Sport Medicine Centre Dr. Victor Lun, MD, CCFP, Dip Sport Med Concussions in Sport.

Sport Medicine Centre

Dr. Victor Lun, MD, CCFP, Dip Sport Med

Concussions in Sport


OutlineOutlineMechanism of InjuryMechanism of Injury

Concussion GuidelinesConcussion Guidelines

Clinical Evaluation Clinical Evaluation

Return to Play ManagementReturn to Play Management

Concussion PreventionConcussion Prevention

Recurrent ConcussionsRecurrent Concussions


Concussion - MechanismsConcussion - Mechanisms

Rapid decelerationRapid deceleration Extension-flexion Extension-flexion

movementmovement RotationRotation Snowboarding – fall on Snowboarding – fall on

the back of the head the back of the head


Concussion - MechanismsConcussion - MechanismsThe brain floats in The brain floats in

cerebrospinal fluid cerebrospinal fluid and is protected by and is protected by the skull. the skull.

The brain will rotate The brain will rotate and twist inside the and twist inside the skull which can result skull which can result in localized and in localized and diffuse damagediffuse damage


Concussion - MechanismsConcussion - Mechanisms

ModModMildMild SevereSevere

Severe (Coma)Severe (Coma) GCS < 8 GCS < 8Moderate Moderate GCS 9 - 12 GCS 9 - 12

Mild Mild GCS 13 - 15 GCS 13 - 15

Teasdale et al Lancet 1974; ii: 81-4Teasdale et al Lancet 1974; ii: 81-4

ConcussionConcussion

?

GCSGCS

““MinimalMinimal””


27+ different grading systems in 27+ different grading systems in literature !!literature !!

No universal agreement with regards to No universal agreement with regards to injury definition and return to play injury definition and return to play guidelinesguidelines

Old Concussion GuidelinesOld Concussion Guidelines


Common elements: memory, loss of Common elements: memory, loss of consciousness, and symptomsconsciousness, and symptoms

Used to assess severity of a concussionUsed to assess severity of a concussionPoor prognostic valuePoor prognostic valueVarying return to play timelinesVarying return to play timelines

Old Concussion GuidelinesOld Concussion Guidelines


New Concussion GuidelinesNew Concussion Guidelines1st International Symposium on

Concussion in Sport, Vienna, 2001, Vienna, 20012nd International Symposium on

Concussion in Sport, Prague, 2004, Prague, 2004• NIH consensus formatNIH consensus format• World’s experts in concussionWorld’s experts in concussion


New Concussion ClassificationNew Concussion Classification

SimpleSimpleComplexComplex

Summary and Agreement Statement of the 2nd International Symposium on Concussion in Sport. Clin J Sports Med 15(2): 48-56 , 2005


What is a Simple Concussion?What is a Simple Concussion?

Symptoms?Symptoms?Pattern of gradual resolutionPattern of gradual resolutionWithout complicationWithout complicationResolution over 7-10 daysResolution over 7-10 days

Memory dysfunction?Memory dysfunction?TransientTransient

Loss of Consciousness?Loss of Consciousness?Transient / “blacked out”Transient / “blacked out”


What is a Complex Concussion?What is a Complex Concussion?

Symptoms?Symptoms?ConvulsionsConvulsions> 10 days> 10 days

Loss of Consciousness?Loss of Consciousness?> 1 minute> 1 minute

Referral to sports concussion Referral to sports concussion specialist recommendedspecialist recommended


Simple or Complex??Simple or Complex??

HistoryHistoryPhysical examPhysical examSerial Serial

assessmentassessmentRetrospective Retrospective

DiagnosisDiagnosis


Evaluation - HistoryEvaluation - History

Circumstances of injuryCircumstances of injurySymptoms immediate post injury Symptoms immediate post injury Current symptomsCurrent symptomsAsk patient, family member, coach Ask patient, family member, coach

etc. to corroborateetc. to corroborateCheck video if availableCheck video if available


> 90% of sport-related > 90% of sport-related concussion have no L.O.C.concussion have no L.O.C.

Any sportAny sport

Evaluation – Evaluation – SymptomsSymptoms


Symptoms often minimized by athleteSymptoms often minimized by athlete Everyone “feels fine”Everyone “feels fine” Better to ask:Better to ask:

1.1. ““On a scale of 0 to 100%, how do you feel?”On a scale of 0 to 100%, how do you feel?”

2.2. ““What makes you not 100%” or “What’s What makes you not 100%” or “What’s missing”missing”



Sport Concussion Sport Concussion Assessment Tool (SCAT)Assessment Tool (SCAT)


Sport Concussion Sport Concussion Assessment Tool (SCAT)Assessment Tool (SCAT)

•Standardized tool •Patient education and physician assessment of sport concussion•Combination of existing tools


SCATSCAT – Symptom Scale – Symptom Scale



HeadachesHeadaches 67%67%

ConfusionConfusion 29%29%

DizzinessDizziness 29%29%

NauseaNausea 21%21%

Neck PainNeck Pain 20%20%

Blurred VisionBlurred Vision 20%20%

FatigueFatigue 15%15%

Light sensitivityLight sensitivity 7%7%

FrequencySymptom


SCATSCAT - Assessment - Assessment


Evaluation - ExaminationEvaluation - Examination NeurocognitiveNeurocognitive

Modified Maddocks questionsModified Maddocks questions5 word recall (immediate & delayed)5 word recall (immediate & delayed)months of year in reversemonths of year in reversereverse digits (string of 5 or 6)reverse digits (string of 5 or 6)

Neurological examNeurological examSpeechSpeechEye motionEye motionPronator DriftPronator DriftGait/ Balance AssessmentGait/ Balance Assessment


If concussion is suspected:If concussion is suspected:

Remove from activity and observeRemove from activity and observe

If prolonged LOC or neurological If prolonged LOC or neurological

concerns, C-spine precautions and concerns, C-spine precautions and

hospital assessmenthospital assessment

Return-to-Play ManagementReturn-to-Play Management


RestRest Rest Rest RestRest

Physical RestPhysical Rest

•No “light” exercise or cross No “light” exercise or cross trainingtraining

•No weight trainingNo weight training

•No physical activity!!!No physical activity!!!



RestRest Rest Rest RestRest

Cognitive restCognitive rest

• School, computer work,

video games




Rest for how long?Rest for how long? If rapid and full recovery, then 24-48 If rapid and full recovery, then 24-48

hourshoursFor the same amount of time as it took For the same amount of time as it took

to become asymptomatic (especially in to become asymptomatic (especially in the pediatric age group)the pediatric age group)


Neuropsychological TestingNeuropsychological Testing Detecting cognitive abnormalitiesDetecting cognitive abnormalities

Memory, concentration, “information Memory, concentration, “information processing”processing”

Best when compared to baseline dataBest when compared to baseline data



Neuropsychological TestingNeuropsychological Testing Types: Traditional 6 hour battery, Types: Traditional 6 hour battery,

Web-based programsWeb-based programs

www.cogsport.com


www.impacttest.com


Return-to-Play ManagementReturn-to-Play Management Graded Exercise ChallengeGraded Exercise Challenge

ExerciseExercise● Aerobic x 10 min HR<130 Aerobic x 10 min HR<130

bpmbpm● Aerobic x 30 min with Aerobic x 30 min with

intervalsintervals● Protected sport-specific Protected sport-specific

practicepractice● Full sport-specific practiceFull sport-specific practice● Return to sportReturn to sport

GoalGoal Increase HRIncrease HR Max. HRMax. HR Add movementAdd movement HR + movementHR + movement Exercise + Exercise +

coordination + coordination + thinkingthinking


24 hours per step

If there is recurrence of symptoms at any stage, return to step 1

Return-to-Play Management Return-to-Play Management

Graded Exercise ChallengeGraded Exercise Challenge


Return to Play ManagementReturn to Play Management

Other factorsOther factors Ready to return (confidence)Ready to return (confidence) EquipmentEquipment

Helmet and mouthguardHelmet and mouthguard


How Many Is Too Many?How Many Is Too Many?

Lack of agreement on number of Lack of agreement on number of concussions “allowed” before concussions “allowed” before termination of season or careertermination of season or career

Evidence of cumulative effectEvidence of cumulative effectWith each successive concussion:With each successive concussion:

Lower threshold for injuryLower threshold for injuryMore severe symptomsMore severe symptomsLonger lasting symptomsLonger lasting symptomsRisk of subsequent injury higherRisk of subsequent injury higher


● Longer period of asymptomatic rest Longer period of asymptomatic rest before starting graded exercise challengebefore starting graded exercise challenge

● Extend the time for each stage of Extend the time for each stage of exertional protocolexertional protocol

● Take period of time/season off if showing Take period of time/season off if showing lower threshold / longer recoverylower threshold / longer recovery

● More conservative with younger patient More conservative with younger patient (“susceptibility”?)(“susceptibility”?)

Managing Recurrent Concussion Managing Recurrent Concussion


QUESTIONS?QUESTIONS?

Sport Medicine Centre Dr. Victor Lun, MD, CCFP, Dip Sport Med Concussions in Sport.

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Transcript of Sport Medicine Centre Dr. Victor Lun, MD, CCFP, Dip Sport Med Concussions in Sport.