WHAT’S NEW IN

“SPORT”

CONCUSSION

Mitchell Shulman MDCM FRCPC CSPQEmergency Department, MUHCAssistant Professor, Dept of Surgery

COPYRIGHT © 2017 BY

SEA COURSES INC.

All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means – graphic, electronic, or mechanical,

including photocopying, recording, or information storage and retrieval systems without prior written

permission of Sea Courses Inc. except where permitted by law.

Sea Courses is not responsible for any speaker or participant’s statements, materials, acts or omissions.

CME FACULTY

DISCLOSURE

Dr. Shulman has no affiliation

with the manufacturer of any

commercial product or provider

of any commercial service

discussed in this CME activity.

HOT TOPIC!

• 250,000 - 300,000 / yr

• High risk of recurrence

• Long term dysfunction eg: Mohamed Ali, Paul Kariya, Troy Aikman

• Annual cost (US) > $1 billion

• >98% of sports related head injuries: concussions

• Misunderstanding still common

CLINICAL DILEMMA

• No proven acute treatment. Injury must run its course

• Final outcome may take years.

Severity unknown until it`s resolved

• UncertaintyAbout when it`s safe to return to competition.

• Multiple criteria / guidelines. Based on subjective clinical factors and durationof impairment

The Glasgow Coma Scale Isn’t Enough!

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

OLD DEFINITION

“A reversible injury to the brain

due to traumatic forces, resulting

in amnesia and/or loss of

consciousness.”

CURRENT DEFINITION

Concussion: brain injury

A complex pathophysiological process affecting the

brain, induced by biomechanical forces

(direct blow to head, face, neck; or, elsewhere on body with an

impulsive force transmitted to the head)

TRAUMATIC BRAIN INJURY

ModMild 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 Scale

GLASGOW COMA SCALE

P.E.A.R.L.S.

• Don’t need:period of unconsciousness

direct hit to head

amnesia

• Must have: concussion related symptomsnormal CT / MRI

Repeated sub-clinical head accelerations will likely

become part of the definition in the near future.

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

NOT JUST A BUMP

ON THE HEAD!

Mild TBI: tri-phasic process

*Hyperglycolysis (hours-days)

*Metabolic depression (days-weeks)

*Metabolic recovery (days-weeks-mos.)

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

EVALUATION OF

ACUTE CONCUSSION

• Evaluate player onsite: Standard Emergency

Principles apply Exclude c-spine injury

• Safely removed

• First aid, then assess concussion

(SCAT3 / other sideline assessment tools)

• DO NOT LEAVE PLAYER ALONE

Serial monitoring

• NOT ALLOWED TO RETURN TO PLAY

On day of injury

Player shows ANY features of a concussion

on field / sidelines

DIAGNOSISPhysical Signs of Mild TBI

• Any loss of consciousness

• Retrograde or anterograde amnesia

• Seizure at time of impact

• Vacant stare

• Inability to focus (easily distracted)

• Slurred speech, slow to answer questionsDelayed verbal / motor responses, slowed reaction times

• Disoriented, unsteady gait

• Memory deficits, personality changeEmotionally unstable, inappropriate behavior, irritability

DIAGNOSISSymptoms

• Headache (nearly always present)

• Dizziness, vertigo, drowsiness

• Lack of awareness“Just not feeling right”, Feeling like “in a fog”

• Nausea, vomiting

• Loss of balance

• Feeling dazed, “dinghy”

• Ringing in the ears (tinnitus)

• Blurred or double vision (diplopia)

• Insomnia

P.E.A.R.L.S.

• High index of suspicion -based on mechanism of injury

-velocity

-damage (in-car, helmet, to surrounding area, etc.)

• Athletes will under report symptoms (lie!)

to stay in the event

WHEN IN DOUBT, SIT THEM

OUT!

DETAILED CLINICAL ASSESSMENT

OUTLINED IN SCAT3 /CHILD SCAT3

Developed by SCAT3 Subcommittee (Meeuwisse, McCrory, Dvorak, Echemendia, Guskiewicz Iverson,

Johnston, McCrea, Putukian, Raftery, Schneider)

EVALUATION (EMERGENCY / OFFICE)

• Individual clinical decision

• Medical assessment:

History detailed

Neurological examination

(including mental status, cognitive

functioning, gait, balance)

• Improvement or deterioration since injury?

(info from parents, coaches, teammates, eyewitness)

• Emergent neuroimaging?

(exclude structural abnormality)

• Neuro-psych testing? ImPACT: Immediate Post-Concussion Assessment and

Cognitive Testing

CT / MRI ?• Especially when suspicion of intra-cerebral

or structural lesion:

• Focal neurologic deficit

• Evidence of significant impact

• Seizure activity > 1 minute

• Worsening symptoms

• Prolonged alteration in consciousness

• Persistent symptoms (fails to improve over 2 -3 weeks)

*Other modalities (eg. fMRI) correlate with symptom severity and

recovery. Although not routinely used, may provide additional

insight.

Alternative imaging technologies: still too early in their

development in concussion. Not recommended except research

setting

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

PROGNOSIS

• 80-90% resolve in 7-10 days

• May take longer in children / adolescents

>3 previous concussions:

9x amnesia (either anterograde / retrograde)

and post concussion symptoms

Retrograde amnesia: 10x poor outcome

Anterograde amnesia: 4.2x poor outcome

L.O.C. not predictive of outcome!!!

MANAGEMENT

• Rest until acute symptoms resolve

Physical Rest No training, playing, exercise, weights

Beware of exertion with activities of daily living

Cognitive Rest No television, extensive reading, video games

Caution re: daytime sleep

MANAGEMENT

• Expect gradual resolution w/in 7-10 days

• Gradual return to school

and social activities

that doesn’t result in

significant exacerbation of symptoms

• Then step-wise return to sport / play

RECOVERED?

• “Feels fine”

• Always ask:

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

2.“What makes you not100% ?”

3. Symptom Checklist – SCAT3

4. Are they confident to return to play?

5. Has their equipment been replaced /

upgraded?

RETURN TO PLAY

• Level 1: No activity, complete rest. once asymptomatic proceed to level 2

• Level 2: Light aerobic exercise (eg walking / stationary cycling)

• Level 3: Sport-specific training (eg. hockey: skating; soccer: running; racing: family car)

• Level 4: Return to sport (supervised private practice; attention to consistent, competitivetimes or abilities)

• Level 5: Return to competition (under observation during practice then competition)

Any re-occurrence of symptoms, athlete goes back to previous level!!!!

• school first, then sports

• 24 hours per step (~ 1 week for full protocol)

• If recurrence of symptoms at any stage: return to previous asymptomatic

level, resume after 24 hr period of rest

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

WE STILL DON’T KNOW

• How many mild TBI’s are too many?

• When is brain really back to normal?

• Is there effective pharmacotherapy?

• Why some athletes are “brain injury prone”?

Age /development

Kids / women are more vulnerable

Genetics (seems to run in families)

Role of other conditions (migraine, ADD)

WE KNOW

• Mild TBI can have long term effects

• Most (but not all) recover quickly

• Age may be important in recovery

• Neuropsychological testing: a useful tool

• Management should involve multiple

components

• Total inactivity is bad but, activity too soon is

also bad

• Psychological support and education make a

difference

WHAT WE’LL COVER

1. Definitions

2. What Happens (Pathophysiology)

3. Evaluation

4. Management

5. What We Know and Don`t Know

6. Prevention

PREVENTION

• Protective equipment

• Mouthguards:

benefit: preventing oral injury

no evidence: concussion reduction

• Head gear / helmets:

reduction in biomechanical forces

not translated to reduction in concussion

reduce head / facial injury

OTHER ISSUES

• Education / Awareness

• Rule changes• If mechanism clear

• Compensatory Behaviour• Use of protective equipment may change

behavior

• Violence / Aggression• Violent behavior that increases concussion risk

must be eliminated

• Promote fair play / respect

PREVENTION

• Reduce risk of falls

• Car seats / seat belts

P.E.A.R.L.S.

• Don’t need:period of unconsciousness

direct hit to head

amnesia

• Must have: concussion related symptoms

normal CT / MRI

P.E.A.R.L.S.

• High index of suspicion -based on mechanism of injury

-velocity

-damage (in-car, helmet, to surrounding area, etc.)

• Athletes will under report symptoms to

stay in the event

WHEN IN DOUBT, SIT THEM

OUT!