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Concussion: Evaluation and Management of Sport Injury
Jeffrey L. Tanji, MDAssociate Medical Director, Sports Medicine, UC Davis Health System
Melita Moore, MDHead Team Physician, UC Davis Intercollegiate Athletics
Mindgame
DisclosuresI have no relevant financial relationships to
any products discussed in this talkI do not intend to talk about an
unapproved/investigative use of a commercial product in this presentation
RationaleStandards of care for sport concussion have
changed dramatically over the last two yearsNew state law mandates certain actions in
the management of concussionSport concussion is under-recognized and
under-reportedCommunity education and awareness are
paramount
ObjectivesDefine a sport concussionList the key symptoms and findings of
concussionDemonstrate the key aspects of the history
and physical in the evaluation of concussionDefine the three steps of medical clearance
to begin rehab after concussion
ObjectivesList the four steps of progression between
medical clearance and true return to playDiscuss several controversies in concussion
managementMindgame is a multi-health system
integrated approach to youth concussion care (Kaiser, Dignity Health, Sutter, UC Davis) in the Sacramento Valley
DefinitionMild traumatic brain injury (TBI)Metabolic, functional (not structural) damage
from direct or indirect traumaClassically, attention, vision, balance,
headache, memory are affected but only short term with relatively rapid recovery
Useful data1.5 to 4 million concussions/year in sport80-90% -no- LOC80-90% return to full activity in 1 week
(NCAA data)We seek to avoid second impact syndrome
which is associated with long term issuesYounger and female athletes take longer to
recover, the younger, the slower to return, discussion that high school athletes may need two weeks minimum
Second impact syndromeA second concussion while still symptomaticGenerally within the same seasonMild trauma can have dramatic effect and
long recoveryMajor brain injury in sport concussion is
almost always associated with second impact
Sport and concussionFootballIce hockey*Women’s soccer*Youth soccerField hockey and lacrosseWrestling
Lingering metabolic effects30 days of vascular spasm and decreased
cerebral flowHyperglycemiaK and Ca channels are disruptedGenerally a bleed is not found on MRI or CTThe “neurometabolic cascade” Hovda DA and
Giza CC, Clin Sport Med 2011:30(1):33-48
Neurometabolic cascade
Concussion: signsLOC less than 10-20%HeadacheVisual difficultiesNausea/vomitingBalance issuesMemory loss/confusion
No return to play that dayCalifornia AB 25 (2012) for a suspected
concussion, there will be no return to play that day
Medical clearance by a licensed professional must be given before return to activity
California AB 2127 (Cooley law) Jan 1, 2015: 7 day mandatory no return to play and to follow protocols
Role of advanced imagingExcludes severe bleed, critical structural
damageDoes not clear an athlete to return to playMisconception by family and athlete“I was told my concussion was normal and I
was cleared to play”When they were told that they could go home
and that the imaging study was normal
Follow upNo need to keep waking a person up hourlyTylenol is ok, no ASA or NSAIDsWorsening status -> ED1-2 workday follow up through Mindgame
SacramentoRest and cognitive rest
Concussion: established treatmentCognitive restNo cell phones, no games, no textingNo television, no readingNo physical activitywww.cdc.gov/concussion
Follow up symptomsSymptoms:HeadacheVisual issuesBalanceSleepEmotions (short fuse?)Concentration
Follow up physical findingsOrientation, EOM and pupillary responseFinger -> nose, heel to shin, rapid alternating
movementsHeel to toe walkingRomberg
Physical findings
No Sx and examination WNLNeurocognitive testing (NCT):Ideally a baseline test has been doneIf no baseline, compare with age related
norms, > 20 percentile
Computer based NCT
Three steps to clearanceNo symptomsNormal focused neurological examinationReturn to baseline or appropriate scores on
neurocognitive testingThen work with coach or athletic trainer for
the progressions to full competition
Rehab progressionRun, jog 20 minutes without symptomsWait one daySprint, interval speed work without SxWait one dayReturn to the field with no contactWait one dayReturn to the field with full contact
Variations in progression timingZurich consensus conference 2013: one day
between stagesUniversity of Pittsburgh: two days between
stagesNational Basketball Association: one hour
between stages
Complex casesPersistent symptomsFormal neuropsychological assessment, work
with a vestibular physical therapist? ENG studies (as if for acoustic neuroma)Debate about gentle walkingFormal neurologist, neuropsychologist or
physiatrist evaluation
Vestibular PT
Take Home PointsNo return to play the same dayNeurocognitive testing (NCT) is becoming
the standard of careNo symptoms, normal exam, normal NCT
clears to begin the progressionProgression: aerobic, sprint, on-field no
contact and finally on-field with contact
ED take home pointsThe findings of a normal imaging study do
not clear an athlete to return to playMust keep follow up outpatient visit for
clearance (state law AB25)No symptoms, normal physical exam and a
normal neurocognitive test are neededThen an athlete begins a rehab progression
before clearance to play
ResourcesMcCrory P, Meeuwisse W, Aubry M, et al.
Consensus statement on concussion in sport, Br J of Sports Med 2013; 47:250-258.
www.cdc.gov/concussionwww.sacramentovalleyconcussion.comwww.aroundthecapitol.com/bills/AB25www.aroundthecapitol.com/bills/AB2127www.sacramentovalleyconcussion.com