UCSF 2 nd Annual Primary Care Sports Medicine Conference ABCs of Musculoskeletal Care Sports Concussion Workshop November 30, 2007

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1 UCSF 2 nd Annual Primary Care Sports Medicine Conference ABCs of Musculoskeletal Care Sports Concussion Workshop November 30, 2007 Bill Durney MBA, ATC UCSF Orthopaedic Surgery & Sports Medicine Practice Manager

2 Incidence Probably under- reported 300,000 per year sport related TBI in USA 20% per year in high school football Most often occur when: - 43% - Making a tackle - 23% - Being tackled - 20% - Blocking - 10% - Being blocked

3 Sports Concussion Signs and Symptoms Cognitive features Unaware of period, opposition, score of game Confusion Amnesia Loss of Consciousness Typical symptoms Headache of pressure in the head Vertigo Nausea Feeling dinged, foggy, stunned, or dazed Visual problems (e.g. stars, flashing lights, diplopia) Hearing problems tinnitus Irritability or emotional changes Physical Signs LOC or impaired conscious stare Poor coordination or balance Concussive convulsion/impact seizure Slow to answer or follow instructions Easily distracted, poor concentration Displaying inappropriate emotions (e.g. laughing, crying) Vomiting Vacant stare / glassy eyed Slurred speech Personality changes Decreased playing ability

4 Concussion Grading Scales At least 20 published head injury grading and return to play systems exist Cantu, Colorado, AAN most popular Remain controversial Most are impractical for clinical use All based on limited scientific evidence

5 1st International Symposium on Concussion in Sport Vienna 2001 ~Recommendations~ Injury grading scales be abandoned in favor of combined measures of recovery in order to determine injury severity (and/or prognosis) and hence individually guide return to play decisions. Clinical construct using an assessment of injury recovery and graded return to play recommended.

6 2nd International Symposium on Concussion in Sport Prague 2004 Continued support of Vienna conference recommendations New classification of concussion in sport: Concussion severity can only be determined in retrospect after all concussion symptoms have cleared, the neurological examination is normal, and cognitive function has returned to baseline. Simple Complex

7 Simple vs. Complex Simple: athlete suffers an injury that progressively resolves without complication over days. No neurophyschological screening Can be appropriately managed by primary care physicians and certified athletic trainers. Cornerstone of management is rest until all symptoms resolve and then a graded programme of exertion before RTP. Complex: athlete suffers an injury where persistent symptoms (including persistent symptom recurrence with exertion), specific sequelae (such as concussive convulsions), prolonged loss of consciousness (more than one minute), or prolonged cognitive impairment exist. evident with repeated concussive trauma Formal neuropsychological testing and other investigations should be considered. Managed by a multidisciplinary team of care.

8 Acute Sport Concussion On Field Management 1. Remove from play 2. Monitor athlete regularly 3. Medical evaluation Physical signs (Head, face, skull, neck, ENT, motor-sensory) Neurological (Pupillary( response, cerebellar testing, speech, coordination, etc.) Orientation (name, date, time, location?) Amnesia (opposing team, score, what was the last play, what happened?) Memory (immediate and delayed) Cognitive assessment (serial 7 s 7 s backwards from 100, months of the year backwards, digits backwards, etc.) 4. Return to play should follow a medically supervised stepwise process *Assessment tools (SCAT, ImPACT,, SAC, etc.)

9 SCAT Card

10 Return to Play Guidelines 1. No activity, complete rest 2. Light aerobic exercise 3. Sport specific exercise 4. Non-contact training drills 5. Full contact training after medical clearance 6. Game play Athlete continues to proceed to the next level if asymptomatic at the current level. If any post-concussion symptoms occur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours. Return to sport decision should be made by a physician.

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13 Following is a list of 10 guidelines from NATA to help prevent and ultimately manage concussions in youth, high school and collegiate settings: 1. If an athlete shows concussion-like signs and reports symptoms after a contact to the head, the athlete has, at the very least,, sustained a mild concussion and should be treated for a concussion. The terms ding and bell ringer are discouraged, because they downplay the significance of the injury. 2. In addition to a thorough clinical evaluation, formal cognitive and postural-stability stability testing is recommended to assist in objectively determining injury severity and readiness to return to play (RTP). NATA strongly recommends that youth leagues, high schools, colleges and a professional teams institute a testing program that incorporates baseline testing of athletes. 3. Once symptom-free, the athlete should be reassessed to establish that cognition and postural stability have returned to normal for that t player. 4. An athlete with a concussion should be referred to a physician n on the day of injury if he or she lost consciousness or experienced amnesia lasting longer than 15 minutes. 5. A team approach should be used in making RTP decisions after concussion. This approach should involve input from the athletic trainer, physician, athlete and any referral sources.

14 6. 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. 7. Athletes who experience loss of consciousness or amnesia should be disqualified from participating on the day of the injury. 8. Because damage to the maturing brain of a young athlete can be catastrophic, younger athletes (under age 18) should be managed more conservatively, using stricter RTP guidelines than those used to manage concussion in the more mature athlete. Therefore, youth athletes are strongly encouraged to never return to play on the same day that a concussion is sustained. 9. Any athlete with a concussion should be instructed to rest, but complete bed rest is not recommended. 10. Because of an increased risk for future concussions, as well as for slowed recovery, athletes with a history of three concussions should be advised that terminating participation in contact sports may be in their best interest.

15 PLAY or NO PLAY? 1. A 15 year old football player comes off the field, sits on the bench, and is visibly crying and emotional. He reports that he wants to play and perform well, but seems slightly off and confused. He reports having a headache which resolves within 15 minutes.

16 PLAY or NO PLAY? 2. A 17 year old male basketball player was diving for a loose ball while an opponent fell on his head, impacting it onto the hardwood. The athlete loses consciousness for a few seconds, then gets up and walks to the sideline. He seems dizzy and confused, and has some amnesia. This is a state playoff game and the coach wants to know his status.

17 PLAY or NO PLAY? 3. A 15 year old male football player reports to your office 3 days after receiving a hit to the head in practice. He reports that he has had a headache since then but that it has been getting better. He has a big game coming up in two days and feels good now.

18 PLAY or NO PLAY? 4. A 15 year old male football player suffers a concussion 3 months ago. He thinks he was knocked out for 1 minute and is fine now. He has had 3 previous concussions. Do you let him play?

19 Appendix A - Graded symptom checklist (GSC) Time of 2 3 h 24 h 48 h 72 h Symptom injury after injury after injury after injury after injury Blurred vision Dizziness Drowsiness Excess sleep Easily distracted Fatigue Feel in a fog Feel slowed down Headache Inappropriate emotions Irritability Loss of consciousness Loss or orientation Memory problems Nausea Nervousness Personality change Poor balance/coord. Poor concentration Ringing in ears Sadness Seeing stars Sensitivity to light Sensitivity to noise Sleep disturbance Vacant stare/glassy eyed Vomiting Note: the GSC should be used not only for the initial evaluation but for each subsequent follow up assessment until all signs and symptoms have cleared at rest and during physical exertion. In lieu of simply checking each symptom present, the ATC can ask the athlete to grade or score the severity of the symptom on a scale of 0 6, where 0 = not present, 1 = mild, 3 = moderate, and 6 = most severe.

20 Appendix B - Physician referral checklist Day of injury referral 1. Loss of consciousness on the field 2. Amnesia lasting longer than 15 minutes 3. Deterioration of neurological function* 4. Decreasing level of consciousness* 5. Decrease or irregularity in respirations* 6. Decrease or irregularity in pulse* 7. Increase in blood pressure 8. Unequal, dilated, or unreactive pupils* 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, agitation* 12. Seizure activity* 13. Vomiting 14. Motor deficits subsequent to initial on-field assessment 15. Sensory deficits subsequent to initial on-field assessment 16. Balance deficits subsequent to initial on-field assessment 17. Cranial nerve deficits subsequent to initial on-field assessment 18. Post-concussion symptoms that worsen 19. Additional post-concussion symptoms as compared with those on the field 20. Athlete is still symptomatic at the end of the game (especially at high school level) Delayed referral (after the day of injury) 1. Any of the findings in the day of injury referral category 2. Post-concussion symptoms worsen or do not improve over time 3. Increase in the number of post-concussion symptoms reported 4. Post-concussion symptoms begin to interfere with the athlete s daily activities (sleep disturbances, cognitive difficulties) *Requires the athlete be transported immediately to the nearest emergency department.

21 References Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the first international conference on concussion in sport, Vienna Br J Sports Med 2002; 36:6-7. Guskiewicz KM,, Bruce SL, Cantu RC, et al. Research based recommendations on management of sport related concussion: summary of the National Athletic Trainers Association position statement. Br J Sports Med 2006; 40:6-10. King N. Post-concussion syndrome: clarity amid the controversy? The British Journal of Psychiatry 2003;183: MacKenzie JD, Siddiqi F, Babb JS, et al. Brain Atrophy in Mild or Moderate Traumatic Brain Injury: A Longitudinal Quantitative Analysis. American Journal of Neuroradiology 2002; 23: McCrory P,, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd international conference on concussion in sport, s Prague Br J Sports Med 2005; 39:

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