Practical Advice Regarding Concussions - PowerPoint by gvz34939

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									     Concussions in Sports




          Kevin deWeber, MD, FAAFP
Primary Care Sports Medicine Fellowship Director
         USUHS/Dewitt Army Hospital
                 August 2009
        Zurich Guidelines

 Consensus Statement on Concussion
  in Sport. 3rd International Conference
  on Concussion in Sport Held in Zurich,
  November 2008.
 Clin J Sports Med May 2009;
  19(3):185.
        Concussion - Definition

 Complex pathophysiological process
  affecting the brain
 Induced by traumatic forces
       Direct or Indirect
   Functional Disturbance rather than
    Structural Injury
       No abnormality on standard structural
        neuroimaging
             Pathophysiology

   Neuronal dysfunction
     Ionic shifts
     Altered metabolism
     Impaired connectivity
     Changes in neurotransmission

   Neuropathological Changes
       No evident structural changes
 Classification


Simple
vs
Complex
          Signs and Symptoms
         One or more of the following:
   Symptoms
       Somatic: Headache
       Cognitive: Feeling “In a Fog”
       Emotional: Lability
   Physical Signs
       Loss of Consciousness, Amnesia
   Behavioral Changes
       Irritability
   Cognitive Impairment
       Slowed reaction times
   Sleep Disturbance
       Drowsiness
        What proportion of athletes recognize
           symptoms as being due to a
                    concussion?
1.   1 of 10                1 of 3
2.   1 of 5                 Implication: YOU
3.   1 of 3                  as the physician
4.   1 of 2                  need to be
                             LOOKING for
5.   Practically all
                             athletes w/
                             concussion
    On the Field Management

   If unconscious, assume concomitant
    cervical spine injury until proven
    otherwise

   Don’t rush to get the athlete off the
    field, but also don’t do your entire
    neuro/mental status exam on the
    field either
        After Initial Questioning

   Give the athlete a few minutes to
    “cool off” and regain composure

   Observe the athlete from “afar”- 10-
    30 feet away
       Look for the blank stare, shaking of the
        head, abnormal body language such as
        a slumped and less aggressive posture
        Sideline Management
   Place the athlete in a area where he/she
    can sit, not be bothered by other athletes
    and coaches, and can hear questions
        Sideline Management

 If a concussion is suspected, notify
  the coaches that the athlete is out
  until further notice
 Consider giving the athlete a few
  minutes to regain his composure
  before beginning the barrage of
  questions
 Assess with brief concussion tool
     Maddocks questions
     SAC
     Etc.
 Brief neuro exam
 Symptom score
 Glascow Coma scale
 Maddocks game
  questions
 Short Assmt of
  Concussion (SAC)
 Balance
 Coordination
           Concussion or not?

   YES – if ANY of the following:
       Symptoms
          OR

       Signs (LOC, neuro deficits, cognitive
        deficits)
                  Pearl

   Once a concussion has been
    diagnosed, take and hide the
    athlete’s helmet/headgear to
    prevent him from returning to the
    game
           Q: For a concussion with no loss of
      consciousness and resolution of symptoms in
        less than an hour, when is return to play
                          safe?
1.   Immediately
2.   Second game of double-header
3.   In 24 hours
4.   In 10 days
5.   Determined on case-by-case
     basis
          Return to Play Rules

   Individualized RTP decisions
       no cookie-cutter RTP guides
 NO ONE returns while still
  symptomatic
 Athletes must be asymptomatic both
  at rest, w/ cognition, and w/ exertion
 Must have normal cognitive function
   “There is data...that, at the collegiate
    and HS level, athletes allowed to RTP
    on the same day may demonstrate
    NP deficits post-injury that may not
    be evident on the sidelines and are
    more likely to have delayed onset of
    symptoms.”
       …Zurich guidelines 2009
                       Pearls

   Be wary of the delayed and recurrent
    symptoms

   Many athletes may seemingly “normalize”
    within minutes of an injury, but then have
    a recurrence and potential worsening
    minutes to hours later
       This concept suggests that very rarely should
        an athlete with a suspected concussion return
        to the game on the same day of an injury
              Explaining the Risks of
                 Premature RTP

   2nd impact syndrome
     Death
     Higher risk in young athletes
   Risk of prolonged symptoms
    with a premature return
    and/or a 2nd concussion
    before full recovery
     Staged Return To Play:
     24 hours for each stage
1.   Cognitive and Physical Rest until
     asymptomatic
2.   Light aerobic exercise
3.   Sport-specific aerobic exercise
4.   Noncontact training drills; light
     resistance training
5.   Full-contact training if medically
     cleared
6.   Game play
         Staged Return to Play

 24 hours for each stage
 Progress to next stage ONLY if
  asymptomatic
 If sxs recur w/ exertion:
       Return to the previous stage      OR
       Rest for an additional 1-3 days   OR
       Return to stage 1
    f/u Management Issues

 Comprehensive evaluation
 Imaging?
 Serial assessments until normalized
 Neuropsych testing
 Symptom treatment
 Activity progression
 Return to play determination
              In-Office (or ED)
           Comprehensive Evaluation
   Comprehensive H&P and detailed
    neuro exam by HCP
     Mental status
     Cognitive function
     Gait and balance

   Clinical status determination
       Improvement vs deterioration
   Determine if emergent neuroimaging
    is needed
           Immediate Imaging?

   Computed tomography and MRI rarely
    have a role in the diagnosis of
    uncomplicated concussions
   Consider an immediate CT scan under the
    following conditions:
       Prolonged loss of consciousness (>60 seconds)
       Post-concussive prolonged seizures
       Major neurological deficits, especially motor
        deficits
       Significant lethargy or rapid/progressive
        worsening of symptoms
       “Concussion Modifiers”
    Things that may influence eval, mgmt, and
         may predict prolonged recovery
   Severe symptoms, or duration >10d
   LOC > 1 minute, or amnesia
   Concussive convulsions (other than immediate)
   Repeated concussions, esp close together or
    progressively requiring less force
   < 18 years age
   Co-morbidities: migraine, depression, ADHD, LD,
    sleep disorders
   Psychoactive drugs, anticoagulants
   Dangerous style of play
   Contact/colllision sport, high sporting level
   ?? Female gender
        Implications for
         “+Modifyers”
 Neuropsych testing more important
 Balance assessment more important
 Neuroimaging more important
 Multi-disciplinary management
     Post-Game Management

   Find out the plans of the athlete for the
    evening
       Who can monitor him?
       Suggest strict rest
       Supply the athlete and/or roommate/parents
        with phone numbers for the physician or ATC
       Give copy of SCAT card
   Schedule follow-up with ATC or MD
       Next day for moderate-severe concussions
       1-3 days for mild concussions
    Monitor for cognitive recovery
      with Neuropsych Testing
 One of the cornerstones of concussion
  evaluation
 Tools available
       Sport Concussion Assessment Tool (SCAT2)
         Poor-man’s   method
       Computerized testing--$$ but GOOD
         ImPACT (Immediate Postconcussion Assessment
          and Cognitive Testing)
         Headminder
         CogSport
         ANAM (Automated Neuropsych Assmt Metrics)
Neuropsychological Testing
   OBJECTIVE evaluation of function
   Baseline testing is VERY helpful
       Allows comparison of baseline to post-injury
        tests
       If baseline testing not available, compare to
        age-matched controls and a percentile
        generated
    Neuropsychological Testing
   When to test and how often?
       most useful when the athlete is asymptomatic

       may be useful for the symptomatic STUDENT
        athlete to help plan school & home mgmt
 Neuropsychological tests
 should neither be the primary
 determinant regarding return-
 to-play, nor should they take
 the place of good clinical
 judgment
Concussion Management
         Symptom Treatment

REST!...
    the only known
    effective treatment
    for a concussion

   Encourage frequent
    breaks from studying

   Encourage good
    hydration and regular
    meals to avoid
    dehydration and
    hypoglycemic-related
    headaches
                 Medications
   Tylenol may be used
    to treat headache
    symptoms if there is
    no immediate intent to
    return-to-play

   NSAIDs safety?
   No sedating meds
            Managing Exercise

   1. Rest completely until asymptomatic and
    NP test suggests resolution

   2. light aerobic exercise
       Preferably indoors

   3. sport-specific exercise
       E.g. running, skating, swimming
                  Managing Exercise
                    (continued)

 4. individual sport-
  specific drills
 5. non-contact team
  practice
       (jersey signifying non-
        contact status)
   6. full practice/game
           Managing Exercise:
               Principles
   To advance to the next stage, the athlete
    has to remain asymptomatic

   If symptoms develop, then consider:
       Rest for an additional 1-3 days
       Return to the previous stage
       Return to stage 1

   Consider making each stage 2-3 days if
    returning from a more severe concussion
    or if multiple concussions during that
    season
Special Populations
          Q: Compared to adults, children’s and
      adolescents’ recovery from concussion can be
                      described as…

1.   Slower recovery            Slower recovery
2.   Same rate of recovery
3.   Faster recovery
       High school athletes’
     recovery from concussion
90
80
70
60
50
40                                       % returned
30
20
10
 0
      1 week     2 weeks      3 weeks
      Collins M, et al. Neurosurg 2006
   Pediatric Athletes (<18)

AAPrecommends
“conservative” management
 NO   return to play on same
  day
 Seriously, NO return to play
  on same day
    Student Athlete Management

 COGNITIVE REST
 If sxs recur with
  cognitive activity,
  time off school may
  be needed
 Involve teacher,
  school nurse,
  principal, coact
Student Athlete Management

 Trial and error; no students alike
 Tailor activities to minimize sxs
     Drive to school
     Reduce length of school day
     Rest periods as needed
     Reduce homework
     Longer time for tests; delayed tests
     Minimize background noise &
      excessive light
Elite vs.     Non-Elite Athletes




 Manage using SAME tx and RTP
  paradigm
 Recommend formal baseline NP
  screening in high-risk sports
        In-Game Return-to-Play
          is CONTROVERSIAL
   Only clear an ADULT, PROFESSIONAL
    athlete for return to same game under
    the following conditions:
       Initial presentation was mild (no LOC)
       Symptoms completely resolve within only a few
        minutes (less than 5-10)
       All neurological testing is normal
       Sport-specific drills (running, cutting, kicking,
        catching) reveal normal speed and coordination
        and do not cause any symptoms
       You truly believe the athlete is being honest
        with regards to the reporting of his symptoms
        Return to Play Decisions:
            The tough cases
       Three or more concussions: end the
        season
           At least 3 months before resuming any
            contact sports
       Decreasing levels of trauma
        producing concussion
           End the career


Robert Cantu, expert opinion, Curr Sports Med Rep 2009
          Persistent Cases
           (>2-3 weeks)
 Multidisciplinary approach needed
 Physician
     Control HA’s with meds
     Referrals

 Full neuropsych testing
 Refer for specific treatment of
  identified problems
        The Role of Imaging

   PET scans, SPECT scans and
    functional MRI may be on the
    horizon to assist with concussion
    diagnosis, severity grading and
    return-to-play
                   Conclusion
   Individualize your approach with each athlete
       Concussion management is not “cookie-cutter”
        medicine

   Disqualifying an athlete from competing for
    the remainder of the season is difficult, and
    must be individualized and based on multiple
    factors

   Determine who your concussion experts are
       Who manages the most?
       Many neurologists and neurosurgeons rarely see or
        manage athletes with concussions
Questions?

								
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