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Concussion: Evaluation and Management of Sport Injury Concussion: Evaluation and Management of Sport Injury

Concussion: Evaluation and Management of Sport Injury - PowerPoint Presentation

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Concussion: Evaluation and Management of Sport Injury - PPT Presentation

Jeffrey L Tanji MD Associate Medical Director Sports Medicine UC Davis Health System Melita Moore MD Head Team Physician UC Davis Intercollegiate Athletics Mindgame Disclosures I have no relevant financial relationships to any products discussed in this talk ID: 245133

return concussion day sport concussion return sport day play normal symptoms progression follow physical clearance www field medical athlete

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Slide1

Concussion: Evaluation and Management of Sport Injury

Jeffrey L.

Tanji

,

MD

Associate Medical Director, Sports Medicine, UC Davis Health System

Melita

Moore, MD

Head Team Physician, UC Davis

Intercollegiate Athletics

MindgameSlide2

Disclosures

I have no relevant financial relationships to any products discussed in this talk

I do not intend to talk about an unapproved/investigative use of a commercial product in this presentationSlide3

Rationale

Standards of care for sport concussion have changed dramatically over the last two years

New state law mandates certain actions in the management of concussion

Sport concussion is under-recognized and under-reported

Community education and awareness are paramountSlide4

Objectives

Define a sport concussion

List the key symptoms and findings of concussion

Demonstrate the key aspects of the history and physical in the evaluation of concussion

Define the three steps of medical clearance to begin rehab after concussionSlide5

Objectives

List the four steps of progression between medical clearance and true return to play

Discuss several controversies in concussion management

Mindgame

is a multi-health system integrated approach to youth concussion care (Kaiser, Dignity Health, Sutter, UC Davis) in the Sacramento ValleySlide6

Definition

Mild traumatic brain injury (TBI)

Metabolic, functional (not structural) damage from direct or indirect trauma

Classically, attention, vision, balance, headache, memory are affected but only short term with relatively rapid recoverySlide7

Useful data

1.5 to 4 million concussions/year in sport

80-90% -no- LOC

80-90% return to full activity in 1 week (NCAA data)

We seek to avoid second impact syndrome which is associated with long term issues

Younger and female athletes take longer to recover, the younger, the slower to return, discussion that high school athletes may need two weeks minimumSlide8

Second impact syndrome

A second concussion while still symptomatic

Generally within the same season

Mild trauma can have dramatic effect and long recovery

Major brain injury in sport concussion is almost always associated with second impactSlide9

Sport and concussion

Football

Ice hockey

*Women’s soccer*

Youth soccer

Field hockey and lacrosse

WrestlingSlide10

Lingering metabolic effects

30 days of vascular spasm and decreased cerebral flow

Hyperglycemia

K and Ca channels are disrupted

Generally a bleed is not found on MRI or CT

The “

neurometabolic

cascade”

Hovda

DA and Giza CC,

Clin

Sport Med 2011:30(1):33-48Slide11

Neurometabolic cascadeSlide12

Concussion: signs

LOC less than 10-20%

Headache

Visual difficulties

Nausea/vomiting

Balance issues

Memory loss/confusionSlide13

No return to play that day

California AB 25 (2012) for a suspected concussion, there will be no return to play that day

Medical clearance by a licensed professional must be given before return to activity

California AB 2127 (Cooley law) Jan 1, 2015: 7 day mandatory no return to play and to follow protocolsSlide14

Role of advanced imaging

Excludes severe bleed, critical structural damage

Does not clear an athlete to return to play

Misconception by family and athlete

“I was told my concussion was normal and I was cleared to play”

When they were told that they could go home and that the imaging study was normalSlide15

Follow up

No need to keep waking a person up hourly

Tylenol is ok, no ASA or NSAIDs

Worsening status -> ED

1-2 workday follow up through

Mindgame

Sacramento

Rest and cognitive restSlide16

Concussion: established treatment

Cognitive rest

No cell phones, no games, no texting

No television, no reading

No physical activity

www.cdc.gov/concussion Slide17

Follow up symptoms

Symptoms:

Headache

Visual issues

Balance

Sleep

Emotions (short fuse?)

ConcentrationSlide18

Follow up physical findings

Orientation, EOM and

pupillary

response

Finger -> nose, heel to shin, rapid alternating movements

Heel to toe walking

RombergSlide19

Physical findingsSlide20

No Sx and examination WNL

Neurocognitive

testing (NCT):

Ideally a baseline test has been done

If no baseline, compare with age related norms, > 20 percentileSlide21

Computer based NCTSlide22

Three steps to clearance

No symptoms

Normal focused neurological examination

Return to baseline or appropriate scores on

neurocognitive

testing

Then work with coach or athletic trainer for the progressions to full competitionSlide23

Rehab progression

Run, jog 20 minutes without symptoms

Wait one day

Sprint, interval speed work without

Sx

Wait one day

Return to the field with no contact

Wait one day

Return to the field with full contactSlide24

Variations in progression timing

Zurich consensus conference 2013: one day between stages

University of Pittsburgh: two days between stages

National Basketball Association: one hour between stagesSlide25

Complex cases

Persistent symptoms

Formal neuropsychological assessment, work with a vestibular physical therapist

? ENG studies (as if for acoustic

neuroma

)

Debate about gentle walking

Formal neurologist, neuropsychologist or physiatrist evaluationSlide26

Vestibular PTSlide27

Take Home Points

No return to play the same day

Neurocognitive

testing (NCT) is becoming the standard of care

No symptoms, normal exam, normal NCT clears to begin the progression

Progression: aerobic, sprint, on-field no contact and finally on-field with contactSlide28

ED take home points

The findings of a normal imaging study do not clear an athlete to return to play

Must keep follow up outpatient visit for clearance (state law AB25)

No symptoms, normal physical exam and a normal

neurocognitive

test are needed

Then an athlete begins a rehab progression before clearance to playSlide29

Resources

McCrory

P,

Meeuwisse

W,

Aubry

M, et al. Consensus statement on concussion in sport, Br J of Sports Med 2013; 47:250-258.

www.cdc.gov/concussion

www.sacramentovalleyconcussion.com

www.aroundthecapitol.com/bills/AB25

www.aroundthecapitol.com/bills/AB2127

www.sacramentovalleyconcussion.com