Current Trends in Sports Related Concussion SEPT2018

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Current Trends in Sports Related ConcussionBILL MOREAU, DC, DACBSP®, FACSM

© 2018 ALL RIGHTS RESERVED

All opinions, viewpoints and recommendations contained in this presentation represent those of the author alone and do not represent the opinions, viewpoints or recommendations of any organization with which the author may be affiliated, including, without limitation, the USOC, ACBSP or NCMIC.

I have no actual or potential conflict of interest in relation to this program/presentation.

This presentation is not meant to offer medical regulatory compliance and is not intended to establish a standard of care.

All content provided, including: text, images, verbal, audio, or other formats were created for informational purposes only. The presentation content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

The speaker is not promoting any service or product.

© 2018 William J Moreau, DC, DACBSP

Disclaimer

Bill Moreau DC DACBSP FACSM

United States Olympic Committee, Managing Director of Sports Medicine

Professor – Southern California University of Health Sciences Associate Professor – University of Western States CMO Team USA - PyeongChang 2018 Olympics, Rio 2016 Summer

Olympic Games, 2015 Toronto Pan American Games Medical Director Team USA – 2014 Sochi Winter Olympics, 2012

London Olympic Games NFL International Think Tank on Concussion University of Washington Sports Health and Safety Institute External

Advisory Board Member

3 Course Description:

This three (3) hour course will provide an overview of current best practices for the evaluation of sports related concussion. Standard assessment of concussion, neuropsychology and additional methods of assessing as well as appropriate referral options of concussed individuals are discussed.

HOUR Topic

1.0 Introduction to the definition of concussion, incidence, and clinical presentation of concussion.

2.0Evaluation of patients with sports related concussion including work shop on the application of the Standardized Assessment of Concussion (SCAT 5).

3.0Patient presentation, history taking skills, orthopedic and neurologic examination, and a discussion of appropriate referral options.

If we accept the best predictor of future injury is a history of prior injury, does it make sense that preventing concussion is a key to preventing concussion?

Is reducing or preventing concussion, or death in sports through physicals even possible??

Focus on What you can Prevent, Manage What you Cannot Prevent

Presentation goal is to focus on 80% of the most common causes athletes die in sport

Outcomes1. Recognize those conditions and events that lead to catastrophic outcomes

in sport.

2. Develop E/M plans for the most commonly encountered conditions.

3. Reduce medical errors through education and planning against the most catastrophic conditions.

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Proposed Prevention Prerequisites

Prevention

Access to Care

Policies

Technique and

Mechanism

Social Pressure

Knowledge

Attitude

Has Sport Injury and Illness Prevention Research Delivered? A Vigorous Debate. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco.

Proposed Prevention PrerequisitesKnowledge

Prevention

Access to Care

Policies

Technique and

Mechanism

Social Pressure

Knowledge

Attitude

Has Sport Injury and Illness Prevention Research Delivered? A Vigorous Debate. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco.

Do We Know What We Need to Know??

As providers seek access to provide services are they adequately trained to meet the standards of care?

01The agreement of matching to other professions requirements is a false leader – we do not regulate others

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Take a Quiz - Concussion

1. What percent of sports related concussion are associated with a loss of consciousness?

2. What structural changes occur in the CNS with concussion?

3. Under which circumstances can a concussed athlete be returned ot play the day of injury?

4. Which medical has been proven to facilitate the recovery of a patient with concussion?

5. What skills are required to properly assess a concussed individual?

Presentation Outcomes

Share early outcomes from Berlin 2016 ACBSP 2014 ACBSP Position Statement on Concussion in Athletics Discuss changes and best practices for SCAT 4 Lessons learned from the NFL Look at trends in concussion evaluation and management

Concussion Is Still Big News

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Concussion

Old Problem New Awareness

The 2016 Berlin Concussion Consensus Guidelines –what is new1. FIRST TIME DOCTORS OF

CHIROPRACTIC WERE INVITED TO ATTEND

2. THREE POSTER PRESENTATIONS WERE ACCEPTED FROM DOCTORS OF CHIROPRACTIC

Defining Concussion

American Associations of Neurological Surgeons (AAN)

A concussion is an injury to the brain that results in temporary loss of normal brain function. It usually is caused by a blow to the head. In many cases, there are no external signs of head trauma. Many people assume that concussions involve a loss of consciousness, but that is not true. In many cases, a person with a concussion never loses consciousness.

AAN Concussion Defined: medical definition of concussion is a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma.

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2016 Berlin Definition of Concussion DEFINITIONS OF A CONCUSSION

A concussion is defined as a traumatically induced transientdisturbance of brain function and is caused by a complex pathophysiological process.

Concussions have also been referred to as mild traumatic brain injuries (MTBI).

Not all MTBI are concussions.

Harmon KG, et al. Br J Sports Med 2013;47:15–26.

Concussion Defined

Concussion is a brain injury and is defined as acomplex pathophysiological process affecting thebrain, induced by biomechanical forces. Several

common features that incorporate clinical, pathologicand biomechanical injury constructs that may

be utilised in defining the nature of a concussivehead injury include:

Concussion Defined (cont)

1. 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.

2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

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Concussion Defined (cont)

3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

4. 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 symptoms may be prolonged.

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Concussion is classified as a mild Traumatic Brain Injury (mTBI)

mTBI may not be observable in routine neurological examinations.

Diagnostic tests typically will not show any changes.

There are several ways concussive injury may be expressed.

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Areas of InvestigationNeuroimaging (CT,MRI)

Contributes little to SRC evaluation

Other imaging modalities such as DWI* and fMRimay provide additional insight but are considered experimental

Impact sensors - not recommended

Genetic profiling – No definite gene association

* Diffusion-weighted magnetic resonance imaging (DWI or DW-MRI) is the use of specific MRI sequences and software that uses the diffusion of water molecules to generate contrast in MR images. Water molecule diffusion patterns can reveal microscopic details about tissue architecture. A special kind of DWI, diffusion tensor imaging (DTI), has been used extensively to map white matter tractography in the brain.

Image” © Cedar Sinai Hopital

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What is Not a Concussion?Head Injury - TBI

TBI

Cerebral ConcussionASDH – Acute Subdural Hematoma EDH – Epidural Hematoma Intracerebral HematomaDAI - Diffuse Axonal Injury Subarachnoid HematomaCerebral Contusion Second Impact Syndrome

Terminology

Hematomas – LOC followed by lucid period, then rapidly deteriorate EDH – or extradural hematoma is usually the most rapidly progressive

intracranial hematomas. ASDH - Subdural Hematoma – Is located under the dura and directly on the

brain. Intracerebral Hematoma – Bleeding is into the brain substance itself. Subarachnoid- hemorrhage confined to surface of the brain

Diffuse Axonal Injury

Associated with MVCAccounts for 1/3 of all head injury deathsMost frequent cause of persistent vegetative stateAxons are shearedMild to Severe

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DIA

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Skull Fracture Indicates significant

force Signs

Obvious deformity

Visible crack in the skull

Raccoon eyes Battle’s sign

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Raccoon eyes & Battle sign

Indicates basilar skull fracture and may be only sign of fracture as this is not well visualized on plain film and may be seen 2-3 days after trauma

Cranial Hematomas

EDH – Epidural Hematoma

Usually associated with skull fracture Usually an arterial bleed that does not tamponade prior to serious

neurological compromise Presentation

Transient LOC at time of injury followed by lucid interval (1/3 of the time) Followed by declining LOC, anisocoria, decerebrate posturing, and

ultimately death

Neurologic Posturing

http://drugline.org/img/ail/938_943_1.png

ASDH –Acute Subdural Hematoma

In high school football, the most common cause of head injury death is a subdural hematoma

These injuries are rare Between 1984 and 1988 research reported 18 incidences of subdural

hematomas in athletes at various levels of football

Subdural Hematoma

Can be divided into 2 categories A simple subdural hematoma presents without cerebral contusion or

edema, usually in the elderly The mortality rate for a simple subdural hematoma is approximately 20% The second category consists of brain contusion with hemispheric

swelling or bleeding The mortality rate for this subdural hematoma is 50%

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Subdural Hematoma

Severe damage is caused by swelling or bleeding, typically due to venous rupture, which results in herniation of brain tissue and cerebral ischemia, potentially causing death.

Although a subdural hematoma may be caused by a single incident, there are patients in whom this severe head injury resulted from repeated head injuries.

In non-athletic severe head injury, epidural hematomas are 3X more common than SDH

ASDH – Presentation

Typically unconscious w/ or w/o hx of traumaAnisocoria, decerebrate posturing, declining LOC

Severe Head Injury Management Keys

Get Help

Stabilize the spine if indicated

Establish and maintain an adequate airway

Apply HF O2

Prepare for vomiting (recovery position)

Reassess the patient’s LOC

Recheck to make sure help is on the way

Management Keys

1. Recognition that a head injury has occurred2. Accurate assessment

Who stays and who goes for further assessment

3. Correct RTP Decision

The Eleven “R’s” of Sports Related Concussion (SRC)

1. Recognize; 2. Remove; 3. Re-evaluate; 4. Rest;5. Rehabilitation; 6. Refer; 7. Recover; 8. Return to sport; 9. Reconsider;10. Residual effects and

sequelae; 11. Risk reduction.12. Recognize

Remember: The basic principles of first aid (danger, response, airway,

breathing, circulation) should be followed.

Do not attempt to move the athlete (other than that required for airway management) unless trained to do so.

Assessment for a spinal cord injury is a critical part of the initial on-field assessment.

Do not remove a helmet or any other equipment unless trained to do so safely.

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CONCEPTS OF IMMEDIATE ON-FIELD ASSESSMENT FOR POSSIBLE CONCUSSIONElements to be assessed for all athletes who are suspected of having a concussion after the first aid / emergency care priorities are completed. Identify any “Red Flags“ or observable signs are noted after a direct or

indirect blow to the head, the athlete should be immediately and safely removed from participation and evaluated by a physician or licensed healthcare professional.

Consideration of transportation to a medical facility should be at the discretion of the physician or licensed healthcare professional.

The GCS is important as a standard measure for all patients and can be done serially if necessary in the event of deterioration in conscious state.

Maddock’s questions and cervical spine exam are critical steps of the immediate assessment; however, these do not need to be done serially.

WHAT IS THE SCAT 5? The SCAT5 is a standardized tool for evaluating concussions by physicians

and licensed healthcare professionals. The SCAT5 cannot be performed correctly in less than 10 minutes. Non-healthcare professionals use the Concussion Recognition Tool 5

(CRT5). For evaluating athletes aged 13 years and older. For children aged 12 years or younger use the Child SCAT 5. Preseason SCAT 5 baseline testing can be useful, but not required. Brief verbal instructions for each test are given in italics. The only equipment required for the tester is a watch or timer.

SCAT 5

The last SCAT was SCAT 3, there is no SCAT 4 Changes from SCAT 3 to SCAT 5

SIDELINE concussion assessment tool

Return to SPORT – not play

Consolidated the instructions

IMPORTANT INSTRUCTIONS IN RED

SCAT 5 most effective in the first 72 hours

Symptom checklist to be completed by the patient

SAC: Added more word sets, set immediate recall to 5 minutes

Brief Neuro Scan added

SCAT 5 is not a GOLD standard, it provides a format to cover the bases.

SCAT 5 is a guide for the assessment of concussed individuals in athletics.

Meeuwisse Willem and Paul McCrory P. Meet the Experts – Sideline Concussion Assessment. Paper presented at: IOC World Conference on Prevention of Injury & Illness in Sport. April 10, 2014; Monaco.

KEY POINTS Any athlete with suspected concussion should be REMOVED FROM PLAY, medically

assessed and monitored for deterioration. No athlete diagnosed with concussion should be returned to play on the day of injury. If an athlete is suspected of having a concussion and medical personnel are not

immediately available, the athlete should be referred to a medical facility for urgent assessment.

Athletes with suspected concussion should not drink alcohol, use recreational drugs and should not drive a motor vehicle until cleared to do so by a medical professional.

Concussion signs and symptoms evolve over time and it is important to consider repeat evaluation in the assessment of concussion.

The diagnosis of a concussion is a clinical judgment, made by a medical professional. The SCAT5 should NOT be used by itself to make, or exclude, the diagnosis of concussion.

An athlete may have a concussion even if their SCAT5 is “normal”.

Recognize and Remove A head impact by either a direct blow or indirect transmission of force

can be associated with a serious and potentially fatal brain injury. If there are significant concerns, including any of the red flags, activation

of emergency procedures and urgent transport to the nearest hospital is required.

The Clinical Cornerstone is to ensure that the concussed individual is identified and removed from

competition.

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The Critical Elements for Screening Concussion on the Sideline

CRITICAL NON-NEGOTIABLE ELEMENTS 1) Identify and Record signs and symptoms2) Obtain the history3) Verbal cognitive evaluation (SAC)4) Balance (Modified BESS)5) Serial Examination

IN THE FUTURE?1. KD Testing2. Visual Testing

On Field Procedures

Start with the Basics

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STEP ONE – Look For Red Flags

These are signs/symptoms of a more serious, or life threatening, brain injury. In a patient who is not lucid or fully conscious, a cervical spine injury should be

assumed until proven otherwise. DO NOT HESITATE to activate EMS

STEP TWO – IDENTIFY SIGNS OF TBI

Observe the field of play; do not allow yourself to be distracted.

Facial injury with head trauma is one of the signs a CT may be indicated.

STEP THREE - MEMORY ASSESSMENTMADDOCK’S QUESTIONS

Some sports do not have a “half”, simply substitute period or event.

Do not forget to ask what happened –you may be surprised.

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STEP FOUR: THE EXAMINATION

Includes: Maddock’s Score Cervical Spine Assessment

STEP FOUR –GLASGOW COMA SCALE (GCS)

Useful to the ED if transported as a predicter of outcome and level of intervention needed.

A dead person scores a 3!

mTBI is defined as a head injury that scores 14 or 15 on the GCS.

Concussion is a mTBI

STEP FOUR: CERVICAL SPINE ASSESSMENT

Remember to assess on the field of play before moving the athlete.

On the sideline additional evaluation of the cervical spine is required.

Test Active ROM b/f Passive ROM Do not limit your evaluation to these

tests, they represent the minimum evaluation.

Additional tests that make sense include UE/LE DTR’s, Foraminal compression, distraction, etc.

Clinical “intuition” can supersede a named test. If you

feel there maybe a fracture present manage as if there IS a

fracture present.

Off Field ProceduresPLEASE NOTE THAT THE NEUROCOGNITIVE ASSESSMENT SHOULD BE DONE IN ADISTRACTION-FREE ENVIRONMENT WITH THE ATHLETE IN A RESTING STATE.

STEP 1: ATHLETE BACKGROUND You Must Know Your Athlete

The SCAT 5 Symptom and all Scores vary by many factors Injury or illness status

Degree of recovery

Education

Primary language

Nationality

Age

Test taking skills


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Symptom Baseline

40% score a “0”.

“Asymptomatic” means normal for that individual.

Best results when self-rated (scored) by the athlete.


What is Normal?Symptom Frequency

Sport concussion assessment tool: baseline values for varsity collision sport athletes. Shehata et al.Br J Sports Med 2009;43:730–734.

University Normal

The mean SCAT baseline PCSS score was approximately 5, although just under half of the athletes scored 0.

Female athletes scored better on tests of neurocognitive function.

PC athletes scored higher than NC athletes on all neurocognitive tests except delayed five-word recall.

Sport concussion assessment tool: baseline values for varsity collision sport athletes. N Shehata et al. Br J Sports Med 2009;43:730–734

Most Frequent Symptoms

The five most frequently reported symptoms for all athletes were:1. Fatigue/low energy (37%)2. Drowsiness (23%)3. Neck pain (20%)4. Difficulty concentrating (18%)5. Difficulty remembering (18%).

Sport concussion assessment tool: baseline values for varsity collision sport athletes. N Shehata et al. Br J Sports Med 2009;43:730–734

What is Normal?Symptom Scores Team USA

Nabhan D, Moreau WJ. Baseline SCAT 3 Symptom Scores for Elite Athletes.: What is Normal ? Manuscript in process. 2014

SAC Score Symptoms Symptom SeverityScore

27.2 (95% CI 26.8-27.6)

2.0(95%CI 1.5-2.6)

3.6 (95% CI 2.5-4.8)

Symptom Scale The time frame for symptoms should be based on the type of test being

administered. At baseline it is advantageous to assess how an athlete “typically” feels

whereas during the acute/post-acute stage it is best to ask how the athlete feels at the time of testing.

The symptom scale should be completed by the athlete, not by the examiner.

In situations where the symptom scale is being completed after exercise, it should be done in a resting state, generally by approximating his/her resting heart rate.

For total number of symptoms, maximum possible is 22 except immediately post injury, if sleep item is omitted, which then creates a maximum of 21.

For Symptom severity score, add all scores in table, maximum possible is 22 x 6 = 132, except immediately post injury if sleep item is omitted, which then creates a maximum of 21x6=126.

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STEP 2: SYMPTOM EVALUATION The athlete should be given

the symptom form and asked to read this instruction paragraph out loud then complete the symptom scale.

For the baseline assessment, the athlete should rate his/her symptoms based on how he/she typically feels and for the post injury assessment the athlete should rate their symptoms at this point in time.

STEP 3: COGNITIVE SCREENINGStandardized Assessment of Concussion (SAC)

Immediate Memory Can be completed using the traditional 5-word per trial list or, optionally, using 10-words per

trial. The literature suggests that the Immediate Memory has a notable ceiling effect when a 5-word list is used.

In settings where this ceiling is prominent, the examiner may wish to make the task more difficult by incorporating two 5–word groups for a total of 10 words per trial.

In this case, the maximum score per trial is 10 with a total trial maximum of 30. Choose one of the word lists (either 5 or 10). Then perform 3 trials of immediate memory

using this list. Complete all 3 trials regardless of score on previous trials. “I am going to test your memory. I will read you a list of words and when I am done, repeat

back as many words as you can remember, in any order.” The words must be read at a rate of one word per second. Trials 2 & 3 MUST be completed regardless of score on trial 1 & 2. Trials 2 & 3: “I am going to repeat the same list again. Repeat back as many words as you

can remember in any order, even if you said the word before.“ Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do NOT inform the athlete that delayed recall will be tested.

IMMEDIATE MEMORY

The Immediate Memory component can be completed using the traditional 5-word per trial list or optionally using 10-words per trial to minimize any ceiling effect.

All 3 trials must be administered irrespective of the number correct on the first trial.

Administer at the rate of one word per second. Please choose EITHER the 5 or 10 word list groups and circle the specific

word list chosen for this test. Instructions:

“I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.

For Trials 2 & 3: I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.

IMMEDIATE MEMORY Pace is important – one word per

second!

ESL individuals may score lower.

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Concentration Choose one column of digits from lists A, B, C, D, E or F and administer

those digits as follows: Say: “I am going to read a string of numbers and when I am done, you

repeat them back to me in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.”

Begin with first 3 digit string. If correct, circle “Y” for correct and go to next string length. If incorrect, circle “N” for the first string length and read trial 2 in the same

string length. One point possible for each string length. Stop after incorrect on both trials (2 N’s) in a string length. The digits should be read at the rate of one per second.

CONCENTRATION DIGITS BACKWARDS Circle the Digit list chosen (A, B, C, D, E, F). Administer at the rate of one digit per

second reading DOWN the selected column.

“I am going to read a string of numbers and when I am done, you repeat them back to me in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.”

MONTHS IN REVERSE ORDER

Now tell me the months of the year in reverse order. Start with the last month and go backward.

1 pt. for entire sequence correct So you’ll say December, November. Go ahead. You can start with any month. The traditional start with December is

best with people who are obviously hurt. Dec - Nov - Oct - Sept - Aug - Jul - Jun - May - Apr - Mar - Feb - Jan

STEP 4: NEUROLOGICAL SCREEN Finger to Nose “I am going to test your coordination now. Please

sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended), pointing in front of you.

When I give a start signal, I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose, and then return to the starting position, as quickly and as accurately as possible.”

Scoring: 5 correct repetitions in < 4 seconds = 1 Note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as “N”.

STEP 4: NEUROLOGICAL SCREENTandem Gait Participants are instructed to stand with their feet together

behind a starting line (the test is best done with footwear removed).

They walk in a forward direction as quickly and as accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step.

Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the same gait.

A total of 4 trials are done and the best time is retained. Athletes should complete the test in 14 seconds. Y/N Athletes fail the test if they step off the line, have a separation

between their heel and toe, or if they touch or grab the examiner or an object.

In this case, the time is not recorded and the trial repeated, if appropriate.

BALANCE EXAMINATIONModified Balance Error Scoring System (mBESS) testing Each of 20-second trial/stance is scored by counting the number of

errors. The examiner will begin counting errors only after the athlete has

assumed the proper start position. The modified BESS is calculated by adding one error point for each error

during the three 20-second tests. The maximum number of errors for any single condition is 10. If the athlete commits multiple errors simultaneously, only one error is

recorded but the athlete should quickly return to the testing position, and counting should resume once the athlete is set.

Athletes that are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition.

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BALANCE EXAMINATIONModified Balance Error Scoring System (mBESS) testing

Types of errors: 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec

3 TRIALS – No FOAM

Balance Testing


BESS• Use three positions for SCAT 3• Use footwear they would be wearing at an event• Use skates for ice hockey• The dominant leg is the one used to kick a ball, make

sure you have the stance correct.

BALANCE EXAMINATIONModified Balance Error Scoring System (mBESS) testing

“I am now going to test your balance. Please take your shoes off (if applicable), roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“

(a) Double leg stance: “The first stance is standing with your feet together with your hands on your hips and with your eyes closed. You

should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“

(b) Single leg stance: “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-

dominant foot. The dominant leg should be held in approximately 30 degrees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.“

(c) Tandem stance: “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both

feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.”

STEP 5: DELAYED RECALL:

The delayed recall should be performed after 5 minutes have elapsed since the end of the Immediate Recall section.

Score 1 pt. for each correct response.

“Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.”

STEP 6: DECISION Total the scores from

each area.

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Document the Examiner

CONCUSSION INJURY ADVICEIn the Field; Minimum Level Includes:

Rest & Rehabilitation After a concussion, the athlete should have physical rest and relative

cognitive rest for a few days to allow their symptoms to improve. In most cases, after no more than a few days of rest, the athlete should

gradually increase their daily activity level as long as their symptoms do not worsen.

Once the athlete is able to complete their usual daily activities without concussion-related symptoms, the second step of the return to play/sport progression can be started.

The athlete should not return to play/sport until their concussion-related symptoms have resolved and the athlete has successfully returned to full school/learning activities.

Rest The reasoning for recommending physical and cognitive rest is the

easing of discomfort during the acute recovery and/or that rest may promote recovery by minimizing brain energy demands following concussion.

There is currently insufficient evidence that complete rest achieves the objectives.

After a brief period of rest during the acute phase (24–48 hours), patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms).

It is reasonable for athletes to avoid vigorous exertion while they are recovering.

The exact amount and duration of rest is not well defined.

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Rehabilitation SRCs can result in diverse symptoms and problems, and can be associated

with concurrent injury to the cervical spine and peripheral vestibular system.

Research supports interventions including psychological, cervical and vestibular rehabilitation.

Submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery.

Further research evaluating rest and active treatments should be performed using high-quality study designs.

ACBSP position statement on concussion in athletics

Regarding the qualifications of Doctors of Chiropractic and their involvement in concussion management, it is the position of the ACBSP that:

1. Doctors of Chiropractic with current ACBSP™ certificates of additional qualifications in sports medicine (DACBSP® and CCSP®) are qualified to manage the concussed individual in any patient population.2. Doctors of Chiropractic may evaluate, diagnosis and manage concussed individuals. The prerequisite management skills for a concussed athlete can be supported by additional experience and education such as the ACBSP concussion registry.3. All healthcare providers involved in the management of concussed individuals have an obligation to maintain current knowledge regarding best practices in concussion management. 4. The ACBSP does not endorse any specific methodology of concussion management because the methods of assessment and management of concussion are in transition.

American Chiropractic Board of Sports Physicians™ Position Statement on Sports Related Concussion in Athletics. Moreau W and Nabhan D. Apr 2014

Regarding current best practices in concussion management it is the ACBSP™ position that:

1. Concussion may be caused by a direct blow to the head or elsewhere on the body.

2. Loss of consciousness is a key symptom but the majority of concussions do not involve a loss of consciousness.

3. Individuals with a concussion may present with a wide range of signs and symptoms such as physical signs of neurologic impairment, or/and symptoms of impaired brain function that may include abnormal behavior.



4. An athlete suspected of having sustained a concussion must be removed from play and immediately assessed by a qualified healthcare provider.

5. A concussed individual must not be allowed to return to play the same day they were concussed.



6. When evaluating a collapsed athlete on the field of play, emergent concerns such as airway, breathing, circulation, spinal trauma or a more serious brain injury should be first excluded.

The initial sideline examination should include a more detailed history and examination of the individual.

Examination should include serial examinations and direct monitoring of vital signs and additional assessments through a standardized concussion neurological examination.


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7. Concussed individuals should not be left alone in the initial phase of their evaluation until their constellation of signs and symptoms are static and a diagnosis can be confirmed.

8. Any increase of symptoms (especially increasing headache, decreasing neurologic function, presence of a focal neurologic deficit, altered vital signs, or repeated vomiting) in a concussed individual requires an urgent evaluation in a hospital setting.

9. Any individual with signs or symptoms of concussion at rest or with exertion should not be allowed to participate in sport until their signs and symptoms have resolved.



10. A consultation from a qualified healthcare provider, including a DACBSP or CCSP, prior to returning-to-play is essential after suspected or known concussion.

11. A graded return-to-play protocol that includes exertion must be followed prior to resumption of full sporting activity.

12. Children and adolescents should be managed more conservatively than adults and they may not be returned to sport until they are completely symptom-free which may require a longer time frame.



13. All athletes must be symptom-free at rest and with exercise prior to return-to-play.

14. The appropriate management of concussed individuals requires careful consideration in regards to the timing and management of the injury. Manual procedures for concussed individuals with clinical presentations of cervical spine and/or vestibular dysfunction may be of benefit, especially if the individual is experiencing neck pain.

15. Cases of concussion in sport where clinical recovery falls outside the expected window of recovery of ten (10) days should receive consideration for management using a multidisciplinary approach.



A recommended current reference for consensus based approach to concussion management is the Consensus Statement on Concussion in Sport: The 4rd International Conference on Concussion in Sport Held in Zurich, November 2012. Agreement exists pertaining to principal messages conveyed within this document, the ACBSP acknowledges the science of concussion is evolving and therefore, management and return-to-play decisions remain in the realm of individualized clinical judgment. Individual management depends on the specific presentation and circumstances that are unique to each individual case. This statement reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It is intended that this document will be formally reviewed and updated prior to June 1 2016.

Soon to be Berlin 2016!



The ACBSP Position Statement on Sports Related Concussion in Athletics is not intended as a standard of care document, and it should not be interpreted as such.


Concussion Incidence 3.8 MM sports related concussions yearly

50% are unreported concussion

Concussion occurs in all sports w/ the highest incidence in Football, hockey, rugby and basketball

(+) history of concussion is associated w/ higher risk of another concussion Greater number, severity and duration of concussion symptoms predicts a

prolonged recovery.


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Risk Factors - Concussion

Reported incidence of concussion is higher in female athletes than in male athletes.

Certain sports, positions and individual playing styles have a greater risk of concussion.

Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.

Pre-injury mood disorders, learning disorders, attention deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion.


Making the Diagnosis Concussion remains a clinical diagnosis ideally made by a healthcare

provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.

Graded symptom checklists provide an objective tool for assessing symptoms of concussion, also tracking the severity of s/s over serial evaluations.

Standardized assessment tools provide a helpful structure for the evaluation of concussion (limited validation)


Concussion Sideline Management

▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licensed healthcare provider trained in the evaluation and management of concussions.

▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination.


Concussion Sideline Management▸ While standardized sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined.

▸ Individual baseline test is also largely unknown.


Concussion Sideline Management Balance disturbance is a specific indicator of a concussion, but not

very sensitive. Balance testing on the sideline may be substantially different than

baseline tests differences in shoe/cleat-type or surface

ankle tape or braces

presence of other lower extremity injury

Imaging is reserved for athletes where intracerebral bleeding is suspected.


Concussion Sideline Management

There is no same day RTP for an athlete diagnosed with a concussion.

Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status.


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Severe Head Injury Management Keys

Get Help

Stabilize the spine if indicated

Establish an adequate airwayApply O2

Reassess the patient’s LOC

Management Keys1. ABCs are always first!2. Recognition that a head injury has

occurred3. Accurate assessment

Who stays and who goes for further assessment

4. Correct RTP Decision5. Appropriate Follow-Up

When to Make a Day-of-Injury Referral -

1. Loss of consciousness on the field

2. Amnesia lasting longer than 15 minutes

3. Deterioration of neurologic 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*

J Athl Train. 2004;39(3):280-297.

*Requires that the athlete be transported immediately to the nearest emergency department.

Day-of-Injury Referral -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, or agitation*

12. Seizure activity*

13. Vomiting

14. Motor deficits subsequent to initial on-field assessment

15. Sensory deficits subsequent to initial on-field assessment

J Athl Train. 2004;39(3):280-297.


Day-of-Injury Referral -16. Balance deficits subsequent to initial on-field assessment

17. Cranial nerve deficits subsequent to initial on-field assessment

18. Postconcussion symptoms that worsen

19. Additional postconcussion symptoms as compared with those on the field

20. Athlete is still symptomatic at the end of the game (especially at high school level)

J Athl Train. 2004;39(3):280-297.


Delayed Referral(after the day of injury)

1. Any of the findings in the day-of-injury referral category

2. Postconcussion symptoms worsen or do not improve over time

3. Increase in the number of postconcussion symptoms reported

4. Postconcussion symptoms begin to interfere with the athlete’s daily activities (ie, sleep disturbances or cognitive difficulties)

J Athl Train. 2004;39(3):280-297.

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Neuropsychological (NP) Testing Are an objective measure of brain behavior relationships and are more

sensitive for subtle cognitive impairment than clinical exam. Most concussions can be managed appropriately without the use of NP

testing. Computerized neuropsychological (CNP) testing should be interpreted

by trained healthcare professionals.


Neuropsychological Testing Paper and pencil NP tests can be more comprehensive, test different

domains and assess for other conditions which may masquerade as or complicate assessment of concussion.

NP testing should be used only as part of a comprehensive concussion management strategy.

The ideal timing, frequency and type of NP testing have not been determined.


Neuropsychological Testing In some cases, properly administered and interpreted NP testing

provides an added value to assess cognitive function and recovery.

It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long term complications.

Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses.


What About Manual Medicine? Manual therapy may be considered especially when there is concomitant

neck pain. (1)

Possible Best Practices Not at the athletic event where the injury occurred.

Only when the s/s are static or resolving.

Consider waiting 2-3 hours w/ observation before performing manual medicine.

1) Harmon KG, et al. Br J Sports Med 2013;47:15–26.

Return to Class

Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion.


Return to Play▸ Concussion symptoms should be resolved before returning to exercise.

▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact.

▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step.

▸ RTP after concussion should occur only with medical clearance from a licensed healthcare provider trained in the evaluation and managementof concussions.


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Risks of Premature RTP▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms.

▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae.

▸ Some studies suggest an association between prior concussions and chronic cognitive dysfunction.


Disqualification from Sport

▸ There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion.

▸ Each case should be carefully deliberated and an individualized approach to determining disqualification taken.


Prevention▸ Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.

▸ Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions.

▸ There is no current evidence that mouth guards can reduce the severity of or prevent concussions.

▸ Secondary prevention may be possible by appropriate RTPmanagement.


Incidence

REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL Study investigated the difference in the reported and non-

reported incidence of concussion

72 HS(9-12) football players over a single football season.

A “reported incident” was defined as a concussion the football staff was aware of through recorded data.

Coaching staff recorded data regarding any player who reported w/ concussion injury to the football staff or required follow-up evaluation by a health care provider for a concussion.

W Moreau, REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL. American Chiropractic Board of Sports Physician’s™ 2005 Sports Science Symposium Abstract – Podium Presentation

REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL To identify “non-reported concussion” an

anonymous questionnaire regarding symptoms related to concussion was issued at the end of the football season to all 72-football players.

The survey asked the athlete five questions. Two questions identified the athletes grade in school and

the position they played

The other questions related to identifying for the athlete some of the common signs of concussion.


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REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL Results: All 72 surveys were returned Results demonstrated:

4 “reported” concussions incidence = 5.6%

The surveys identified that 47 athletes sustained symptoms consistent with concussion during the season for an unreported concussion rate of 65%.


REPORTING FREQUENCY OF CONCUSSION IN HIGH SCHOOL FOOTBALL CONCLUSION:

There is a significant difference in the incidence of concussion as reported to the coaching staff or health care providers verses the incidence of symptoms of concussion experienced by the athlete.


Soccer Upper limb to head contact

accounts for 50% of concussions Adolescent football (soccer) players experience a

significant number of concussions Being female may increase the risk of suffering a

concussion and injuries on the head and face The use of football headgear may decrease the risk

of sustaining these injuries.

Bicycle HelmetsGet oneHelmet usage is increasing Ensure proper fitMake sure it is worn correctly 85% of head injuries could be prevented with

a helmet Universal use of helmets could prevent one

death every day and one brain injury every four minutes

HistoryWhat is the million dollar question

we always need to ask?

HistoryHave you ever hurt your head before?Do not ask if they have had a concussion

before because they might not know what a concussion is!

So what is a concussion?

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Second Impact Syndrome A subsequent and possibly fatal brain injury that can

occur when a second head injury is received before the initial head injury has resolved

Can be associated with concussion An athlete may present with a seemingly mild

concussion; however, within seconds, the athlete may develop symptoms of second-impact syndrome

Second-impact syndrome has a mortality rate of up to 50%

It must be prevented whenever possible and recognized early when it occurs

Second Impact Syndrome Athlete appears stunned and with or without losing

consciousness, gets up under own power, and collapses soon thereafter

Rapidly dilating pupils, loss of eye movement, beginning respiratory failure from brainstem deficiency

Occurs faster than an epidural hematoma

Is considered a “controversial” condition

Differential Weighted Diagnosis?ConcussionWhat grade?What system?What's the big question?

MTBI Assessment In addition to the concussion injury assessment the

evaluation should also include an assessment of:1. Cervical spine

2. Cranial nerves to identify any cervical spine or vascular intracerebral injuries.

Post-Traumatic Amnesia (PTA)1. Retrograde Amnesia

Partial or total loss of the ability to recall events that have occurred immediately preceding brain injury.

Varies with the time of measurement post-injury and hence is poorly reflective of injury severity

2. Anterograde AmnesiaReduced ability to form new memoryMay lead to decreased attention and

inaccurate perception (ie. Poor School Performance)

frequently the last function to return.

First Follow the EAP

1 ABCs Disability (AVPU) R/O Spinal or other life threatening injury

Will the future be CAB?

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A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and / or symptoms (some examples listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following:

- Symptoms (e.g., headache), or- Physical signs (e.g., unsteadiness), or- Impaired brain fxn (confusion) or- Abnormal behavior (e.g., change in personality).


Trends in Concussion Evaluation and Management

Concussion Cares Treatment approach depend on clinician ability to DDX among various

conditions associated with PCS.

Early education, cognitive behavioral therapy, and aerobic exercise therapy have shown efficacy in certain patients but have limitations of study design.

Rehabilitation of Concussion and Post‐concussion Syndrome. Leddy J et al. Sports Health. Mar 2012; 4(2): 147–154.

The Diagnosis of Concussion is Influenced by: Medical Team Awareness. With a and reliability in diagnosing

concussion. comprehensive program in concussion management, there is internal consistency

Athlete Self-Report. Unfortunately, even well-educated athletes have a high rate (40-50%) of not reporting concussion, especially w/ a prior concussion.

Over-Reliance on Computerized Testing. Concussion DX must be clinical, computerized testing cannot make a diagnosis. These tests may help make a clinical decision, but they are not valid indicators of a diagnosis as a stand-alone tool.

NCAA Sport Science Institute hosted a Concussion Task Force. Jul 11, 2013

Association Between Recovery and Risk

Acute Effects and Recovery Time Following Concussion in Collegiate Football Players The NCAA Concussion Study. McCrea et al. JAMA. 2003;290(19):2556‐2563

Concussion - Neurometabolic Cascade

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Metabolic Cascade Accumulation of calcium within the mitochondria peaks at 2 days post

injury, and it resolves within 4 days. (1) A reduction in glucose level is seen within 24 hours, which remains evident

for 5–10 days after injury.(2) Oxidative metabolism in the cortex is restored by 10 days post injury, but a

reduction is still evident in the hippocampus.(2) There is also PET evidence of decreased global cerebral metabolism in

humans that lasts for 2–4 weeks. These studies provide evidence to guide the introduction of exercise following concussion.(3)

1) Fineman JR et al. Hyperoxia and alkalosis produce pulmonary vasodilation independent of endothelium‐derived nitric oxide in newborn lambs. Pediatr Res. 1993;33(4 Pt 1):341‐346.

2) Yoshino A et al. Changes in local cerebral glucose utilization following cerebral conclusion in rats: evidence of a hyper‐ and subsequent hypometabolic state. Brain Res. 1991;561(1):106‐119.

3) Bergsneider M, Hovda DA, Shalmon E, et al. Cerebral hyperglycolysis following severe traumatic brain injury in humans: a positron emission tomography study. J Neurosurg. 1997;86(2):241‐251.

Exercise and Concussion

Cerebral pressure auto-regulation (CPA) is an protective mechanism against secondary ischemic damage that maintains homeostasis in the presence of varying arterial blood pressure (BP) and cerebral perfusion pressure

Cerebrovascular stability may be compromised in head-injured patients, due to an inability to maintain stable pressure during fluctuations created by exercise.

The normal interaction of CPA and exercise-induced metabolic changes protects the brain from both hypoperfusion and hyperperfusion.

Disruption of this auto-regulatory mechanism could be the cause of symptoms experienced by concussed patients during physical exertion.

Exercise and Concussion, Part 1 Local and Systemic Alterations in Normal Function. Kozlowski K. International Journal of Athletic Therapy and Training Mar2013 19 2 p23

Dual Task Rehabilitation Individualized dual-task home-based exercises, were performed for

approximately 30 minutes, six times a week for seven weeks. Practiced body stability with sensory deprivation

standing with closed eyes,

standing on soft surfaces w different bases of support (e.g. tandem standing, standing on one foot)

W body transport activities (e.g. transferring from one chair to another, transferring from sit to stand).

Participants were asked to perform balance exercises while performing either a second motor task (e.g. throwing and catching a ball) or a second cognitive task (e.g. naming objects or remembering numbers).

A dual task home‐based rehabilitation programme for improving balance control in patients with acquired brain injury a single blind randomized controlled pilot study. Peirone E et.al. Clinical Rehabilitation Apr2014 (28) 4 p329

Concussion is an Area of Knowledge that is in Transition

Special Considerations for the Young Individual

Concussion in Adolescents• Younger athletes (H.S. and lower) have been show to exhibit longer recovery times

compared to adults.(1)

• Concussions seem to have more symptoms and last longer in females. (2)

• Second Impact Syndrome (a person under age 21, whose initial concussion symptoms are unresolved, may suffer sudden death if there is a second concussion within two weeks of the first concussion), it is clear that adolescents must to be protected from this potential catastrophic event.(3)

• A gene may exist that causes some individuals to be more susceptible to concussions.(4)

1) Field, Collins et al. Does age play a role in recovery from sports related concussion? J Pediatr 2003; 142(5):788-795.

2) Bazarian and Atabaki. Predicting post-concussion syndrome after MBTI. Acad Emerg Med 2001; 8(8):788-795

3) Cantu, RC: Head injuries in Sport. Brit J Sports Med 1996; 30:289-2964) Apolipoprotein E-epsilon 4 Genotype predicts poor outcome in survivors of traumatic brain injury.

Neurol 1999; 52:244-249

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Concussion in Adolescents• Many concussed individuals may be unable to concentrate (focus). They may not be able

to read or absorb material and may develop an increased headache while doing so.

• When this occurs, they might be able to participate in an activity for only a few minutes before symptoms increase. If a rest break can be interspersed between those few minute intervals, these activities can be done.

• As the symptoms abate, longer intervals can be spent reading, watching TV and using the computer.

• Continuing to do activities, or exercise that increases symptoms, can delay the recovery from the concussion.

Concussion in AdolescentsSCHOOL ATTENDANCE AND ACTIVITIES

• While some individuals may be able to attend school without increasing their symptoms, the majority will probably need some modifications depending on the nature of the symptoms.

• Trial and error may be needed to discover what they can and cannot do.• If students are unable to attend school for an entire day without symptoms, they may

attend for a half day. • Some students may only be able to attend for one period, some not at all, due to severe

headaches or other symptoms. • Frequent breaks with rest periods in the nurse’s office may be necessary. • Often, alternating a class with a rest period may be helpful. • Math causes more symptoms in my patients than other subject classes. • As recovery proceeds, gradually hours spent in school may be increased.

REF: Lee M.A. Adolescent Concussions— Management Recommendations (A Practical Approach). Spring 2006 CSMS Committee on the Medical Aspects of Sports.

Concussion in AdolescentsSCHOOL ATTENDANCE AND ACTIVITIES

• Depending on their symptoms, some students may need to be driven to school to avoid walking and should be given elevator passes to avoid stairs.

• They should not attend gym or exercise classes initially.• Workload and homework may need to be reduced. • Frequent breaks while doing homework may be helpful. • Term papers should be postponed. • Pre-printed class notes and tutors may help to relieve the pressure of schoolwork.• Tests: If there are concentration and memory problems, quizzes, tests, PSAT tests,

SAT tests and final exams should be delayed or postponed. If test results are poor, a note to the school should request that the scores be voided. Extra time (un-timed tests) may be necessary initially when test taking is resumed.

REF: Lee M.A. Adolescent Concussions— Management Recommendations (A Practical Approach). Spring 2006 CSMS Committee on the Medical Aspects of Sports.

When is a student ready toreturn to school after concussion?

• Should be seen by a health care professional experienced in evaluating for concussion.• Make decisions about a student’s readiness to return to school based on the number,

type and severity of symptoms experienced by the student. • Offer guidance about when it is safe for a student to return to school and appropriate

levels of cognitive and physical activity. • Once permission is given for the student to return to the classroom, school professionals

can help monitor him/her closely. • With proper permission, school professionals can confer on their observations and share

those observations with the family and other professionals involved in the student’s recovery.

1. CDC Returning to School After a Concussion: A Fact Sheet for School Professionals. Accessed June 18, 2018 https://www.cdc.gov/headsup/pdfs/schools/tbi_returning_to_school-a.pdf12. Nebraska Department of Education. Return to Learn, Oct 2014. https://www.education.ne.gov/wp-content/uploads/2017/07/BRIDGING-THE-GAP-Booklet-plus-Appendices.pdf

Additional Cares and Considerations

Females and Concussion

Girls are 68% more likely to suffer sports related concussions. The reasons for this are anatomy and biomechanical differences:

Heads are smaller Neck muscles are not as strong Different styles of play Different training techniques Cultural norms Increasing numbers of highly competitive female athletes.

In basketball girls were 300 percent more likely to get a concussion.

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Neuroimaging

Conventional structural neuroimaging is normal in concussive injury.

The following suggestions are made:1. Brain CT and MR contributes little to concussion

evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists.

Canadian Head CT Rule

Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391-96.

Pharmacological Therapy Pharmacological therapy in sports concussion may be

applied in two distinct situations.1. The management of specific prolonged symptoms (eg, sleep

disturbance, anxiety, etc)2. Where drug therapy is used to modify the underlying

pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms.

McCrory P, et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. Clin J Sport Med 2009;19:185–200.

Pharmacological Therapy This approach to management should be only considered by

clinicians experienced in concussion management. An important consideration in RTP is that concussed athletes

should not only be symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion.

Antidepressant therapy may be used for management, the decision to return to play while still on such medication must be considered carefully by the treating clinician.


Pre-participation Concussion Evaluation A concussion history is important but know many athletes will

not recognize all the concussions they may have suffered A detailed concussion history is of value History may:1. Pre-identify athletes that fit into a high risk category2. Provide an opportunity for the healthcare provider to

educate the athlete in regard to the significance of concussive injury


Role of Pre-participation Concussion Evaluation A structured concussion history should include specific

questions as to previous symptoms of a concussion, not just the perceived number of past concussions.

It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable.


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Role of Pre-participation Concussion Evaluation History should also include information about all previous

head, face or cervical spine injuries. Questions pertaining to disproportionate impact versus

symptom severity alert the clinician to the individual’s increased vulnerability to injury.

Details regarding protective equipment is useful. Comprehensive pre-participation concussion evaluation

allows for modification and optimization of protective behavior and education.


Patient Instructions

Warning Signs to Seek Immediate Help

Inability to awaken the patient Severe or worsening headaches Somnolence or confusion Restlessness, unsteadiness or seizures Difficulties with vision Vomiting, fever or stiff neck Urinary or bowel incontinence Weakness or numbness involving any part of the body

Concussion Patient Directions

1. Avoid strenuous activity for 24 hours after the injury2. Do not take mediations without consulting your physician3. Eat a “regular” diet, Avoid alcohol4. Do not drive until you are fully recovered5. Do Not take aspirin, sleeping pills, or ibuprofen.6. Call your doctor or return to the ER if any of the following

occur:a. Becomes sleepy or is difficult to awaken. b. Vomitingc. Trouble with balanced. The eyes move oddly, difficulty with focusing, unequal pupil sizee. Persisting or increasing headachef. Restlessness or irritability, personality changesg. Convulsions or seizuresh. New swelling at the area of the head injuredI. Increased neck stiffnessJ. NumbnessK. Ringing in the earsL. Shortness of breathM.ConfusionN. Visual problems

Criteria for Hospital Admission Hospital admission for further observation or treatment is indicated

when;An athlete has persistent confusionLethargyFocal neurologic signsAbnormal findings on the brain CT scanWhen the clinical picture is confounded because of seizures.Admission should also be considered if no responsible person

is available at home to monitor the patient for progression of symptoms.

The Postconcussion Syndrome Athletes may experience somatic, affective or cognitive

symptoms that gradually taper in severity over days, weeks or even months after a concussion.

Postconcussion symptoms may result from brain injury or from trauma involving head and neck structures.

The most common symptoms are headache and dizziness.

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The Postconcussion Syndrome The most common symptoms are headache and dizziness Other symptoms include;

Blurred vision Neck pain Fatigue Problems sleeping Emotional or cognitive disturbances Tinnitus Problems with balance or coordination Loss of hearing, taste or smell

The Postconcussion Syndrome Athletes with unilateral or multifocal brain lesions on CT or MRI

scan may be more likely to have neuropsychologic symptoms

Referral to a psychologist for neuropsychologic testing and treatment is indicated when an athlete is suspected of having neuropsychologic symptoms after a concussion.

Additional Testing Brain imaging, if not previously performed, is indicated in the

athlete with chronic headaches after a concussion.

The athlete who is experiencing dizziness may be evaluated with audiologic testing.

Premature return to play by a symptomatic athlete places that athlete at greater risk for subsequent concussion and cumulative brain injury.

Concussion Home Instructions I believe that ____ sustained a concussion.

To make sure he/she recovers, please follow the following important recommendations:

1. Please remind __ to report for a follow-up evaluation.

2. Please review the items outlined on the enclosed Physician Referral Checklist.If any of these problems develop prior to the f/u visit, please call____ at __ or contact the local emergency medical system or your family physician.

3. Otherwise, you can follow these instructions:

J Athl Train. 2004;39(3):280-297.

Concussion Home InstructionsIt is OK to:

Use acetaminophen (Tylenol) for headaches

Use ice pack on head and neck as needed for comfort

Eat a regular diet

Return to school

Go to sleep

Rest (no strenuous activity or sports)

J Athl Train. 2004;39(3):280-297.

Concussion Home InstructionsThere is no need to:

Check eyes with flashlight

Wake up every hour

Test reflexes

Stay in bed

J Athl Train. 2004;39(3):280-297.

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Additional MATERIALS

Evaluation ofAcute Concussion


Evaluation Key features of this exam should encompass:1. A comprehensive history2. Detailed neurological examination

� Thorough assessment of mental status� Cognitive function� Gait and balance.

3. Determination of clinical status of the patient� Improvement or deterioration since the time of injury

4. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

On-field or Sideline Evaluation ofAcute Concussion Sideline evaluation of cognitive function is an

essential component in the assessment of this injury.

Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective.

Duration of LOC is an acknowledged predictor of outcome.

Classification of Concussion

Grading Systems

Zachery Lystedt Law As of July 26, 2009,

1. All school coaches will have to take a training course on the nature and risk of concussions and head injuries including continuing to play after a concussion or head injury.

2. Each school year prior to initiating any turnouts or competition, all school athletes and their parents/guardians must have received training on concussions and head injuries and provide the school with a signed statement indicating they have taken this training.

3. All athletes suspected of suffering a concussion or brain injury will be removed from practice or competition and not returned to play until cleared in writing by a licensed health care provider trained in the evaluation and management ofconcussions.

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Zachery Lystedt Law As of July 26, 2009,

4. All non-profit youth organizations using school facilities shall:a. Provide the school with written Proof of Insurance covering their youth athletes

with limits required by the law andb. All coaches, players and parents of youth teams shall have similar training as

outlined for school coaches prior to the start of any practice, andc. The non-profit youth groups shall indicate in writing their compliance with the

insurance coverage and required head injury training prior to receiving access to school facilities.

Currently the training materials are being developed by expert doctors at Harborview Medical Center, Seattle Children's Hospital, and the University of Washington Hospital in conjunction with WIAA (Washington Interscholastic Activities Association

Why all the work on RTP?? TBI may develop into a severe injury

cerebral, epidural, or subdural hematomaThese are medical emergencies

To specifically avoid one condition Second Impact Syndrome

Today’s Return to Play Management The cornerstone of concussion management is physical and

cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.

The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies.

The importance of considering each person as an individual can not be over emphasized

Concussion Management Modifiers

Graduated Return to Play Protocol A stepwise progression

Athlete should continue to proceed to the next level if asymptomatic at the current level.

Each step should take 24 hours an athlete would take one week to proceed through the full

rehabilitation protocol

If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a 24-hour period of rest has passed.

Rehabilitation Stage Functional Exercise Objective

1. No activity Complete physical and cognitive rest Recovery

2. Light aerobic exercise Walking, swimming stationary cycling -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, eg, passing drills in football and ice hockey; may start progressive resistance training

Exercise, coordination, and cognition load

5. Full contact practice Following medical clearance, participate in normal training activities

Restore confidence and assessment of sports specific functional skills

6. Return to play Normal game play

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Disqualifying the Athlete 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.

Exertional exercises should be included Athletes who return on the same day because symptoms

resolved quickly (<20 minutes) should be monitored closely after they return to play.

They should be repeatedly reevaluated on the sideline after the practice or game and again at 24 and 48 hours postinjury to identify any delayed onset of symptoms.

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete Athletes who experience LOC or amnesia should be

disqualified from participating on the day of the injury. The decision to disqualify should be based on a

comprehensive physical examination; assessment of postconcussion signs and symptoms; functional

impairments, and consideration of past history of concussions)

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete If assessment tools* are not used, a 7-day symptom-free

waiting period before returning to participation is recommended.

Assessment tools include; the SAC, BESS, neuropsychological test battery, and symptom checklist

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete Be more conservative with athletes who have a history of

concussion.

Athletes with a history of concussion are at increased risk for: Sustaining subsequent injuries

Slowed recovery of postconcussion s/s

Cognitive dysfunction

Postural instability after subsequent injuries

J Athl Train. 2004;39(3):280-297.

Disqualifying the Athlete -Permanently

Consider permanently disqualification for athletes:

1. With a history of 3 or more concussions?

2. Who experience slowed recovery?

3. Who have had multiple grade three concussions?

J Athl Train. 2004;39(3):280-297.

Signs and Symptoms of Concussion

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DX involves the assessment of a range of domains: Clinical symptoms Physical signs Behavior Balance Sleep Cognition

A detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination.



IN OFFICE ASSESSMENT

A. A medical assessment including comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning, gait and balance.

This is encompassed by the SCAT 5 in conjunction with cranial nerves and vitals.

213 IN OFFICE ASSESSMENTB. A determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury.Clinical: diminishing performance on SCAT 5 tests, deterioration of vital signs/nerve function

214

IN OFFICE ASSESSMENT

C. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

Ambulance transport, high flow O2 with airway management, CT is imaging of choice

215 FURTHER INVESTIGATION Imaging: not helpful for concussion at this time.

Vital if SDH is suspected. Balance testing: reliable and valid Genetic markers: interesting but don’t help us

clinically Electrophysiology: abnormal if concussed, but

don’t help clinically

216

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Neuropsychological Assessment Cognitive recovery may occur with, before of after

symptom resolution.Don’t use IMPACT as sole RTP determinant

Neuropsychologist referral for prolonged casesAvailability in other clinics?

217 ROLE OF PHARMACOLOGY

No NSAIDS!!!!!

Tylenol is ok.

Any other meds are experimental at best.

218

MODIFIERS Female LOC > 1 min Amnesia doesn’t tell us much Neither do seizures… Depression may be concussion related.

219 Elite Athletes

Get managed just like everyone else….

220

Physical Examination Inspection

Eyes Pupil size and reactivity Conjugate gaze

Palpation Head Neck

Cervical spine AROM PROM

Motor Exam UE LE!

Cranial Nerve Screen1. CN 1 – Smell2. CN 2 – Visual acuity / visual fields3. CN 3, 4, 6 - Pupil reflexes, Size, Field of gaze (peripheral

fields)4. CN 5 – Jaw clinch, face sensation5. CN 6 – see above6. CN – 7 Smile, Frown, raise eyebrows7. CN – 8 Acoustic – softly rub fingers near each ear for

example8. CN – 9/10 Palate elevation, uvula deviation9. CN – 11 Resisted head rotation, shrugging shoulders10. CN – 12 Stick out the tongue and move it side to side.

Balance Testing

Postural stability deficits lasting approximately 72 hours following sport-related concussion.

Postural stability testing a reliable and valid tool for objectively assessing the motor domain of neurologic function.

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Balance Error Scoring System (BESS)

A clinical field test that can be used for sideline evaluations of an athlete's postural stability after a MTBI.

The BESS measures an athlete's postural stability through a clinical-assessment battery and is scored by counting the errors the athlete commits during the tests

The BESS can be used to compare baseline scores with scores after an MTBI.

AdvantagesIt can be used for sideline applicationLess expensive than force-platform systemsRequires less training for administration

Balance Error Scoring System (BESS) One of the signs of a concussion is poor balance.

An athlete's balance and equilibrium can be tested quickly on the sideline.

The BESS consists of 3 tests lasting 20 seconds each, performed on two different surfaces, firm and foam

BESSTest

Balance Error Scoring System The athlete first stands with the feet together, hands on the hips,

eyes closed (double leg stance). Holds this stance for 20 seconds while the number of balance

errors are recorded. Errors are:

Opening the eyesHands coming off hipsA step Stumble or fallMoving the hips more than 30 degrees Lifting the forefoot or heelRemaining out of testing position for more than 5

seconds)

Balance Error Scoring System

The test is then repeated with a single-leg stance using the non-dominant foot

A third time using a heel-toe stance with the non-dominant foot in the rear (tandem stance).

All three tests are performed on a firm surface (grass, turf, court), and again on a piece of medium-density foam (a piece of foam can easily be carried in a travel trunk or equipment bag for road games).

Clinicians who use the BESS as part of their sideline assessment for concussion should not administer the test immediately after a concussion due to the effects of fatigue.

Neuropsychological Tests

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Computerized Neuropsychological Tests

Factors Influencing Neuropsychological Test Performance

Exertional/Provocative Tests Forty yard sprint 1 0 - push-ups, setups, knee bends Any appearance of symptoms is abnormal

Headache Dizziness Nausea Visual disturbance Unsteadiness

DO NOT FORGET THE EXERTIONAL TESTS! The are not asymptomatic until they are asymptomatic at rest and

with exertion.

Take a Quiz - Concussion

1. What percent of sports related concussion are associated with a loss of consciousness? 10%

2. What structural changes occur in the CNS with concussion? None3. Under which circumstances can a concussed athlete be returned

ot play the day of injury? Never4. Which medication has been proven to facilitate the recovery of a

patient with concussion? None5. What skills are required to properly assess a concussed

individual? SCAT 5 Cranial Nerve, Memory, Symptoms, Vital Signs, Balance, Vision.

Questions?

[email protected]

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Current Trends in Sports Related Concussion SEPT2018

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