04/08/2016 ACCESSIBILITY! ACCESSIBILITY! ACCESSIBILITY! AFFABILITY

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Adrian Lindsey
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Edward D. Snell, MD Director Division Primary Sports Medicine Head Team Physician Pittsburgh Pirates Allegheny Health Network Sports Medicine Xx/xx/xx ACCESSIBILITY!

1 Edward D. Snell, MD Director Division Primary Sports Medicine Head Team Physician Pittsburgh Pirates Allegheny Health Network Sports Medicine Xx/xx/xx ACCESSIBILITY! ACCESSIBILITY! ACCESSIBILITY! Athletes want seen quickly so that they don t lose time If you don t see them they are going elsewhere You have to inform your staff ahead of time because they can hurt your credibility with the athlete. AFFABILITY Spouse Friends Agents Coaches Parents Other medical professionals 1

ABILITY Patients/Athletes expect Competent An EXPERT Cutting Edge Technology

for your actions Transparency is always best Make good reasonable decisions

prevalence Discuss signs and symptoms Discuss how physicians may treat patient

2 ABILITY Patients/Athletes expect Competent An EXPERT Cutting Edge Technology Great Work Ethic Successful Treatment Program ACCOUNTABILITY Take Responsibility for your actions Transparency is always best Make good reasonable decisions Objectives: Briefly review the definition of concussion Review cause and prevalence Discuss signs and symptoms Discuss how physicians may treat patient with concussions Discuss legal issues Review academic accommodations Review return to play protocol 2

Severe Moderate Mild http://a.espncdn.com/photo/2012/0824/otl_e_concussion_ill_ b1_576.

concussions are serious 4 th International Conference on Concussion in Sport Guidelines (Zurich 2012): Complex,

Impulsive force transmitted to head Rapid onset, short-lived impairment May or may not involve Loss of Consciousness No

3 Severe Moderate Mild b1_576.jpg Concussions are by Definition Mild Traumatic Brain Injury Don t be fooled.concussions are serious 4 th International Conference on Concussion in Sport Guidelines (Zurich 2012): Complex, pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Impulsive force transmitted to head Rapid onset, short-lived impairment May or may not involve Loss of Consciousness No abnormality seen on regular head imaging Functional & metabolic disturbance Glucose Sodium Potassium Calcium Oxygen 3

http://cdn.bleacherreport.net/images_root/slides/photos/00 1/411/518/107844000_crop_650x440.jpg?1318299135 CDC: 3.

15 cases per 100,000 athlete exposures 750,000 diagnosed concussions per year in outpatient setting HS athletes who had a concussion, are 3 times more likely to suffer

4 1/411/518/ _crop_650x440.jpg? CDC: 3.8 millions sports-related TBIs per year 13-15% of all high age sports injuries are concussions cases per 100,000 athlete exposures 750,000 diagnosed concussions per year in outpatient setting HS athletes who had a concussion, are 3 times more likely to suffer another one during the same season EDs treat 173,000+ sports & recreation related TBI yearly (19 or younger) H %20ED%20rooms.jpg 5 Categories of Concussion-related impairment Symptoms Physical signs Behavioral changes Cognitive Impairment Sleep Disturbance 4

Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance http://doublegsports.com/wpcontent/uploads/2012/11/353724-2966-16.

5 Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Symptoms Somatic: Headache Dizziness Photophobia (light hurts) Phonophobia (sounds hurt) Visual problems (difficulty focusing or seeing multiple images) Nausea Vomiting Cognitive: feeling in a fog Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Physical Signs Loss of Consciousness Amnesia Retrograde (before event) Anterograde (after event) Unsteadiness or uneasiness of gait Slow or incoherent speech Blank stare 5

6 Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Behavioral Changes Nervousness / Anxiety Irritability Depression Inappropriate laughing or crying Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Cognitive Impairment Difficulty with concentration Difficulty with memory Slowed reaction time Confusion (WORSENING confusion is worrisome) Signs & Symptoms Symptoms Physical Signs Behavioral Changes Cognitive Impairment Sleep Disturbance Sleep Disturbance Trouble falling asleep Trouble staying asleep Sleeping too much 6

When a player shows ANY sign of concussion: Medical evaluation, including C-spine If no ATC or

) Serial evaluations If questionable, do provocative testing 40 yard sprint 5 pushups / sit-ups / knee

bleacherreport.net/images_root/slides/photos/ 000/511/832/106878913_display_image.jpg?

jpg If medical evaluation is concerning, immediately send to ER LOC alone is not a modifying factor

7 When a player shows ANY sign of concussion: Medical evaluation, including C-spine If no ATC or healthcare professional available, must be held out Sideline Assessment tool (SCAT-3, NFL, etc.) Serial evaluations If questionable, do provocative testing 40 yard sprint 5 pushups / sit-ups / knee bends Note: Orientation questions are the LEAST sensitive in suspected concussion 000/511/832/ _display_image.jpg? /45/05/484505_m21.jpg If medical evaluation is concerning, immediately send to ER LOC alone is not a modifying factor for concussion LOC > 1 minute may change management decisions Motor or convulsive phenomenon following a concussion warrant no special management modification 7

Balance Testing (BESS or objective) Valid and reliable testing component Neuroimaging Not useful initially unless concern

jpg When an athlete shows any of the concussion symptoms: SIT THEM OUT WHEN IN DOUBT: SIT OUT Situations in which to call

) Athlete loses consciousness Athlete is experiencing: Neck pain Inability to move or feel extremities In these

8 Balance Testing (BESS or objective) Valid and reliable testing component Neuroimaging Not useful initially unless concern for intracranial bleeding or other emergencies When an athlete shows any of the concussion symptoms: SIT THEM OUT WHEN IN DOUBT: SIT OUT Situations in which to call for medical assistance (sideline physician, trainer, EMS, etc.) Athlete loses consciousness Athlete is experiencing: Neck pain Inability to move or feel extremities In these situations, do NOT move the athlete Concussed athlete becomes listless or unresponsive 60/img/photos/2012/08/10/e1/57/concussions_ a.jpg 8

If signs of concussion PULL FROM ACTIVITY If no need for ER evaluation Rest with zero-to-minimal brain/physical activity for 48-72

No TV, no reading, no music, no playing, no cell phone, no computers, no video games Call physician for appointment within 7-10 days

) No aspirin (Excedrin, etc.) http://webmm.ahrq.gov/media/cases/im ages/case115_fig01.

9 If signs of concussion PULL FROM ACTIVITY If no need for ER evaluation Rest with zero-to-minimal brain/physical activity for hours. No TV, no reading, no music, no playing, no cell phone, no computers, no video games Call physician for appointment within 7-10 days Acetaminophen ONLY (Tylenol) for headaches in the first 72 hours No ibuprofen (Advil, Motrin, etc.) No naproxen (Aleve, etc.) No aspirin (Excedrin, etc.) ages/case115_fig01.jpg Preference to hold from school for at least 3 days After 72 hours May NOW give ibuprofen, naproxen Be cautious of aspirin in children Depending on symptoms, may increase mental activity 9

Every physician treats concussions differently, but general principles

individualized http://mommasaid.net/wpcontent/uploads/2013/02/concussion.

0 through 6 Pt asked to rate the average severity of each symptom over

10 Every physician treats concussions differently, but general principles are the same Each patient is an individual Management of concussions is individualized Post-Concussion Symptom Score point scale 22 symptoms, ratings 0 through 6 Pt asked to rate the average severity of each symptom over the previous 24 hours Administered at EACH visit to monitor symptom progression 10

History Injury description LOC Amnesia Retrograde Anterograde Treatments

Examination should always performed by physician Initial Evaluation:

tracking Horiz / Vert Saccades Clock drawing Coordination Balance Delayed

Time from concussion Examination Age of athlete Level of play Risk factors

11 History Injury description LOC Amnesia Retrograde Anterograde Treatments prior to visit PMH focusing on risk factors for prolonged recovery Examination should always performed by physician Initial Evaluation: Orientation Immediate Memory Concentration Cranial Nerve Exam Visual tracking Horiz / Vert Saccades Clock drawing Coordination Balance Delayed Recall Physician Assessment A number of factors go into assessment Symptoms Time from concussion Examination Age of athlete Level of play Risk factors Diagnostics needed? Symptomatic treatment? School / work accommodations Return to play? Follow-up interval? 11

walking, exercise bike) Sunglasses for photophobia Quiet rooms / ear plugs for phonophobia 1-2 months: Concussion Rehabilitation Cognitive Therapy Vestibular Therapy Dual Tasking Physical Therapy

12 Post-acute Symptoms: NSAIDs Tylenol Ice / heat Massage Mild physical activity (e.g. walking, exercise bike) Sunglasses for photophobia Quiet rooms / ear plugs for phonophobia 1-2 months: Concussion Rehabilitation Cognitive Therapy Vestibular Therapy Dual Tasking Physical Therapy (neck symptoms) Oculomotor training MRI Brain non-contrast Full Neurocognitive Evaluation Prolonged symptoms Medical Treatment Concussive symptoms can greatly affect school performance Good days / Bad days There are a number of modifications that can be made in conjunction with the school counselor School accommodations Physical Education Physical Accommodations Academic Modifications I prefer alternating ½ days x 1-2 wks Work accommodations Restrict driving based on symptoms Consider hazard level Follow-up every 1-4 weeks 12

13 Pain Medications NSAIDs Anti-depressants Beta blockers Neuromodulators Vitamins/mineral supplements PT CBT Tylenol Narcotics NSAIDs Ibuprofen Naprosyn Voltaren Indocin 13

14 TCAs SSRIs Mixed Beta blockers Calcium channel blockers Amantadine Gabapentin Pregablin Muscle Relaxants 14

15 B2 Magnesium Omega 3 fatty acids 15

RTP Protocol 5 steps, 5 day minimum Progressively increasing CV stress and sport specific

present Neuropsych testing Brief (C3 Logix, ImPACT, etc.

neuropsychologist Cognitive recovery USUALLY occurs AFTER symptom recovery Should be used as AID

16 RTP Protocol 5 steps, 5 day minimum Progressively increasing CV stress and sport specific exercise May be administered by ATC or PT Designed to try to bring out symptoms of concussion if present Neuropsych testing Brief (C3 Logix, ImPACT, etc.) None MAKE the diagnosis ONLY used as a TOOL in concussion management Formal Evaluated by neuropsychologist Cognitive recovery USUALLY occurs AFTER symptom recovery Should be used as AID in decision process only

Most professional societies no longer grade concussions AAN still does Individuals are individuals Their own symptoms Their own recovery speed Kids like to compare concussions Can be detrimental to

17 Most professional societies no longer grade concussions AAN still does Individuals are individuals Their own symptoms Their own recovery speed Kids like to compare concussions Can be detrimental to the recovery process Occurs when brain suffers a concussion, while still suffering the effects of a previous one Rapid brain swelling leads to catastrophic effects May occur minutes, days, or even weeks after initial concussion Often fatal, but severely disabling if not fatal Etiology In question Perhaps brain arterioles lose their ability to regulate dilation Lose control over cerebral blood flow Leads to edema The diagnosis itself is EXTREMELY RARE and has even been called into question CDC: about 1.5 cases per year, most of which had no reported prior concussion A large topic in itself Small % of athletes suffer disproportionately severe and long-term sequelae Role of tau protein and its hyperphosphorylation Very little is known about what type, frequency, or amount of trauma is necessary to induce the accumulation of these pathological proteins Cause and effect has NOT been established _ _brain_oct226spl-1.jpg 17

http://3.bp.blogspot.com/_xdn0qqwsp1a/sypow7fp- vi/aaaaaaaaess/tsn- ET4gXX8/s400/chris_henry 390421gm-a.

are NO studies that show helmets provide additional protection against concussions One study showed leather-style helmets = Riddell Evolution Helmets MAY worsen concussion rates due to reckless play

18 vi/aaaaaaaaess/tsn- ET4gXX8/s400/chris_henry gm-a.jpg In athletes with verified CTE, a very small portion of them have self-reported or medically reported concussive episodes May be due to chronic, sub-concussive trauma More studies are needed There are NO studies that show helmets provide additional protection against concussions One study showed leather-style helmets = Riddell Evolution Helmets MAY worsen concussion rates due to reckless play Mouthpieces Not effective in reducing concussions Are effective for preventing dental trauma Rule changes may make some difference Education Coaching proper tackling All 50 states + D.C. have concussion laws. Most concussion in sports laws include three action steps: Educate Coaches, Parents, and Athletes: Inform and educate coaches, athletes, and their parents and guardians about concussion through training and/or a concussion information sheet. Remove Athlete from Play: An athlete who is believed to have a concussion is to be removed from play right away. Obtain Permission to Return to Play: An athlete can only return to play or practice after at least 24 hours and with permission from a health care professional. _new/ harrisburg-capitol-750a.photoblog600.jpg 18

Concussions are serious, and need to be treated correctly Important to recognize the signs and symptoms of concussion When an athlete appears concussed, they MUST be held from athletic participation

19 Concussions are serious, and need to be treated correctly Important to recognize the signs and symptoms of concussion When an athlete appears concussed, they MUST be held from athletic participation Only a physician should clear an athlete to return Refer to your state laws regarding parent and coach education Concussion Management at the NFL, College, High School, and Youth Sports Levels. Maroon J., Bost J. Clinical Neurosurgery. Vol. 58 (2011). pp Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November McCrory, et al. Clin J Sport Med (2009);19: The Role of Age and Sex in Symptoms, Neurocognitive Performance, and Postural Stability in Athletes after Concussion. Covassin T, et al. Am J Sports Med : Early Indicators of Enduring Symptoms in High School Athletes With Multiple Previous Concussions. Schatz P., et al. Neurosurgery 68: , 2011 Sports Concussion and the Risk of Chronic Neurological Impairment. McCrory P. Clin J Sport Med 2011;21:

POLICY / PROCEDURE DOCUMENT Effective Date 08/19/2010. Concussion Assessment, Management, and Return to Play Guidelines

Beacon Medical Group Sports Medicine POLICY / PROCEDURE DOCUMENT Effective Date 08/19/2010 TITLE: Document of (Entity) POLICY: PATIENT POPULATION: Concussion Assessment, Management, and Return to Play