sports concussion update 10 th annual steadman hawkins sports medicine symposium june 7 2013 chae...
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Sports Sports Concussion Concussion
UpdateUpdate1010thth Annual Steadman Hawkins Sports Annual Steadman Hawkins Sports
Medicine SymposiumMedicine SymposiumJune 7 2013June 7 2013
Chae Ko, MDChae Ko, MDSteadman Hawkins Clinic of the CarolinasSteadman Hawkins Clinic of the Carolinas
Primary Care Sports Medicine FellowPrimary Care Sports Medicine Fellow
DefinitionDefinition
““Concussion Concussion is a brain injury is a brain injury and is and is defined as a complex defined as a complex pathophysiological process affecting pathophysiological process affecting the brain, induced by biomechanical the brain, induced by biomechanical forces”forces”
DefinitionDefinition
Concussion may be caused by a direct blow to the Concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body with an head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head“impulsive” force transmitted to the head
Concussion typically results in the rapid onset of Concussion typically results in the rapid onset of short-lived impairment of neurologic function that short-lived impairment of neurologic function that resolves spontaneously. resolves spontaneously. However, in some cases However, in some cases symptoms and signs may evolve over a number of symptoms and signs may evolve over a number of minutes to hours.minutes to hours.
Concussion may result in neuropathological Concussion may result in neuropathological changes but the acute clinical symptoms largely changes but the acute clinical symptoms largely reflect a functional disturbance rather than a reflect a functional disturbance rather than a structural structural injury and as such, no abnormality is injury and as such, no abnormality is seen on standard structural neuroimaging studies.seen on standard structural neuroimaging studies.
• HeadachesHeadaches• DizzinessDizziness• Insomnia Insomnia • FatigueFatigue• Gait Gait • NauseaNausea• Vision Vision • SeizuresSeizures
• Attention Attention difficultiesdifficulties
• ConcentratiConcentrationon
• Memory Memory problemsproblems
• OrientationOrientation
• Irritability• Depression• Anxiety• Sleep Disorders• Emotional Control• Relationships, marriage, school and employment
Sideline EvaluationSideline Evaluation The player should be evaluated The player should be evaluated by a physician or other by a physician or other
licensed healthcare providerlicensed healthcare provider onsite using standard onsite using standard emergency management principles and particular emergency management principles and particular attention should be given to excluding a cervical spine attention should be given to excluding a cervical spine injuryinjury
The appropriate disposition of the player must be The appropriate disposition of the player must be determined by the treating healthcare provider in a determined by the treating healthcare provider in a timely manner. timely manner. If no healthcare provider is available, If no healthcare provider is available, the player should be safely removed from practice or the player should be safely removed from practice or play and urgent referral to a physician is arrangedplay and urgent referral to a physician is arranged
Once the first aid issues are addressed Once the first aid issues are addressed an assessment an assessment of the concussive injury should be made using the of the concussive injury should be made using the SCAT 3 or other sideline assessment toolsSCAT 3 or other sideline assessment tools
The player should not be left alone following the injury The player should not be left alone following the injury and serial monitoring for deterioration is essential over and serial monitoring for deterioration is essential over the initial few hours following injurythe initial few hours following injury
A player with diagnosed concussion should not be A player with diagnosed concussion should not be allowed to return to play on the day of injuryallowed to return to play on the day of injury
Grading / Grading / Classification of Classification of
ConcussionConcussion•Many different guidelines and classification systems in the past
•There has been nearly one new guideline every year for the past 20 years
•As of the 4th International Symposia on Concussion in Sport (Zurich), concussion is no longer graded or classified
Neuropsychological Neuropsychological EvaluationEvaluation
Important in overall assessment and RTPImportant in overall assessment and RTP Should not be sole basis of management Should not be sole basis of management
decisionsdecisions Aid to clinical decision makingAid to clinical decision making
Formal NP testing not required for allFormal NP testing not required for all Best done when asymptomatic but may Best done when asymptomatic but may
be beneficial at other stages in certain be beneficial at other stages in certain situationssituations
Baseline testing is not mandatory Baseline testing is not mandatory
Cognitive Adjust academic
workload and school attendance
Adjust non-academic activities
Leisure reading Video games Texting and
computers
ManagementManagement
Cornerstone Cornerstone initial period of rest until initial period of rest until acute symptoms resolveacute symptoms resolve
80 – 90% resolve in short period80 – 90% resolve in short period 7 – 10 days7 – 10 days
Children and adolescentsChildren and adolescents May take longerMay take longer
Expect gradual resolutionExpect gradual resolution Gradual return to school and social Gradual return to school and social
activities that does not significantly activities that does not significantly exacerbate symptomsexacerbate symptoms
Postconcussive Postconcussive SymptomsSymptoms
Persistent symptoms > 10 daysPersistent symptoms > 10 days 10-15%10-15%
Consider other issuesConsider other issues DepressionDepression AnxietyAnxiety
Should be managed in Should be managed in multidisciplinary mannermultidisciplinary manner
Pharmacotherapy Pharmacotherapy
Child And Adolescent Child And Adolescent AthleteAthlete
Child SCAT3Child SCAT3 Adult recommendation may apply down to Adult recommendation may apply down to
age 13age 13 Modify school attendance and activitiesModify school attendance and activities No return to sport or activity until No return to sport or activity until
successful return to school successful return to school More conservative RTP approach More conservative RTP approach
recommendedrecommended Extend symptom free period before RTP Extend symptom free period before RTP
protocol protocol Consider extended graded exertion steps Consider extended graded exertion steps
Elite AthletesElite Athletes
Managed the same Managed the same regardless of level of regardless of level of
participation participation
PreventionPrevention
Protective equipmentProtective equipment MouthguardsMouthguards
No evidence of concussion reductionNo evidence of concussion reduction HelmetsHelmets
Reduction in biomechanical forces but no Reduction in biomechanical forces but no evidence in reducing concussion incidence evidence in reducing concussion incidence
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Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Heads up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). www.cdc.gov/NCIPC/pub-res/tbi_toolkit/physicians/mtbi/mtbi.pdf. Accessed 2012 September 21.
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McCrory P, Meeuwisse W, Aubry M, Cantu B, Dvorak J, et al. Consensus statement on Concussion in Sport 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med 2013;23:89–117.
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Child SCAT3 DifferencesChild SCAT3 Differences
Child Maddocks questionsChild Maddocks questions Symptom scale Symptom scale
Child specificChild specific 4 point rating scale4 point rating scale
Parent rating of child’s symptomsParent rating of child’s symptoms OrientationOrientation
No time of dayNo time of day Reverse days of the weekReverse days of the week No single leg stanceNo single leg stance
Canadian Head CT RuleCanadian Head CT Rule
Applies to patients with GCS=13-15 following minor head Applies to patients with GCS=13-15 following minor head trauma with witnessed LOC.trauma with witnessed LOC.
Patients with any of the below need a CT:Patients with any of the below need a CT:
1.GCS<15 after 2hrs.
2.Suspected open or depressed skull fracture.
3.Any sign of basilar skull fracture.
4.Two or more episodes of vomiting.
5.Age 65 or older.
New Orleans CriteriaNew Orleans Criteria
Applies to patients with GCS=15 following minor head Applies to patients with GCS=15 following minor head trauma.trauma.
Patients with any of the below need a CT:Patients with any of the below need a CT:
1.Headache
2.Vomiting
3.Age > 60
4.Intoxication
5.Persistent anterograde amnesia
6.Visible trauma above the clavicle
7.Seizure
NEXUS II CriteriaNEXUS II Criteria
““BEAN BASH” CriteriaBEAN BASH” Criteria
Behavioral Abnormality
Emesis (intractable)
Age >65
Neurological Deficit
Bleeding Disorder
Altered Mental Status
Skull Fracture
Hematoma of the Scalp
Age and Age and Developmental LevelDevelopmental Level
Younger athletes take longer Younger athletes take longer to recoverto recover High school versus collegeHigh school versus college High school versus professionalHigh school versus professional
Children undergo more Children undergo more cerebral swelling with more cerebral swelling with more severe mild TBI, which may severe mild TBI, which may account for delayed recovery account for delayed recovery compared to older athletescompared to older athletes
Immature brain is up to 60x Immature brain is up to 60x more sensitive to glutamate more sensitive to glutamate (part of the metabolic cascade (part of the metabolic cascade that follows concussion)that follows concussion) All this may account for SIS All this may account for SIS
only occurring in children.only occurring in children.
Gender DifferencesGender Differences
Females have a higher Females have a higher rate of concussionrate of concussion
Females are Females are cognitively impaired cognitively impaired 1.7x more frequently 1.7x more frequently than malesthan males
Females had Females had significantly more significantly more post-concussive post-concussive symptoms as well as symptoms as well as poorer performance poorer performance on follow-up testing on follow-up testing (ImPACT)(ImPACT)