Sports Related Concussion. Joshua T. Williams, PT, DPT, OCS, SCS, CSCS

Transcription

1 Sports Related Concussion Joshua T. Williams, PT, DPT, OCS, SCS, CSCS

2 Concussion & Traumatic Brain Injury Glasgow Coma Scale Minimal Mild Mod Severe? Sports concussion Severe GCS 8 Moderate GCS 9-12 Mild GCS Teasdale et al Lancet 1974; ii: 81-4

3 Definition Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

4 Common Features 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 neurologic function that resolves spontaneously. However in some cases symptoms and signs may evolve over a number of minutes to hours. 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, post-concussive symptoms may be prolonged.

5 got your bell rung

6 Signs & Symptoms Symptoms Somatic Cognitive Emotional Signs Physical Behavioral Cognitive Sleep

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8 Evaluation/Management Concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess, and manage. No perfect diagnostic test or functional marker to rely on for immediate diagnosis Should evaluate when player shows ANY features of concussion

9 On-field/Side-line Management The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available the player should be safely removed from practice or play and urgent referral to a physician arranged. When in doubt, sit them out!

10 Side-line Management Once the first aid issues are addressed an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury. A player with diagnosed concussion should not be allowed to return to play on the day of injury.

11 2. Scoring 4. Patient Information 1. Sideline Assessment 3. Instructions

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21 On-going Management Serial assessment in the acute stage should be performed to monitor athlete for deteriorating status Tools like SCAT3 are designed for rapid screening and should not replace full and comprehensive neuropsychological screening Tools like SCAT3 should not function as stand alone tools for on-going management

22 On-going Management Follow-up necessary to monitor progress or deterioration Comprehensive history and detailed neurological exam Daily focused exam of symptoms, cognitive function, and balance/coordination to monitor course of recovery

23 On-going Management Need for neuroimaging? Force plate testing? Genetic testing/markers? Electrophysiological recording techniques (i.e. evoked response potential (ERP), cortical magnetic stimulation, electroencephalography)?

24 On-going Management Neuropsychological testing (i.e. IMPACT testing) Important component of overall assessment and management Should not be used as sole basis for clinical decisions Formal testing not required for all (may take more conservative RTP route) Should be performed/interpreted by trained neuropsychologist Usually performed following resolution of symptoms Baseline is helpful, but not necessary

25 Management CORNERSTONE = REST Physical Rest No training, playing, exercise, weights Beware of exertion with activities of daily living Cognitive Rest No television, extensive reading, video games? School? Caution re: daytime sleep

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27 Home Care Avoid medications other than acetaminophen Avoid ingesting alcohol, illicit drugs, or other substances (caffeine, energy drinks) that may interfere with cognitive function Avoid driving/operating machinery until cleared to do so No need to wake the athlete at night No need for bed rest Eat well-balanced diet/stay hydrated

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29 Recovery Majority (80-90%) resolve in short (7-10 day) period May take longer in children and adolescents

30 Return to Play Don t guess, test Progressive exertion program when Normal clinical exam Resolution of symptoms at rest Pre-injury motor control and neurocognitive function Off medications

31 Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage 1. No activity Symptom limited physical and cognitive rest. Recovery 2.Light aerobic exercise Walking, swimming or stationary cycling keeping 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 e.g. passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load 5.Full contact practice Following medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff 6.Return to play Normal game play

32 Modifiers May influence investigation and management May predict potential for prolonged or persistent symptoms Multidisciplinary approach coordinated by a physician with specific expertise in management of concussion.

33 FACTORS Symptoms Signs Sequelae Temporal Threshold MODIFIER Number Duration (>10 days) Severity Prolonged LOC (>1min) Amnesia Concussive convulsions Frequency repeated concussion over time Timing injuries close together Recency recent concussion or TBI Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Age Co and Pre-morbidities Medication Behaviour Sport Child and adolescent (< 18 years old) Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Psychoactive drugs Anticoagulants Dangerous style of play High risk activity Contact and collision sport High sporting level

34 Age as a Modifier Children and adolescents may take longer to recover and may require a more prolonged RTP program compared to adults Full assessment may require patient, parent, and possibly teacher/coach input. Children (<13yo) should use child SCAT3 (ages 5-12) Children may require more frequent updates to baseline assessments Neuropysch testing may take place sooner after injury and ideally would be interpreted by pediatric neuropsychologist Other modifiers accentuated in child and adolescent population

35 Multiple Concussions Requires more conservative RTP program Requires further assessment when baseline function changes, sustains concussions with lessening forces, increased severity, prolonged recovery Potential long term consequences?

36 Chronic Traumatic Encephalopathy (CTE) Possible result of multiple concussive and subconcussive trauma? Depression, memory impairments, cognitive deficits????????????????

37 Equipment May protect from other injuries such as dental injuries (mouthguard) &/or facial and skull injuries (helmets), but no evidence to support prevention of concussions May lead to over-confidence and increased risk taking behaviors

38 Education & Prevention Take advantage of pre-participation screening Modifiers present? Equipment Signs & symptoms Athletes, parents, coaches Resources

39 Legal Aspects Be aware of any and all governing bodies and their policies regarding concussion management Document evaluation, potential modifiers, management (including education), treatment, return-to-play, participation progression, and communication within the team

40 Oklahoma Statutes Title 70 Section Enacted in July 2010 (SB 1700) Education for coaches, athletes, parents/guardians Annual completion of concussion and head injury information sheet Immediate removal from play if concussion suspected No return to play until evaluated by licensed health care provider trained in the evaluation and management of concussion and received written clearance for return to play