Sports Concussion Management Jim Chesnutt MD OHSU Sports Medicine Orthopaedics and Rehabilitation and Family Medicine Recognize Remove Refer Return ID: 364695
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2013 Sports Concussion Management
Jim Chesnutt, M.D. OHSU Sports MedicineOrthopaedics and Rehabilitationand Family Medicine
Recognize: Remove: Refer : ReturnSlide2
Concussions: The ProblemWe now realize
concussions occur more often than previously thoughtYoung athletes are at risk for serious short-term and long-term problems There is much variation in the knowledge of Health Care Providers managing concussed athletes
New and emerging technologies will lead to a continuing evolution of careSlide3
What is a Concussion?A concussion is a mild traumatic brain injury that interferes with normal function of the brain
Evolving knowledge- “dings” and “bell ringers” are brain injuries- no such thing as a mild
concussionLoss of consciousness is not common
in
concussion(<90%) and is not prognostic factor unless >30 minutesSlide4
ConcussionsEstimated 300,000- 3 mil sports-related head injuries in
athletes yearly9% of all sports injuries700-2000?
head-injuries in Oregon HS athletes based on OSAA
participation #
s
Pros: lower incidence possibly 10x lowerSlide5
Newer Data High School RIO 08-09Injury rate per 100,000 player exposures Football 52
Girls’ Lacrosse 39 Girls’
soccer 35 Boys’ Lacrosse
32
Wrestling
22
Girls
basketball
20
Boys
’
soccer
17
Softball 15Boys basketball 7 Slide6
ConcussionSymptoms are variable for each individual in terms of type, intensity and durationClassified into three main areas:
physical ( HA, dizzy)emotional ( agitated, quiet, depressed),
cognitive ( memory, processing)
Cumulative impairment can occur
3x more likely to get a second concussionSlide7
Second Impact SyndromeInjury before recovery from the previous head injuryMay cause brain swelling from loss of normal control of brain blood flowRare but deadly, more common in teenagers
Prevention is the key…….Do not return to play too earlySlide8
The Goal of Appropriate TreatmentMinimize the duration of symptomsReturn to play as soon as safely possibleAvoid entirely the risk of second impact syndrome
Minimize the rate of chronic post concussion syndromeSlide9
Recovery from concussion80% of concussion recover well if managed actively in the first 3 weeks.Average recovery time for youth with concussion is about 3 weeksLoss of consciousness is not a prognostic factor for recovery unless >30 minImaging is not usually helpful ( mostly done in first 48 hrs if decline mental status increased HA or neurologic deficit)Slide10
Landmark Guidelines 2008-9 Clin J. Sports Med 2009,19:185-200( balance testing, SCAT2 and new science )Slide11
New Guidelines just published!Slide12
New in Oregonin 2008-9
State-wide concussion management program involving all high schoolsEstablish state-wide physician network Uniform evaluation and management protocolConsultation service for coaches, athletes, parents, and physicians
ImPACT baseline suggested for contact and collision sport athletes: www.impacttest.comSlide13
Concussions: The Oregon PlanIdentified Regional Leaders Portland: OHSUEugene: SlocumBend: The Center
Each provides oversite of schools in their regions and help local doctors/trainers care for their own athletesSlide14
Oregon Concussion Awareness and Management Program (OCAMP) The Oregon Concussion Assessment and Management Program (OCAMP) is a group made up of physicians, neuropsychologists, athletic directors, certified athletic trainers, educators and representatives from OSAA, ODE and OADA. We are working with OSAA and ODE to develop a model to support students as they return safely to full participation in athletics and academics. Slide15
Oregon Concussion Awareness and Management Program (OCAMP)Slocum Orthopaedic and Sports Medicine CenterMick Koester,M.D.
mkoester@slocumcenter.com OHSU Sports MedicineJim Chesnutt, M.D chesnutt@ohsu.edu
Charles Webb, D.O. webbch@ohsu.eduThe Center/ St CharlesSondra Marshall,PhD
sbmarshall@stcharleshealthcare.org
Leah
Schock
, PhD.
lschock@stcharleshealthcare.org
Contact us for questions or to sign up!Slide16
Max’s Law: Sports Concussion (SB 348- April 2009) Max Condradt is an OR brain- injured athlete hurt in footballLaw focused on no return-to- play the same day as concussion Medical release needed to return to playYearly coach concussion education required
Effective: July 2009Slide17Slide18Slide19
New Concussion Guidelines1. No Same Day Return to Play
2. Return to Play Recommendations
*
approximately one week out*
Symptoms fully resolved
-and-
Complete a structured, graded exertion protocol over approximately 5-7 days without symptomsSlide20
Concussions: Return to PlayA Step-wise symptom limited program
1. Rest until asymptomatic ( physical,mental)2. Light aerobic exercise ( exercise bike)
3. Sport- specific exercise4. Non-contact training drills ( wt lifting or sleds)
5. Full contact training (after medical clearance)
6. Return to competition( game play)
Each stage is about 24 hrs or longer
and return to stage one if symptoms reoccurSlide21Slide22
Module 1: Word DiscriminationModule 2: Design MemoryModule 3: X's and O’sSlide23Slide24
Purpose of Care Plan:
Guide recovery , Educate, Manage exertional and school activity Educational resources: State TBI Teams
Develop concussion education programs and return to academic programs, and assist with 504 plans if needed.
Call :
877.872.7246 or
Email:
tbi@wou.eduSlide25
Return to School
50
60Slide26
OSAA Concussion Return to Play FormSlide27
Keys to RecoveryResting the brain & getting good sleepNo additional forces to head/ brainManaging/ facilitating physiological recoveryAvoid activities that produce symptomsNot over-exerting body or brain
Ways to over-exertPhysicalEmotionalCognitive! (concentration, learning, memory)Slide28
Return to Play considerationsAll symptoms need to resolveThis includes HA, especiallyFollow symptom logNeurocognitive scores usually normalize after symptoms resolveIf symptoms recur with exercise, school, work or play: remove from activity/ modify RTP planSlide29
When Return to Play? ….to full shedule at school?No longer have symptoms
No longer need medicine to control symptoms.Neuro-cognitive function & balance back to “normal.”After rest and gradual activity (exertion)Cleared by medical professional.
Zurich: Recognition that the child/ adolescent student-athlete may take longer, and we should proceed more cautiouslySlide30
Comprehensive/ Team- Based Treatment ModalitiesRest from school and activitiesSchool modificationsRehabilitation, cognitive and visual therapyMedicationsNeuropsycholgy testingPsychiatry/ Neurology as neededEducational
counsellingSlide31
OHSU Concussion Managementwww.ohsusportsmedicine.com or 503-494-4000 Pre-season Impact baseline testingCan do whole team or individualsAthletic trainers on- field and in injury clinic
Post –concussion evaluationsPhysician and ATC evaluations & Impact testingConcussion Rehabilitation Team PT, Vestibular/ENT, SLP/ cognitive,OT/visionPediatric Neuropsychology testing if chronicSport Concussion Support Group
(student/family)Slide32
OHSU Concussion Rehab TeamA. Speech -language pathologist: for evaluation and treatment to address cognitive and executive function issuesB. Physical therapy: for vestibular therapy and neck and associated
orthopaedic issues.C. Occupational Therapy: for visual and functional therapy.This is on the 1st floor of OHSU Center for Health and Healing.
Please call 503-494-3151 to schedule an appointment but this will likely need to be approved by your insurance Slide33
Concussion Medication ManagementFish oil and
tylenol early, NSAID after 72 hrsAmitriptyline
10 mg pills. Take10-50mg ( 1-5 pills) at night at bedtime as directed for Headache/nerve pain and to help with sleep.
Amantadine
100 mg BID
is used for concussion symptoms.Please take one pill in Am then after one week consider adding one more at noon. Continue for about 2-4 weeks to see if this helps with your concussion- related symptoms.
Topimax: 50 mg BID
start 25 HS, increase q3-7
Antidpressants, aleve, anti-seizure meds, Bblocker,triptanSlide34
When Return to Play?Criteria for RTPNo longer have symptomsNo longer need medicine to control symptoms.Neurocognitive function & balance back to “normal.”
After rest and gradual activity (exertion)Cleared by medical professional.Zurich: Recognition that the child/ adolescent student-athlete may take longer, and we should proceed more cautiouslySlide35
SummaryMust improve early identification & diagnosis
Coach, athlete, parent, medical educationCareful individualized clinical assessment and tracking from time of injurySCAT2
Neuropsychological Testing ( Impact, Axon, or full)
Implement
active
treatment in home &
school
school accommodations, 504 plan, OCAMP.org
Free coaches education:
www.osaa.org/healthandsafety/concussion.aspSlide36
ConcussionFinal thoughts….
Be alert for subtle symptomsAdhere to guidelines to limit contact for about one week and transition back to playConsider use of neuropsych testing
Document baseline, deficits and improvementBe aware of cumulative trauma and risk for permanent damage
Be more conservative with younger athletes Slide37
Sports Concussion ManagementContact our sports medicine team for questions:Jim Chesnutt, M.D. chesnutt@ohsu.edu
Charles Webb, D.O. webbch@ohsu.edu Ryan Petering, M.D. petering@ohsu.edu
Melissa Novak D.O. novakm@ohsu.edu
Rachel
Bengtzen
M.D.
bengtzen@ohsu.edu
www.ohsusportsmedicine.com
or 503-494-4000