No relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the

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2 No relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

3 24 year old Olympic ice hockey player gets hit in the head by an opponent. He is dazed but then feels fine with no headaches or other symptoms. His physical, cognitive exam and balance exam is normal.

4 Can he return in the same game? When can he return to play? Follow-up

5 Grade 1 - Recovery within min Grade 2 - Symptoms Grade 3 - LOC

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7 Individualized symptombased approach Retrospective grading of severity Stepwise process to return to play No Return to Play in the Same Game

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9 Visible signs Evaluation in dressing room No RTP in the same day Follow up Progressive stepwise process in return to activity Neuropsychological testing before return to play once symptoms disappear

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11 When can he return to play? Provocation of exercise Gradual increase in intensity Pediatric Group

12 Practice Contact Aerobic exercise Sportspecific drills Complete rest

13 LOC > 1 minute Amnesia # of symptoms Recent/frequent concussions Recurrent concussions with less force

14 Child and Adolescence <18 Co/Pre morbid states (ADHD, depression) Medication (psychoactive) Behaviour

15 Important tool in return to play Should not be done until symptom-free Return to play a medical decision Zurich Consensus on Concussion in Sport, 2012

16 Most concussions will settle within 7-10 days Do not need formal neuropsych testing in those concussions

17 Baseline testing in the elite athlete and perhaps contact sports Better evaluation SCAT3 Card is useful

18 Abnormal NP/ Abnormal Symptoms Abnormal NP/ Normal Symptoms 116 (39%) 91 (30%) (11%) 61 (20%) 93 Normal NP/ Abnormal Symptoms Normal NP/ Normal Symptoms 300 N=300 from merged physician evaluation and neuropsych testing databases for Echemendia, Lovell et al, 2008,

19 Cognitive testing in all concussions (SCAT3) and follow up Formal neuropsych evaluation in the elite Baseline testing in elite athletes

20 No return to play in the same game Longer recovery Slower return to play Return to learn before return to play Physical/cognitive rest Neuropsych testing is developmentally sensitive

21 Increased risk of recurrent concussion Slower recovery in athletes with concussion Second Impact in young athletes Guskiewicz et al. JAMA 2003;290:

22 Involves 10% of athletes Return to normal cognitive and somatic functioning within days >3 months BIGLER ET AL. J NEUROPSYCHOL SOC 2008 PRIGATANO ET AL.CURR OPIN PSYCHIATRY 2011

23 Physical and cognitive rest Neck physiotherapy Submaximal exercise therapy Vestibular Rehabilitation Psychological therapy Cognitive therapy Pharmacological therapy

24 Management of specific prolonged symptoms (sleep, anxiety, headache, etc.) Modify the underlying pathophysiology with the aim of shortening the duration of symptoms MCCRORY BJSM 2002

25 Medications should only be prescribed by physicians with experience in concussion management With RTP athletes should not be talking meds that would mask symptoms

26 Prolonged post concussion Multiple concussions Threshold for concussion is very low Diminished academic or athletic performance MRI abnormalities SEDNEY ET AL CLINICS SPORT MED 2011

27 Return to play in the same game?. NO Rapid Return to play? Be Careful in contact sports. Do not cheat! Stepwise Process takes 7 days for most athletes. Computerized cognitive assessment in elite / professional sport? Pro sport yes/ all elite non-pro sport Practically? SCAT3

28 Use of Modifiers of severity and recovery in return to play? Yes Longer Recovery Activity? Gradual increase in activity. Can start even if symptomatic as long as no exacerbation. Treatment? Begin Treatment early (physiotherapy, Vestibular, psychological, submaximal activity, pharmacology) Treatment of post concussion? Multidisciplanary

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