Post on 11-Jul-2020
Mark J. Harary, MD
Primary Care Sports Medicine
St Charles Orthopedics, LLP
Facts, Definitions, etc
Appropriate Recognition
Comprehensive
Management
Treatment
Consequences of Concussions
Neurocognitive Testing
“Return to Play” Progression
1.5-4 million sports related concussions occur each year Concussions from non-sports related injuries are also
fairly common
Over 60% of concussions in high school sports are from football
Soccer is the leading sport for concussions in high school females
High school athletes who sustain a concussion are 3x more likely to sustain a second concussion
If not appropriately treated, a patient who sustains concussion is 4-6 times more likely to sustain a second Cumulative effects
A concussion is a Mild Traumatic Brain Injury.
“Concussus:” derived from the latin “to shake violently”
Concussions may range from “bell ringers” to prolonged loss of consciousness.
Loss of consciousness is not diagnostic or prognostic of concussion
Concussion typically results in the rapid onset of short-lived impairment of neurologic function.
Concussion results in a functional disturbance rather than a structural injury.
The “invisible” injury
Concussions common and more serious than previously recognized Old treatment guidelines
“Mild” initial symptoms may lead to long lasting symptoms
Media exposure High exposure athletes have played through concussions
and return to play quickly after concussions
Youth athletes are more at risk for bad outcomes than their “professional counterparts” given their vulnerable/developing brains
Symptoms Reported
• Headache
• Nausea
• Balance problems
• Double/fuzzy vision
• Sensitivity to noise/light
• Feeling sluggish
• Feeling “foggy”
• Change in sleep pattern
• Concentration/memory issues
Signs Observed
• Appears dazed
• Confused about play
• Answers question slowly
• Forgets plays, score, opponent
• Personality change
• Retrograde amnesia
• Anterograde amnesia
• Loss of consciousness
Not all concussions are associated with LOC.
Only about 10%
Not all concussions present with headache.
About 85%
Concussions cannot be diagnosed by an X-ray, CT scan or MRI
Concussion symptoms are secondary to a SUPPLY/DEMAND issue…
Energy/Metabolic Crisis secondary to decreased blood flow and increased demand for glucose
American Academy of Neurology (1997)
Graded concussions
Vienna Guidelines (2001)
Prague Guidelines (2004)
Simple versus Complex
Zurich Guidelines (2008)
No same day RTP
No simple versus complex
No grading scheme
All concussions should be TREATED
*Education Program*
(Baseline Neurocognitive Testing)
Appropriate recognition
Appropriate ER evaluations
Appropriate Treatment with Follow-up visits
Graduated Return to Activity
EDUCATION, EDUCATION, EDUCATION
That is why we are here!!
Coaching staff, referees, parents, athletes, medical providers should be able to recognize a concussion
Appropriate preventive measures in sports
No tolerance on poor technique (ie, spear tackling)
Injured players MUST have a return to play assessment with documentation by a medical practitioner well versed in concussion management
WEAR THEM! There is no “concussion” helmet or mouthguard All helmets should be refurbished after the season
and stamped with approval Before season, all helmets should be fit to athlete–
there should be no movement with head movement
This should be done again if the athlete has a change in his hairstyle
Before each wear, helmets should be checked for inflated bladder, cheek pad placement
Mouthguards should be molded to thepatient and NOT cut for comfort.
Patients with head injury should be seen in the ER if there is loss of consciousness or if there are any focal neurologic symptoms
Rule out more serious intracranial pathology
CT scan
MRI
No one should get a
clearance note from the
ER.
WHEN IN DOUBT, SIT THEM OUT!
If a player is removed from play for concussive symptoms with or without LOC
No return to play
Take away the athlete’s helmet, cleat, etc
Continue to monitor for worsening symptoms
An adult must be responsible for following the athlete
Decision whether to go to ER
Athlete’s with concerning symptoms should be taken out of play IMMEDIATELY.
There should be no same day return to play in the adolescent population
** Avoid re-injury **
Patient should be seen by a medical provider trained in concussion management.
REST
Cognitive and physical
“Return to play” protocol
6 step protocol to return to play is much more conservative in youth than in older athletes.
Increased sleep
Good sleep hygiene
Low threshold to start melatonin
Take naps when available
No sports, gym, cardiovascular conditioning, strength training
May need to be out of school/work to allow for appropriate rest
Reduced course/work load
“Accommodations”
Minimal TV, computers, texting, video gaming, etc
Avoid loud noise, bright lights, vibration, etc
No concerts, no “gigs”
Symptoms generally resolve completely in 7-10 days, but may be longer in youth and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of untreated concussion)
If not treated properly, the patient is at increased risk of long term effects
Post Concussive Syndrome
Second Impact Syndrome
Chronic Traumatic Encephalopathy [CTE]
Emotional Problems
ADHD/LD??
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
All Athletes No Previous Concussions 1 or More Previous Concussions
WEEK 1
WEEK 2
WEEK 3
WEEK 4
WEEK 5
N=134 High School athletes Collins et al., 2006, Neurosurgery
It’s the law…
July 2012
NY is the 33rd state to pass such a law
1) Permission slips
2) Immediate removal from participation
3) Medical clearance before RTP
Long term effects…
PCS
Second impact syndrome
CTE
ADHD/LD
Depression
Anxiety
Chronic headaches
Fatigue
Sleep difficulties
Personality changes (e.g. increased irritability, emotionality)
Sensitivity to light or noise
Dizziness when standing quickly
Deficits in short-term memory, problem solving and general academic functioning
A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event.
Can result in devastating/catastrophic increase in intracranial pressure Vasomotor paralysis, edema, massive swelling, brain
herniation, death
This catastrophic demise is very rapid and carries a 50% mortality rate along with almost a 100% morbidity rate
Most common in the high school population secondary to poor auto-regulatory control of intracranial blood flow
Approximately 50 high school students have died since 1997
“Punch-drunk”
The condition, which occurs in people who have suffered multiple concussions or sub-concussive blows.
Thought to be caused by the loss of neurons, scarring of brain tissue, collection of senile plaques, diffuse axonal injury, neurofibrillarytangles and damage to the cerebellum.
Parkinsonian movements, signs of dementia, speech problems, paranoia, etc.
Neurocognitive Testing/Evaluation Evaluates attention/concentration, memory/recall,
processing speed, and reaction time
Ideal to have baseline vs. post-concussive information
Pen and Paper versions are time consuming and expensive
Computerized models have simplified this ImPACT, CogState, HeadMinder
Testing done in 30 minutes or less
Able to test large numbers of athletes to obtain baselines
Results available as soon as testing is over
*Education*Baseline
Testing
Concussion
* Post-Injury Testing
* Clinical Eval
0 1-3 Days 3+ Days
* Sideline Eval* ER Eval
* F/u Clinical
Asymptomatic at rest
“RTP” progression
1. Rest until asymptomatic (physical, mental) 2. Light to moderate aerobic activities with no weight
training Goal is to increase HR
3.Increased weight training and aerobic activities. Add plyometrics and balance/proprioceptive challenge. Sports-specific, aggressive non-contact training Goal is intense, noncontact activity
4. Full contact training Goal is to reintegrate into full contact practice
5. Return to contact competition (game play) Goal is to return to competition
Each stage is at least 24 hrs and return to previous stage if symptoms reoccur