These are the CURRENT conceptsvery likely to evolve 80-90% of
concussions resolve in 7-10 days Majority of concussions do not
involve loss of consciousness No same day return to play Sports
Concussion Assessment Tool (SCAT-3) New Imaging and Treatment
options are on the horizon State of the Art treatment currently:
Rest
Slide 5
Background Concussion
Slide 6
Background CDC estimates 1.6 3.8 million concussions occur
annually in sports/rec activities in the US each year 33% of all
concussions are sports- related (ages 5-19)
Slide 7
Background
Slide 8
Definition: Concussion (Zurich 2012) Concussion is a brain
injury and is dened as a complex pathophysiological process
affecting the brain, induced by biomechanical forces. Several
common features that incorporate clinical, pathologic and
biomechanical injury constructs that may be utilized in dening the
nature of a concussive head injury include: 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.
Concussion typically results in the rapid onset of short-lived
impairment of neurologic function that resolves spontaneously.
However in some cases symptoms and signs may evolve over a number
of minutes to hours. Concussion may result in neuropathological
changes but the acute clinical symptoms largely reect a functional
disturbance rather than a structural injury and as such, no
abnormality is seen on standard structural neuroimaging studies.
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, post-concussive
symptoms may be prolonged.
Slide 9
Definition: Concussion (AMSSM): A traumatically induced
transient disturbance of brain function and involves a complex
pathyphysiological process. Concussion is a subset of mild
traumatic brain injury which is generally self-limited and at the
less-severe end of the brain injury spectrum
Slide 10
Definitions Concussion and Traumatic Brain Injury
Slide 11
Definitions Post-Concussion Syndrome AMSSM Position Statement
2013: Difficult to determine where concussion ends and
post-concussion syndrome begins Symptoms and signs that persist for
weeks to months Zurich 2012: Prolonged Symptoms: Symptoms > 10
days 10-20% of concussions
Slide 12
Definitions Second Impact Syndrome Numerous case reports,
essentially all under 22 years old Rare, but devastating event
Unclear whether this has occurred in an asymptomatic person Head
trauma on already injured brain worsening metabolic changes in the
cells Coherent for 15-60 seconds rapid coma and respiratory
failure
Slide 13
Concussion Legislation Colorados Senate Bill 40 The Jake
Snakenberg Youth Concussion Act Signed March 29, 2011
Slide 14
Colorado Senate Bill 40
Slide 15
Senate Bill 40 Requirements 1.Training of coaches 2.Removal
from play 3.Notification of a parent 4.Sign-off on return to play
be medical provider
Slide 16
Concussion Presentation Multiple manifestations No two
concussions are exactly the same Headache most common symptom;
dizziness second 90% do not include loss of consciousness
Slide 17
Signs and Symptoms
Slide 18
Symptoms Randolph, et al (2009): 12 Validated Symptoms:
Concussion Symptom Inventory Headache Nausea Balance
problem/dizziness Fatigue Drowsiness In a fog Difficulty
concentrating Difficulty remembering Sensitivity to light
Sensitivity to noise Blurred vision Feeling slowed down
Slide 19
On-field/Sideline Evaluation of Acute Concussion Should occur
if concussion even suspected Player evaluated by physician or other
licensed healthcare provider If no healthcare provider available
remove from practice/play, refer ABCs, Exclude cervical spine
injury After first aid issues addressed Sideline assessment tool Do
not leave player alone monitor over a few hours A player with a
diagnosed concussion should NOT be allowed to return to play on the
day of injury When in doubtsit them out!
Slide 20
Sport Concussion Assessment Tool
Slide 21
SCAT 3
Slide 22
Symptoms
Slide 23
SCAT 3
Slide 24
Slide 25
Slide 26
Referral to Emergency Department? Worsening/Severe headache
Deteriorating mental status Active vomiting Focal neurologic
findings Numbness, tingling, weakness, seizure, unequal pupils
Slide 27
Office or Emergency Department Evaluation Full history,
detailed neurological exam Essentially perform a SCAT3 Determine
clinical statusimproving or deteriorating? Determine need for
emergent neuroimaging in order to exclude a more severe brain
injury involving a structural abnormality
Slide 28
Investigations/Studies
Slide 29
Postural stability testing Often returns to normal after 72
hours post-conc Force plate technology Balanced Error Scoring
System
Slide 30
Investigations/Studies Imaging of the Brain CT, MRItypically
normal If suspicion of intracerebral or structural lesion exists
Imaging Prolonged disturbance of conscious state Focal neurological
deficits Worsening symptoms
Slide 31
Investigations/Studies Imaging of the Brain Alternative imaging
Several methods being investigated Exciting area of research
Slide 32
Investigations/Studies Electrophysiological Recording
Techniques Electroencephalogram (EEG) Evoked response potential
(ERP) Cortical magnetic stimulation Reproducible abnormalities in
post- concussive state Not all studies differentiate concussed
athletes from controls
Slide 33
Investigations/Studies Neuropsychological AssessmentComputer
Testing Evaluating cognitive recovery Important component in
overall assessment and return to play Baseline testing useful Aids
in clinical decision makingbut not the sole basis of management
decisions
Slide 34
Investigations/Studies Neuropsychological Assessment Formal
Neuropsych testing Trained Neuropsychologist Not required for all
May be beneficial in prolonged symptoms Help identify other
conditions
Slide 35
Investigations/Studies Genetic testing and Biomarkers
Insufficient evidence for routine clinical use Apo E4, ApoE
promotor gene, Tau polymerase IGF-1, IGF binding protein 2,
Fibroblast growth factor, Cu-Zn superoxide dismutase, nerve growth
factor, S-100 Serum and Cerebral Spinal Fluid biomarkers being
evaluated
Slide 36
Management Cornerstone REST
Slide 37
Management Rest Physical Rest No training, playing, exercise,
weight lifting Exertion with ADLs Cognitive rest Minimize TV,
extensive reading, video games Limit to exacerbation of
symptoms
Slide 38
Management Return to school and social activities Encouraged
School Accommodations Extra time or delay tests and quizzes until
student is asymptomatic Partial days CDC: educational materials for
teachers/administrators
Slide 39
Management Gradual resolution 80-90% of concussions resolve in
a short period (7-10 days) Recovery may be longer in children and
adolescents May require multiple office visits
Slide 40
Recovered? Everyone says they feel fine Ask: 1.On a scale of
0100%, how do you feel? 2.What makes you not 100%? 3.Symptom
ChecklistSCAT 3
Slide 41
Graduated Return to Play Protocol 24 Hours per step (so almost
a week for full protocol) If symptoms recur return to previous
level Evaluation by health care provider required for school age
athletes Rehabilitation stageFunctional exercise at each stage of
rehabilitation Objective of each stage 1. No activitySymptom
limited physical and cognitive rest. Recovery 2.Light aerobic
exercise Walking, swimming or stationary cycling keeping 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 e.g. passing drills in
football and ice hockey. May start progressive resistance training
Exercise, coordination, and cognitive load 5.Full contact
practiceFollowing medical clearance participate in normal training
activities Restore confidence and assess functional skills by
coaching staff 6.Return to playNormal game play
Slide 42
Difficult casespersistent symptoms Symptoms >10 days
Sports-related concussions less likely to result in PCS Consider
other issues:Depression? Chronic headaches? Learning disorders?
Multidisciplinary clinic Childrens Hospital Complex Concussion
Clinic Sub-symptomatic exercise may be beneficial
Slide 43
Management Pharmacotherapy Useful for prolonged symptoms Sleep
disturbance Anxiety Anti-depressants Upon return to play should not
be on medications that could mask symptoms Avoid NSAIDs in first
48-72 hours TCAs, Amantadine, Methylphenidate commonly reported as
being used for management Antioxidants?
Slide 44
Other Treatment Vestibular Therapy Balance Therapy Transcranial
LEDChronic TBI Red and Near-Infrared LED applied
transcranially
Slide 45
Chronic Sequelae? Chronic cognitive dysfunction Chronic
Traumatic Encephalopathy Chronic Neurocognitive Impairment CTE
unknown incidence in athletic populations, cause/effect not yet
demonstrated between CTE and concussions or exposure to contact
sport Acknowledge potential for long-term problems in all athletes
To Be Determined
Slide 46
Prevention Protective equipment Mouth guards Prevent oral
injuries Head gear and helmets Reduce impact forces, not
concussions Reduce head and facial injury Cervical muscle
strengthening?
Slide 47
Other Issues Rule Changes Checking Limiting contact practices
Heading in soccer (50% of concussions are due to arm to head
contact) Education of athletes, parents, coaches Awareness of
concussion symptoms and signs Web-based resources, social
media
Slide 48
Questions How many concussions is too many? Who will develop
CTE? Number of hits? More significant concussions? Evolving role of
advanced imaging? What treatments may prove beneficial in
concussion? Validation of tools? Prevention?
Slide 49
Key Points These are the CURRENT conceptsvery likely to evolve
80-90% of concussions resolve in 7-10 days Majority of concussions
do not involve loss of consciousness No same day return to play
Sports Concussion Assessment Tool (SCAT-3) Imaging and Treatment
options are on the horizon State of the Art treatment: Rest
Slide 50
References Consensus statement on concussion in sport: the 4th
International Conference on Concussion in Sport held in Zurich,
November 2012. Br J Sports Med 2013;47:250-258. McCrory P, Johnston
K, Meeuwisse Wet al. Summary and agreement statement of the 2nd
International Conference on Concussion in Sport, Prague 2004. Br J
Sports Med 2005;39:196204. Efficacy of amantadine treatment on
symptoms and neurocognitive performance among adolescents following
sports-related concussion. Reddy CC, Collins M, Lovell M, Kontos
AP. J Head Trauma Rehabil. 2013 Jul-Aug;28(4):260-5. Management
strategies and medication use for treating paediatric patients with
concussions. Kinnaman KA, Mannix RC, Comstock RD, Meehan WP 3 rd.
Acta Paediatr. 2013 Sep;102(9):e424-8. Vestibular and balance
treatment of the concussed athlete.Aligene K, Lin E.
NeuroRehabilitation. 2013;32(3):543-53. Should we treat concussion
pharmacologically? The need for evidence based pharmacological
treatment for the concussed athlete. McCrory P. Br J Sports Med.
2002 Feb;36(1):3-5. American Medical Society for Sports Medicine
position statement: concussion in sport. Harmon KG, Drezner J,
Gammons M, Guskiewicz K, Halstead M, Herring S, Kutcher J, Pana A,
Putukian M, Roberts W; American Medical Society for Sports
Medicine. Clin J Sport Med. 2013 Jan;23(1):1-18.