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CONCUSSION UPDATE ZURICH 2008.ppt

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					    CONCUSSION
   MANAGEMENT:

          ImPACT

    David R. Wiercisiewski, MD
Director, Carolina Sports Concussion
          Program at CNSA
          STATISTICS

Incidence in HS football = 6%-8% per year.
Boy’s + Girl’s soccer = football.
Girl’s basketball 250% greater risk than Boy’s
Sports and recreational injuries with LOC =
    300,000 per year.
Sports and recreational injuries with and without
LOC = 1.6 million per year.
              DEFINITION


Complex pathophysiologic
  process affecting the
  brain, induced by
  traumatic biomechanical
  forces.
   COMMON FEATURES

Caused by a direct or indirect blow to the head,
face or neck.
Results in rapid onset of short-lived
impairment of neurological function.
A concussion may or may not involve LOC.
The clinical symptoms reflect a functional
rather than a structural disturbance.
     PATHOPHYSIOLOGY
Mechanism of Injury
  Rotational
  Linear
  Impact deceleration
Chemical/Vascular
  1st 7-10 days
  ↑K / ↑Ca / ↑glc / ↑glut
  ↓CBF
  “Period of vulnerability”
        CONCUSSION
       CLASSIFICATION


Recommendation to abandon the “simple”
   versus “complex” nomenclature with no
   endorsement of any other specific
   classification system.
 PRIMARY AREAS OF FOCUS


Rule out more serious intracranial pathology
Prevent Second Impact Syndrome
Prevent repeat injury during post-concussion
period of “vulnerability”.
Prevent against cumulative effects of injury
    Neurobehavioral deficits
    Lowered threshold to injury
             GENERAL
           MANAGEMENT

Majority of injuries will recover spontaneously.
Physical and cognitive rest are required while
symptomatic.
When symptom free and improved “functionally”
graduated return to play protocol should be utilized.
Same day return to play—NEVER!!!
CONCUSSION
EVALUATION
     PLAN—PLAN—PLAN

Agree on an approach to the management of
concussions with other health care providers on the
team.
Baseline cognitive testing if available.
Use a standardized PCS symptom scale
    (i.e. SCAT2)
Perform serial assessments
Identify your referral patterns ahead of time
          CONCUSSION
          RECOGNITION

Symptoms—somatic (headache), cognitive
(feeling like in a fog) and emotional (lability).
Physical signs—LOC and amnesia.
Behavioral changes—irritability.
Cognitive impairment—slowed reaction times.
Sleep disturbance—drowsiness.
           EVALUATION
Neurological assessment
    Motor
    Pupillary response
    Coordination/postural control


Mental status testing
    Attention
    Memory
    Processing speed
MENTAL STATUS TESTING

Be familiar with the different screening tools
and their requirements.

Use tools that have been validated and
published in peer-reviewed literature.

Results should be interpreted and integrated
into the other relevant clinical information.
  NEUROCOGNITIVE
COMPUTERIZED TESTING

           ImPACT (UPMC)

           CogSport (Australia)

           CRI (Headminder)

           ANAM (NRH)
COMPUTERIZED TESTING

Format allows portability and efficiency.
Each vendor has their unique menu of
cognitive domains that their product measures.
20 – 30 minutes to administer.
Used as a “tool” to measure recovery and not
to make a diagnosis or solely direct
management.
        FEATURES OF
      COGNITIVE TESTING

                        Limitations:
Must assess pertinent        “Normal” range
                             Sensitivity
domains.
                             Specificity
                             Learning effects
Baseline testing             Early return to baseline
                             while still symptomatic
improves evaluation.         Without baseline testing it
                             can be more difficult to
                             interpret
    CAROLINA SPORTS
  CONCUSSION PROGRAM

First sports concussion program in the greater Charlotte area.
Began in February 2007.
First year provided post-injury care only.
Subsequent years we have provided free baseline tests to
middle and high school athletes participating in “high risk”
sports through monies donated by SunTrust Bank.
Baseline testing program currently offered in 5 counties.
Utilize the ImPACT neurocognitive testing tool.
    IMMEDIATE POST-
CONCUSSION ASSESSMENT and
COGNITIVE TESTING (ImPACT)

8 separate tests          6 composite scores
     Word memory               Verbal memory
     Design memory             Visual memory
     X’s and O’s               Visual motor speed
     Symbol Match              Reaction time
     Color Match               Impulsivity
     Three Letters             Total symptom score
     Interference tests
CONCUSSION SYMPTOM SCALE
Standardized survey
with 0-6 scale rating
Developed by Lovell
and Collins in 1998
Sensitive tool to
measure recovery
Symptoms generally
classified into 3 main
categories: Physical,
Cognitive, and
Emotional/Behavioral
  OVERVIEW OF ImPACT

Proven in measures of reliability and validity
Provides useful concussion screening and
management information
Validated with multiple peer-reviewed studies
Does not substitute for medical evaluation and
treatment
Does not substitute for comprehensive
neuropsychological testing
PREDICTING RECOVERY
     TIMELINES

   ALL ATHLETES ARE NOT
     CREATED EQUALLY
         CONCUSSION
          MODIFIERS

Symptoms—Number, duration (>10 days) and
            severity.
Signs—Prolonged LOC (>1 min.), amnesia.
Sequelae—Concussive convulsions.
Temporal—Frequency (number of
            concussions),
          Timing/”recency”
           CONCUSSION
            MODIFIERS
Threshold—Repeated concussions occurring with
less force or slower recovery.
Age—Child and adolescent < 18 years old.
Co-morbidities—Migraine, depression or other
    mental health disorders, ADHD, learning
    disabilities and sleep disorders.
Medication—Psychoactive drugs and
    anticoagulants.
Behavior—Style of play.
Sport—Contact or collision sport, high-risk.
  SPECIAL
POPULATIONS
CHILD AND ADOLESCENT
      ATHLETES

Clinical evaluation should include academic
performance and behavior in school.
Neurocognitive testing may be performed earlier to
aid in academic accommodations during recovery.
Return to exertion or game play should be slower
when compared to the adult athlete. Also there
should be particular focus on “cognitive rest”.
Never return to play on same day!
     ELITE vs. NON-ELITE
         ATHLETES
Both groups should
follow the same
treatment and return to
play paradigm
Neurocognitive testing
is preferred but
providing for non-elite
athletes may be
restricted by financial
resources
CASE STUDIES
       RETURN TO PLAY
         PROTOCOL

No activity while symptomatic.
Light aerobic exercise.
Sport-specific exercise—no head impact drills.
Non-contact training drills.
Full contact practice.
Return to game play.
NFL CONCUSSION
  GUIDELINES
        Established in 2009.
        No same day return to
        practice or game play.
        Players encouraged to
        be honest and report
        symptoms.
        Independent neurology
        opinion for each injury.
CHRONIC TRAUMATIC
 ENCEPHALOPATHY
   CHRONIC TRAUMATIC
     ENCEPHALOPTHY
NFL Survey—
  > 50 = 5x risk
  30-49 = 19x risk
Comparative data from
the Framingham heart
study.
Concept of
subconcussive trauma.
Sports Legacy Institute.
    CTE
TAU PROTEIN
      Protein that invades
      cortical nerve cells and
      shuts them down
      effectively killing them.
      Unlike Alzheimer’s
      disease and the
      neurofibrillary tangles
      associated with that
      disease, the build up of
      tau is related to trauma
      or injury.
        DISQUALIFICATION
           LONG TERM
3 fold risk to have
concussion if have 3
concussions in previous
7 years
2 or more concussions
have longer recovery
times
3 or more concussions:
     8 fold risk of LOC
     5.5 fold risk of PTA
     5.1 risk of confusion
  INJURY PREVENTION

Protective Equipment—Mouthguards and
helmets.
Rule changes.
Risk Compensation—use of protective
equipment results in a behavioral change and
may subsequently result in a paradoxical
increase in injury rates.
Aggression versus violence in sports.
      FUTURE DIRECTIONS
   Gender effects on injury, severity and outcome.
   Pediatric injury and management paradigms.
   Validation of SCAT2 as a sideline assessment tool.
   Concussion surveillance using consistent definitions
    and outcome measures.
   Long-term outcomes.
   Formal review of “concussion in sport” guidelines
    and update prior to December 1, 2012 by panel of
    international experts.
PROTECTING THE “3 LB. UNIVERSE”
  OBSERVATIONS FROM CLINIC

Moving the mountain.
   Improved awareness and increase in concussion recognition.
   Gap in club sports.
Dealing with the devil.
   The sickness of our sports culture.
Creating a road map.
   Defining expectations of recovery based on the individual’s unique
   medical history and mechanism of injury.
Kids are real people too!
   Emotional response to the injury.
My “uneasy” chair.
   How many is too many?
THANK YOU

				
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