Concussions at a Glance

Kristian Goulet, MDPediatric Sports Medicine and Concussion Specialist

A Little About Men Son of a Hockey Coachn Played Junior B/A in Ottawa Arean Recruited to play University Hockeyn Realized I wasn’t smart enough to succeed at

both school and sport-so one had to goboth school and sport-so one had to gon Pediatric Residency in New Mexicon Sports Medicine Fellowship at Harvard U

n I was the head team doctor for Northeastern Men’s Varsity Hockey Team

n Worked with, New Mexico Scorpions (CHL) and many high school programs in the States.

n I have given talks at the local, state and national levellevel

n 1 of 5 Pediatric Sports Medicine Physicians in the Country

n 1 of only 6 doctors in Canada Certified to interpret IMPACT Tests

n Research interests in Concussion Prevention

Objectives

n To briefly define what a concussion isn To explain the underlying

Pathophysiology/Biomechanicsn To describe the epidemiologyn To describe the epidemiologyn To outline symptomsn Current management issues (CTE)n Prevention (If we have time)n My Sports Medicine Clinic

DEFINITIONSn Concussion is defined as

“a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”

n It is typically defined as “mild” by a Glasgow Coma Scale (GCS) score of 13-15 (at 30 mins)

McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Stateent on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich November 2008. Br J Sports Med. 2009 May;43 Suppl 1:i76-90.

Common Themes Of Concussions1. Typically results in the rapid onset of short-lived impairment of

neurologic function that resolves spontaneously. n Indeed 90% of athletes are symptom-free within 10 days.

2. Largely reflect a functional disturbance rather than a structural injury.

3. Results in a set of clinical symptoms +/- LOC. Resolution typically 3. Results in a set of clinical symptoms +/- LOC. Resolution typically follows a sequential course; however symptoms may be prolonged. (McCrory et al 2009).

McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Stateent on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich November 2008. Br J Sports Med. 2009 May;43 Suppl 1:i76-90.

4. Occurs with head injury due to contact and/or acceleration/deceleration forces.

5. May be caused either by a direct blow to the head, face, neck or elsewhere on the the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.

BIOMECHANICAL

Rotational vs Linear Acceleration

n Rihn JA, Anderson DT, Lamb K, et al. Cervical spine injuries in American football. Sports Med 2009;39(9):697–708.

n Broglio SP, Schnebel B, Sosnoff JJ, et al. The biomechanical properties of concussions in high school football. Med Sci Sports Exerc 2010;14(1):13–7.

Pathophysiology

n General Overview First

Symptoms attributed to

n A combination of cellular ionic disturbances,decreased CBF, AA abnormalities, and glucose metabolic dysfunction

n CAUSING AXONAL DAMAGEn CAUSING AXONAL DAMAGE

EPIDEMIOLOGY

n It has been estimated that 1.6 million to 3.8 million of concussions occur annually as a direct result of participation in athletics

n An accurate number is difficult to estimateq surveys in the ER have found that more than 80% of

individuals cant recognize the symptoms of a concussion** individuals cant recognize the symptoms of a concussion**

n *Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006;21(5): 375–8.

n ** Delaney JS; Abuzeyad F; Correa JA; Foxford R Recognition and characteristics of concussions in the emergency department population. AUDelaney JS; Abuzeyad F; Correa JA; Foxford R SOJ Emerg Med 2005 Aug;29(2):189-97

n Delaney, SJ, Lacroix, VJ, Leclerc, S, et al. Concussions during the 1997 Canadian football league season. Clin J Sports Med 2000; 54:1488.

n Bernstein DM 1999. Recovery from mild head injury. Brain Inj 1999 Mar;13(3):151-72

Sport Impact ClassificationHigh-contact Sports

● Ice Hockey● Football● Soccer● Martial Arts● Rugby

Noncontact Sports● Running●Swimming● Tennis● Weight Training

Medium-contact Sports● Basketball ● Baseball● Cheerleading● Skiing● Volleyball

Just to give you an idea

n A postseason retrospective survey of 233 high school football players found 47.2% of players reported having at least 1 concussion. q Multiple concussions were noted in 34.9%Multiple concussions were noted in 34.9%

nLangburt W, Cohen B, Akhthar N, et al. Incidence of concussion in high school football players of Ohio and Pennsylvania. J Child Neurol 2001;16(2):83–5.

Signs and Symptoms

n Symptoms of sport-related concussion can be grouped into 4 general categories:

1. Sleep disturbance2. Somatic (headache)3. Emotional4. Cognitive

Reddy CC. A treatment paradigm for sports concussion. Brain Injury Professional 2004;4:24–5.

Signs and Symptomsn The hallmarks of concussion are confusion and

amnesia, often without preceding LOC*

n In fact the majority of concussions in sports occur without LOC (80%) and are often unrecognized**

n Symptoms may not be apparent until hours later

* Report of the Quality Standards Subcommittee. Practice parameter: the management of concussion in sports (summary statement). Neurology 1997; 48:581.

** Collins MW; Grindel SH; Lovell MR; Dede DE; Moser DJ; Phalin BR; Nogle S; Wasik M; Cordry D; Daugherty KM; Sears SF; Nicolette G; Indelicato P; McKeag DB Relationship between concussion and neuropsychological performance in college football players. JAMA 1999 Sep 8;282(10):964-70

Signs

n Amnesia, retrograde or antegraden Disorientation n Appearing dazedn Acting confusedn Forgetting game rules or play

assignmentsInability to recall score or

n Headachen Dizzinessn Nausea or vomitingn Difficulty balancingn Vision changesn Photophobia

Phonophobian Inability to recall score or opponent

n Inappropriate emotionalityn Physical incoordinationn Imbalancen Seizuren Slow verbal responsesn Personality changes

n Phonophobian Feeling “out of it”n Difficulty concentrating n Tinnitus n Drowsinessn Sadnessn Hallucinationsn None initially

n WHY DOES ALL THIS MATTER?

n Concussionn Post Traumatic Headachen Subdural hematoman Epidural hematoma

Differential Diagnosis for an Differential Diagnosis for an Acute Head InjuryAcute Head Injury

n Epidural hematoman Intraparenchymal hemorrhagen Second impact syndromen Cervical spine injuryn Seizure/epilepsy

Repeat Insult

n A repeated head injury can result in a prolonged period of PCS and have more deleterious consequences (SIS).

Second Impact Syndrome

n Saunders and Harbaugh 1984

n “Rapid and progressive brain injury resulting from a second episode of closed-resulting from a second episode of closed-head injury while the athlete still is symptomatic from the first episode.”

Saunders, RL, Harbaugh, RE. The second impact in catastrophic contact-sports head trauma. JAMA 1984; 252:538. Collins MW; Lovell MR; Mckeag DB. Current issues in managing sports-related concussion. JAMA 1999 Dec 22-29;282(24):2283-

5.Cantu, RC, Voy, R. Second impact syndrome: a risk in any sport. Physician Sports Med 1995; 23:27

SISn The result is rapid mental deterioration,

mental status change, and often fatal uncal herniation.

n SIS is associated with a mortality rate of 70%-80%70%-80%

n Completely preventable through the prompt recognition of concussive and PCS

n Signifies the need for close monitoring

Long Term Effects

n Approximately 225,000 new patients each year show long-term deficits from mild TBI, q approximately = to the # of patients diagnosed

annually with breast cancer, multiple sclerosis, and traumatic spinal cord injury combined

n Meaney,DF and D.H Smith, Biomechanics of Concussion. Clin Sports Med 30 (2011) 19–31

Potential Long Term Effects:

1) Alzheimer’s 2) Learning disability3) Decreased attention4) ALS5) Parkinson’s6) Dementia6) Dementia7) Second impact syndrome8) More severe concussions in the future9) Personality change10) CTE11) Depression12) Persistence of any acute symptom

n Frequent, diffuse, extracellular amyloid plaques.

n Sparse intraneural neurofibrillary tangles.n Seen in Alzheimer’s Disease, but in a very

Chronic Traumatic Encephalopathy

n Seen in Alzheimer’s Disease, but in a very distinct distribution (antorhinal cortex/hippocampus).

n Omalu, Neurosurgery 2005, “The NFT distribution is notably different from that observed in normal aging and AD.”

Andre WatersTerry LongTerry Long

Mike Webster

Chris Benoit

Chronic Traumatic Encephalopathy

n Mike Webster: 3y HS, 4y college, NFL 17y, offensive line

n Known to have sustained multiple concussions

n After retirement: Dysthmic d/o, memory deficits, couldn’t keep appointments, deficits, couldn’t keep appointments, Parkinsonian sx, dementia.

n Described by relatives as glassy eyed, go days without eating.

n Died of MI, age 50yo.n Brain sent for autopsy.

Chronic Traumatic Encephalopathyn Terry Long, 14y total football.n Known to have sustained multiple concussions.n Retired: Became quiet, fearful, paranoid, lock

himself indoors for days, multiple suicide attempts.n 45yo, suicide with ethylene glycol.n Autopsy: Neurofibrillary tangles, similar distribution. n Autopsy: Neurofibrillary tangles, similar distribution. n Andre Waters, 44yo, suicide by gunshot to the head.n Chris Benoit, 40yo, strangled wife, 7yo son, hung

himself in the basement.

Boston U’S CTE Program

Ø Sports Legacy InstituteØ Created by Dr Robert Cantu and Chris

Nowintzky (ex Harvard football player and WWF wrester)

Ø Involved in Concussion Research, Education Ø Involved in Concussion Research, Education and Advocacy

Ø Home of the Brain BankØ I am the clinical supervisor of their

concussion education program called S.L.I.C.E

n Case Studiesq Lou Creekmurq Mike Borichq John Grimsleyq John Grimsleyq Tom McHaleq 18 Year-Old

Management

n In their review of Primary Care Physicians Notebaert and Guskiewicz (2005) found that many clinicians don’t have a comprehensive concussion assessment plan.concussion assessment plan.

Notebaert AJ, Guskiewicz KM. Current trends in athletic training practice forconcussion assessment and management. J Athl Train 2005;40:320–5.

n Now in many States, legislation dictates that any child with a concussion cannot return to sports until he is cleared by

n A physiciann A health trained professionaln A health trained professional trained in

concussions

Assessmentn Traditionally assessment has been based on

q +/- LOCq Return to activity based on the grade of concussion.

n More recent thinking emphasizes: q No longer “concussion grades”q No longer “concussion grades”q stresses physical and cognitive rest; q and recommends a sequential, functional progression as

symptoms clear and do not return with exertion, with careful monitoring by a physician.

1. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 1997; 48:581.

Important considerations in the management of MTBI include

1. Identification of immediate neurologic emergencies 2. Identification of high-risk individuals for SIS3. Recognition and management of neurologic

sequelae sequelae 4. Prevention of cumulative and chronic brain injury

Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 1997; 48:581.

On the Sidelinen Westmead post-traumatic amnesia scale

(WPTAS) n Simple to perform, taking less than 1 min in

the acute setting, and correlates with the findings in more detailed neuropsychologic findings in more detailed neuropsychologic testing.

n Shores EA; Lammel A; Hullick C; Sheedy J; Flynn M; Levick W; Batchelor J. The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early identification of cognitive impairment in patients with mild traumatic brain injury. J Neurol Neurosurg Psychiatry. 2008 Oct;79(10):1100-6. Epub 2008 Jan 25.

n Ponsford J; Willmott C; Rothwell A; Kelly AM; Nelms R; Ng KT. Use of the Westmead PTA scale to monitor recovery of memory after mild head injury. Brain Inj. 2004 Jun;18(6):603-14

WPTASn The questions include:

1. What is your name? 2. What is the name of this place? 3. Why are you here? 4. What month are we in? 5. What year are we in? 6. In what town/suburb are you in? 6. In what town/suburb are you in? 7. How old are you? 8. What is your date of birth? 9. What time of day is it? (morning, afternoon, evening) 10. Three pictures are presented for subsequent recall

n Any incorrect response is considered a positive test for cognitive impairment after head injury.

Maddocks questionsn The Maddocks questions

q scientifically validated (any incorrect response indicates concussion)q Quick, simple and practical

n Which field are we at? n Which team are we playing today? n Who is your opponent at present? n Which half/period is it? n How far into the half is it? n How far into the half is it? n Which side scored the last touchdown/goal/point? n Which team did we play last week? n Did we win last week?

Standardized Assessment of Concussion (SAC),n Can be employed for sideline evaluation (5-

10 minutes).n Based on a scored scale testing:

q orientation, immediate memory, concentration, and delayed item recall. and delayed item recall.

n These different parameters are tabulated, providing a score that grossly assesses an athlete’s ability to return to competition.

n Can be ordered through a medical bookstore or Internet.

Several Other Instruments are available:

1. Sport Concussion Assessment Tool (SCAT) q medical evaluation and a checklist for the

athleteAlso provides information about concussions q Also provides information about concussions

SCAT 2

SCAT 2

n The SCAT and SAC are good tests of cognitive functioning, they have a “ceiling effect.” q Meaning that a patient could do well on these q Meaning that a patient could do well on these

tests without having recovered fully.

n For this reason, a number of computerized tests are available (discussed later)

Other Warning Signs

n The following warning signs should prompt the caregiver to seek immediate medical help:q Inability to awaken the patient q Severe or worsening headaches q Somnolence or confusion q Restlessness, unsteadiness, or seizures q Restlessness, unsteadiness, or seizures q Difficulties with vision q Vomiting, fever, or stiff neck q Urinary or bowel incontinence q Weakness or numbness involving any part of the body

n Observation is recommended for at least 24 hours after a MTBI because of the risk of intracranial complications.

Commission on Clinical Policies and Research, American Academy of Family Physicians The management of minor closed head injury in children. Committee on Quality Improvement, American Academy of Pediatrics.. SOPediatrics 1999 Dec;104(6):1407-15.

Lawler, KA, Terregino, CA. Guidelines for evaluation and education of adult patients with mild traumatic brain injuries in an acute care hospital setting. J Head Trauma Rehabil 1996; 11:18.

Recovery

n Between 80-90% of kids get better within 10-14 days.

n I wouldn’t see these kids ( 3 week- 1 yr)n Issues arise with preexisting conditions, n Issues arise with preexisting conditions,

conversion disorders etc

Factors Influencing Recovery

n Age n Gender n History of prior concussion

Cognitive reserven Cognitive reserven Pre-existing Medical Conditions

NEUROPSYCHOLOGICAL TESTINGn And what I call the IMPACT EPIDEMIC

Why do we need baseline neurocognitive assessments in sports?

n “Nobody in football should be called a n “Nobody in football should be called a genius. A genius is a guy like

Norman Einstein.”

-- Football commentator and former player, Joe Theisman

**or just look at twitter comments during NFL lockout

NEUROPSYC TESTING

n The use of neuropsyc testing provides an objective data

n But how good is that data? Depends who you ask….ask….

n They measure domains, such as attention, working memory, visual motor speed, reaction time

n Examples include ImPACT, CogSport, Headminder and ANAM (Military)

n Neurocognitive assessment was implemented in the NFL 1993, NHL 1996 and MLB in 2004

Psychometric Properties and Utility of Neuropsychological Testingn Pen and Paper

q Vs

n Computerize

Downside to CPU Testing

n Examiner typically cannot directly observe the athlete taking the test.

n Computer-based tests sample from selective neuropsychological domains rather than a global assessment of cognitive function.assessment of cognitive function.

n 30% Sandbagn Group testing?n Repeat Baselinesn How accurate/reproducible/representative?

n Concussion in Sport (CIS) group at the International Symposia on Concussion in Sport-2004, 2006, 2008q The application of neuropsychological (NP) testing

in concussion has been shown to be of clinical in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation

q should be an important component in any return to play protocol

q McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008. Br J Sports Med 2009;43(Suppl 1):i76–90.

n “It must be emphasized, however, that NP assessment should not be the sole basis of management decisions; rather, it should be seen as an aid to the clinical decision-making seen as an aid to the clinical decision-making process in conjunction with a range of clinical domains and investigational results.”

q McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008. Br J Sports Med 2009;43(Suppl 1):i76–90.

Personal Bias

n Overusedn Misused-should never be given while a

patient is symptomaticn Must determine if it is a valid testn Must determine if it is a valid testn Sensitivity issues and reproducibilityn See Work by Randolph

n ONLY THOSE HEALTH PROFESSIONALS TRAINED IN NEUROCOGNITIVE TESTING SHOULD IMPLEMENT AND INTERPRET THIS TESTTHIS TEST

n IT CAN BE DANGEROUS TO USE THIS TEST OTHERWISE!!!

n If things aren’t going as planned then what?

NeuroimagingNeuroimagingn Neuroimaging is usually normal in patients with a concussion or MTBIn However there is a defined incidence of abnormalities, which may be clinically important

Computed Tomography

n CT imaging can be completed in seconds and is still the modality of choice in emergency departments within the first 48 hourshoursq Good for Skull Fractures and ICH

n Equal to 300 xraysBorg J; Holm L; Cassidy JD; Peloso PM; Carroll LJ; von Holst H; Ericson K Diagnostic

procedures in mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004 Feb;(43 Suppl):61-75

MRIn Compared with CT scanning, MRI is more sensitive in

showing small areas of contusion or petechial hemorrhage, axonal injury, and small extra-axial hematomas

n Now becoming modality of choice but generally reserved for follow up care.

Umile, EM, Sandel,ME, Alavi, A, et al. Dynamic imaging in mild traumatic brain injury: support for the theory of medial temporal vulnerability. Arch Phys Med Rehabil 2002; 83:1506.

Chen, SH, Kareken, DA, Fastenau, PS, et al. A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography. J Neurol Neurosurg Psychiatry 2003; 74:326.

Kelly, JP, Rosenberg, JH. Diagnosis and management of concussion in sports. Neurology 1997; 48:575.

n Traditional MRI sequences have been designed to look at macroscopic structural damage.

n Newer sequences have been developed to detect both structural and functional abnormalities These include susceptibility-weighted imaging n These include susceptibility-weighted imaging arterial spin labeling, diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI), functional MRI (fMRI), magnetic resonance spectroscopy (MRS), magnetoencephalography (MEG), and PET Scans.

Treatment

n Emerging Mentodsn While in Boston we were using the most

cutting edge treatment modalities to get the athletes back to sport as safely and quickly athletes back to sport as safely and quickly as possible.

General Principles

n Hydrate, glucose control, and sleep hygienen Limit cognitive and physical stress

Treating The Difficult Concussion

n This is basically all I saw while in Bostonn Athletes from all over the countryn We specific medications for sleep,

depression, cognitive difficulties (this is an depression, cognitive difficulties (this is an 1hr talk in of itself)

n Melatonin, amytryptilline, trazadone, methylphenidate, amantidine, SSRI (steroids?)

n Other mediciations include doenpezil, rivastigmine, cytidine diphosphoryl choline,, sertraline, pramiracetam bromocriptine, and atomoxetine.atomoxetine.

Medical TherapiesMeehan 2011 :

1. The athlete’s symptoms have exceeded the typical recovery period for a sport related concussion.

2. The symptoms are negatively affecting the patient’s life to such a degree that the possible benefit of treatment outweighs the potential risks of the treatment outweighs the potential risks of the medication being considered.

3. The clinician caring for the athlete is knowledgeable and experienced in the assessment and management of sport-related concussion or concussive brain injury in general.

Meehan, WP III. Medical Therapies for Concussion Clin Sports Med 30 (2011) 115–124

Concussion and RTP

n JAMA 2003 Guskiewicz et al q 75% of same-season repeat concussion occurred

<7 days from the first; 92% < 10 days

n A seven-day waiting period would likely result n A seven-day waiting period would likely result in resolution of symptoms and normalized cognitive function

n A seven-day waiting period may prevent a majority of repeat concussions

n IT IS FAR FROM THAT SIMPLE AND THAT APPROACH IS NO LONGER RECOMMENDED!

n Any return to play regimen must be individualized to each athlete

n Progress should be monitored by clinicians n Progress should be monitored by clinicians who have the appropriate level of training.

n Return to play is allowed only when the player’s signs and symptoms have resolved and when he or she has demonstrated the ability to progress stepwise through several ability to progress stepwise through several levels of activity without any recurring symptoms.

n Many guidelines have been put forth…

n Activity should move through the following steps, with advancement only if there are no symptoms.

n If symptoms recur, the athlete should rest for 24 to 48 hours and try to progress again, dropping back if symptoms recur.

Step

Level of activity

1 No activity, complete rest. Once asymptomatic, proceed to level 2.

2 Light aerobic exercise such as walking or stationary cycling, no resistance training.

3 Sport specific exercise - for example, skating 3 Sport specific exercise - for example, skating in hockey, running in soccer; progressive addition of resistance training at steps 3 or 4.

4 Non-contact training drills.

5 Full contact training after medical clearance.

6 Game play.

Preventionn Athletes who have had one concussive episode

are nearly six times more likely to have a second episode.q Therefore, effective preseason counseling is

essentialIt is important to stress the importance to n It is important to stress the importance to athletes of reporting PCS

n Prevention involves the creation of an increased awareness in coaches and athletic trainers.

n Johnston, KM, McCrory, P, Mohtadi, NG, Meeuwisse, W. Evidence-Based review of sport-related concussion: clinical science. Clin J Sport Med 2001; 11:150.

n The simplest of these preventative measures seem to be rule changes, rule enforcement, and player and coach education.

n Cantu RC, Mueller FO. The prevention of catastrophic head and spine injuries in high school and college sports. Br J Sports Med 2009;43(13):981–6.

n In their review Daneshvar et al 2011 recommend q Preparticipation examinations should be mandatory. q Concussion education should be afforded to all athletes, q Proper strength and conditioning, especially focused on

strengthening the muscles of the neck, is a suitable way to strengthening the muscles of the neck, is a suitable way to limit the forces experienced by the head.

q Properly trained coaches, athletic trainers, and medical staff

q Quality officiating can help to identify potentially dangerous situations and ensure the activity does not result in injury

Daneshvar DH, Nowinski,CJ, McKee, AC and RC. Cantu, The Epidemiology of Sport-Related Concussion. Clin Sports Med 30 (2011) 1–17

Other Pertinent Issues

n Preseason trainingn Helmets?n Facial protection?

Mouth guards?n Mouth guards?n Playing surfacen How much force is needed?n Is there a “concussion threshold?”

n In their extensive historic review of ice hockey Biasca et al 2002 found that with the introduction of ice hockey helmet have resulted in a decrease in fatal and resulted in a decrease in fatal and catastrophic head injuries but with an actual increase in the concussion rate

n But What Does That Mean?

Biasca N, Wirth S, Tegner Y. The avoidability of head and neck injuries in icehockey: an historical review. Br J Sports Med 2002;36(6):410–27.

n Strengthening neck and back muscles are the only interventions shown to consistently decrease concussions

Ways to protect yourself from obtaining a concussion:

n Be a good skater-strong balance and agilityn Keep your head up while stickhandlingn Be aware and alert-know where you and the other

players areAlways approach the boards on an anglen Always approach the boards on an angle

n Protect yourself with yoru arms when going into the boards

n Know the danger zone-3-4 feet away from the boards

n Get physically strong especially neck musclen +/- mouthgaurd?

Ways to avoid causing injuries in others:

n Never hit from behindn Never hit to the headn Be responsible with your stickn No suicide passesn Communicate on the icen Respect your opponent

Typical Approach in my SM Office

n For more information on my approach in the Eastern Ontario Concussion Clinic please contact me at kristiangouletmd@gmail.com

n We do offer IMPACT Testing-both baseline testing and post injury tests.

n Lovell MR. Evaluation of the professional athlete. In: Bailes JE, Lovell MR, Maroon JC, editors. Sports-related concussion. St Louis (MO): Quality Medical Publishing; 1999. p. 200–14.

n To book an appointment for your player it is best to have the player referred by their family doctor.This allows more time for the consultconsult

n Call 613 254 9777, email eocc@activecare.ca or visit us online at www.activecareclinics.ca

Links for Concussion Information General Info: Canadian Content www.thinkfirst.ca

From the Centers for Disease Control USA:

General concussion informational links:www.cdc.gov/concussioninyouthsports

For Coaches: For Coaches: www.cdc.gov/concussion/pdf/Coach_Guide-a.pdfwww.cdc.gov/concussion/pdf/coaches_Engl.pdf

For School Nurses:www.cdc.gov/concussion/HeadsUp/schools.html

For Athletes/Parents:www.cdc.gov/concussion/pdf/athletes_Eng.pdfwww.cdc.gov/concussion/pdf/parents_Eng.pdf