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Concussion in Sport _July 2006_

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					   Concussion in Sport:
A Primary Care Perspective




              Dr. Mark Lees
       Department of Family Medicine
        University of Saskatchewan
              July 20th, 2006
                 Overview

   Background
   Case #1
   Clinical review
   “On-field” management
   Case #2
   In-office follow-up / management
   Summary & take home messages
     What Exactly is a Concussion?
   Traumatic biomechanical force (direct or
    indirect)
   Complex pathophysiological process
   Acute symptoms a result of functional
    disturbance, not a structural injury
         Concussion: Background

   Neurologic impairment
       Rapid onset
       Short lived
       Spontaneous resolution
   Graded set of clinical syndromes
   Typically associated with grossly normal
    structural neuroimaging studies
        Concussions: Classification
   Simple                    Complex:
       Most common               Persistent symptoms or
        form                       cognitive impairment
       Resolves over 7-          Seizures
        10 days
                                  Prolonged LOC (> 1
       No intervention
                                   minute)
        except complete
        REST and graded           Multiple concussions
        return to play             requiring progressively
                                   less impact
              Concussion Facts
   Occurs every 4 minutes in Canada
   We only see a miniscule fraction of them
   Average age for a first concussion is 10 years
   1/3rd of those graduating from high school
   Most common in young adult males
   RR of 2nd concussion = 4.0
   20% concussions from organized sports
    (remainder from MVA, playground, work)
   80 percent of individuals with a past concussion
    did not recognize it as such
                                  Source: Ontario Brain Injury Web Site
          More Concussion Facts

   Minor league hockey players (ages 9-17)
    in Canada:
       10 % of players per season
       2.8 concussions per 1000 player hours
                      Case #1
   Spectator at 12 y.o niece’s playoff Pee Wee
    hockey game in Tisdale
   Star player caught with her head down and
    checked hard hitting head on the ice
   Get’s up about 5 seconds later, skating away
    from the play and looking a little wobbly
   The coach, who somehow knows you are a
    family medicine resident, calls you over to the
    bench and asks you to have a look at her to
    make sure she is ok to keep playing
What would you like to do now?
                 Assessment: Acute Injury
        ABC’s
        C-spine precautions:
             Canadian C-Spine
              Rule

                   Sensitivity = 100%
                   Specificity = 42.5%




The Canadian C-spine rule for radiography in alert and
stable trauma patients.
JAMA 2001 Oct 17;286(15):1841-8
                    Canadian CT Head Rule
        Any (adult) patient with a mild TBI & any of …
              GCS <15 two hours after injury
              Suspected open or depressed skull fracture
              Any sign of basilar skull fracture
              2+ episodes of emesis                   Excluded from study:
                                                       • Neuro deficit
              65 years of age or older                • Anti-coagulation
              Retrograde amnesia > 30 minutes         • Bleeding disorder
              Dangerous mechanism                     • Hx of Seizure
                   pedestrian struck by motor vehicle
                   occupant ejected from motor vehicle
                                                                                   Sensitivity = 100%
                   Fall from 3 feet or 5 stairs                                    Specificity = 88%

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.
JAMA 2005 Sep 28;294(12):1511-8
Now that you’re happy you’ve ruled
 out the really worrisome stuff …


 How do we best assess her for a
         concussion?
    Assessment: Signs and Symptoms

   Immediate Signs:
        Altered consciousness (LOC, disorientation)
        Impaired attention:
             Vacant stare, delayed responsiveness, inability to focus
        Slurred speech
        Poor co-ordination / balance
        Personality changes (emotionally labile)
        Memory deficits
        Decreased playing ability
        Tonic posturing / convulsive movements
    Concussion: Signs and Symptoms

   Immediate Symptoms:
       Headache
       Dizziness
       Nausea
        Assessment: Acute Injury
                         Sport Concussion Assessment Tool (SCAT)
                                   www.thinksmart.ca

   Cognition:
       Memory:
          What venue are we at?
          What period is it?

          Who scored last?

          Did we win our last game? Who did we play?

          5 word recall (immediate + delayed)

       Concentration
            Months in reverse, digits backwards
        Assessment: Acute Injury

   Neurologic screening:
       Speech
       Eye motion & pupils
       Pronator drift
       Gait
     Management: Acute Injury

   “When in doubt, sit them out”
   No player should be allowed to play if
    symptomatic
     Management: Acute Injury
1.   Player should not be allowed back into current
     game or practice
2.   Player should be monitored and observed for
     several hours post injury
3.   Medical evaluation
4.   Don’t let player drive
5.   Not to be left alone for 24-48 hours
6.   RTP should be a medically supervised process
      Management: ER Transfer?

   Worsening headache
   Development of focal neurologic deficits
   You’re worrying about not already having
    done so
                  Case #2

   16 y.o Tony seen with his mom
   Mom concerned regarding persistent
    headaches over the last 2 weeks after
    hitting his head while skateboarding
   Mom says she is worried that he might
    have “blood on the brain” and wants an
    MRI done (today)
           Case #2 Continued

   Detention last week at school as didn’t
    finish home work – says was too tired to
    get it done as he has had trouble falling
    asleep at night
   Mom states Tony is more moody than
    usual, yelling at his younger sister a lot.
    Tony says she is intentionally trying to
    bother him
           Case # 2 continued

   Tony feels his mom is “stupid and
    overreacting” and wants to go home
   Says he has felt like this several times
    before and it eventually gets better
                        History
   Accident details
       LOC?
       Amnesia?
   Thorough headache history
       Constant occipital pain, not progressive
       Worse during gym class and playing video games
   Concussion history
       Unrecognized?
    Concussion: Signs and Symptoms

   Delayed Signs:
       Dizziness, vertigo
       Persistent headache
       Poor attention and concentration
       Memory dysfunction
       Nausea/vomiting
       Photophobia
       Anxiety or depression
       Sleep disturbances
       Irritability
       So I have a concussion …

   Tony thinks this is really
    cool and wonders if
    maybe he should stay
    home for a week from
    school and recover
   What do you tell him?
        Return to Play Protocol
1.   NO activity – complete physical AND
     cognitive rest
2.   Light aerobic exercise
3.   Sport specific exercise
4.   Non-contact training drills
5.   Full contact training after medical
     clearance
6.   Game play
     Why won’t you let me play?!?

   If playing while symptomatic …
       Greater risk for another injury:
            Another concussion
                 Symptoms more severe and long lasting
                 Second-Impact syndrome (rare)
                 Cumulative neuropsychological impairment? (punch-drunk)
            Other injury
       Longer time to recovery
       So I have a concussion …

   Mom doesn’t think this is
    very cool at all and starts
    lecturing Tony about not
    wearing a helmet
   What do you tell them?
              In Office Management
   Concussion history
   Prevention
       Protective equipment
            No clinical evidence
            Risk compensation?
            Throw bike helmets out after impact
       Promotion of fair play
   Education (signs, symptoms, risks)
       Coaches, parents, kids
       www.thinkfirst.ca
   Supervised return to play
   Baseline / pre-participation cognitive assessment
    Neuropsychological Assessment

   Useful in complex concussions
   Cognitive recovery may precede or follow
    clinical symptom resolution
   Can be used as a part of RTP decision
    making
   Should be performed only after
    asymptomatic
   Web based computerized testing available
    ImPACT Computerized Testing
   Neurocognitive test instrument:
       attention, memory, processing speed, and reaction time
   Takes 20 minutes to complete
   Computer or web based
   Costs:
       High school $500 / year
       University $600 / year
       Teams & clubs $700 / year
       Clinics $600 for 10 baseline tests and 15 post injury tests
   Used in Canada by OHL, York University, UNB, U of
    Waterloo, SFU, Laurentian
The Easy to Remember Take Home
           Message(s)

   Concussions are common and often
    unrecognized by the patient
   “When in doubt, sit them out”
   No player should be allowed to play if
    symptomatic

				
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