current concepts in concussion management wi

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Concussion Update: Current Concepts in the Management of Concussion

BILL MOREAU, DC, DACBSP®

© 2017 ALL RIGHTS RESERVED

© 2017 William J Moreau, DC, DACBSP

This publication is intended to provide current and accurate information about the subjects covered and is designed to help doctors of chiropractic to maintain their professional expertise. This publication and accompanying program are offered with the understanding that neither the speakers nor sponsoring organizations are rendering any therapeutic or other professional services. Individuals using this publication or orally conveyed information in dealing with a patient's care should also fully research original and current sources of authority.

All opinions, viewpoints and recommendations contained in this presentation represent those of the author alone and do not

represent the opinions, viewpoints or recommendations of any organization with which the author may be affiliated, including,

without limitation, the USOC or/and the ACBSP.

DisclaimerAll opinions, viewpoints and recommendations contained in this presentation represent those of the author alone and do not represent the opinions, viewpoints or recommendations of any organization with which the author may be affiliated, including, without limitation, the USOC.

• I receive payment for presentations including air travel

• I serve as a VICIS council member

• I am a paid consultant to the Allegheny Health Network

Bill Moreau DC DACBSP FACSM United States Olympic Committee, Managing Director

of Sports Medicine Professor – Southern California University of Health

Sciences Associate Professor – University of Western States CMO Team USA - Rio 2016 Summer Olympic Games,

2015 Toronto Pan American Games Medical Director Team USA – 2014 Sochi Winter

Olympics, 2012 London Olympic Games NFL International Think Tank on Concussion University of Washington Sports Health and Safety

Institute External Advisory Board Member

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What is the Role of Manual Therapy in Olympic Sports Medicine?

62012 London Games Analytics: A Quick Look Trends & Analytics at Your Fingertips

London Olympic & Paralympic EMR Analytics: • Total athletes inputted: 4,346

• Olympians• Paralympians• OTC Residents• Developmental Teams

• Total documents• Generated for Games: 3,784• Overall: 11,306

• Olympic Games• Injuries: 58

• Shoulder impingement• Ankle Sprains• Stress Fractures

• Illnesses: 85• Most common: upper respiratory infection

Percentage of documents* produced for Games by provider type:

* Total documents for Games: 3,784

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Rio Team USA Snap Shot

• 17 days of competition between more than 11,300 athletes representing 205 nations.

• The first Olympics to be held in South America

• Team USA topped the medal chart in every category for only the seventh time in Olympic history and the first since 1948

• Lead all nations with 121 medals, including 46 golds, 37 silvers and 38 bronzes.

Athlete Illness

Staff Illness

• 4,871 patient encounters

• $516,930 in service value

• 105 Providers

2016 Rio Summer Games Analytics: A Quick Look Trends & Analytics

The DC is the Third Most Common Healthcare Provider at the RIO Olympic Games

Provider Number

ATC 33

DC (CAQ) 18

MT 16

MD/DO 28

PT 10

The DC Leads Rio Olympic Service Value by Profession

4,871 total encounters$516,730 in service

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The DC Accounts for the Majority of Clinical Services at the Olympics.

Planning to Meet the Challenge

• Each Game or event brings unique challenges and opportunities for the sports medicine team

• MERP

• Iowa and working HS Football– It gets cold, really cold!– ASDH – time to treat

• Sochi Winter Games– We will use electronic surveillance….– ID = immediate passage to an ID hospital 75 miles away– Terrorism

• Rio Games– Water quality– ID– Footprint of the venues and transportation– Public vs. Private Hospitals and the “law of the land”

What are the Odds to Win a Gold Medal?

• There are 306 events at the Olympics this summer, with one gold medal per event.

• There are more than 7.3 billion people worldwide.

• That’s fewer than 42 events for every billion people

0.0000042%forty two ten-millionth(s)%

Defining High Performance

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• What does it take to be the best in the world -

On a specific day at a specific time competing against the best the world has to offer?

What matters when anything could? The answer, quite simply, is everything. Everything matters. When anything could, everything does.

HEAD INJURYOTHER TBI

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TBI

• Cerebral Concussion

• ASDH – Acute Subdural Hematoma

• EDH – Epidural Hematoma

• Intracerebral Hematoma

• DAI - Diffuse Axonal Injury

• Subarachnoid Hematoma

• Cerebral Contusion

• Second Impact Syndrome

Terminology

• Hematomas – LOC followed by lucid period, then rapidly deteriorate• EDH – or extradural hematoma is usually the most rapidly progressive intracranial hematomas.• ASDH - Subdural Hematoma – Is located under the dura and directly on the brain.• Intracerebral Hematoma – Bleeding is into the brain substance itself.• Subarachnoid- hemorrhage confined to surface of the brain

Diffuse Axonal Injury

• Associated with MVC

• Accounts for 1/3 of all head injury deaths

• Most frequent cause of persistent vegetative state

• Axons are sheared

• Mild to Severe

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DIA

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Skull Fracture• Indicates significant

force

• Signs

– Obvious deformity

– Visible crack in the skull

– Raccoon eyes

– Battle’s sign

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Raccoon eyes & Battle sign

Indicates basilar skull fracture and may be only sign of fracture as this is not well visualized on plain film and may be seen 2-3 days after trauma

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Cranial Hematomas EDH – Epidural Hematoma

• Usually associated with skull fracture• Usually an arterial bleed that does not tamponade

prior to serious neurological compromise• Presentation

– Transient LOC at time of injury followed by lucid interval (1/3 of the time)

– Followed by declining LOC, anisocoria, decerebrate posturing, and ultimately death

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Neurologic Posturing

http://drugline.org/img/ail/938_943_1.png

ASDH –Acute Subdural Hematoma

• In high school football, the most common cause of head injury death is a subdural hematoma

• These injuries are rare– Between 1984 and 1988 research reported 18 incidences

of subdural hematomas in athletes at various levels of football

Subdural Hematoma

• Can be divided into 2 categories– A simple subdural hematoma presents without cerebral

contusion or edema, usually in the elderly– The mortality rate for a simple subdural hematoma is

approximately 20% – The second category consists of brain contusion with

hemispheric swelling or bleeding – The mortality rate for this subdural hematoma is 50%

Subdural Hematoma

• Severe damage is caused by swelling or bleeding, typically due to venous rupture, which results in herniation of brain tissue and cerebral ischemia, potentially causing death.

• Although a subdural hematoma may be caused by a single incident, there are patients in whom this severe head injury resulted from repeated head injuries.

• In non-athletic severe head injury, epidural hematomas are 3X more common than SDH

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ASDH – Presentation

• Typically unconscious w/ or w/o hx of trauma

• Anisocoria, decerebrate posturing, declining LOC

Severe Head Injury Management Keys

• Get Help

• Stabilize the spine if indicated

• Establish and maintain an adequate airway

– Apply HF O2

– Prepare for vomiting (recovery position)

• Reassess the patient’s LOC

• Recheck to make sure help is on the way

Management Keys

1. Recognition that a head injury has occurred

2. Accurate assessment– Who stays and who goes for further assessment

3. Correct RTP Decision

Concussion Update: New Trends and Best Practices in the Management of Concussion

BILL MOREAU, DC, DACBSP®

© 2017 ALL RIGHTS RESERVED

Presentation Outcomes

Share early outcomes from Berlin 2016 ACBSP 2014 ACBSP Position Statement on Concussion in Athletics Discuss changes and best practices for SCAT 4 Lessons learned from the NFL Look at trends in concussion evaluation and management Q/A if time allows

Concussion Is Still Big News

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Concussion

Old Problem New Awareness

If we accept the best predictor of future injury is a history of prior injury, does it make sense that preventing concussion is a key to preventing concussion?Is reducing or preventing concussion even possible?

Proposed Prevention Prerequisites

Prevention

Access to Care

Policies

Technique and

Mechanism

Social Pressure

Knowledge

Attitude

Has Sport Injury and Illness Prevention Research Delivered? A Vigorous Debate. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco.

The 2016 Berlin Concussion Consensus Guidelines –what is new1. First time a doctor of chiropractic was invited to

attend

2. Three poster presentations were accepted from doctors of

chiropractic

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Concussion

DEFINITION OF A CONCUSSION

A concussion is defined as a traumatically induced transientdisturbance of brain function and is caused by a complex pathophysiological process.

Concussions have also been referred to as mild traumatic brain injuries (MTBI).

Not all MTBI are concussions.

Harmon KG, et al. Br J Sports Med 2013;47:15–26.

Concussion Defined

Concussion is a brain injury and is defined as acomplex pathophysiological process affecting thebrain, induced by biomechanical forces. Several

common features that incorporate clinical, pathologicand biomechanical injury constructs that may

be utilised in defining the nature of a concussivehead injury include:

Concussion Defined (cont)

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

2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

83 Concussion Defined (cont)

3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

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ACBSP position statement on concussion in athletics

Regarding the qualifications of Doctors of Chiropractic and their involvement in concussion management, it is the position of the ACBSP that:

1. Doctors of Chiropractic with current ACBSP™ certificates of additional qualifications in sports medicine (DACBSP® and CCSP®) are qualified to manage the concussed individual in any patient population.2. Doctors of Chiropractic may evaluate, diagnosis and manage concussed individuals. The prerequisite management skills for a concussed athlete can be supported by additional experience and education such as the ACBSP concussion registry.3. All healthcare providers involved in the management of concussed individuals have an obligation to maintain current knowledge regarding best practices in concussion management. 4. The ACBSP does not endorse any specific methodology of concussion management because the methods of assessment and management of concussion are in transition.

American Chiropractic Board of Sports Physicians™ Position Statement on Sports Related Concussion in Athletics. Moreau W and Nabhan D. Apr 2014

Regarding current best practices in concussion management it is the ACBSP™ position that:

1. Concussion may be caused by a direct blow to the head or elsewhere on the body.2. Loss of consciousness is a key symptom but the majority of concussions do not involve a loss of consciousness. 3. Individuals with a concussion may present with a wide range of signs and symptoms such as physical signs of neurologic impairment, or/and symptoms of impaired brain function that may include abnormal behavior.



4. An athlete suspected of having sustained a concussion must be removed from play and immediately assessed by a qualified healthcare provider.

5. A concussed individual must not be allowed to return to play the same day they were concussed.



6. When evaluating a collapsed athlete on the field of play, emergent concerns such as airway, breathing, circulation, spinal trauma or a more serious brain injury should be first excluded.

The initial sideline examination should include a more detailed history and examination of the individual.

Examination should include serial examinations and direct monitoring of vital signs and additional assessments through a standardized concussion neurological examination.



7. Concussed individuals should not be left alone in the initial phase of their evaluation until their constellation of signs and symptoms are static and a diagnosis can be confirmed.

8. Any increase of symptoms (especially increasing headache, decreasing neurologic function, presence of a focal neurologic deficit, altered vital signs, or repeated vomiting) in a concussed individual requires an urgent evaluation in a hospital setting.

9. Any individual with signs or symptoms of concussion at rest or with exertion should not be allowed to participate in sport until their signs and symptoms have resolved.


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10. A consultation from a qualified healthcare provider, including a DACBSP or CCSP, prior to returning-to-play is essential after suspected or known concussion.

11. A graded return-to-play protocol that includes exertion must be followed prior to resumption of full sporting activity.

12. Children and adolescents should be managed more conservatively than adults and they may not be returned to sport until they are completely symptom-free which may require a longer time frame.



13. All athletes must be symptom-free at rest and with exercise prior to return-to-play.

14. The appropriate management of concussed individuals requires careful consideration in regards to the timing and management of the injury. Manual procedures for concussed individuals with clinical presentations of cervical spine and/or vestibular dysfunction may be of benefit, especially if the individual is experiencing neck pain.

15. Cases of concussion in sport where clinical recovery falls outside the expected window of recovery of ten (10) days should receive consideration for management using a multidisciplinary approach.



A recommended current reference for consensus based approach to concussion management is the Consensus Statement on Concussion in Sport: The 4rd International Conference on Concussion in Sport Held in Zurich, November 2012. Agreement exists pertaining to principal messages conveyed within this document, the ACBSP acknowledges the science of concussion is evolving and therefore, management and return-to-play decisions remain in the realm of individualized clinical judgment. Individual management depends on the specific presentation and circumstances that are unique to each individual case. This statement reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It is intended that this document will be formally reviewed and updated prior to June 1 2016.

Soon to be Berlin 2016!



The ACBSP Position Statement on Sports Related Concussion in Athletics is not intended as a standard of care document, and it should not be interpreted as such.


Concussion Incidence 3.8 MM sports related concussions yearly

50% are unreported concussion

Concussion occurs in all sports w/ the highest incidence in Football, hockey, rugby and basketball

(+) history of concussion is associated w/ higher risk of another concussion

Greater number, severity and duration of concussion symptoms predicts a prolonged recovery.


Risk Factors - Concussion Reported incidence of concussion is higher in female

athletes than in male athletes. Certain sports, positions and individual playing styles

have a greater risk of concussion. Youth athletes may have a more prolonged recovery

and are more susceptible to a concussion accompanied by a catastrophic injury.

Pre-injury mood disorders, learning disorders, attention deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion.


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Making the Diagnosis

Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.

Graded symptom checklists provide an objective tool for assessing symptoms of concussion, also tracking the severity of s/s over serial evaluations.

Standardized assessment tools provide a helpful structure for the evaluation of concussion (limited validation)


Concussion Sideline Management

▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licensed healthcare provider trained in the evaluation and management of concussions.▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination.



▸ While standardized sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined.

▸ Individual baseline test is also largely unknown.



Balance disturbance is a specific indicator of a concussion, but not very sensitive.

Balance testing on the sideline may be substantially different than baseline tests differences in shoe/cleat-type or surface

ankle tape or braces

presence of other lower extremity injury

Imaging is reserved for athletes where intracerebral bleeding is suspected.



There is no same day RTP for an athlete diagnosed with a concussion.

Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status.


Severe Head Injury Management Keys Get Help

Stabilize the spine if indicated

Establish an adequate airway Apply O2

Reassess the patient’s LOC

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Management Keys1. ABCs are always first!2. Recognition that a head injury has occurred3. Accurate assessment

Who stays and who goes for further assessment

4. Correct RTP Decision5. Appropriate Follow-Up

Day-of-Injury Referral -1. Loss of consciousness on the field2. Amnesia lasting longer than 15 minutes3. Deterioration of neurologic function*4. Decreasing level of consciousness*5. Decrease or irregularity in respirations*6. Decrease or irregularity in pulse*7. Increase in blood pressure8. Unequal, dilated, or unreactive pupils*

J Athl Train. 2004;39(3):280-297.

*Requires that the athlete be transported immediately to the nearest emergency department.

Day-of-Injury Referral -9. Cranial nerve deficits

10. Any signs or symptoms of associated injuries, spine or skull fracture or bleeding*

11. Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation*

12. Seizure activity*

13. Vomiting

14. Motor deficits subsequent to initial on-field assessment

15. Sensory deficits subsequent to initial on-field assessment

J Athl Train. 2004;39(3):280-297.


Day-of-Injury Referral -16. Balance deficits subsequent to initial on-field assessment

17. Cranial nerve deficits subsequent to initial on-field assessment

18. Postconcussion symptoms that worsen

19. Additional postconcussion symptoms as compared with those on the field

20. Athlete is still symptomatic at the end of the game (especially at high school level)

J Athl Train. 2004;39(3):280-297.


Delayed Referral(after the day of injury)1. Any of the findings in the day-of-injury referral

category

2. Postconcussion symptoms worsen or do not improve over time

3. Increase in the number of postconcussion symptoms reported

4. Postconcussion symptoms begin to interfere with the athlete’s daily activities (ie, sleep disturbances or cognitive difficulties)

J Athl Train. 2004;39(3):280-297.

Neuropsychological (NP) Testing

Are an objective measure of brain behavior relationships and are more sensitive for subtle cognitive impairment than clinical exam.

Most concussions can be managed appropriately without the use of NP testing.

Computerized neuropsychological (CNP) testing should be interpreted by trained healthcare professionals..


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Neuropsychological Testing

Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion.

NP testing should be used only as part of a comprehensive concussion management strategy.

The ideal timing, frequency and type of NP testing have not been determined.


Neuropsychological Testing

In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery.

It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long term complications.

Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses.


What About Manual Medicine?

Manual therapy may be considered especially when there is concomitant neck pain. (1)

Possible Best Practices Not at the athletic event where the injury occurred.

Only when the s/s are static or resolving.

Consider waiting 2-3 hours w/ observation before performing manual medicine.

1) Harmon KG, et al. Br J Sports Med 2013;47:15–26.

Return to Class

Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion.


Return to Play

▸ Concussion symptoms should be resolved before returning to exercise.▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact.▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step.▸ RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and managementof concussions.


Risks of Premature RTP

▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. ▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae.▸ Some studies suggest an association between prior concussions and chronic cognitive dysfunction.


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Disqualification from Sport

▸ There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion.

▸ Each case should be carefully deliberated and an individualized approach to determining disqualification taken.


Prevention

▸ Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.▸ Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions.▸ There is no current evidence that mouth guards can reduce the severity of or prevent concussions.▸ Secondary prevention may be possible by appropriate RTP management.


Incidence

REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL Study investigated the difference in the reported and non-

reported incidence of concussion 72 HS(9-12) football players over a single football season.

A “reported incident” was defined as a concussion the football staff was aware of through recorded data.

Coaching staff recorded data regarding any player who reported w/ concussion injury to the football staff or required follow-up evaluation by a health care provider for a concussion.

W Moreau, REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL. American Chiropractic Board of Sports Physician’s™ 2005 Sports Science Symposium Abstract – Podium Presentation

REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL To identify “non-reported concussion” an

anonymous questionnaire regarding symptoms related to concussion was issued at the end of the football season to all 72-football players.

The survey asked the athlete five questions. Two questions identified the athletes grade in school and

the position they played

The other questions related to identifying for the athlete some of the common signs of concussion.


REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL Results: All 72 surveys were returned Results demonstrated:

4 “reported” concussions incidence = 5.6%

The surveys identified that 47 athletes sustained symptoms consistent with concussion during the season for an unreported concussion rate of 65%.


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REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL CONCLUSION:

There is a significant difference in the incidence of concussion as reported to the coaching staff or health care providers verses the incidence of symptoms of concussion experienced by the athlete.


Soccer Upper limb to head contact

accounts for 50% of concussions Adolescent football (soccer) players experience a

significant number of concussions Being female may increase the risk of suffering a

concussion and injuries on the head and face The use of football headgear may decrease the risk

of sustaining these injuries.

Bicycle HelmetsGet oneHelmet usage is increasing Ensure proper fitMake sure it is worn correctly 85% of head injuries could be prevented with

a helmet Universal use of helmets could prevent one

death every day and one brain injury every four minutes

Mild Traumatic Brain InjuryIs There Such A Thing?

MTBI

HistoryWhat is the million dollar question

we always need to ask?

HistoryHave you ever hurt your head before?Do not ask if they have had a concussion

before because they might not know what a concussion is!

So what is a concussion?

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Second Impact Syndrome A subsequent and possibly fatal brain injury that can

occur when a second head injury is received before the initial head injury has resolved

Can be associated with concussion An athlete may present with a seemingly mild

concussion; however, within seconds, the athlete may develop symptoms of second-impact syndrome

Second-impact syndrome has a mortality rate of up to 50%

It must be prevented whenever possible and recognized early when it occurs

Second Impact Syndrome Athlete appears stunned and with or without losing

consciousness, gets up under own power, and collapses soon thereafter

Rapidly dilating pupils, loss of eye movement, beginning respiratory failure from brainstem deficiency

Occurs faster than an epidural hematoma Is considered a “controversial” condition

Differential Weighted Diagnosis?ConcussionWhat grade?What system?What's the big question?

MTBI Assessment In addition to the concussion injury assessment the

evaluation should also include an assessment of:1. Cervical spine

2. Cranial nerves to identify any cervical spine or vascular intracerebral injuries.

Post-Traumatic Amnesia (PTA)

1. Retrograde Amnesia Partial or total loss of the ability to recall events that have

occurred immediately preceding brain injury. Varies with the time of measurement post-injury and hence is

poorly reflective of injury severity2. Anterograde AmnesiaReduced ability to form new memoryMay lead to decreased attention and

inaccurate perception (ie. Poor School Performance)

frequently the last function to return.

SCAT 3 – Best practices FOR clinical implementation

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SCAT 3

SCAT 3 is not a GOLD standard, it provides a format to cover the bases.

SCAT 3 is a guide for the assessment of concussed individuals in athletics.

Meeuwisse Willem and Paul McCrory P. Meet the Experts – Sideline Concussion Assessment. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco.

SCAT 3 SCAT3 to be done in resting state. Best done 10

or more minutes post exercise. For individuals age 13 and older To be administrated by medical staff Additional questions or languages are

acceptable The Child SCAT and Concussion Recognition

Tools are for individuals who are not healthcare providers to raise attention to F/U


First Follow the EAP

1 ABCs Disability (AVPU) R/O Spinal or other life threatening injury

Will the future be CAB?

What is a Concussion?

A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and / or symptoms (some examples listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following:

- Symptoms (e.g., headache), or- Physical signs (e.g., unsteadiness), or- Impaired brain fxn (confusion) or- Abnormal behavior (e.g., change in personality).


Page OneFor Acute Assessment at the time of injury.

Not needed for clinical E/M

PG1 -Sideline Assessment

Potential signs of concussion Objective signs? Non-specific Quick assay of

concussion related signs


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PG1 -Sideline AssessmentGlasgow Coma Scale

Wide use of the GCS-E would hold mild traumatic brain injury cases in the treatment loop, improve access to counselling, rehabilitation services, and personal injury compensation, and reduce the “cognitive dissonance” between victims of mild traumatic brain injury and treating professionals.

Use of the GCS-E for assessment of PTA duration revealed that longer lengths of amnesia following mild TBI were associated with greater incidence of dizziness, depression and cognitive impairments during the first weeks after injury.

Results suggest that the GCS-E is a useful tool for the prediction of symptoms associated with mild TBI.

An extended Glasgow Coma Scale (GCS‐E) with enhanced sensitivity to mild brain injury. Nell V and Kruger J. Arch Phys Med Rehabil. 2000 May;81(5):614‐7. Utility of Glasgow Coma Scale‐Extended in symptom prediction following mild traumatic brain injury. Drake A et al. Brain Inj. 2006 May;20(5):469‐75.

PG1 -Sideline Assessment

Perform once – at time of injury Acceptable to be changed to be sport specific


PG2- Background

Length of time to recovery is related to the prognosis!


PG2- Symptoms


• 40% score “0” on baseline• 60% score something.

• “Asymptomatic” means normal for that individual.

• Best results achieved when the athlete completes the form themselves.

PG2- Symptoms


• Total number of symptoms = is anything that is not a “0”

• Symptom severity score = add the numbers

PG2- Symptoms


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PG2- Symptoms


PG2- Symptoms


• One second per word – pace is important• Average score is 14• Read list b/f each test cycle except the delayed

test• Cultural changes alter scores (Spanish clumps)

PG2- Symptoms

Meeuwisse Willem and Paul McCrory P. Meet the Experts – Sideline Concussion Assessment. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco. Sport concussion assessment tool: baseline values for varsity collision sport athletes N Shehata et al. Br J Sports Med 2009;43:730–734

• Two mistakes in a row of same line b/f test is stopped.• Months can start at any point in the cycle, successfully completed by 91.6% of subjects.

• Some countries do not name the months

PG2- Symptoms


• Minimum screen (i.e. do more!)• Add Spurling’s test for example

• Often the cause of prolonged symptoms

PG2- Symptoms


• Use same footwear as expected at an event.

• Tandem Gait requires tape on the floor.

PG2- Symptoms


• Finger to nose Coordination Exam• Upper Limb Coordination – Finger‐to‐nose task:

o Which arm was tested: right / lefto Scoring: 5 correct repetitions in < 4 sec. = 1o Coordination score: _________ of 1o Must fully touch nose and fully extend elbow after touching nose.

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PG2- Symptoms


•Do not re‐read the word list.

3 TRIALS – No FOAM


Balance Testing


BESS• Use three positions for SCAT 3• Use footwear they would be wearing at an

event• Use skates for ice hockey• The dominant leg is the one used to kick a

ball, make sure you have the stance correct.

Tandem Gait Participants stand with their feet together behind a starting line,

(footwear removed). They walk forward direction as quickly (within 14 seconds) and

as accurately as possible for 3 M with foot heel-to-toe gait. After crossing the end of the 3m line, they turn 180 degrees and

return to the starting point using the same gait. A total of 4 trials are done and the best time is retained. Athletes should complete the test in 14 seconds. Fail the test if they step off the line, have a separation between

their heel and toe, or if they touch something. In this case, the time is not recorded and the trial repeated, if

appropriate.


You Must Know Your Athlete

The SCAT 3 Symptom and all Scores vary by many factors Injury or illness status

Degree of recovery

Education

Primary language

Nationality

Age

Test taking skills


Symptom Baseline 40% score a “0”.

“Asymptomatic” means normal for that individual.

Best results when self-rated (scored) by the athlete.


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What is Normal?Symptom Frequency

Sport concussion assessment tool: baseline values for varsity collision sport athletes. Shehata et al.Br J Sports Med 2009;43:730–734.

University Normal

The mean SCAT baseline PCSS score was approximately 5, although just under half of the athletes scored 0.

Female athletes scored better on tests of neurocognitive function.

PC athletes scored higher than NC athletes on all neurocognitive tests except delayed five-word recall.

Sport concussion assessment tool: baseline values for varsity collision sport athletes. N Shehata et al. Br J Sports Med 2009;43:730–734

Most Frequent Symptoms

The five most frequently reported symptoms for all athletes were:1. Fatigue/low energy (37%)2. Drowsiness (23%)3. Neck pain (20%)4. Difficulty concentrating (18%)5. Difficulty remembering (18%).

Sport concussion assessment tool: baseline values for varsity collision sport athletes. N Shehata et al. Br J Sports Med 2009;43:730–734

What is Normal?Symptom Scores Team USA

Nabhan D, Moreau WJ. Baseline SCAT 3 Symptom Scores for Elite Athletes.: What is Normal ? Manuscript in process. 2014

SAC Score Symptoms Symptom SeverityScore

27.2 (95% CI 26.8-27.6)

2.0(95%CI 1.5-2.6)

3.6 (95% CI 2.5-4.8)

Principles of the NFL Approach

GAME CHANGING POLICY GEARED TOWARD CONCUSSION PREVENTION: THE NFL EXPERIENCE ELLENBOGEN R. IOC WORLD CONFERENCE ON PREVENTION OF INJURY & ILLNESS IN SPORT. INTERNATIONAL PERSPECTIVES ON PREVENTION OF SPORT RELATED CONCUSSION: ARE WE GAINING GROUND? MONACO 10 APRIL 2014.


Player Safety First: prevention, diagnosis, management A public health issue not simply an NFL or American football issue Requires a team effort, no one specialty owns it, everyone has a

voice USA media is not the place to debate the science Data matters: measuring and video everything Rules make a difference Research must be disruptive Advocacy and education are key

Game changing policy geared toward concussion prevention: The NFL experience Ellenbogen R. IOC World Conference on Prevention of Injury & Illness in Sport. International perspectives on prevention of sport related concussion: Are we gaining ground? Monte‐Carlo, 10 April 2014

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Principles of the NFL Approach Concussion is overwhelmingly (5:1) an injury

of game versus practice contact. Less than 10% of players have multiple

concussions in a single season. 2013 drop them players with multiple

concussions drop in players with multiple concussions due to more conservative management.


YEAR 2 Concussion within 1 Season

3 Concussion within 1 Season

2012 15 22013 11 1



Position at Time of Injury - Contact with Player Only1. Defensive Secondary2. Offenses Line3. Running Back4. Linebacker5. Tight EndOverall Team Play1. Offense2. Defense3. Special Teams



• There is a 40% decrease of concussions since the rule change on kick-off returns in 2011

• Days loss for concussions (practices and games) has more than doubled between 2009 in 2013 with a mean of 13.6 days in 2013

General Themes

One third of concussions occurred during preseason 50% of all preseason concussions occur during practice 3% of concussions occur in the regular season during practice (14

contact practices) Pre-in regular season: sign overall 20% of concussions occur in

practice and 80% during games


Five important NFL protocol enhancements

1. Enhanced return to play protocol for 20142. Upgrading standardized neuropsychological

consultants and testing3. Set up EAPs in all 32 NFL stadiums4. Highly successful pilot of the unaffiliated

neurological consultant program5. Concussion training for all NFL medical

teams with the unaffiliated neurological consultant program


RTP Principles

Each player in each concussion is unique and must be treated individually

Rested key (cognitive and physical) until symptoms abate. Monitor for delayed symptoms.

Athletes proceed to next step based on milestones: symptom, clinical criteria, activity performance, NOT time

Any increase in symptoms, activity stopped regardless of stage; if asymptomatic, activity may be reproduced.

Athlete is seen by at least one member of the medical team (ATC/physician) every day after concussion

These are general NFL guidelines not rules


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Day of Injury

NFL game day protocol Full official NFL sideline evaluation in locker room (unless hospitalize)

on day of injury, documented in EMR Madden rule always an effect:

if a player is diagnosed with a concussion and removed from a game, he must leave the field and be immediately escorted to the locker/training room, and a member of the medical staff (e.g., an ATC, paramedic, MD, fellow, or resident capable of medical intervention) must remain with the player to observe him if his injury does not require immediate hospitalization

Game day sequential evaluation in locker room to support and monitor athlete progress


NFL Conclusions

This is a public health issue This is a team sport Media is not the place to debate the science of concussion Data matters: measure everything Rules make a difference Research must be disruptive Advocacy and education are key


trends in concussion evaluation and management

Concussion Cares

Treatment approach depend on clinician ability to DDXamong various conditions associated with PCS.

Early education, cognitive behavioral therapy, and aerobic exercise therapy have shown efficacy in certain patients but have limitations of study design.

Rehabilitation of Concussion and Post‐concussion Syndrome. Leddy J et al. Sports Health. Mar 2012; 4(2): 147–154.

The Diagnosis of Concussion is Influenced by: Medical Team Awareness. With a and reliability in diagnosing

concussion. comprehensive program in concussion management, there is internal consistency

Athlete Self-Report. Unfortunately, even well-educated athletes have a high rate (40-50%) of not reporting concussion, especially w/ a prior concussion.

Over-Reliance on Computerized Testing. Concussion DX must be clinical, computerized testing cannot make a diagnosis. These tests may help make a clinical decision, but they are not valid indicators of a diagnosis as a stand-alone tool.

NCAA Sport Science Institute hosted a Concussion Task Force. Jul 11, 2013

Association Between Recovery and Risk

Acute Effects and Recovery Time Following Concussion in Collegiate Football Players The NCAA Concussion Study. McCrea et al. JAMA. 2003;290(19):2556‐2563

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Concussion - Neurometabolic Cascade

Metabolic Cascade Accumulation of calcium within the mitochondria peaks at 2

days post injury, and it resolves within 4 days. (1) A reduction in glucose level is seen within 24 hours, which

remains evident for 5–10 days after injury.(2) Oxidative metabolism in the cortex is restored by 10 days post

injury, but a reduction is still evident in the hippocampus.(2) There is also PET evidence of decreased global cerebral

metabolism in humans that lasts for 2–4 weeks. These studies provide evidence to guide the introduction of exercise following concussion.(3)

1) Fineman JR et al. Hyperoxia and alkalosis produce pulmonary vasodilation independent of endothelium‐derived nitric oxide in newborn lambs. Pediatr Res. 1993;33(4 Pt 1):341‐346.

2) Yoshino A et al. Changes in local cerebral glucose utilization following cerebral conclusion in rats: evidence of a hyper‐ and subsequent hypometabolic state. Brain Res. 1991;561(1):106‐119.

3) Bergsneider M, Hovda DA, Shalmon E, et al. Cerebral hyperglycolysis following severe traumatic brain injury in humans: a positron emission tomography study. J Neurosurg. 1997;86(2):241‐251.

What is the Lowest Threshold to Diagnose Concussion?

McCrory BJSM 2013

Exercise and Concussion

Cerebral pressure auto-regulation (CPA) is an protective mechanism against secondary ischemic damage that maintains homeostasis in the presence of varying arterial blood pressure (BP) and cerebral perfusion pressure

Cerebrovascular stability may be compromised in head-injured patients, due to an inability to maintain stable pressure during fluctuations created by exercise.

The normal interaction of CPA and exercise-induced metabolic changes protects the brain from both hypoperfusion and hyperperfusion.

Disruption of this auto-regulatory mechanism could be the cause of symptoms experienced by concussed patients during physical exertion.

Exercise and Concussion, Part 1 Local and Systemic Alterations in Normal Function. Kozlowski K. International Journal of Athletic Therapy and Training Mar2013 19 2 p23

Exercise and Concussion Dual Task Rehabilitation Individualized dual-task home-based exercises, were

performed for approximately 30 minutes, six times a week for seven weeks.

Practiced body stability with sensory deprivation standing with closed eyes, standing on soft surfaces w different bases of support (e.g.

tandem standing, standing on one foot) W body transport activities (e.g. transferring from one chair to

another, transferring from sit to stand).

Participants were asked to perform balance exercises while performing either a second motor task (e.g. throwing and catching a ball) or a second cognitive task (e.g. naming objects or remembering numbers).

A dual task home‐based rehabilitation programme for improving balance control in patients with acquired brain injury a single blind randomized controlled pilot study. Peirone E et.al. Clinical Rehabilitation Apr2014 (28) 4 p329

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Conclusions

Concussion is an Area of Knowledge that is in Transition

Special Considerations for the Young Individual

Concussion in Adolescents• Younger athletes (H.S. and lower) have been show to exhibit longer

recovery times compared to adults.(1)

• Concussions seem to have more symptoms and last longer in females. (2)

• Second Impact Syndrome (a person under age 21, whose initial concussion symptoms are unresolved, may suffer sudden death if there is a second concussion within two weeks of the first concussion), it is clear that adolescents must to be protected from this potential catastrophic event.(3)

• A gene may exist that causes some individuals to be more susceptible to concussions.(4)

1) Field, Collins et al. Does age play a role in recovery from sports related concussion? J Pediatr 2003; 142(5):788-795.

2) Bazarian and Atabaki. Predicting post-concussion syndrome after MBTI. Acad Emerg Med 2001; 8(8):788-795

3) Cantu, RC: Head injuries in Sport. Brit J Sports Med 1996; 30:289-2964) Apolipoprotein E-epsilon 4 Genotype predicts poor outcome in survivors of traumatic brain injury.

Neurol 1999; 52:244-249

Concussion in Adolescents• Many concussed individuals may be unable to concentrate (focus).

They may not be able to read or absorb material and may develop an increased headache while doing so.

• When this occurs, they might be able to participate in an activity for only a few minutes before symptoms increase. If a rest break can be interspersed between those few minute intervals, these activities can be done.

• As the symptoms abate, longer intervals can be spent reading, watching TV and using the computer.

• Continuing to do activities, or exercise that increases symptoms, can delay the recovery from the concussion.

Concussion in AdolescentsSCHOOL ATTENDANCE AND ACTIVITIES• While some individuals may be able to attend school without

increasing their symptoms, the majority will probably need some modifications depending on the nature of the symptoms.

• Trial and error may be needed to discover what they can and cannot do.

• If students are unable to attend school for an entire day without symptoms, they may attend for a half day.

• Some students may only be able to attend for one period, some not at all, due to severe headaches or other symptoms.

• Frequent breaks with rest periods in the nurse’s office may be necessary.

• Often, alternating a class with a rest period may be helpful. • Math causes more symptoms in my patients than other subject

classes. • As recovery proceeds, gradually hours spent in school may be

increased.

REF: Lee M.A. Adolescent Concussions— Management Recommendations (A Practical Approach). Spring 2006 CSMS Committee on the Medical Aspects of Sports.

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Concussion in AdolescentsSCHOOL ATTENDANCE AND ACTIVITIES• Depending on their symptoms, some students may need to be driven

to school to avoid walking and should be given elevator passes to avoid stairs.

• They should not attend gym or exercise classes initially.• Workload and homework may need to be reduced. • Frequent breaks while doing homework may be helpful. • Term papers should be postponed. • Pre-printed class notes and tutors may help to relieve the pressure of

schoolwork.• Tests: If there are concentration and memory problems, quizzes, tests,

PSAT tests, SAT tests and final exams should be delayed or postponed. If test results are poor, a note to the school should request that the scores be voided. Extra time (un-timed tests) may be necessary initially when test taking is resumed.

REF: Lee M.A. Adolescent Concussions— Management Recommendations (A Practical Approach). Spring 2006 CSMS Committee on the Medical Aspects of Sports.

Additional Cares and Considerations

Girls and Concussion

Girls are 68% more likely to suffer sports related concussions. The reasons for this are anatomy and biomechanical

differences: Heads are smaller Neck muscles are not as strong Different styles of play Different training techniques Cultural norms Increasing numbers of highly competitive female athletes.

In basketball girls were 300 percent more likely to get a concussion.

Neuroimaging Conventional structural neuroimaging is normal in

concussive injury. The following suggestions are made:1. Brain CT and MR contributes little to concussion

evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists.

Canadian Head CT Rule

Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391-96.

Pharmacological Therapy Pharmacological therapy in sports concussion may

be applied in two distinct situations.1. The management of specific prolonged symptoms

(eg, sleep disturbance, anxiety, etc)2. Where drug therapy is used to modify the underlying

pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms.

McCrory P, et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. Clin J Sport Med 2009;19:185–200.

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Pharmacological Therapy This approach to management should be only considered

by clinicians experienced in concussion management.

An important consideration in RTP is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion.

Antidepressant therapy may be used for management, the decision to return to play while still on such medication must be considered carefully by the treating clinician.


Pre-participation Concussion Evaluation A concussion history is important but know many

athletes will not recognize all the concussions they may have suffered

A detailed concussion history is of value History may:1. Pre-identify athletes that fit into a high risk category2. Provide an opportunity for the healthcare provider

to educate the athlete in regard to the significance of concussive injury


Role of Pre-participation Concussion Evaluation A structured concussion history should include

specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions.

It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable.


Role of Pre-participation Concussion Evaluation History should also include information about all

previous head, face or cervical spine injuries. Questions pertaining to disproportionate impact

versus symptom severity alert the clinician to the individual’s increased vulnerability to injury.

Details regarding protective equipment is useful. Comprehensive pre-participation concussion

evaluation allows for modification and optimization of protective behavior and education.


Patient InstructionsWarning Signs to Seek Immediate Help Inability to awaken the patient Severe or worsening headaches Somnolence or confusion Restlessness, unsteadiness or seizures Difficulties with vision Vomiting, fever or stiff neck Urinary or bowel incontinence Weakness or numbness involving any part of the body

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Concussion Patient Directions

1. Avoid strenuous activity for 24 hours after the injury

2. Do not take mediations without consulting your physician

3. Eat a “regular” diet, Avoid alcohol

4. Do not drive until you are fully recovered

5. Do Not take aspirin, sleeping pills, or ibuprofen.

6. Call your doctor or return to the ER if any of the following occur:

a. Becomes sleepy or is difficult to awaken.

b. Vomiting

c. Trouble with balance

d. The eyes move oddly, difficulty with focusing, unequal pupil size

e. Persisting or increasing headache

f. Restlessness or irritability, personality changes

g. Convulsions or seizures

h. New swelling at the area of the head injured

I. Increased neck stiffness

J. Numbness

K. Ringing in the ears

L. Shortness of breath

M. Confusion

N. Visual problems

Criteria for Hospital Admission

Hospital admission for further observation or treatment is indicated when;An athlete has persistent confusionLethargyFocal neurologic signsAbnormal findings on the brain CT scanWhen the clinical picture is confounded because

of seizures.Admission should also be considered if no

responsible person is available at home to monitor the patient for progression of symptoms.

The Postconcussion Syndrome Athletes may experience somatic, affective or

cognitive symptoms that gradually taper in severity over days, weeks or even months after a concussion.

Postconcussion symptoms may result from brain injury or from trauma involving head and neck structures.

The most common symptoms are headache and dizziness.

The Postconcussion Syndrome The most common symptoms are headache and dizziness Other symptoms include;

Blurred vision Neck pain Fatigue Problems sleeping Emotional or cognitive disturbances Tinnitus Problems with balance or coordination Loss of hearing, taste or smell

The Postconcussion Syndrome Athletes with unilateral or multifocal brain lesions on CT

or MRI scan may be more likely to have neuropsychologic symptoms

Referral to a psychologist for neuropsychologic testing and treatment is indicated when an athlete is suspected of having neuropsychologic symptoms after a concussion.

Additional Testing Brain imaging, if not previously performed, is indicated

in the athlete with chronic headaches after a concussion.

The athlete who is experiencing dizziness may be evaluated with audiologic testing.

Premature return to play by a symptomatic athlete places that athlete at greater risk for subsequent concussion and cumulative brain injury.

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Concussion Home Instructions I believe that ____ sustained a concussion.

To make sure he/she recovers, please follow the following important recommendations:

1. Please remind __ to report for a follow-up evaluation.2. Please review the items outlined on the enclosed

Physician Referral Checklist.If any of these problems develop prior to the f/u visit, please call____ at __ or contact the local emergency medical system or your family physician.

3. Otherwise, you can follow these instructions:

J Athl Train. 2004;39(3):280-297.

Concussion Home InstructionsIt is OK to:Use acetaminophen (Tylenol) for headachesUse ice pack on head and neck as needed for

comfortEat a light dietReturn to schoolGo to sleepRest (no strenuous activity or sports)

J Athl Train. 2004;39(3):280-297.

Concussion Home InstructionsThere is no need to:

Check eyes with flashlight

Wake up every hour

Test reflexes

Stay in bed

J Athl Train. 2004;39(3):280-297.

Additional MaTERIALS

Evaluation ofAcute Concussion


Evaluation Key features of this exam should encompass:1. A comprehensive history2. Detailed neurological examination

� Thorough assessment of mental status� Cognitive function� Gait and balance.

3. Determination of clinical status of the patient� Improvement or deterioration since the time of injury

4. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

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On-field or Sideline Evaluation ofAcute Concussion Sideline evaluation of cognitive function is an

essential component in the assessment of this injury.

Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective.

Duration of LOC is an acknowledged predictor of outcome.

Sideline Evaluation of Acute ConcussionWhen a player shows ANY features of a concussion:(a) The player should be medically evaluated onsite using

standard emergency management principles, and particular attention should be given to excluding a cervical spine injury.

(b) The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.

(c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 or other similar tool.


Sideline Evaluation of Acute ConcussionWhen a player shows ANY features of a concussion:

(d) The player should not be left alone following the injury, and serial monitoring for deterioration is essential over the initial few hours following injury.

(e) A player with diagnosed concussion should not be allowed to return to play on the day of injury. Occasionally, in adult athletes, there may be return to play on the same day as the injury.


No one test should be used solely to determine recovery or RTP.

Concussion presents in many different ways.

Documenting Information1) mechanism of injury2) initial signs and symptoms3) state of consciousness4) findings on serial testing5) instructions given to athlete &/or parent6) date and time of the athlete’s RTP7) relevant info on the player’s hx of prior concussion

and associated recovery pattern(s)

Standardized Assessment Of Concussion (SAC) 5 minutes to administer Measures of: OrientationImmediate MemoryNeurologic screening Loss of Consciousness (occurrence, duration) Post-Traumatic AmnesiaRetrogradeAnterograde

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SAC

Sensation Coordination Concentration Exertion Maneuvers Delayed Recall (5 words)

Classification of Concussion

Grading Systems

Zachery Lystedt Law

As of July 26, 2009,

1. All school coaches will have to take a training course on the nature and risk of concussions and head injuries including continuing to play after a concussion or head injury.

2. Each school year prior to initiating any turnouts or competition, all school athletes and their parents/guardians must have received training on concussions and head injuries and provide the school with a signed statement indicating they have taken this training.

3. All athletes suspected of suffering a concussion or brain injury will be removed from practice or competition and not returned to play until cleared in writing by a licensed health care provider trained in the evaluation and management ofconcussions.

Zachery Lystedt Law

As of July 26, 2009,

4. All non-profit youth organizations using school facilities shall:a. Provide the school with written Proof of Insurance covering

their youth athletes with limits required by the law andb. All coaches, players and parents of youth teams shall have

similar training as outlined for school coaches prior to the start of any practice, and

c. The non-profit youth groups shall indicate in writing their compliance with the insurance coverage and required head injury training prior to receiving access to school facilities.

Currently the training materials are being developed by expert doctors at Harborview Medical Center, Seattle Children's Hospital, and the University of Washington Hospital in conjunction with WIAA (Washington Interscholastic Activities Association

Why all the work on RTP?? TBI may develop into a severe injury

cerebral, epidural, or subdural hematomaThese are medical emergencies

To specifically avoid one condition Second Impact Syndrome

Today’s Return to Play Management The cornerstone of concussion management is physical

and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.

The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies.

The importance of considering each person as an individual can not be over emphasized

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Concussion Management Modifiers

RETURN-TO-PLAY SAME-DAY It is essential the sports physician understands:

1. It is the safest course of action to hold an athlete out of action.

2. Determine the athlete is asymptomatic at rest before resuming any exertional activity.

3. Amnesia may be permanent.

Graduated Return to Play Protocol A stepwise progression Athlete should continue to proceed to the next level if

asymptomatic at the current level.

Each step should take 24 hours an athlete would take one week to proceed through the full

rehabilitation protocol

If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a 24-hour period of rest has passed.

Rehabilitation Stage Functional Exercise Objective

1. No activity Complete physical and cognitive rest Recovery

2. Light aerobic exercise Walking, swimming stationary cycling -intensity @ 70% MPHR- no resistance training

Increase HR

3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; no head impact activities

Add Movement

4. Non-contact training drills

Progression to more complex training drills, eg, passing drills in football and ice hockey; may start progressive resistance training

Exercise, coordination, and cognition load

5. Full contact practice Following medical clearance, participate in normal training activities

Restore confidence and assessment of sports specific functional skills

6. Return to play Normal game play

Disqualifying the Athlete Athletes who are symptomatic at rest and after exertion

for at least 20 minutes should be disqualified from returning to participation on the day of the injury.

Exertional exercises should be included

Athletes who return on the same day because symptoms resolved quickly (<20 minutes) should be monitored closely after they return to play.

They should be repeatedly reevaluated on the sideline after the practice or game and again at 24 and 48 hours postinjury to identify any delayed onset of symptoms.

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete Athletes who experience LOC or amnesia should be

disqualified from participating on the day of the injury.

The decision to disqualify should be based on a comprehensive physical examination; assessment of postconcussion signs and symptoms;

functional impairments, and consideration of past history of concussions)

J Athl Train. 2004;39(3):280-297.

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Disqualifying the Athlete If assessment tools* are not used, a 7-day symptom-

free waiting period before returning to participation is recommended.

Assessment tools include; the SAC, BESS, neuropsychological test battery, and symptom

checklist

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete Be more conservative with athletes who have a

history of concussion.

Athletes with a history of concussion are at increased risk for: Sustaining subsequent injuries

Slowed recovery of postconcussion s/s

Cognitive dysfunction

Postural instability after subsequent injuries

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete -Permanently Consider permanently disqualification for athletes:

1. With a history of 3 or more concussions

2. Who experience slowed recovery.

3. Who have had multiple grade three concussions

J Athl Train. 2004;39(3):280-297.

Signs and Symptoms of Concussion

Sideline Examination Physical and mental testing is used as to determine a

baseline for patient evaluations

The examinations need to be organized and documented.

Signs and Symptoms of Concussion

DX involves the assessment of a range of domains: Clinical symptoms Physical signs Behavior Balance Sleep Cognition

A detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination.


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Signs and Symptoms of Concussion Symptoms and Signs of Acute Concussion

If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted.

Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability)

Physical signs: (eg, loss of consciousness, amnesia)

Behavioral changes: (eg, irritability)

Cognitive impairment: (eg, slowed reaction times)

Sleep disturbance: (eg, drowsiness)


4th Zurich Consensus & SCAT3

ON FIELD ASSESSMENT

When a player shows ANY features of a concussion:

A. The player should be evaluated by a physician or otherlicensed healthcare provider onsite using standard emergency management principles and particular attentionshould be given to excluding a cervical spine injury.

238

ON FIELD ASSESSMENT


B. The appropriate disposition of the player must be determined by the treating healthcare provider in a timelymanner. If no healthcare provider is available, the playershould be safely removed from practice or play andurgent referral to a physician arranged.

239 ON FIELD ASSESSMENT


C. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools.

NOTE: The SCAT3 does not include vitals and cranial nerve examination. We have added these as a part of the EMR form, as it is our assertion that these should be performed prior to the SCAT3.

240

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ON FIELD ASSESSMENT


D. The player should not be left alone following the injuryand serial monitoring for deterioration is essential overthe initial few hours following injury.

241 ON FIELD ASSESSMENT


E. A player with diagnosed with a concussion should not beallowed to RTP on the day of injury.

242

IN OFFICE ASSESSMENT

A. A medical assessment including comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning, gait and balance.

This is encompassed by the SCAT3 in conjunction with cranial nerves and vitals.

243 IN OFFICE ASSESSMENTB. A determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury.Clinical: diminishing performance on SCAT3 tests, deterioration of vital signs/nerve function

244

IN OFFICE ASSESSMENT

C. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

Ambulance transport, high flow O2 with airway management, CT is imaging of choice

245 FURTHER INVESTIGATION

Imaging: not helpful for concussion at this time. Vital if SDH is suspected.

Balance testing: reliable and valid Genetic markers: interesting but don’t help us

clinically Electrophysiology: abnormal if concussed, but

don’t help clinically

246

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Neuropsychological Assessment

Cognitive recovery may occur with, before of after symptom resolution.Don’t use IMPACT as sole RTP determinant

Neuropsychologist referral for prolonged casesAvailability in other clinics?

247 ROLE OF PHARMACOLOGY

No NSAIDS!!!!!

Tylenol is ok.

Any other meds are experimental at best.

248

MODIFIERS

Female LOC > 1 min Amnesia doesn’t tell us much Neither do seizures… Depression may be concussion related.

249 Elite Athletes

Get managed just like everyone else….

250

Physical Examination

Inspection Eyes

Pupil size and reactivity Conjugate gaze

Palpation Head Neck

Cervical spine AROM PROM

Motor Exam UE LE!

Cranial Nerve Screen1. CN 1 – Smell2. CN 2 – Visual acuity / visual fields3. CN 3, 4, 6 - Pupil reflexes, Size, Field of gaze

(peripheral fields)4. CN 5 – Jaw clinch, face sensation5. CN 6 – see above6. CN – 7 Smile, Frown, raise eyebrows7. CN – 8 Acoustic – softly rub fingers near each ear for

example8. CN – 9/10 Palate elevation, uvula deviation9. CN – 11 Resisted head rotation, shrugging shoulders10. CN – 12 Stick out the tongue and move it side to

side.

Balance Testing Postural stability deficits lasting approximately 72

hours following sport-related concussion.

Postural stability testing a reliable and valid tool for objectively assessing the motor domain of neurologic function.

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Balance Error Scoring System (BESS) A clinical field test that can be used for sideline

evaluations of an athlete's postural stability after a MTBI. The BESS measures an athlete's postural stability through

a clinical-assessment battery and is scored by counting the errors the athlete commits during the tests

The BESS can be used to compare baseline scores with scores after an MTBI.

Advantages It can be used for sideline applicationLess expensive than force-platform systemsRequires less training for administration

Balance Error Scoring System (BESS) One of the signs of a concussion is poor balance.

An athlete's balance and equilibrium can be tested quickly on the sideline.

The BESS consists of 3 tests lasting 20 seconds each, performed on two different surfaces, firm and foam

BESSBalance Error Scoring System The athlete first stands with the feet together, hands on the hips, eyes

closed (double leg stance). Holds this stance for 20 seconds while the number of balance errors are

recorded. Errors are:

Opening the eyes Hands coming off hips A step Stumble or fall Moving the hips more than 30 degrees Lifting the forefoot or heel Remaining out of testing position for more than 5 seconds)

Balance Error Scoring System The test is then repeated with a single-leg stance using

the non-dominant foot A third time using a heel-toe stance with the non-

dominant foot in the rear (tandem stance). All three tests are performed on a firm surface (grass,

turf, court), and again on a piece of medium-density foam (a piece of foam can easily be carried in a travel trunk or equipment bag for road games).

Balance Error Scoring System Clinicians who use the BESS as part of their sideline

assessment for concussion should not administer the test immediately after a concussion due to the effects of fatigue.

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Neuropsychological TestsComputerized Neuropsychological Tests

Factors Influencing Neuropsychological Test Performance

Exertional/Provocative Tests Forty yard sprint 1 0 - push-ups, setups, knee bends Any appearance of symptoms is abnormal

Headache Dizziness Nausea Visual disturbance Unsteadiness

DO NOT FORGET THE EXERTIONAL TESTS! The are not asymptomatic until they are asymptomatic at rest and with

exertion.

American Academy of Neurology’s 62nd Annual Meeting in Toronto April 2010 Research has shown that

reaction time is slower after a concussion—even as long as several days after other symptoms are gone.

A simple, inexpensive device to measure reaction time: a cylinder attached to a weighted disk. The examiner releases the device and the athlete catches it as soon as possible.

American Academy of Neurology’s 62nd Annual Meeting in Toronto

For the study, the researchers gave the test to 209 Division I college football, wrestling and women’s soccer athletes during their preseason physicals. Then any athlete who had a concussion diagnosed by a physician during the season took the test again within three days of the concussion.

Eight athletes had concussions during the study. Of those, seven of the athletes had a prolonged reaction time after the concussion compared to the preseason time. Catching the object took about 15 percent longer

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current concepts in concussion management wi

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