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
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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