[PDF] - Disclosure Current Standards for Managing Sports Concussion PDF Document

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Current Standards for Managing Sports Concussion

A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco

Primary Care Medicine: Update 2017

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Disclosure

Founder, RunSafe™
Founder, SportZPeak Inc.
Sanofi, Investigator initiated grant

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Objectives:

1. What is a concussion?
2. How do you manage a concussion

initially?

3. When would an athlete return to

activities?

4. What are the long term consequences of

concussion?

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What is a Concussion?

Type of mild traumatic brain injury
Blow to head, neck, body  force to head.
Neurologic impairment within 48 hours of trauma.
Symptoms usually resolve in 1-2 weeks

spontaneously but in some cases can be prolonged.

May or may not include loss of consciousness.

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Physical Cognitive Emotional Sleep

Concussion Symptoms

http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. 6

Shear and Strain

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Pathophysiology - Neurometabolic Cascade

Force to brain Ion fluxes; vasocon- striction Need glucose but less blood flow

Energy crisis

Giza CC and Hovda DA, J of Athletic Training, 2001. Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. 8

OLD SCHOOL - Grading Concussions (AAN)

Severity Signs/Symptoms Grade I (mild) Transient confusion, no LOC, resolves in <15 minutes Grade 2 (moderate) Transient confusion, no LOC, resolves in > 15 minutes Grade 3 (severe) Any LOC: brief (sec) or prolonged (minutes)

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Concussion Severity?

Concussion grading is retrospective
Historically concussions were graded on the

sideline based on amnesia and LOC at time of injury.

– American Academy of Neurology, 1997; Cantu, 2001

Studies have shown these factors not to be

predictive of recovery.

Only when the athlete recovers can you tell

how severe the concussion was

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Case 1

17 y/o high school lacrosse player presents to your

ffice with a concussion. He is a senior and his last

high school game is in 4 weeks. He has no history

f concussion, depression, or anxiety.

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What is the likelihood that he will be back to play in his last game?

A. High: 90% of sports concussion patients are

better within 3 weeks of injury.

B. Moderate: 65% of sports concussion patients

are better within 3 weeks of injury.

C. Low: 25% of sports concussion patients are

better within 3 weeks of injury.

D. Zero: sports concussion patients should rest

from contact for at least 4 weeks post injury.

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Concussion Symptom Evaluation

SYMPTOMS

s/p 6d Headache

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“Pressure in Head”

3

Neck Pain Nausea / Vomiting Dizziness

2

Blurred Vision Balance Problems

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Sensitivity to Light

2

Sensitivity to Noise

1

Feeling Slowed Down

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Feeling like “in a Fog”

SYMPTOMS

s/p 6d “Don’t Feel Right”

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Difficulty Concentrating

3

Difficulty Remembering

3

Fatigue / Low Energy

2

Confusion Drowsiness

2

Trouble Falling Asleep More Emotional Irritability

2

Sadness Nervous / Anxious TOTAL

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13 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 14 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 15

Red Flags

Transport to the nearest emergency department if patient experiences any of the following:

Increased headache or neck pain severity
Increased drowsiness, can’t be awakened
Increased confusion or disorientation
Unusual behavior change
Loss of consciousness or seizures
Weakness or numbness in arms or legs
Repeated vomiting
Fluid leaking from ears/nose
Slurred speech

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Concussion Evaluation: Physical exam

Normal neck exam
Normal neurologic exam

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Postural Stability

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Concussion Treatment

Cognitive rest
Physical rest
Medication
Tylenol
Ibuprofen after first 72 hours
No driving
No Etoh

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Diagnostic Imaging

Neuroimaging (CT, MRI)

Most patients do not require imaging
Use when suspicion of intracerebral structural lesion

exists:

prolonged loss of consciousness
focal neurologic deficit
worsening symptoms
Deterioration in conscious state

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NSAIDs for Headaches

No studies show that NSAIDs harmful
Anectodally, Naproxen > Ibuprofen > Tylenol
OK to Medicate if symptomatic and it helps
70% adolescent patients treated in a headache

clinic with chronic posttraumatic headaches met criteria for medication overuse headaches

Be careful of overmedicating

Halstead ME, Sports Health , 2016

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Melatonin

May have utility in reducing post traumatic

headache after mTBI

– Kuczynski A et al. Dev Med Child Neurol. 2013. – Barlow KM et al. Trials. 2014.

Growing interest in sleep disorders that

contribute to post concussion syndrome

?role for melatonin as treatment

– Sullivan KA et al. Appl Neuropsychol Adult, 2016

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Unclear Evidence

Some use but no evidence in Pediatric

concussions

Stimulants: Amantadine, Methylphenidate
IV hypertonic saline
IV therapies such as ketorolac, prochlorperazine,

metoclopramide, or ondansetron

Halstead ME, Sports Health , 2016

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Case 2

16 y/o high school student presents to your office with concussion sustained 3 days ago during

football. He reports headache, fogginess, and

dizziness that is mild to moderate intensity at home but moderately severe at school. He is resting from sports.

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What do you recommend he do with respect to school?

A. Continue school without adjustments.
B. Continue school but no test-taking.
C. Attend ½ days of school for a week, no test-

taking.

D. Rest from school until can tolerate 1-2 hours of

work at home.

E. Rest completely from school for a week.

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Return to Learn Progression

No school. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. 15 min cognitive activity at a time. Return to full day of school.

http://www.chop.edu/service/concussion-care-for-kids/returning-to- school.html 30 min schoolwork at a time until can do 1- 2 hours. Return to ½ day of school.

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UCSF Concussion Clinic School Note

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How Much Cognitive Rest Post Concussion?

88 patients (11-22 y/o) seen at pediatric ED randomized

Strict rest x 5 days vs. “usual care” of 1-2 days rest,

then stepwise return to activity

Strict rest = no school, work, or physical activity

–Neurocognitive and balance outcomes same – Strict rest group had more daily post concussive symptoms and slower symptom resolution

Thomas DG et al. Pediatrics. 2015 Slide courtesy of Cindy Chang MD

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Symptom Resolution after Sport Concussion

50% recovered and returned to play in 1 week; 90% in 3

weeks (Collins et al. Neurosurgery, 2006.)

7-10 days avg. symptom resolution.

(3rd International Conference on Concussion in Sport (2008). Clin J Sport Med, 2009.)

High schoolers take longer to recover based on

neuropsychological testing compared to college athletes. (Field et al, J Pediatr, 2003.)

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Case 3

16 y/o high school student presents to your office Monday morning with concussion sustained playing soccer 3 days ago (Friday). She initially had headache, dizziness, and fogginess, but those symptoms resolved yesterday. She is now asymptomatic with a normal neurologic exam. She has no deficits on balance testing. She has no deficits on memory testing.

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A. Today (Monday)
B. Tomorrow (Tuesday)
C. In 2 days (Thursday)
D. 1 week post injury (Saturday)
E. 2 weeks post injury

Assuming she remains asymptomatic, when would you clear her to return to full contact soccer games?

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Concussion Legislation

50 states have adopted youth concussion laws
California: education code 49475 (effective 1/2012)
1. Athletes and guardians sign a concussion

information form yearly

2. Athlete suspected of having concussion removed

at time of injury for the rest of the day

3. Athlete can return only after cleared by healthcare

professional trained in evaluation and management of concussion

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Concussion legislation

California Assembly Bill 2127 (in effect 1/2015)
Adds to AB 25

–FB full-contact practice limits: –No more than 2/week during preseason and season –These practices cannot exceed 90 minutes –No full-contact in off-season –Once clear must follow gradual return to play protocol

f at least 7 days under supervision of licensed

provider

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Concussion legislation

AB 2007 – Concussion Mgmt in Youth Sports Act

2016 –Requires youth sports participants to undergo the same safety protocols as high school athletes

AB 1451 - Coaches Concussion Training Law 2013

–Mandatory education every 2 years

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Return to Play Progression

Light aerobic activity Sport specific activity Game play

Non-contact training Full contact practice

Clinician clearance Asymptomatic 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196.

Tuesday Thursday Wednesday Friday Saturday 35

Return to play activity examples

Step Objective Activities 1 Recovery No activity 2 Increase heart rate Walking, swimming, or stationary bike. < 70% max heart rate. No weights. 3 Add movement Skating drills in hockey, running drills in soccer. No head impact activities. 4 Add coordination and cognitive load More complex drills (passing). Can start weights. 5 Restore confidence and assess functional skills by coaching staff Full-contact practice 6 Normal game play

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 36

UCSF concussion clinic sports note

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Case 3

The student athlete follows up with you as scheduled in the office on Thursday to consider full contact clearance for Friday. She did 1 hour of high intensity non contact training earlier Thursday afternoon. She felt good except for a very mild headache during the sprinting workouts. The headache is now gone. Her neurologic exam, balance testing, and memory testing is normal.

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Return to Play Progression

Light aerobic activity Sport specific activity Game play

Non-contact training Full contact practice

Clinician clearance Asymptomatic 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196.

Tuesday Thursday Wednesday 39

What do you do next?

A. Clear her for full contact practice on Friday followed

by full contact game on Saturday.

B. Have her return to sport specific activity on Friday,

then do non contact training Saturday and see you next week to consider full clearance.

C. Recommend rest from sports over the weekend,

follow up with you next week.

D. Recommend rest from sports for one week, follow up

with you in 2 weeks.

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Return to Play Progression

Light aerobic activity Sport specific activity Game play

Non-contact training Full contact practice

Clinician clearance Asymptomatic 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196.

Tuesday Thursday Wednesday

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Symptoms during return to play

If symptomatic during a step of the return to play

protocol…

Stop activity
Rest until symptoms resolve, at least 24 hours.
Resume return to play protocol at the step where athlete

was last asymptomatic

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 42

Case 4

30 y/o recreational rugby player comes to your office with her 5th lifetime concussion. She suffered this most recent injury when she took a relatively insignificant hit to the body during a game. She immediately had headache, photophobia, nausea and came out of play. Her 4th concussion led to headaches x 6 months and interfered with her ability to do her job. She recovered 3 months ago from that injury.

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Should she retire from rugby?

A. Yes. An athlete with 3 concussions or more should no

longer play contact sports.

B. Yes. She likely has early onset dementia and should

stop playing contact sports.

C. Yes. She is showing a decreased threshold for injury

with increased severity of injury.

D. No. She can return as long as she wears a rugby scrum

cap for protection.

E. No. She can return as long as she plays a lower risk

position.

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Is Concussion Really a “Mild” Traumatic Brain Injury?

http://www.bu.edu/cte/about/what-is-cte/

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Chronic Traumatic Encephalopathy

Athletes and military personnel
Chronic, progressive depression, cognitive

impairment, aggression

Diagnosed at autopsy: tau protein deposition
Difficult to draw causality – no prospective data yet
Concerning association between professional sports

participation and long term neurologic/psychological problems

Gardner A et al. Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med. 2013 Jun 26. Randolph C. Is chronic traumatic encephalopathy a real disease? Current Sports Med Review, 2014. 46

Prevention: Protective gear

Benson BW et al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med. 2013. 47

How Many Concussions is Too Many?

Individualized to athlete.
Concussion hx.

–Number. –Less force. –More frequent. –Increased severity of sxs –Increased duration of sxs. –Age: possibly more consequences if younger at time of concussion.

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Keys to Managing Sports Concussion

Treatment is rest.
Gradual return to learn.
Gradual return to play.
Note for school and sports each visit.
Monitor for repeat injury.
No recommended protective gear
Association between concussion and dementia (causality

not proven)

Treat each case individually.

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