No relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
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.
Can he return in the same game? When can he return to play? Follow-up
Grade 1 - Recovery within 15-20 min Grade 2 - Symptoms Grade 3 - LOC
Individualized symptombased approach Retrospective grading of severity Stepwise process to return to play No Return to Play in the Same Game
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
When can he return to play? Provocation of exercise Gradual increase in intensity Pediatric Group
Practice Contact Aerobic exercise Sportspecific drills Complete rest
LOC > 1 minute Amnesia # of symptoms Recent/frequent concussions Recurrent concussions with less force
Child and Adolescence <18 Co/Pre morbid states (ADHD, depression) Medication (psychoactive) Behaviour
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
Most concussions will settle within 7-10 days Do not need formal neuropsych testing in those concussions
Baseline testing in the elite athlete and perhaps contact sports Better evaluation SCAT3 Card is useful
Abnormal NP/ Abnormal Symptoms Abnormal NP/ Normal Symptoms 116 (39%) 91 (30%) 207 32 (11%) 61 (20%) 93 Normal NP/ Abnormal Symptoms Normal NP/ Normal Symptoms 300 N=300 from merged physician evaluation and neuropsych testing databases for 1997-2004 Echemendia, Lovell et al, 2008,
Cognitive testing in all concussions (SCAT3) and follow up Formal neuropsych evaluation in the elite Baseline testing in elite athletes
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
Increased risk of recurrent concussion Slower recovery in athletes with concussion Second Impact in young athletes Guskiewicz et al. JAMA 2003;290:2549-2555.
Involves 10% of athletes Return to normal cognitive and somatic functioning within 30-90 days >3 months BIGLER ET AL. J NEUROPSYCHOL SOC 2008 PRIGATANO ET AL.CURR OPIN PSYCHIATRY 2011
Physical and cognitive rest Neck physiotherapy Submaximal exercise therapy Vestibular Rehabilitation Psychological therapy Cognitive therapy Pharmacological therapy
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
Medications should only be prescribed by physicians with experience in concussion management With RTP athletes should not be talking meds that would mask symptoms
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
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
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