Dr Mark Fulcher Sports and Exercise Medicine Physician Axis Sports Medicine Specialists

Transcription

1 Dr Mark Fulcher Sports and Exercise Medicine Physician Axis Sports Medicine Specialists 16:30-17:25 WS #163: ACC Sports Concussion Guidelines 17:35-18:30 WS #175: ACC Sports Concussion Guidelines (Repeated)

2 CONCUSSION & HEAD INJURY A Clinic-based approach DR MARK L FULCHER SPORT AND EXERCISE PHYSICIAN AXIS SPORTS MEDICINE SPECIALISTS

3 CONCUSSION IN SPORT Copyright ACC 3

4 CONCUSSION IN SPORT Consensus statement Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Paul McCrory, 1 Willem H Meeuwisse, 2,3 Mark Aubry, 4,5,6 Bob Cantu, 7,8 Jiři Dvořák, 9,10,11 Ruben J Echemendia, 12,13 Lars Engebretsen, 14,15,16 Karen Johnston, 17,18 Jeffrey S Kutcher, 19 Martin Raftery, 20 Allen Sills, 21 Brian W Benson, 22,23,24 Gavin A Davis, 25 Richard G Ellenbogen, 26,27 Kevin Guskiewicz, 28 Stanley A Herring, 29,30 Grant L Iverson, 31 Barry D Jordan, 32,33,34 James Kissick, 6,35,36,37 Michael McCrea, 38 Andrew S McIntosh, 39,40,41 David Maddocks, 42 Michael Makdissi, 43,44 Laura Purcell, 45,46 Margot Putukian, 47,48 Kathryn Schneider, 49 Charles H Tator, 50,51,52,53 Michael Turner 54 Copyright ACC 4

5 CONCUSSION IS... A complex pathophysiological process affecting the brain Induced by biomechanical forces Resulting in largely functional rather than structural injury CONCUSSION IS A BRAIN INJURY CONSENSUS STATEMENT ON CONCUSSION IN SPORT: THE 4TH INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT, ZURICH, NOVEMBER 2012, BJSM Copyright ACC 5

6 PREVIOUS CONCEPTS REINFORCED Concussion is not a benign injury Complication rate is low No way of predicting which athletes are going to have complications Management must be conservative Aim at reducing the overall burden of head injury/trauma Copyright ACC 6

7 TRAUMATIC BRAIN INJURIES 3 TBIs occur every minute 75-85% of these are mtbis (concussions) 80-90% of mtbis resolve in 7-10 days 21,000 concussions over a 10 year period Cost ACC $1.6 million per year Copyright ACC 7

8 CONCUSSION EPIDEMIOLOGY Concussion rate has increased over the past two decades Women sustain more concussions Greater risk during competition Copyright ACC 8

9 SPORTS COLLABORATION GROUP Copyright ACC 9

10 SPORTS COLLABORATION GROUP Copyright ACC 10

11 SPORTS COLLABORATION GROUP Endorsed the consensus guidelines Concussion should be managed by doctors A standardised approach is needed More primary care education needed Copyright ACC 11

12 A DOCTOR PROBLEM Copyright ACC 12

13 CONTUSION SECOND IMPACT SYNDROME VAULT FRACTURE SUBDURAL DIFFUSE BRAIN INJURY EPIDURAL HAEMATOMA LACERATION INTRA-CEREBRAL HAEMATOMA CONCUSSION MILD TRAUMATIC BRAIN INJURY POST TRAUMATIC ENCEPHALOPATHY CEREBRAL CONTUSION Copyright ACC 13

14 MEDICAL REVIEW At time of injury Before returning to activity Prior to returning to sport Copyright ACC 14

15 NUMBER 1 ALL PATIENTS THOUGHT TO HAVE HAD A CONCUSSION NEED TO SEE A DOCTOR Copyright ACC 15

16 TOOLS FOR ASSESSMENT Pocket Concussion Recognition Tool (CRT) For non-medical / first responders SCAT 3 For use by medical professionals Validated for those 13 years of age and older Child SCAT 3 For use by medical professionals For 5 to 12 year olds Copyright ACC 16

17 SCAT 3 Copyright ACC 17

18 SCAT 3 Assessment Sideline Assessment & Maddocks Score Background information Symptoms Standardised Assessment of Concussion (SAC) Balance Error Scoring System (BESS) Instructions Athlete / Carer Advice Copyright ACC 18

19 CLINIC BASED ASSESSMENT Copyright ACC 19

20 SYMPTOMS Variable Not always severe Not always present when you see them Hard to quantify How bad are they?

21 HISTORY KEY CONSIDERATIONS Don t need to be knocked out Blow does not need to be to the head Patient may appear normal High index of suspicion

22 SCAT 3 BACKGROUND Copyright ACC 22

23 SCAT 3 SYMPTOMS Copyright ACC 23

24 NUMBER 2 ANY PATIENT WITH NEUROLOGIC SYMPTOMS HAS HAD A BRAIN INJURY Copyright ACC 24

25 MODIFIERS Factors Symptoms Number Duration (>10 days) Severity Signs Prolonged LOC (>1min) Amnesia Modifier Sequelae Concussive convulsions Temporal Frequency repeated concussion over time Timing injuries close together Recency recent concussion or TBI Threshold Age Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Child and adolescent (< 18 years old) Co and Pre-morbidities Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Psychoactive drugs Anticoagulants Behaviour Dangerous style of play Sport High risk activity Contact and collision sport High sporting level Copyright ACC 25

26 ADOLESCENT ATHLETES Developing brains Generally require longer to recover More likely to have complications Be more conservative Copyright ACC 26

27 EXAMINATION Copyright ACC 27

28 SCAT 3 SAC Copyright ACC 28

29 SCAT 3 SAC Copyright ACC 29

30 SCAT 3 SAC Copyright ACC 30

31 SCAT 3 SAC Copyright ACC 31

32 SCAT 3 SAC Copyright ACC 32

33 SCAT 3 SAC Copyright ACC 33

34 BALANCE ERROR SCORE (BESS) Copyright ACC 34

35 NUMBER 3 USE THE SCAT3 ASSESSMENT TOOL Copyright ACC 35

36 SCAT 3 SAC Copyright ACC 36

37 SAC STANDARDISED QUICK TO PERFORM OBJECTIVE Point of comparison Copyright ACC 37

38 CHILD SCAT 3 Copyright ACC 38

39 CHILD SCAT 3 Copyright ACC 39

40 SCAT 3 NORMATIVE SCORES SCAT 3 baseline data: Average No. of symptoms = 1.3 Average Symptom Score = 2.2 Average SAC / 30 = 26.1 Brookes et al, Br J Sports Med 2014;48: Copyright ACC 40

41 EXAMINATION Copyright ACC 41

42 IMAGING True concussion has no imaging findings Acute CT if intracranial lesion suspected fmri Copyright ACC 42

43 MANAGEMENT Copyright ACC 43

44 MANAGEMENT THE FIRST 24 HOURS Don t leave the athlete/patient alone No driving or alcohol Simple analgesia and rest Information and action plan (SCAT3) Neurological observation or further investigation Copyright ACC 44

45 MENTAL & PHYSICAL REST Not just sport School commitments Time off Exam and assignments Employment Copyright ACC 45

46 MENTAL AND PHYSICAL REST Copyright ACC 46

47 RESETTING EXPECTATIONS 200 contracts in NZ 600 contracts in NZ and Australia Copyright ACC 47

48 RESETTING EXPECTATIONS NEW ZEALAND SECONDARY SCHOOLS 60% NRL UNDER 20 COMPETITION ITM CUP (NPC) SUPER RUGBY $200,000 33% NRL AVERAGE 43 GAME CAREER $100,000 Copyright ACC 48

49 RETURN TO ACTIVITY DECISIONS 90% resolve within seven days Symptom free Graduated return to sport and activity Neuro-psychological testing Often difficult and pressured decisions Copyright ACC 49

50 RETURN TO LEARN AND PLAY CLASSROOM PLAYING FIELD - Mental and physical rest Subtle variations in guidelines - Between codes - Between countries - Between governing bodies Copyright ACC 50

51 RETURN TO PLAY Mental and physical rest till asymptomatic Light aerobic exercise Sport-specific exercise Non-contact drills and resistance training Full contact FOLLOWING MEDICAL CLEARANCE RETURN TO PLAY Copyright ACC 51

52 RETURN TO ACTIVITY Need to be asymptomatic for 24 hours at each phase Any symptoms Rest for a further 24 hours Resume at the earlier level Need medical review before returning to sport Copyright ACC 52

53 RETURN TO PLAY NZ RUGBY 14 DAYS 2 DAYS 2 DAYS 2 DAYS 2 DAYS 0 Mental and physical rest till asymptomatic Light aerobic exercise Sport-specific exercise Non-contact drills and resistance training Full contact FOLLOWING MEDICAL CLEARANCE RETURN TO PLAY Copyright ACC 53

54 RETURN TO PLAY PLANNER NZ RUGBY DAY 1 DAY 15 DAY 17 DAY 19 DAY 21 DAY 23 Mental and physical rest till asymptomatic Light aerobic exercise Sport-specific exercise Non-contact drills and resistance training Full contact FOLLOWING MEDICAL CLEARANCE RETURN TO PLAY APPROXIMATELY 3 WEEKS Copyright ACC 54

55 PROBLEMS WITH AN EARLY RTA Impaired Performance Increased risk of MSK injury Repeat Concussion Post-Concussion Syndrome Second Impact Syndrome Copyright ACC 55

56 NUMBER 4 REST AND EDUCATION ARE THE KEY TREATMENTS PREVENT FURTHER HARM Copyright ACC 56

57 NUMBER 4.5 MOST PEOPLE GET BETTER IN 7-10 DAYS Copyright ACC 57

58 LATEST NEWS Copyright ACC 58

59 NEUROPSYCHOLOGICAL TESTS Symptoms may resolve before injury has resolved Aim of these tests are to identify any persisting deficits ImPACT and CogState Sport Copyright ACC 59

60 NEUROPSYCHOLOGICAL TESTS Comparison to normal Wide population variation Normal data not available for women and adolescents Comparison to baseline Test when symptoms resolved Is only part of the assessment Copyright ACC 60

61 SAME DAY RETURN TO PLAY In general a concussed athlete should not return to play In some situations may appear to occur Elite Sport Time needed to assess the athlete Experienced clinicians required If not felt to be concussed can return Copyright ACC 61

62 MULTIPLE CONCUSSIONS Current consensus is that there may be long-term effects No rules and individualised decisions about participation Increasing frequency Less force Longer recovery Copyright ACC 62

63 PREVENTION Headgear and Helmets Mouth-guards Neck Strengthening Shoulder Pads Rule Changes Copyright ACC 63

64 GENETICS Relationship is unclear Apo E4/Tau Polymerase/ APO Promoter Gene Delayed recovery after concussion? Modest increase in concussion incidence in those who are ApoE4 positive Copyright ACC 64

65 NUMBER 5 KNOW WHEN TO REFER Focal or evolving neurology Multiple concussions Prolonged symptoms Children and those with modiers Sportswear sign Less force Longer recovery Copyright ACC 65

66 TAKE HOME MESSAGES 1. Involve a doctor 2. If in doubt sit them out 3. Use the SCAT3 assessment tool 4. Prevent further harm Rest Graded return to play 4.5 Majority of patients get better within 7-10 days 5. Know when to refer Copyright ACC 66

67 LINKS SCAT th Consensus Statement ACC Guidelines ments/reference_tools/wpc pdf Copyright ACC 67

68 CONTACT US DR MARK L FULCHER AXIS SPORTS MEDICINE SPECIALISTS M.FULCHER@AXISSPORTSMEDICINE.CO.NZ Copyright ACC 68