Concussion Protocol


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CSUS Concussion Protocol, Presented June 2012 & September 2012

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Concussion Protocol

  1. 1. Sac State Concussion Protocol Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder surgery Medical Director Team Physician ConsultantSacramento State Athletics Sacramento River Cats Oakland A’s MiLB - AAA
  2. 2. Concussion: Classic Definition• Immediate transient impairment of neural function – A mild Traumatic Brain Injury (TBI) – Loss of Consciousness (LOC) not required
  3. 3. Concussion• Symptoms are variable for each individual in terms of type, intensity and duration• Symptoms are classified: – Somatic (i.e. headache, dizziness) – Neuropsych (i.e. agitation, quiet, depression) – Cognitive (i.e. memory, processing)
  4. 4. Concerns with Concussions• Bleeding• Associated neck injury• Second Impact Syndrome• Cumulative effects of repeated concussions
  5. 5. Second Impact Syndrome• 2nd head injury before sx’s • Loss of autoregulation of the from 1st injury have cleared brain’s blood supply – Can be remarkably minor – Vascular engorgement – ↑ ICP -> Brain herniation – Brain stem failure rapid (2-5• Next 15 seconds to minutes min) – Conscious but stunned – Collapses, semi-comatose • 50% Mortality! – Pupils dilate, respiratory failure Prevention is the key! Do not return to play too early!!!
  6. 6. Long term effects of Concussion• Dementia pugilistica – Severe form of chronic TBI commonly manifests as declining mental & physical abilities such as dementia & parkinsonism• Many recent studies show an increased risk: – Dementia – Alzheimers disease – Depression Guo, Neurology, 2000 Guskiewicz, Neurosurgery, 2005 Guskiewicz, Medicine & Science in Sports, 2007
  7. 7. Not just Football!• Injury rate in HS per 1000 exposures – Football = 0.44 – Girls soccer = 0.35 – Girls basketball = 0.24 – Boys soccer = 0.23• Most injuries occur in football players due to the large number of participants
  8. 8. Year Gym WBB MBB MSOC WSOC SB FB Total2004-5 0 1 2 2 1 1 72005-6 0 0 2 0 2 1 52006-7 1 0 1 1 3 0 62007-8 0 2 1 1 0 0 7 112008-9 2 2 0 1 5 1 8 19
  9. 9. Grading SystemsGrade Colorado AAN Cantu No LOC No LOC No LOC Grade I Confusion Confusion PTA < 30 min or Mild No Amnesia PCSS < 15 min PCSS < 30 min No LOC LOC < 5 min and Grade II No LOC Confusion PTA > 30 min orModerate PCSS > 15 min Amnesia PCSS > 30 min < 24 h LOC > 5 min orGrade III LOC LOC PTA > 24 min orSevere PCSS > 7 days LOC = Loss of Consciousness PTA = Post-Traumatic Amnesia PCSS = Post-Concussion Signs or Symptoms
  10. 10. Concussion: New Science• HS athletes with < 15 min on-field symptoms exhibit deficits on formal neuropsychologic testing – Re-emergence of active symptoms one week post-injury – Symptoms often return with exertion• Suggests we are returning athletes too early
  11. 11. International Symposiums on Concussion in Sport• 2001 – Vienna• 2004 – Prague• 2008 - Zurich
  12. 12. New Definition• Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: – May be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head. – Typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. – May result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. – 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, post-concussive symptoms may be prolonged. – No abnormality on standard structural neuroimaging studies is seen.
  13. 13. Zurich 2008 Statement No Grading System!!!
  14. 14. Diagnosis of Concussion• Symptoms – Somatic - headache – Cognitive - feels like in a fog – Emotional – lability• Physical signs – LOC, amnesia – Gait & balance evaluation (BESS)• Behavioral changes – irritability• Sleep disturbance - drowsiness• Cognitive impairment – slowed reaction times – Neuropsych testing
  15. 15. Diagnosis of Concussion• Concussion injury severity correlates with: – Number & duration of acute signs and symptoms – Degree of impairment on neuropsychological testing• Determination of severity can only be made after: – All symptoms have cleared – Normal neurologic examination – Baseline cognitive function has returned
  16. 16. ImPACT Testing• Computerized neuropsychological testing – Memory, attention, processing speed – Documents subtle impairments – Key in management of complex concussions• Used extensively in professional, collegiate, and high school athletes• “Baseline” testing prior to entrance to university
  17. 17. Professional Sports• NFL – ImPACT testing, League guidelines established – 1993 – 1994 Steeler’s Project – 1994 – 1995 NFL Neuropsychology Pilot Program – 1996 – 2000 Non-computer based testing – 2001 – 2007 Adoption of computer based testing – Adopted by NHL, MLB, MLS, Indy Racing, US Ski Team – Hundreds of colleges & thousands of high schools• MLB – ImPACT testing, Protocol team dependent
  18. 18. Collegiate Sports• Most schools using Neuropsych testing• Pac 10 Conference – All use neuropsych testing & symptoms for RTP• Mayo Clinic, Syracuse University, Indiana University, University of Utah, Pittsburgh, Indiana University, Washington University– Montana, N Arizona, N Colorado, Portland St.
  19. 19. Neuroimaging• Standard CT, MRI usually do not reveal significant structural lesions• Not needed for most concussions• Recommended to patients – Decompensate – Concern for structural lesion – Prolonged disturbance of conscious state – Focal neurological deficit – Seizure activity – Persistent clinical or cognitive symptoms
  20. 20. Concussion - Concensus• 80 – 90% of concussions resolve without complication within 7 – 10 days
  21. 21. Treatment - Acute• Physical AND Cognitive rest – Cognitive activities may worsen sx’s & delay recovery – Minimize driving, school work, computer, gaming, etc.• No alcohol or meds• Supervision – 24-48 hours• Serial evaluation & follow-up• Appropriate communication/education• Rule out concomitant injuries
  22. 22. Concussion Modifiers Factors Modifier Number Symptoms Duration (> 10 days) Severity Signs Prolonged LOC (> 1 min), Amnesia Sequelae Concussive convulsions Frequency – repeated concussions over time Temporal Timing – injuries close together in time “Recency” – recent concussion or TBI Repeated concussions occurring with progressively less impact force or Threshold slower recovery after each successive concussion Age Child & adolescent (< 18 years old) Migraine, depression or other mental health disorders, ADHD, learningCo & Pre-morbidities disabilities, sleep disorders Medication Psychoactive drugs, anticoagulants Behavior Dangerous style of play Sport High risk activity, contact & collision sport, high sporting level
  23. 23. Return to Play – Day of Injury• NO RTP - Day of injury – Collegiate & HS players may demonstrate NP deficits post-injury that may not be evident on sidelines & more likely to have delayed onset of symptoms – Adult NFL players may be returned to same day play with team physicians experienced in concussion management & sufficient resources (access to neuropsychologists, consultants, neuroimaging, etc) & immediate, complete neuro-cognitive assessment
  24. 24. New Guidelines: RTP• No Same Day Return to Play• Return to Play Recommendations – Approximately one week out• Symptoms fully resolved – -and-• Completed a structured, graded exertion protocol over approximately 5-7 days without symptoms
  25. 25. Graduated Return to Play Protocol Functional exercise at each Rehabilitation stage Objective of each stage stage1. No activity Complete physical & cognitive rest Recovery Walking, swimming, or stationary2. Light aerobic exercise cycling keeping intensity < 70% MPHR. Increase HR No resistance training Skating drills in hockey, running drills in3. Sport-specific exercise soccer. No head impact activities Add movement Progression to more complex training4. Non-contact training Exercise, coordination, & cognitive drills (e.g. passing drills in football) May drills load start progressive resistance training Following medical clearance, Restore confidence & assess5. Full contact practice participate in normal training activities functional skills by coaching staff6. Return to play Normal game play
  26. 26. Graduated RTP Protocol• Each stage is about 24 hours or longer• Advance to next level only if asymptomatic for 24 hrs• No symptom modifying medications• If symptoms occur, – Drop back to previous asymptomatic level – Try to progress again in 24 hours• Neurocognitive score may normalize before or after symptoms resolve
  27. 27. Concussion: Final Thoughts• Be alert for subtle symptoms• Physical / cognitive rest and limit contact for a minimum of one week & transition back to play• Neuropsych testing – Document baseline, deficits and improvement• Be aware of cumulative trauma & risk for permanent damage
  28. 28. Thank You!