Concussion: Evaluation and Management of Sport Injury

Jeffrey L. Tanji, MDAssociate Medical Director, Sports Medicine, UC Davis Health System

Melita Moore, MDHead Team Physician, UC Davis Intercollegiate Athletics

Mindgame

DisclosuresI have no relevant financial relationships to

any products discussed in this talkI do not intend to talk about an

unapproved/investigative use of a commercial product in this presentation

RationaleStandards of care for sport concussion have

changed dramatically over the last two yearsNew state law mandates certain actions in

the management of concussionSport concussion is under-recognized and

under-reportedCommunity education and awareness are

paramount

ObjectivesDefine a sport concussionList the key symptoms and findings of

concussionDemonstrate the key aspects of the history

and physical in the evaluation of concussionDefine the three steps of medical clearance

to begin rehab after concussion

ObjectivesList the four steps of progression between

medical clearance and true return to playDiscuss several controversies in concussion

managementMindgame is a multi-health system

integrated approach to youth concussion care (Kaiser, Dignity Health, Sutter, UC Davis) in the Sacramento Valley

DefinitionMild traumatic brain injury (TBI)Metabolic, functional (not structural) damage

from direct or indirect traumaClassically, attention, vision, balance,

headache, memory are affected but only short term with relatively rapid recovery

Useful data1.5 to 4 million concussions/year in sport80-90% -no- LOC80-90% return to full activity in 1 week

(NCAA data)We seek to avoid second impact syndrome

which is associated with long term issuesYounger and female athletes take longer to

recover, the younger, the slower to return, discussion that high school athletes may need two weeks minimum

Second impact syndromeA second concussion while still symptomaticGenerally within the same seasonMild trauma can have dramatic effect and

long recoveryMajor brain injury in sport concussion is

almost always associated with second impact

Sport and concussionFootballIce hockey*Women’s soccer*Youth soccerField hockey and lacrosseWrestling

Lingering metabolic effects30 days of vascular spasm and decreased

cerebral flowHyperglycemiaK and Ca channels are disruptedGenerally a bleed is not found on MRI or CTThe “neurometabolic cascade” Hovda DA and

Giza CC, Clin Sport Med 2011:30(1):33-48

Neurometabolic cascade

Concussion: signsLOC less than 10-20%HeadacheVisual difficultiesNausea/vomitingBalance issuesMemory loss/confusion

No return to play that dayCalifornia AB 25 (2012) for a suspected

concussion, there will be no return to play that day

Medical clearance by a licensed professional must be given before return to activity

California AB 2127 (Cooley law) Jan 1, 2015: 7 day mandatory no return to play and to follow protocols

Role of advanced imagingExcludes severe bleed, critical structural

damageDoes not clear an athlete to return to playMisconception by family and athlete“I was told my concussion was normal and I

was cleared to play”When they were told that they could go home

and that the imaging study was normal

Follow upNo need to keep waking a person up hourlyTylenol is ok, no ASA or NSAIDsWorsening status -> ED1-2 workday follow up through Mindgame

SacramentoRest and cognitive rest

Concussion: established treatmentCognitive restNo cell phones, no games, no textingNo television, no readingNo physical activitywww.cdc.gov/concussion

Follow up symptomsSymptoms:HeadacheVisual issuesBalanceSleepEmotions (short fuse?)Concentration

Follow up physical findingsOrientation, EOM and pupillary responseFinger -> nose, heel to shin, rapid alternating

movementsHeel to toe walkingRomberg

Physical findings

No Sx and examination WNLNeurocognitive testing (NCT):Ideally a baseline test has been doneIf no baseline, compare with age related

norms, > 20 percentile

Computer based NCT

Three steps to clearanceNo symptomsNormal focused neurological examinationReturn to baseline or appropriate scores on

neurocognitive testingThen work with coach or athletic trainer for

the progressions to full competition

Rehab progressionRun, jog 20 minutes without symptomsWait one daySprint, interval speed work without SxWait one dayReturn to the field with no contactWait one dayReturn to the field with full contact

Variations in progression timingZurich consensus conference 2013: one day

between stagesUniversity of Pittsburgh: two days between

stagesNational Basketball Association: one hour

between stages

Complex casesPersistent symptomsFormal neuropsychological assessment, work

with a vestibular physical therapist? ENG studies (as if for acoustic neuroma)Debate about gentle walkingFormal neurologist, neuropsychologist or

physiatrist evaluation

Vestibular PT

Take Home PointsNo return to play the same dayNeurocognitive testing (NCT) is becoming

the standard of careNo symptoms, normal exam, normal NCT

clears to begin the progressionProgression: aerobic, sprint, on-field no

contact and finally on-field with contact

ED take home pointsThe findings of a normal imaging study do

not clear an athlete to return to playMust keep follow up outpatient visit for

clearance (state law AB25)No symptoms, normal physical exam and a

normal neurocognitive test are neededThen an athlete begins a rehab progression

before clearance to play

ResourcesMcCrory P, Meeuwisse W, Aubry M, et al.

Consensus statement on concussion in sport, Br J of Sports Med 2013; 47:250-258.

www.cdc.gov/concussionwww.sacramentovalleyconcussion.comwww.aroundthecapitol.com/bills/AB25www.aroundthecapitol.com/bills/AB2127www.sacramentovalleyconcussion.com