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3 11 concussion
 

3 11 concussion

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a recent talk on sport concussion, more to come!!

a recent talk on sport concussion, more to come!!

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  • Andy Cannon Concussion tested our child (3) points below baseline, didn't tell her nor parents, and left her playing. Two weeks later with post concussion issues, she could only attend High School part time. Two weeks after that she was required by outside medical to receive education at home. Two years later still dealing with post concussion issues, she has not been able to physically attend full time school. Too bad he does not follow his own recommendations.
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    3 11 concussion 3 11 concussion Presentation Transcript

    • Concussion be gone
    • Is it Safe for Your Patient’s Brain to Play Sports? Andrew Cannon, MHS, PT, SCS Dir., Sports Medicine, NRHN Team PT, Lecturer, Merrimack College NHIAA Sports Medicine Board NH-SCAC
    • Northeast Rehabilitation Hospital Acute Care Rehabilitation – We have, on-site:  Pain Clinic  Pharmacy  Outpatient Therapies  Orthotics & Prosthetics  23 Outpatient Clinics Clinic, Wheelchair Clinic,  Home Care Low-Vision Clinic, Driving Assessments  and more… Programs consist mainly of:  Stroke  Neurological  Brain Injury  Spinal Cord Injury  General Rehab  Multi-trauma
    • New Hampshire Sport Concussion Advisory CouncilMission: Improve concussion-related safety of NH athletes
    • Does academic performance relate to physical activity? 7,961 school kids Age 7-15 Consistently across age groups and gender academic performance was correlated with physical activity and fitness measurementsDwyer T, Relation of academic performance to physical activity and fitness in children.Ped ExSci 13:225-237 2001
    • What is a Concussion CDC A type of brain injury that changes the way the brain normally works. Caused by a bump, blow, or jolt to the head that causes the head and brain to move rapidly back and forth. Children and adolescents are among those at greatest risk for concussion Sport related concussion in US 1.6 - 3.8 million 6-10% of all sports related injuries Ages 5-18 the 5 leading sports/recreational activities resulting in concussion are?
    • What % of concussions in children are sport related? < 10 YO = 18.2% 10-14 YO = 53.4% 15-19 YO = 42.9% In contact sports 20% suffer concussion each season Estimated concussions are under reported by 65%! 60 % high school students participate in sports The sheer volume makes sport related concussion a public health issue!
    • Zurich Consensus Statement Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Direct or indirect blow to the head or body with “impulsive” force to the head Typically rapid onset of short-lived impairment of neurological function that resolves spontaneously – 90% resolve 1-2 weeks – 10% suffer prolonged post-concussive symptoms
    • Zurich Consensus Statement Concussion
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 however,
postconcussive
symptoms
may
be
prolonged. Acute clinical sx’s largely represent a functional disturbance, not a structural one No abnormality on standard structural neuroimaging studies is seen in isolated concussion SOFTWARE NOT HARDWARE
    • Chelsea Davis, 16 year old American diver, 2005 world championships broken nose, laceration, no concussion!
    • Evolving Knowledge LOC not required “Mild” traumatic brain injury (mTBI) – With some disagreement? PCS Neurometabolic/neurochemical imbalance – Neuronal depolarization, impaired axonal function – Energy crisis: cerebral blood flow; glucose demand – Problem with the software, not the hardware
    • discover magazine.com/2004/dec/lights-out/article
    • TheMolecularPathophysiologyof ConcussiveBrainInjuryGarni Barkhoudarian, MD, David A. Hovda, PhDChristopher C. Giza, MDClin Sports Med 30 (2011) 33-48
    • Evolving Knowledge Second Impact Syndrome – Further impact before resolution may be catastrophic – Diffuse cerebral edema – Does it exist? Multiple Concussions – Subsequent concussions with less provocation – Prolonged recovery – PCS
    • Seminal Study (Barth et al., 1989) Problem in MTBI: Adequate controls, controlling for premorbid functioning, detecting change Test-retest design – collegiate football players Baseline neuropsychological testing, serial post- injury testing 10 universities – n=2350 players baseline tested Neurocognitive deficits at 24 hrs and 5 days post- injury, with return to preseason baseline by Day 10 Sports arena recognized as a unique, relatively well- controlled lab for assessing mTBI.
    • Recovery From Concussion: How Long Does it Take? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2N=134 High School athletes Collins et al., 2006, Neurosurgery
    • Studies Reporting Individual Recovery Rates Authors Sample Population Tests Utilized Total Days Total Days Individual Size Cognitive Symptom Recovery Resolution Resolution Rates McCrea, 94 College Paper and Pencil 3-5 Days 7 Days 91%Guskiewicz et recovered al. w/in 7 days 2003Iverson et al. 30 High School Computer 10 days 7 Days 50% 2006 ImPACT recovered w/in 7 days Collins 134 High School Computer NR NR 40%Lovell, et al. ImPACT recovered 2006 w/in 7 days
    • Concussion Epidemiology 7.5 million kids participate in HS sports, 3.1, 4.4 Published estimates – CDC: 100,000 annual HS concussions – 9% of high school sports injuries – 19.3% high school football injuries! Only MVAs cause more in 15-24 age group 1 in 20 HS football players per season Under-reported!!! – Especially in football…don’t ask, don’t tell!
    • Concussion Epidemiology Injury rate per 100,000 player games in high school athletes – Football 47 – Girls soccer 36 – Boys soccer 22 – Girls basketball 21 – Wrestling 18 – Boys basketball 7 – Softball 7Data from HS RIO, JAT, 2007
    • Concussion Epidemiology Head injury in younger players may impair developing brain Females at higher risk for sustaining a concussion than males in the same sport - especially at lower levels of competition
    •  Explosion girls sports in NH since Title IX in 1971, now in NH, 1 in 3 girls participate Girls sustain concussion 68% more often than boys Youth basketball rate is 3x higher for girls Lacrosse, soccer, hockey
    • Signs and Symptoms of Concussion Signs Observed by Others – Appears dazed or stunned – Confused about events – Answers questions slowly – Repeats questions – Can’t recall events prior to injury – Can’t recall events after injury – Loss of consciousness – Shows behavior or personality changes – Forgets class schedule or assignments
    • 4 Symptom CategoriesCognitive Emotional• Difficulty remembering • Irritability• Difficulty concentrating • Sadness• Feeling slowed down • Feeling more emotional• Feeling mentally foggy • NervousnessPhysical • Sleep• Headache • Drowsiness• Fatigue • Sleeping less than usual• Dizziness • Sleeping more than usual• Sensitivity to light and/or • Trouble falling asleep noise• Nausea• Balance problems
    • ONE OR MORE SIGN OR SYMPTOMS IS A CONCUSSION
    • What grade is it? Demonstrating
true
international
consensus
on
this issue,
the
Zurich
statement
makes
no
mention whatsoever
of
concussion
grading
scales. Prague,
2004
put
forth
simple
and
complex
as
an option
to
I,
II,
III The
NH
State
Advisory
Council
on
Sport‐Related Concussion
agrees
with
the
individual‐athlete management
and
decision‐making
approach
and supports
the
use
of
careful
monitoring
of
clinical symptoms
(somatic,
cognitive,
emotional),
physical signs,
behavior,
balance,
sleep
and
cognition
in
the assessment
and
monitoring
of
concussion.
    • Why worse in kids?Traditionally,
young
age
at
the
time
of brain
injury
has
been
thought
to
have protective
benefitsHowever,
growing
literature,
strongly indicates
that
the
immature
brain
is
more vulnerable
    • Hypotheses 
Skills
not
yet
well
established
at
the
time
of
insult
could
be more
susceptible
to
disruption
than
well‐established
ones 
The
brain
systems
responsible
for
skill
acquisition
could
be affected
directly
by
diffuse
injury 
Functional
recovery
may
be
restricted
by
the
injured
child’s smaller
repertoire
of
existing
skills 
Injury
to
the
immature
brain
could
interfere neurobiologically
with
the
intricate
sequence
of
chemical and
anatomic
events
necessary
for
normal
development.
    • Effective Concussion Program Education & Awareness (Pre-Injury) Baseline Neuropsychological & Balance Testing (preseason) On Field Surveillance Standardized Sideline Assessment Post-Injury Neuropsychological & Balance Re-Testing Management – Physical Exertion – Cognitive Exertion (Academics) Gradual Return-To-Play Protocol
    • Acute Management Call 911: – Extended (or late) loss of consciousness(15 seconds) – Seizure/posturing – Vomiting (?repeated?) – Any worsening of symptoms (e.g., headache getting worse, increased disorientation, etc…) – Frank amnesia – If you think you should!
    • On-Field or Sideline Evaluation Medically evaluated using standard emergency management principles After addressing first aid issues, assessment of the concussive injury using a standardized assessment tool (SCAT, BESS, SAC, etc) Serial monitoring for deterioration over the the initial hours following injury
    • ER/ Medical Evaluation Medical assessment should include – Comprehensive history – Detailed neurological examination – Assessment of mental status and cognitive functioning – Assessment of gait and balance
    • Treatment Current Cornerstones: – Physical & cognitive rest until symptoms resolve and then – Graded program of exertion prior to medical clearance and return to play
    • Treatment Physical Rest – NO activity:  No gym class  No bike riding  No weightlifting  No sports – games or practice  Controversy – light activity?  Leddy, et al, 2010 – CJSM – Sub-symptom activity
    • Treatment Cognitive Rest – NO/reduced activity: – School limitations  No school? Reduced schedule?  No [standardized] tests  Rest  Reduced load – assignments, etc – Home/social limitations  TV, computer, videogames, IM/texting  Reading – ? Sub-symptom activity ?
    • Concussion/ mTBI Definition Disturbance of brain function is related to: – neurometabolic dysfunction, rather than structural injury – typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). Concussion results in a constellation of symptoms: – physical, cognitive, emotional and sleep-related
    • Zurich CIS Consensus Child and adolescent student-athlete – Strongly endorsed view no return to practice or play until clinically completely symptom free – Cognitive rest highlighted – More conservative return to play approach; appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. – It is not appropriate for a child or adolescent student- athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance. – Concussion modifiers apply even more than adults and may mandate more cautious RTP advice.
    • Return to School Resume activities as tolerated – No symptom exacerbation or recurrence – Increase task time/complexity as tolerated Requires coordinated effort – Nurse – Guidance/Psychologist – Teachers – Administration ACE (Acute Concussion Eval) CDC Tool kit
    • Return to Sport [Young] athletes: NO same day return
    • Return to Sport Tolerating full school activities – student-athlete! Complete resolution of symptoms Return to baseline on neurocognitive tests Stepwise progression – gradual return Supervised by athletic trainer, team/ personnel MD, neuropsychologist, sports PT, RN – Athletic trainer – licensed medical professional – not coach or fitness!!
    • Return to Play Protocol First few days after injury physical and cognitive rest is required Proceed to next level only if asymptomatic at the current Any post concussive symptoms occur, drop back to the previous asymptomatic level, try again in 24 hours Age 5-18, slower recovery, worse injury, more conservative care – 1. No activity, complete rest. – 2. Light exercise such as walking or stationary cycling. – 3. Sport specific activity (i.e. running, skating in hockey). – 4. "On surface" practice without body contact. – 5. "On surface" practice with body contact, once cleared to do so by a physician. The time required to progress from full non-contact exercise to contact will vary with the severity of the concussion. – 6. Game play.
    • Neurocognitive testing comparing the injured athlete to their own baseline data is the cornerstone concussion management
    • Tools Standardized assessment of concussion(SAC) BESS SCAT II Computerized – Impact – CogState – Etc.
    • Contribution of Neuropsychological Testing to Concussion ManagementImPACT revealscognitive deficitsin asymptomaticathletes within 4days post-injury N=115 MANOVA p<.000000
    • ImPACT Reaction Time ImPACT Processing SpeedN=115 MANOVA p<.000000
    • To evaluate concussion recovery, we cannot rely on athlete symptom report alone! (How many other injuries do we allow the athlete to decide when they can return to play?)
    • Clinicians’ Return to Play Decisions 100 80 ATC used GSC, SAC, BESS (testing w/ symptom report) 60 40 ATC used only GSC 20 (player symptom report) 00 Marshall, Guskiewicz, & McCrea; In Review, 2006.
    • Preseason Baseline computerized Neuropsychological Testing 25 minute computer-based test – Memory, Processing Speed, Reaction Time – Baseline symptoms Conducted in group format (up to 15 per) Load on computers in lab Baseline data available for comparison post- injury Ages 11-18 (currently) 11-14 15-18
    • Balance (Postural Stability) Testing
    • Concussions And Heading Exposure Cause Cognitive Impairments In Soccer Players Reductions in soccer players compared to the non contact sport athletes reflects subtitle deficits in the attention processes related to updating information in working memory. These results also suggest that heading exposure alone affects cognitive processing in soccer athletes. AYSA over 10 to headDo Minor Head Impacts in Soccer Cause Concussive Injury? A Prospective Case-Control Study Neurosurgery: April 2009 - Volume 64 - Issue 4 - p 719-725
    • Post-Concussion Syndrome 85-90% of concussed young athletes will recover within 1 to 2 weeks The remainder may have symptoms lasting from weeks to months interfering with school and daily life Subtle deficits may persist a lifetime
    • Post Concussion Syndrome 3 or more sx’s lasting greater than 3 or 6 weeks with or without exertion Often considered if just 1 sx lingers with or without exertion Acute care rest, when is rest not enough Meds, NP for skill adjustment Sub Threshold Exercise?
    • University Buffalo Sports Medicine PCS TreatmentThe athlete with PCS performs graded stationary cycleexercise under close observation, attempting to reach aheart rate target of 85% of age-predicted maximum. Bloodpressure and perceived state of effort are measured every2 minutes, and the athlete is instructed to stop the activitythe moment he or she feels any symptoms of concussion.Typical symptoms at the threshold are localized headache,feeling pressure in the head or the eyes, visualdisturbance, and foggy thinking. The symptom-free exer-cise duration and intensity become the threshold forsymptom regeneration, and we have the athlete return tothe laboratory to exercise at 15% below threshold for 2 or 3weeks.
    • Progression? The opportunity to exercise is perceived as a very positive activity (often leading to an immediate reduction in depressive symptoms). It is imperative that the athlete not go beyond the new exercise limit, which most athletes are keen to do. After the 2 or 3 weeks of sub-threshold exercise, the athlete is reassessed to see if the threshold has changed. The exercise program is then realigned to be 15% less than the new threshold. Integrate BESS as well We started this evening by agreeing that exercise is a cornerstone!
    • Heads Up: Concussion in High School Sports Parent Fact Sheet Athlete Fact Sheet Guide for Coacheswww.cdc.gov/ncipc/tbi/coaches_tool_kit.htm
    • NHSCAC Organizational Structure NH State Advisory Sport Concussion Advisory Council Advisory Council Chair Art Maelender, Ph.D. Advisory Council Vice-Chair Laura Decoster, ATC Coordinating Agency/Project Director Brain Injury Association of NH/Steven Wade
    •  The
New
Hampshire
State
Advisory
Council
on
Sport‐ Related
Concussion
was
created
to
provide
guidance
for school
and
youth
league
administrators,
coaches,
parents and
athletes
on
this
very
important
topic.
The
purpose
of this
consensus
statement
is
to
guide
the
creation
and implementation
of
a
best‐practice
model
for
sport‐related concussion
management
including
safe
return
to
sports and
return
to
school.
This
statement
does
not
include specific
protocols
but
serves
as
the
basis
for
such
protocols. Medical
science
concerning
sport‐related
concussion
is
a rapidly
growing
field;
the
most
recent
research
was
used
in the
preparation
of
this
statement.
Statements
are
based
on evidence
but
users
should
be
aware
that
there
are
still many
areas
of
controversy
in
this
relatively
young
research field.


Because
of
this
fact,
this
document
will
be
reviewed at
least
yearly
to
take
advantage
of
advances
in
our knowledge
about
concussions.
    • Executive
Summary A
concussion
is
a
serious
injury.
Colloquial
terms
such as
"ding"
or
"bell
ringer"
minimize
and
trivialize
an
injury that
may
have
lasting
consequences.
Those
terms
should be
eliminated
from
the
concussion
vocabulary.
All
injuries to
the
brain,
regardless
of
how
apparently
minor
they seem,
should
be
managed
appropriately. Neither
loss
of
consciousness
nor
amnesia
is
a
required element
for
the
diagnosis
of
a
concussion.

In
the
majority of
concussions,
neither
is
present.
    •  A
young
athlete
(through
high
school)
who
experiences concussion
signs
or
symptoms
after
a
direct
or
indirect blow
to
the
head
should
not
return
to
activity
on
the
same day.
Some
brain
injuries
evolve
slowly
and
the
true
severity of
an
injury
may
not
be
apparent
initially. Signs
and
symptoms
of
concussion
may
fall
into multiple
categories
in
somatic,
cognitive
and
emotional domains.
Headache,
fatigue,
irritability,
difficulty concentrating
and
sleep
disturbance
are
a
few
examples. Coaches,
athletes,
parents
and
school
officials
should
be familiar
with
common
signs
and
symptoms
so
concussions and/or
their
sequelae
do
not
go
unrecognized.
    •  Each
concussion
is
unique.
Concussion
grading
scales fail
to
account
for
the
individuality
of
this
injury
and
may result
in
an
athlete
being
sent
back
to
activity
too
soon
or held
out
too
long.
In
place
of
concussion
grading
scales, healthcare
providers
are
advised
to
manage
concussions on
an
individual
basis
including
careful
monitoring
of clinical
symptoms,
physical
signs,
behavior,
balance,
sleep and
cognition
in
the
assessment
and
monitoring
of concussion.
Once
all
signs
and
symptoms
have
resolved,
a monitored
gradual,
structured
return
to
activity
is recommended.
    •  School
personnel
(nurse,
guidance,
teachers)
should
be informed
of
the
occurrence
of
a
concussion
and
student‐ athletes
who
have
suffered
a
concussion
should
be monitored
at
school
for
academic
performance
difficulties and
behavior
changes. Evidence
suggests
that
pediatric
athletes
may
be
more vulnerable
to
concussion,
may
require
a
longer
recovery period
and
may
suffer
more
long‐term
sequelae
than adults.
There
may
also
be
an
increased
risk
of
second‐ impact
syndrome,
an
often‐fatal
brain
swelling,
which
has almost
exclusively
been
documented
in
young
athletes.
    •  Neurocognitive
baseline
assessment
of
athletes
who participate
in
collision
or
contact
sports
is
recommended whenever
it
is
feasible
as
it
can
be
used
by
healthcare providers
as
objective
evidence
of
an
injured
athlete’s return
to
cognitive
normalcy.

However,
neurocognitive testing
is
only
one
element
of
what
should
be
a multipronged
approach
to
assessing
and
managing
sport concussion.
Neurocognitive
test
administration
should
be appropriately
supervised
and
test
results
should
be interpreted
by
neuropsychologists.
    •  Athletic
programs,
both
school
and
community‐based, should
adopt
a
sport
concussion
management
protocol. The
NH
Council
has
developed
a
template
for
such
a program
that
should
be
adapted
according
to
each programs
resources
and
in
consultation
with
team physicians. Coaches,
athletes
and
interested
parties
(parents, administrators,
etc.)
should
receive
current
basic
education on
the
topic
of
sport‐related
concussion. Physicians
must
stay
abreast
of
current
practice guidelines
and
topics
regarding
the
appropriate management
of
athletes
who
have
suffered
a
concussion, especially
return‐to‐play
decision‐making.
    • A few take home’s You need an office plan! Amnesia important for subacute recovery, not predcitive of protracted On field dizziness best predictor of protracted recovery! Sub acute it is “fogginess” LOC <30 sec not predictive
    • THANKS