Overview of ‘Concussion In Sport’

SymposiumSymposium

Margo Mountjoy M.D.Sports Medicine

Health and Performance Centre

January 17, 2013

Statistics

Incidence of sport-related concussion in

Canada estimated to be 30, 000 per year.

Likelihood of an athlete in a contact sport Likelihood of an athlete in a contact sport

sustaining a concussion

Up to 19% per season

Symposium Overview

Definition

Diagnosis

TreatmentTreatment

Return to play

Special populations

Prevention

What is a Concussion?

“... a complex

pathophysiological process

affecting the brain, affecting the brain,

induced by traumatic

biomechanical forces”

McCrory et. Clin J Sports Med 19(3): 185-195, 2009

•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

•Most concussions have a quick onset of symptoms that

resolve almost immediately

•Most changes that happen with the brain affect how it

functions, rather then its structure.

•As a result tests like MRI, CT Scans, X-ray do not show

findings

Symposium Overview

Definition

Diagnosis

TreatmentTreatment

Return to play

Special populations

Prevention

Clinical Diagnosis of Exclusion

Symptoms

•Headache

•Dizziness

•Nausea

Physical signs • Loss of consciousness

• Balance difficulties

• Seizure

• Sleep disturbance•Nausea

•Blurred vision

•Ringing in the ears

•Slurred speech

• Sleep disturbance

Behavioural changes• Irritablity

• Emotional lability

• Personality changes

Clinical Diagnosis of Exclusion

Cognitive impairment

Slowed reaction times

Impaired calculation

Memory disturbance

Field of Play Assessment

1.Standard emergency clinical assessment

2. Cervical spine injury

3. Intracranial injury 3. Intracranial injury

4. Loss of consciousness

5. Serial assessments over first few hours

Under no circumstances should the athlete return to play on the same day!!!

Remove from field of play

Field of Play: Management

Medical assessment

Monitor for signs of deterioration

Office AssessmentHistory

Mechanism of injury

Early symptoms and signs

History of previous concussions

Co-morbidities

Current symptomatology

Physical Examination

Neurological examination

BESS testing

SCAT2 (to be renamed SCAT3 plus a new Child SCAT!)

“Concussion Recognition Tool –CRT”

Investigations: Current and Future

•Neuropsychological testing

•Genetic testing

•F MRI

•King Devick (eye tracking)

Symposium Overview

Definition

Diagnosis

TreatmentTreatment

Return to play

Special populations

Prevention

Treatment

• Physical Rest

• No sport

•Cognitive Rest

•Minimize screen time

•Time from school • Avoid active play

• No gym at school

•Time from school

•Regular sleep

•Avoidance of ETOH/drugs

Clinical Treatment

First address if any….

•Cervical spine injury•Cervical spine injury

•Headache

•Depression

Symposium Overview

Definition

Diagnosis

Treatment

Return to play

Special populations

Prevention

Return to Play

Return to Play

•Must pass the graded exertion (previous slide)

•Must feel confident to RTP

•New helmet if needed•New helmet if needed

•Other behaviours/ factors

•Other multiple/ recent injuries

Symposium OverviewDefinition

Diagnosis

Treatment

Return to play

Special populations

Prevention

Special Population: Pediatric

•Age specific physical and cognitive rest issues

•Symptom resolution may take longer

•Extend symptom free period before starting RTP protocol

•Extend length of the graded exertion protocol

Special Population: Elite vs. Non-Elite

No difference in treatment!

An athlete is a person/ patient first!An athlete is a person/ patient first!

Symposium Overview

Definition

Diagnosis

TreatmentTreatment

Return to play

Special populations

Prevention

Prevention: Pre-Event Screening

•Number of prior concussions

•Non-sport head injuries

•Previous facial/ dental injuries

•Type of player (aggressive)

•Ability to take a hit•Ability to take a hit

•Baseline SCAT taken?

•Protective equipment

Helmet age

Helmet fitting

Mouth guard

Full face mask

Prevention: Athlete Skills and Education

�Be a good skaterWork on balance and agility

�Keep your head upPractice stick handling

�Keep your arms upWhen going into boards use hands & arms to absorb shock

�Approach boards on an angle�Approach boards on an angle

�Know the Danger Zone3-4 feet from boards

�Neck Strengthening� May help reduce concussions

Prevention: Athlete Skills

•Don’t hit from behind

•If you see the numbers, don’t hit

• Control your stick responsibly

• Do not make suicide passes

•Don’t hit to the head

•Hit with shoulders, not elbows, hands, or stick

• Communicate with teammates

• RESPECT YOUR OPPONENTS!!!!

Prevention: Sport Rule Changes

�Federation rule changes

�Implementation & monitoring

�“Zero” tolerance head checking�“Zero” tolerance head checking

�Body checking – pee wee hockey

�Political Legislation- Lystedt Law