely to have a delayed onset of symptoms and neuropsychologi­ cal deficits following injury as a result of same-day return to play.4 The current recommendations use a stepwise process and graduated return-to-play protocol as defined in Table 2. Essentially, an athlete should progress to the next level if he or she remains asymptomatic within the current level. Therefore, it takes about 1 week to progress through the full rehabilita­ tion protocol because each step should take approximately 24

hours. However, if any postconcussion symptoms occur dur­ ing the graduated return-to-play program, the patient should “drop back” to the previous asymptomatic level and attempt progression again after a 24-hour period o f rest. Patients who fail to recover or who exhibit persistent concussion-related symptoms should be referred to specialists with experience managing concussions in a multidisciplinary approach.

A more conservative return-to-play protocol has been pro­ posed for children and adolescents that includes extended periods without symptoms and/or longer periods o f graded exertion. This approach is recommended because o f the different physi­ ologic responses of children and adolescents to head trauma and the longer time needed for recovery.4 Participation in school- related extracurricular activities, including athletics, is not usually recommended until the patient has fully resumed school activi­ ties.16 Lastly, each return-to-play progression, regardless o f the patient’s age, should be individualized, with the final clearance documented by a licensed healthcare provider knowledgeable in the evaluation and management o f concussions.11

Pharmacologic therapy. The use of medications in treating concussion is tailored mainly to the management of symptoms. According to the most recent position statement on concussion in sport from the American Medical Society for Sports Medicine, no convincing evidence has been found of the effectiveness of any particular medication in treating the acute symptoms of concussion.11 Acetaminophen is currently recommended in the treatment of postconcussive headaches, with the addition of physical measures such as massage, the application ofice, and rest in a dim, quiet environment. Sleep disturbances should initially be managed with conservative measures, such as sleep hygiene, but medical and/or cognitive therapy or even referral

TABLE 2. Graduated return-to-play protocol4

Rehabilitation stage’ Functional exercise O bjective o f stage

1. N o activ ity Complete physical and cognitive rest until medical clearance Recovery

2. L ight aerobic exercise Walking, swimming, stationary cycling; <70% MPHR, 15 minutes Increase in heart rate

3. S port-specific exercise Skating or running drills (no head-impact activities); <80% MPRH, 45 minutes Addition of movement

4. N o n co n ta c t tra in ing drills Complex training drills, start o f resistance training; <90% MPRH, 60 minutes Exercise, coordination, and cognitive load

5. Fu ll-contact practice Normal training activity if symptom-free Restoration of athlete's confidence; assessment of functional skills by coaching staff

6. R eturn to play

MPHR, m a x im u m p r e d ic te d h e a r t r a te P a t ie n t m u s t b e s y m p to m – f re e f o r 2 4 h o u rs b e fo re p ro g re s s in g t o n e x t r e h a b ilita t io n s tage .

26 T H E C L IN IC A L A D V IS O R • SEPTEMBER 201 6 • w w w .C lin ica lA d v is o r.c o m

Postconcussion syndrom e encompasses sym ptom s including headache, dizziness, neuropsychiatric sym ptom s, and cognitive im p a irm en t.

to a sleep specialist should be considered for a patient with pro­ tracted symptoms. Stimulants are not currently recommended for treating cognitive symptoms, such as decreased attention. True vertigo and balance dysfunction may be mitigated by meclizine or diazepam, but these drugs should be used judi­ ciously because they can affect cognitive function. There is currently insufficient evidence to determine the effectiveness o f vestibular therapy in patients with vertiginous symptoms. Patients who have depressive symptoms should be screened and treatment with medication and/or cognitive therapy should be considered if the symptoms persist beyond 6 to 12 weeks."

Complications Second-impact syndrome is a rare but potentially fatal compli­ cation leading to diff use cerebral swelling that can occur after a patient who is still symptomatic from an earlier concussion sustains a second head injury.17 The term postconcussion syndrome encompasses the symptom complex of headache, dizziness, neuropsychiatric symptoms, and cognitive impairment.18 These symptoms can develop in the first few days after a mild TBI but typically resolve w ithin a few weeks to few months. Patients can also exhibit isolated symptoms as sequelae that include posttraumatic headaches and/or posttraumatic vertigo. The incidence of posttraumatic epilepsy is increased 2-fold after mild TBI, with 50% of cases occurring during the first year and 80% within the first 2 years.* 1 2 3'1 However, prophylactic treatment w ith anticonvulsants is not currently recommended because it has not been shown to be effective. Chronic traumatic encephalopathy (CTE) has been one of the most publicized potential long-term complications, with increasing reports of dementia occurring in National Football League players who have a history o f multiple concussions. CTE is a neurodegen- erative disease that is associated with repetitive brain trauma and pathologically characterized by the accumulation o f an abnormal tau protein in specific areas o f the brain. Patients should be aware o f this potential long-term complication of cumulative head trauma, although most experts agree that larger-scale, epidemiologic studies are required to understand the causes and develop prevention strategies."

Conclusion Concussions remain a complex and common type of mild TBI evaluated by primary care providers. Diagnosis and management remain challenging because o f insufficient scientific evidence to support much of the clinical decision making required for

P O L L P O S IT IO N

W hich of the following best describes your opinion about sports concussions?

■ I strongly recommend that children and adolescents do not participate in contact sports.

■ I have advised parents o f the potential dangers o f contact sports.

W ith new protocols in place, it is much safer than before.

For more polls, visit ClinicalAdvisor.com/Polls.

good patient care. It is essential that healthcare providers be able to recognize the symptoms and signs of a concussion, but it is equally important that athletes, coaches, officials, and parents be educated so that patients are properly evaluated. Healthcare providers trained in the evaluation and management of con­ cussion are therefore important in establishing the diagnosis. Standardized diagnostic tools provide a helpful and uniform approach to assessing and following a patient with a concussion. However, further research is needed to determine their accuracy. The mainstay of treatment remains physical and cognitive rest. No athlete with a concussion should be allowed to return to play on the day of the injury or while he or she is symptomatic. Moreover, the decision to return to play should be a medical one, with clearance given by a licensed healthcare provider. A provider with any uncertainty regarding an athlete’s return to play should follow the mantra “when in doubt, sit them out.” ■

Shaun Lynch, PA-C, MS, MMSc, is a physician assistant and an assistant professor in PA studies at Eton University in North Carolina.

References 1. Injury prevention & control: traumatic brain injury & concussion.

Centers fo r Disease C ontrol and Prevention website, http://www.cdc.gov/

TraumaticBrainlnjury/index.html. Updated February?, 2016,

2. Marin JR, W eaver MD, Yealy DM, Mannix RC. Trends in visits fo r trau­

matic brain injury to emergency departments in the United States. JAMA.

2 0 14;311 (18): 1917-1919.

3. Langlois JA, Rutland-Brown W , W ald MM. The epidemiology and

impact o f traumatic brain injury: a b rie f overview.) Head Trauma Rehabil.

2006:21 (5):375-378.

www.ClinicalAdvisor.com • T H E C L IN IC A L A D V IS O R • SEPTEMBER 2016 27

MANAGING CONCUSSION IN PRIMARY CARE

4. M cCrory P, Meeuwisse W , Aubry M, e t al. Consensus statement on

concussion in sport: the 4th International Conference on Concussion in

Sport held in Zurich, Novem ber 2012. Clin J Sport Med. 2 0 13;23(2):89-117,

5. Duhaime AC, Beckwith JG, Maerlender AC, e t al. Spectrum o f acute

clinical characteristics o f diagnosed concussions in college athletes wearing

instrumented helmets: clinical article.J Neurosurg. 20I2;117:1092-1099.

6. Kelly JP, RosenbergJH. Diagnosis and management o f concussion in

sports. Neurology. l997;48(3):575-580.

7. Cantu RC. Posttraumatic retrograde and anterograde amnesia: patho­

physiology and implications in grading and safe return to play.J Athl Train.

20 0 1 ;36(3):244-248.

8. Lee ST, Lui TN . Early seizures after mild closed head injury. J Neurosurg.

l992;76(3):435-439.

9. Practice parameter: the management o f concussion in sports (summary

statement). Report o f the Quality Standards Subcommittee. Neurology.

1997;48(3):581 -585.

10. Giza CC, KutcherJS, Ashwal S, e t al. Summary o f evidence-based

guideline update: evaluation and management o f concussion in sports:

re po rt o f the Guideline Development Subcommittee o f the American

Academy o f Neurology. Neurology. 2 0 13;80(24):2250-2257.

11. Harmon KG, DreznerJA, Gammons M. e t al, American Medical Society

fo r Sports Medicine position statement: concussion in sport. BrJ Sports

Med. 2013;47:15-26.

12. Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW.

Abnormalities on magnetic resonance imaging seen acutely following

mild traumatic brain injury: correlation w ith neuropsychological tests and

delayed recovery. Neuroradiology. 2004;46(7):550-558,

13. Lawler KA, Terregino CA. Guidelines fo r evaluation and education o f

adult patients w ith mild traumatic brain injuries in an acute care hospital

setting. J Head Trauma Rehab'll. 1996; 11:18-28.

14. Evans RW. Concussion and mild traumatic brain injury. UpToDate.

http://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-

injury. Updated April 29, 2015.

15. Concussion recognition, diagnosis, and acute management. In: Graham

R, Rivara FP, Ford MA, Mason Spicer C, eds. Sports-Related Concussions

in Youth: Improving the Science, Changing the Culture. Washington, DC:

National Academies Press; 2014:99-180.

16. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning fo l­

lowing a concussion. Pediatrics. 2013;132:948-957.

17. Wetjen NM, Pichelmann MA, AtkinsonJL. Second impact syndrome: concus­

sion and second injury brain complications.) Am Coll Surg. 2010;211 (4):553-557.

18. Bazarian JJ, W ong T, Harris M, Leahey N, Mookerjee S, Dombovy M.

Epidemiology and predictors o f post-concussive syndrome after m inor

head injury in an emergency population. Brain Inj. 1999;13(3): 173-189.

19. Annegers JF, Grabow JD, Groover RV, Laws ER Jr; Elveback LR, Kurland LT

Seizures after head trauma: a population study Neurology. 1980;30(7 Pt I ):683-689,

All electronic documents accessed August 4, 2016.

“Looks like another case of someone over forty trying to understand Snapchat.”

28 THE CLIN ICAL ADVISOR • SEPTEMBER 2 0 16 • www.ClinicalAdvisor.com

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30 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions 2.0 CONTACT HOURS

0.5 CONTACT HOURS

30 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 31

ow back pain (LBP) ranks fi fth as the reason pa- tients present for healthcare provider visits in the United States and second as the most common

chief complaint.1 It is prevalent among all age groups, rang- ing from adolescents to older adults.2 The annual healthcare costs and economic losses associated with LBP in the United States exceed $90 to $100 billion.3,4 LBP remains the most common reason for disability among patients under age 45.

The prevalence for continued pain or disability from LBP is 60% to 80% after 1 year.3,4 Patients with a prior his- tory of work absenteeism showed a 40% prevalence for future occurrences.3,4 Therefore, it is imperative for pri- mary care providers (PCPs) to have a clear knowledge re- garding the diagnosis and treatment of a variety of lumbar diagnoses, as patients’ LBP treatments typically begin under their care.

■ Presentation Nonspecific LBP (NSLBP) is typically described as a mechanical type of pain that varies with patients’ physical activity and posture.2 NSLBP is unrelated to a recognizable pathology, osteoporosis, structural deformity, or radicular syndrome.2 It may be related to degenerative changes in the intervertebral disk, facet joints, vertebral endplate sclerosis, or presence of osteophytes and is typically seen among working-age patients.2

Patients with NSLBP experience back pain that is in- creased by changes in position, upon fl exion, and/or with numbness and weakness.4 Pain noted with prolonged sitting is a key factor in differentiating it from lumbar stenosis.5 The association between degenerative disk disease and LBP, based on cross-sectional studies, is signifi cant and typically related to aging and environmental factors.2,4 One study of

L

Evidence-based practice guidelines for the diagnosis and treatment of

lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 31

Abstract: Low back pain remains one of the most common patient complaints.

It can exist alone or with the presence of lower extremity symptoms. Review

of evidence-based guidelines will assist primary care providers in the

identifi cation and treatment of various lumbar disorders in addition to

ruling out specifi c lumbar spinal pathologies.

Keywords: back pain treatments, low back pain, lumbar radiculopathy, lumbar spinal stenosis

By Robert L. Metzger, DNP, APRN, FNP-BC

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

32 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

retrospective chart reviews indicated that the presence of midline LBP, located directly over the spinous processes, was associated with an 84% accuracy for degenerative disk disease as the source of LBP.6

LBP with lower extremity pain exists in approximately 25% to 57% of all lumbar cases.7 Lumbar stenosis is typi- cally acquired through degenerative changes or changes from

pathology or prior surgery and is described as narrowing present in the spinal neuroforaminal spaces, lateral recesses, or central canal, but typically refers to narrowing of the central canal.5,8 Although narrowing of the neuroforaminal canals or central canal is present, there is a poor correlation between the degree of narrowing and symptoms, as some patients remain asymptomatic.9

An important factor to consider when discussing patient symptoms is that the canal space increases in fl exion and decreases in extension and loading; therefore, patients with lumbar stenosis tend to do better with forward fl exion, such as when pushing a grocery cart.8,10 Degenerative lumbar stenosis is uncommon for individuals under age 50, and the diagnosis and severity are largely dependent on the history and physical exam.10

Symptoms of lumbar stenosis include wide base gait, presence or absence of LBP, and neurogenic claudica- tion.5,9-12 Neurogenic claudication is described as radiating pain into the bilateral or unilateral buttock, anterior thigh,

or posterior pain down the leg to the calf and sometimes to the feet that is worsened with standing, walking, or extension and improved with sitting and bending forward.5,9-12 Neu- rogenic claudication can include a sensation of weakness and/or heaviness, paresthesias, fatigue, hamstring tightness, and occasional nocturnal cramps.9 Neurogenic claudication is the most common fi nding for lumbar stenosis and can

severely impact patients’ functionality, affecting their quality of life.12

Lumbar radiculopathy is defi ned as pain radiating from the lower back into the legs, which is the result of disk ma- terial beyond the disk space margins

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