sport medicine centre dr. victor lun, md, ccfp, dip sport med concussions in sport
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Sport Medicine Centre
Dr. Victor Lun, MD, CCFP, Dip Sport Med
Concussions in Sport
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OutlineOutlineMechanism of InjuryMechanism of Injury
Concussion GuidelinesConcussion Guidelines
Clinical Evaluation Clinical Evaluation
Return to Play ManagementReturn to Play Management
Concussion PreventionConcussion Prevention
Recurrent ConcussionsRecurrent Concussions
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Concussion - MechanismsConcussion - Mechanisms
Rapid decelerationRapid deceleration Extension-flexion Extension-flexion
movementmovement RotationRotation Snowboarding – fall on Snowboarding – fall on
the back of the head the back of the head
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Concussion - MechanismsConcussion - MechanismsThe brain floats in The brain floats in
cerebrospinal fluid cerebrospinal fluid and is protected by and is protected by the skull. the skull.
The brain will rotate The brain will rotate and twist inside the and twist inside the skull which can result skull which can result in localized and in localized and diffuse damagediffuse damage
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Concussion - MechanismsConcussion - Mechanisms
ModModMildMild SevereSevere
Severe (Coma)Severe (Coma) GCS < 8 GCS < 8Moderate Moderate GCS 9 - 12 GCS 9 - 12
Mild Mild GCS 13 - 15 GCS 13 - 15
Teasdale et al Lancet 1974; ii: 81-4Teasdale et al Lancet 1974; ii: 81-4
ConcussionConcussion
?
GCSGCS
““MinimalMinimal””
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27+ different grading systems in 27+ different grading systems in literature !!literature !!
No universal agreement with regards to No universal agreement with regards to injury definition and return to play injury definition and return to play guidelinesguidelines
Old Concussion GuidelinesOld Concussion Guidelines
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Common elements: memory, loss of Common elements: memory, loss of consciousness, and symptomsconsciousness, and symptoms
Used to assess severity of a concussionUsed to assess severity of a concussionPoor prognostic valuePoor prognostic valueVarying return to play timelinesVarying return to play timelines
Old Concussion GuidelinesOld Concussion Guidelines
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New Concussion GuidelinesNew Concussion Guidelines1st International Symposium on
Concussion in Sport, Vienna, 2001, Vienna, 20012nd International Symposium on
Concussion in Sport, Prague, 2004, Prague, 2004• NIH consensus formatNIH consensus format• World’s experts in concussionWorld’s experts in concussion
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New Concussion ClassificationNew Concussion Classification
SimpleSimpleComplexComplex
Summary and Agreement Statement of the 2nd International Symposium on Concussion in Sport. Clin J Sports Med 15(2): 48-56 , 2005
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What is a Simple Concussion?What is a Simple Concussion?
Symptoms?Symptoms?Pattern of gradual resolutionPattern of gradual resolutionWithout complicationWithout complicationResolution over 7-10 daysResolution over 7-10 days
Memory dysfunction?Memory dysfunction?TransientTransient
Loss of Consciousness?Loss of Consciousness?Transient / “blacked out”Transient / “blacked out”
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What is a Complex Concussion?What is a Complex Concussion?
Symptoms?Symptoms?ConvulsionsConvulsions> 10 days> 10 days
Loss of Consciousness?Loss of Consciousness?> 1 minute> 1 minute
Referral to sports concussion Referral to sports concussion specialist recommendedspecialist recommended
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Simple or Complex??Simple or Complex??
HistoryHistoryPhysical examPhysical examSerial Serial
assessmentassessmentRetrospective Retrospective
DiagnosisDiagnosis
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Evaluation - HistoryEvaluation - History
Circumstances of injuryCircumstances of injurySymptoms immediate post injury Symptoms immediate post injury Current symptomsCurrent symptomsAsk patient, family member, coach Ask patient, family member, coach
etc. to corroborateetc. to corroborateCheck video if availableCheck video if available
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> 90% of sport-related > 90% of sport-related concussion have no L.O.C.concussion have no L.O.C.
Any sportAny sport
Evaluation – Evaluation – SymptomsSymptoms
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Symptoms often minimized by athleteSymptoms often minimized by athlete Everyone “feels fine”Everyone “feels fine” Better to ask:Better to ask:
1.1. ““On a scale of 0 to 100%, how do you feel?”On a scale of 0 to 100%, how do you feel?”
2.2. ““What makes you not 100%” or “What’s What makes you not 100%” or “What’s missing”missing”
Evaluation – Evaluation – SymptomsSymptoms
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Sport Concussion Sport Concussion Assessment Tool (SCAT)Assessment Tool (SCAT)
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Sport Concussion Sport Concussion Assessment Tool (SCAT)Assessment Tool (SCAT)
•Standardized tool •Patient education and physician assessment of sport concussion•Combination of existing tools
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SCATSCAT – Symptom Scale – Symptom Scale
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Evaluation – Evaluation – SymptomsSymptoms
HeadachesHeadaches 67%67%
ConfusionConfusion 29%29%
DizzinessDizziness 29%29%
NauseaNausea 21%21%
Neck PainNeck Pain 20%20%
Blurred VisionBlurred Vision 20%20%
FatigueFatigue 15%15%
Light sensitivityLight sensitivity 7%7%
FrequencySymptom
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SCATSCAT - Assessment - Assessment
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Evaluation - ExaminationEvaluation - Examination NeurocognitiveNeurocognitive
Modified Maddocks questionsModified Maddocks questions5 word recall (immediate & delayed)5 word recall (immediate & delayed)months of year in reversemonths of year in reversereverse digits (string of 5 or 6)reverse digits (string of 5 or 6)
Neurological examNeurological examSpeechSpeechEye motionEye motionPronator DriftPronator DriftGait/ Balance AssessmentGait/ Balance Assessment
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If concussion is suspected:If concussion is suspected:
Remove from activity and observeRemove from activity and observe
If prolonged LOC or neurological If prolonged LOC or neurological
concerns, C-spine precautions and concerns, C-spine precautions and
hospital assessmenthospital assessment
Return-to-Play ManagementReturn-to-Play Management
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RestRest Rest Rest RestRest
Physical RestPhysical Rest
•No “light” exercise or cross No “light” exercise or cross trainingtraining
•No weight trainingNo weight training
•No physical activity!!!No physical activity!!!
Return-to-Play ManagementReturn-to-Play Management
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RestRest Rest Rest RestRest
Cognitive restCognitive rest
• School, computer work,
video games
Return-to-Play ManagementReturn-to-Play Management
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Return-to-Play ManagementReturn-to-Play Management
Rest for how long?Rest for how long? If rapid and full recovery, then 24-48 If rapid and full recovery, then 24-48
hourshoursFor the same amount of time as it took For the same amount of time as it took
to become asymptomatic (especially in to become asymptomatic (especially in the pediatric age group)the pediatric age group)
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Neuropsychological TestingNeuropsychological Testing Detecting cognitive abnormalitiesDetecting cognitive abnormalities
Memory, concentration, “information Memory, concentration, “information processing”processing”
Best when compared to baseline dataBest when compared to baseline data
Return-to-Play ManagementReturn-to-Play Management
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Neuropsychological TestingNeuropsychological Testing Types: Traditional 6 hour battery, Types: Traditional 6 hour battery,
Web-based programsWeb-based programs
www.cogsport.com
Return-to-Play ManagementReturn-to-Play Management
www.impacttest.com
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Return-to-Play ManagementReturn-to-Play Management Graded Exercise ChallengeGraded Exercise Challenge
ExerciseExercise● Aerobic x 10 min HR<130 Aerobic x 10 min HR<130
bpmbpm● Aerobic x 30 min with Aerobic x 30 min with
intervalsintervals● Protected sport-specific Protected sport-specific
practicepractice● Full sport-specific practiceFull sport-specific practice● Return to sportReturn to sport
GoalGoal Increase HRIncrease HR Max. HRMax. HR Add movementAdd movement HR + movementHR + movement Exercise + Exercise +
coordination + coordination + thinkingthinking
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24 hours per step
If there is recurrence of symptoms at any stage, return to step 1
Return-to-Play Management Return-to-Play Management
Graded Exercise ChallengeGraded Exercise Challenge
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Return to Play ManagementReturn to Play Management
Other factorsOther factors Ready to return (confidence)Ready to return (confidence) EquipmentEquipment
Helmet and mouthguardHelmet and mouthguard
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How Many Is Too Many?How Many Is Too Many?
Lack of agreement on number of Lack of agreement on number of concussions “allowed” before concussions “allowed” before termination of season or careertermination of season or career
Evidence of cumulative effectEvidence of cumulative effectWith each successive concussion:With each successive concussion:
Lower threshold for injuryLower threshold for injuryMore severe symptomsMore severe symptomsLonger lasting symptomsLonger lasting symptomsRisk of subsequent injury higherRisk of subsequent injury higher
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● Longer period of asymptomatic rest Longer period of asymptomatic rest before starting graded exercise challengebefore starting graded exercise challenge
● Extend the time for each stage of Extend the time for each stage of exertional protocolexertional protocol
● Take period of time/season off if showing Take period of time/season off if showing lower threshold / longer recoverylower threshold / longer recovery
● More conservative with younger patient More conservative with younger patient (“susceptibility”?)(“susceptibility”?)
Managing Recurrent Concussion Managing Recurrent Concussion
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QUESTIONS?QUESTIONS?