Consensus Statement on Concussion in Sport - PowerPoint Presentation

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Consensus Statement on Concussion in Sport

Wade M. Rankin, DO, CAQSM

KAFP Annual Meeting

November 10, 2016Slide2

ObjectivesRefine the definition for concussion. Discuss diagnosis and usual treatment for outpatient management of concussions.Discuss return to play criteria and considerations for continued monitoring.Slide3

McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313Slide4

What’s New?Sport Concussion Assessment Tool revision (SCAT3)Pocket SCAT3

Abandon simple vs. complex terminologyEmphasis on balance assessment

Modifiers influencing investigation and management

Pediatric management strategySlide5

OUTLINEProcess

Definition

Classification

Incidence

Risk Factors

Signs and Symptoms

Evaluation

Investigations

Management

Recovery

Special Populations

Other Issues

SCAT 3/Child SCAT3Slide6

Process1

st Vienna in 2001, 2

nd

Prague 2004, 3

rd

Zurich 2008

4th meeting in Zurich 2012

NIH consensus development conference format

Pre-defined group of questions

Body of literature identified

Presentation by experts in open session day 1

Discussion / debate closed session with consensus panel on day 2

Document drafted by authors and circulated to panel

Knowledge translation5th International Consensus Conference on Concussion in Sport held October 27-28, 2016 is Berlin, GermanySlide7

DefinitionsSlide8

Traumatic Brain Injury

Mod

Mild

Severe

Severe GCS ≤ 8

Moderate GCS 9 - 12

Mild GCS 13 - 15

Teasdale et al Lancet 1974; ii: 81-4

Sports concussion

?

“Minimal”

Glasgow Coma ScaleSlide9

Injury Definition: Sports concussion

“Concussion is a brain injury and is defined as a complex pathophysiological

process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include

”

McCrory P, et al. Br J Sports Med 2013;47:250–258Slide10

DefinitionConcussion 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.

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.

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.

McCrory P, et al. Br J Sports Med 2013;47:250–258.Slide11

DefinitionConcussion 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 a small percentage of cases, post-concussive symptoms may be prolonged.

McCrory P, et al. Br J Sports Med 2013;47:250–258.Slide12

ClassificationRetained the concept that the majority (80-90%) of concussions resolve in a short (7-10 day) period

May be longer in children and adolescentsSlide13

IncidenceCDC Reports -1.6-3.8 million sports related concussions annually in the US

-5-9% of all sports related injuries -30% of all concussions in people between 5-19 years old are sports related

-Football, wrestling, girls’ soccer, boys’ soccer and girls’ basketball most common sports in order

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide14

Risk FactorsPrevious concussionHx of concussion associated with a 2.5-5.8 times higher risk of another concussionNumber, severity, durationHigher number, severity and duration of symptoms are predictors of prolonged recovery

Dizziness-greatest predictor for recovery taking longer than 21d

Cognitive or migraine symptoms often require more recovery time

Migraines

Hx

of pre-existing migraine HA may be a risk factor for a concussion

May be associated with a prolonged recovery

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide15

Risk Factors

SexSports with similar rules females sustain more concussion than their male counterparts

Females report higher number and severity of symptoms and longer duration than male athletes

Age

Youth have a more prolonged recovery and are more susceptible to concussions

Sport, position and style of play

Most common mechanism for concussion is player to player contact

“backs”(QB, RB, WR and DB) in professional football have 3x greater risk than lineman

Kick-offs have 4x the concussion risk as rushing or passing plays

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide16

FACTORS

MODIFIER

Symptoms

Number

Duration

Severity

Signs

Prolonged LOC (>1min)

Amnesia

Sequelae

Concussive convulsions

Temporal

Frequency –repeated concussion over time

Timing – injuries close together

“Recency” – recent concussion or TBI

Threshold

Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

Age

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 Slide17

Risk FactorsMay influence investigation and managementMay predict potential for prolonged or persistent symptomsMultidisciplinary approach coordinated by a physician with specific expertise in management of concussion.Slide18

EvaluationSlide19

Signs and SymptomsSymptoms - somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g.

lability)

Physical signs (e.g. loss of consciousness, amnesia)

Behavioural

changes (e.g.

irritablity

)

Cognitive impairment (e.g. slowed reaction times)

Sleep disturbance (e.g. drowsiness)

If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted.Slide20

Signs and SymptomsHeadache-most common reported symptom

Dizziness- the second most common

Loss of Consciousness only occurs in 10% of concussion

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide21

On-field or sideline evaluation of acute concussion The player should be medically evaluated 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.

An assessment of the concussive injury should be made using the SCAT3 or other similar tool.

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 (see management section)

.

Slide22

Evaluation in emergency room or office by medical personnel A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance.

A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury.

A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality

Essentially, these points are included in the

SCAT3

assessmentSlide23

InvestigationsNeuroimaging (CT, MRI)Contributes little to concussion evaluation

Use when suspicion of intracerebral structural lesion exists:prolonged loss of consciousness

focal neurologic deficit

worsening symptoms

Deterioration in conscious state

Newer structural and functional imaging modalities are still at early stage of development in concussionSlide24

InvestigationsBalance assessmentBalance error scoring system (BESS)

Neuropsychological assessmentBest done after symptom resolution

Most sensitive when compared to baseline

Genetic Testing

Significance unknown for Apolipoprotein (Apo) E4,

ApoE

promotor gene, Tau polymerase, other genetic and cytokine factors Slide25

ManagementSlide26

ManagementCORNERSTONE =

rest until asymptomatic

Rest from activity

No training, playing, exercise, weights

Beware of exertion with activities of daily living

Cognitive rest

No television, extensive reading, video games/cell phones, screen time

Caution re: daytime sleep

Academic accommodations

REST = ABSOLUTE REST!Slide27

Sports Concussion

Follow-up Management

Rest

Rest

Rest

Expect gradual resolution in 7-10 days

Start graded exercise rehabilitation when asymptomatic at rest and post-exercise challengeSlide28

RecoveryHow long asymptomatic before exercise?

If rapid and full recovery, then 24-48 hoursOne approach is to require that they remain asymptomatic (before starting exertion) for the same amount of time as it took for them to become asymptomatic.Slide29

Symptoms in Sports concussion

Everyone “feels fine

”

Always ask:

1.“

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

2.“

what makes you not 100%?”

3. Checklist – SCAT3Slide30

Graded Exertion Protocol

24 hours per step If there is recurrence of symptoms at any stage, return to previous step

Rehabilitation stage

Functional exercise at each stage of rehabilitation

Objective of each stage

1. No activity

Complete 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 playSlide31

Same day return to play?Return to play must follow same basic management with full clinical and cognitive recovery before RPTSame Day?

“It was unanimously agreed that no RTP on the day of concussive injury should occur.

There are data demonstrating that at the collegiate and high school levels, athletes allowed to RTP on the same day may demonstrate NP deficits post injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms.”

McCrory P, et al. Br J Sports Med 2013;47:250–258.Slide32

Return to Play / SportMust pass graded exertion first

=remain asymptomatic

Is the athlete

confident

to go back?

New helmet/head gear?

Other “protective” equipment / behaviors / factors?

Consider implications of multiple/recent injurySlide33

Return to SchoolNo standardized guidelines for returning the athlete to school

If student develops increasing symptoms with cognitive stress

May require academic accommodations including

Reduced workload

Extended test taking time

Days off

Shortened school day

Withhold an athlete from contact sports if they have not returned to their ‘academic baseline’ following their concussion

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide34

Management IssuesConsider role for psychological approachesPharmacotherapy

Prolonged symptoms (sleep disturbance, anxiety)

Modify underlying pathophysiology

Upon return to play should not be on medication that could mask symptoms

Antidepressants?Slide35

Management IssuesPreparticipation Evaluation History:Type of sport?

Number of prior concussions?

Prior facial, dental injuries?

Non-sporting head injuries?

Type of player (“physical”?)

Ability to “take a hit”

Protective equipment (helmet age)

Position played (‘back’)Slide36

Management IssuesDx with ConcussionSequester an essential piece of equipment(helmet) to avoid an ‘inadvertent’ RTP

Concussed player should not be left alone if kept on site

Regular monitoring for deterioration of physical or mental status is essential

Should not RTP on the same day of practice or competition

Harmon KG, et al. Br J Sports Med 2013;47:15–26.Slide37

Management IssuesDx with ConcussionAppropriate disposition needs to be arranged

Provider should arrange or discuss F/U evaluation with parents/guardian

Should arrange for athlete to be accompanied or monitored once allowed to leave the venue

Take home written information should be discussed/given to the athlete or accompanying party

Harmon KG, et al.

Br J Sports Med 2013;47:15–26.Slide38

Management IssuesDx with Concussion

Frequent awakening of concussed athlete is no longer recommendedSleep should not be interrupted as it is likely restorative

Advise caretakers that it is desirable to let the athlete sleep

Aspirin and NSAIDS are generally avoided post-concussion

Harmon KG, et al.

Br J Sports Med 2013;47:15–26.Slide39

Special PopulationsSlide40

Child and Adolescent AthleteAdult recommendations can apply down to age 10Below 10 require age appropriate symptom checklists

Include both patient and parent, teacher, etc.

Possibly use

neuropsych

testing before symptoms resolve to assist planning school management

Please see Child-SCAT3

NOTE:

Pediatric subcommittee is developing age-specific SCAT for <10 years of age (Purcell, Gioia, Davis)Slide41

Child and Adolescent AthleteConsider age specific physical and cognitive rest issues

Symptom resolution may take longerConsider extending symptom free period before starting return to play protocol

Consider extending length of the graded exertion protocol

Do not return to play same daySlide42

Elite vs non-eliteAll athletes should be managed the same regardless of level of participationHowever, available resources and expertise may facilitate a more aggressive management approachSlide43

Other IssuesSlide44

PreventionProtective equipmentMouthguards have benefit in prevention oral injury, but no evidence of concussion reductionHead gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence

Helmets reduce head and facial injury in skiing and snowboarding

Helmets reduce other forms of head injury (e.g. fracture) in cycling, equestrian, motor sportsSlide45

Other IssuesRule changesConsider where clear cut mechanism is implicated (NFL/NHL rules changes)

Risk compensationUse of protective equipment may change behavior

Aggression vs violence

Violent behavior that increases concussion risk should be eliminated

Promote fair play and respectSlide46

Knowledge TransferEducation of athletes, parents, coaches, sports physiciansAwareness of concussion symptoms and signsFair play and respectSlide47

Future DirectionsValidation of the SCAT3On-field injury severity predictors

Gender effects on injury risk, severity and outcome

Pediatric injury and management paradigms

Virtual reality tools in the assessment of injury

Rehabilitation

strategies

(

e.g

.

exercise

therapy

)Novel Imaging modalities and their role in clinical assessmentConcussion surveillance using consistent definitions and outcome measuresClinical assessment where no baseline assessment has been performed‘Best-practice’ neuropsychological testing Long term outcomesMany were addressed at 5th Consensus Conference-awaiting reportSlide48

THANK YOU!

Consensus Statement on Concussion in SportSlide49

SCAT 3Please see handoutSlide50
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Potential Signs of ConcussionAny loss of consciousness? Y n“if so, how long? _________________________________________________“Balance or motor incoordination (stumbles, slow / labored movements, etc.)? Y nDisorientation or confusion (inability to respond appropriately to questions)? Y n

loss of memory: Y n“if so, how long?“_______________________________________________

“Before or after the injury?“________________________________________

Blank or vacant look: Y n

Visible facial injury in combination with any of the above: Y nSlide52
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Sens-32-75%, Spec-86-100%, FP-29-68%, FN-0-11%Slide54
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Neck Examination:Range of motion Tenderness Upper and lower limb sensation & strengthFindings:_______________________________________________________________ Slide63

Athlete InformationSlide64

Return to PlaySlide65

Patient Information HandoutSlide66

Child-SCAT3Slide67
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Pocket SCAT2