A SPORTS MEDICINE PHYSICIAN’S
PERSPECTIVE

DAVID CARFAGNO, D.O., CAQSM
SCOTTSDALE SPORTS MEDICINE
Team Doc/Fan

Team Doc
INJURY

RTP
PT HISTORY, RTP , COMMUNICATION
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Sports injuries rank 2nd highest in terms of
cause of injury, after home and leisure accidents;
and rank third in...
1.
2.
3.
4.

Course set up
Resources
Staff
Yourself

PREPARATION
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DAY OF WEEK, ‘FRI
NIGHT GAMES’
AWARENESS OF
CLINICAL SETTINGS
IMPACT ON TEMPORAL
DECISIONS, FOLLOW UP,
ETC.
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ADMIT vs. DISCHARGE vs. TRANSFER TO HIGHER LEVEL
OF CARE or SPECIALIZED CARE

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IMPORTANCE OF TIMELY DIAGNOSIS

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RES...
Q. The current consensus on concussion in sport
recommends neurologic imaging only in
situations of prolonged alteration o...
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

Importance of effective communication between
members of healthcare team, from on-field  ED
 Level 1 Trauma Center...


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18 year old Junior College Football Player
sustained a head injury today while playing
football.
Seen by ATC, Team P...








Concussions are an important and common injury for
athletes.
Challenge is for ED physicians to screen quickly ...


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Zurich Guidelines
2012
Complex
pathophysiological
process affecting
brain due to
traumatic
biomechanical forces.

Co...


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

Direct blow to head, face, neck or elsewhere with
an “impulsive” force transmitted to head
Rapid onset of short-l...









Neurochemical and neurometabolic changes
Increase in glucose and oxidative metabolism
Increase in demand fo...




Jordan et al found Apolipoprotein E (ApoE) E4
assoc w/ increased severity of chronic TBI (cTBI)
in high-exposure box...






National High School Federation Data, 20082010: 2.50 injuries/10,000 athlete exposures.
CDC: During 2001-2005, an...




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Somatic: headache, nausea, vomiting, motor
problems, fatigue, dizziness, visual disturbance,
photophobia, phonoph...






ABCD, sideline tests (e.g., SCAT 2), rule out
structural intracranial lesions
Monitor for initial few hours follo...
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Glasgow Coma Scale (GCS)
King-Devick Test
Bess Test
SCAT 2
Maddocks Questions

King-Devick
Test
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Basic neurological scale that quantifies level of
consciousness
Score ranges from 3 (unconscious) to 15 (alert...
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Tests for eye saccade
(quick, simultaneous
movements of eyes in
same direction)
Uses charts of numbers
Charts b...






Postural stability testing,
assesses cognitive motor
function
Quantifiable, modified
Romberg test – three 20secon...


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Calculated for athlete>10 y/o
Preseason baseline testing can be helpful.
Calculated based on symptoms, physical ...
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At what venue are we today?
Which half is it now?
Who scored last in this match?
What did you play last week?
...
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Comprehensive history, physical assessment (e.g., cspine, obvious skull depressions, CSF
rhinorrhea/otorrhea...




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1) Avoid CT scans in low risk patients based on
validated decision rules
2) Avoid placing indwelling catheters in...




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Related to the burden, nature and duration of
symptoms
Modifiers (Zurich ’09)
1. Age
2. Prior h/o concussion
3. L...
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Acute or subacute subdural hematoma
Epidural hematoma (rapid deterioration after a
“lucid” interval)
Intrap...
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Cervical spine injury
Skull fracture
Intracranial hemorrhage
Seizures
Post-concussion Syndrome (PCS)
Seco...
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Evoked response potential (ERP)
Cortical magnetic stimulation
Electroencephalography
Biochemical and CSF markers ...
CT/MRI

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Whenever suspicion of intracerebral
structural lesion exists
1. Prolonged disturbance of conscious stat...
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Evaluate brain-behavior relationships
Sensitive in assessment of brain injury
Unique contribution in RTP
Newe...
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Endorsed as a "cornerstone" of concussion
management by Vienna and Prague Consensuses.
imPACT (Immediate Post-c...
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Physical and cognitive
rest until symptoms
resolve, then graded
program of exertion
prior to medical
clearance and R...
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All but one U.S. states have active or pending
laws on RTP for youth sports and full elimination
of same-day RTP aft...
Rehabilitation Stage
1.

Functional Exercise

No activity

Complete rest

•imPACT testing
2.

Light aerobic exercise

No r...
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Management of sleep disturbance, anxiety,
depression
Management of headache, vomiting, dizziness
Before RTP, the c...
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May need additional management considerations

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Symptoms, signs, sequelae, temporal, threshold

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Age, co- and premo...
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Internet based neurocognitive assessment tool
for use by professionals who manage and
monitor sports related concussion...
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College football players showed mild cognitive
impairment on the CRI after commonly looked at
symptoms subsided
4...
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All 436 received baseline CRI’s before football
started

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Total of 647 CRI obtained

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70 of the 436 athletes had a ...
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Median time between concussions and RTP was 10
days.

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28 of the 70 concussed cleared to RTP had a decline
in their C...
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Designed to incorporate and expand principles in
previous consensuses (Vienna and Prague)
Simple vs. complex...
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Symptomatic athlete should not return to play,
same-day RTP controversial, safest course of
action: hold an athle...
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Helmets and mouth guards
1. Injury rates similar between helmeted and nonhelmeted sports.
2. No helmet in any sports pr...
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How many is too many?
Influence of gender and genetics on injury risk,
severity and outcome
Pediatri...
Source CSHB 15(JUD)
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Definition, epidemiology, causation, risks, and
RTP guidelines
All covered earlier


Guidelines established by ASAA along with
governing body of each school district to educate


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Coaches
Athletes
Par...
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School provides this information to
parent/guardian of athletes under 18
Athletes under 18 can not participate in sp...
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Athlete removed from sporting event
May not return to play w/o being cleared in
writing by qualified person (QP) with...
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Health care provider licensed in the state or
exempt from licensure
Person acting under supervision who is licens...
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School district not liable for injury or death
caused by concussion by actions of QP if
Action/inaction occurred during...
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Previous slide can not be construed to impair or
modify ability of a person to recover damages
Youth organization me...
62
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Roughly 12,000 new cases of SCI a year
Sports-related events causing approximately
7.6%

Semin Spine Surg 22:173-180
...
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Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture

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Classi...
65
66
67
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Buffalo Bills TE
Fractured C3 and C4 on Sept. 9th 2007
Everett could fill nothing below his neck
following impac...
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He started walking again on December 7th, 2007
70
71
Recall the hit by Jadeveon Clowney
 How much time do you thinkCoaches spennt preparing and teaching him
 He spent practi...
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Same principles apply to sports medicine
Situational preparedness is critical to outcome
Our stake are higher, more...
74
J Athl Train. 2005;40(3):155–161

75
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Burners/Stringers
Strains and Sprains
Cervical Spine Fractures
Spear Tacklers Spine
Herniation and Cervical Dis...
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Transient sensory and/or motor loss involving
arms and/or legs
2 mechanisms of injury
Traction and compression
Se...
Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
78
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Physical Exam


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Test for muscle weakness: C4-C5 deltoids, C5-C6
triceps, C6-C7 triceps.
Test for sensory loss...
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The most common cervical injury seen in sports
are stingers and burners.
True or False

81
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Most common injury
No neurological or osseous injury
Cervical xray needed to r/o possible fracture
Pts return to ...


C1-Jefferson fracture
Traumatic burst fracture from axial load
 Presents with neck pain and likely neurologic injury
...
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C2: Hangman’s Fracture
Traumatic spondy from axial load and extension
 Presents with neck pain, instability
 Palpate ...
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Burst fractures
Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the ...
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Loss of Lordosis
Cervical Stenosis
Narrowing of disc
space
Preexisting bony or
ligamentous injury
seen on stu...
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Measuring canal width accurately and taken in all
factors that may change canal width is difficult
Torg Ratio: midsa...
X-ray

MRI
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Herzog* found that many athletes had larger
than normal vertebral body width
Blackley** demonstrated that measuremen...
NFL football players with
stenosis
 Jermichael Finley
 Jarvis Jones
 David Wilson
 Chris Berman
 Archie Manning
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Defined as the loss of the cerebral spinal fluid
(CSF) around the cord or actual cord
deformation
Best determined wi...
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Far less common than lumbar herniation
Usually only affects older athletes
Two types: hard and soft

Bull NYU Hosp ...
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Tx: nonoperative unless myelopathy or
progressive neurolgic deficit present
Nonoperative tx includes rest, ice, N...
96
97
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Every patient suspected of cervical spine injury
needs complete physical examination
Immobilize head and neck
Asse...
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Careful attention should be directed towards
-neurological complaints
-head trauma
-headaches
-mental status changes
-m...
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Following head and neck examination, careful
motor and sensory exam of extremities should be
performed

Semin Spine Sur...
Semin Spine Surg 22:173-180
101
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Lift and slide
maneuver used
Causes less motion of
C-spine then rolling
pt
DOCTOR should be
head of injured
athle...
103
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Team physician should use
multiple assistants to position
pt
DOC at head
Minimum of 4 with doc
controlling C...
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Key to successfully maneuvering the injured pt….
Practice, practice, practice. Don’t let the injury be
the first tim...
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Only remove equipment that may obstruct
breathing
Tools and techniques that cause least amount of
torque should...
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Helmeted pts are difficult to collar
Once on spine board, pt can have sandbags or
foam blocks taped to board for i...
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Team physician should accompany the injured
athlete
Provides Continuity of care
Provides ED doc accurate clinic...
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Once pt is stable and transferred to the hospital,
standard diagnostic evaluation of the C-spine
should be performed

...
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CT use continues to expand with cervical neck
injuries
A diagnostic study showed that CT had higher
sensitivity, hig...
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MRI studies are warranted when suspected
ligamentous injury or cervical disc herniation is
present

Semin Spine Surg 22...
EBMedicine.net • April 2009
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Dependent of context of injury
Known risk factors
Number of previous injuries
Pressure from player, coaches, a...
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Generally speaking, athletes can RTP when they
are:
asymptomatic,
 have full ROM,
 regain preinjury strength,
 imagi...
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Neurological findings of cervical myelopathy
Continued discomfort, decreased ROM
Following C1-C2 fusion, cervi...
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RTP following injury is complicated and pt
specific
No universally accepted RTP criteria
Communication is es...
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USA football was established in 2002 by the NFL
and the NFL Players Association
It’s a nonprofit program
The...
118
David Carfagno, D.O., C.A.Q.S.M.




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Board Certifications: Internal Medicine, Sports Medicine
(CAQ), Ringside Medicin...
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective
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Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective

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Dr. David Carfagno is the principal at Scottsdale Sports Medicine Institute, and a frequent presenter on sports medicine topics around the country.

Concussions and neck injuries are a chronic issue among athletes, particularly in both collegiate and professional football. While their severity is getting more attention today, there are still unique factors that physicians and medical personnel should be aware of.

Published in: Health & Medicine, Sports
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  • Injury Prevention & Control: Traumatic Brain Injury Only Mississippi nowCurrent Zurich guidelines for physical and cognitive rest states that an initial period of rest ma be of benefit , however further research to evaluate the long term outcome of rest and the optimal amount and type of rest is needed.
  • WEAKNESS WAS OBSERVATIONAL STUDY, NO CONTROL FOR TIME BETWEEN INJURT AND RTP
  • Qualified persons: a) health care provider licensed in the state or exempt from licensure under state laws b) person acting under direct supervision of of a licensed physician
  • Fatal- deathSerious-No permanent functional disability but severe injury (example: a fractured vertebra with no paralysis).National Center for Catastrophic Sport Injury Research
  • Kid spears a blocker and escapes without injury
  • During axial loading, compressive forces create a buckling effect in the cervical spine.100 This buckling produces large angulations within the cervical spine as a means of releasing the additional strain energy produced by the vertical loading, and this buckling is the causative factor of injury This buckling produces large angulations within the cervical spine as a means of releasing the additional strain energy produced by the vertical loading The resultant injury is influenced by the velocity of the applied load, the point of contact on the head relative to the axis of the cervical spine, the resultant mode of buckling, and the type of surface with which the head came into contact
  • Grade I < 2 weeksGrade II: 2 weeks-1 YearGrade III: > 1 Year
  • The injury to the brachial plexus may be caused by traction, which stretches the plexus, or a direct blow resulting in compression at Erb’s point by the shoulder pads
  • False
  • David Wilson was originally diagnosed with stenosis this year and is currently getting a 2nd opinion. He had an injury during week 4 of this season
  • Soft disc refers to acute process with nucleus pulposus herniates through posterior annulus resulting in cord or root compression, injury usually a result of uncontrolled lateral bending of neckHard represents a chronic degenerate process with formation of marginal osteophytes
  • When assessing airway, only oral protective devices should be removed like mouth guards. If the injured player is wearing a helmet, it should be left on and removed at hospital once pt is stableOnly jaw thrust maneuver should be used for air-way management, head tilting is not recommended
  • Neurological complaints either unilateral or bilateral, cranial nerve abnormalities (abnormal pupil response or extraocular movements),
  • For football helmets, authors have reported that a screwdriver, or cordless screwdriver, is faster,86,144,145 easier to use,86 and creates less torque145 and motion86 at the head than many of the cutting tools commonly used to remove the face mask.
  • Helmet and shoulder pads should not be removed for risk of hyperextending neck and causing further injury Once in the hospital, the pads and helmet can be removed using techniques like the flat torso method
  • Once thought to be an adjunct tool, CT is now becoming the study of choice due to its ability to provide clearer bony detailIts important to know that even in cases with adequate c-spine films, large numbers of injuries where missed **Joint Surg 87:2388-2394, 2005 **
  • Head and Neck Injuries in Sports: A Sports Medicine Physician's Perspective

    1. 1. A SPORTS MEDICINE PHYSICIAN’S PERSPECTIVE DAVID CARFAGNO, D.O., CAQSM SCOTTSDALE SPORTS MEDICINE
    2. 2. Team Doc/Fan Team Doc
    3. 3. INJURY RTP
    4. 4. PT HISTORY, RTP , COMMUNICATION
    5. 5.    Sports injuries rank 2nd highest in terms of cause of injury, after home and leisure accidents; and rank third in terms of severity, after traffic accidents and violence. Approximately 11,000 persons/day receive treatment in U.S. EDs for injuries sustained during sports, recreation, and exercise activities. One of every six ED visits for an injury results from participation in sports or recreation. Clin Rehabil. 2000 Dec;14(6):651-6. CDC Injury Research Agenda, 2011
    6. 6. 1. 2. 3. 4. Course set up Resources Staff Yourself PREPARATION
    7. 7.    DAY OF WEEK, ‘FRI NIGHT GAMES’ AWARENESS OF CLINICAL SETTINGS IMPACT ON TEMPORAL DECISIONS, FOLLOW UP, ETC.
    8. 8.  ADMIT vs. DISCHARGE vs. TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE  IMPORTANCE OF TIMELY DIAGNOSIS  RESOURCES  LEVEL 1  CONSULTANTS  ANCILLARY TESTING  CASE BASED
    9. 9. Q. The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness, focal neurological deficits, or worsening symptoms. A. True B. False
    10. 10.   Importance of effective communication between members of healthcare team, from on-field  ED  Level 1 Trauma Center/Specialist. Importance of Expeditious Diagnosis Risk of death (immediate or later)  Malpractice/Lawsuits   Disposition   Clinical suspicion Ongoing assessment
    11. 11.   18 year old Junior College Football Player sustained a head injury today while playing football. Seen by ATC, Team Physician, recommended to go to ED for further management.
    12. 12.     Concussions are an important and common injury for athletes. Challenge is for ED physicians to screen quickly for small subset of patients with potentially life-threatening intracranial lesions and/or increased risk for sequelae while minimizing cost, unnecessary testing, radiation exposure and admissions* Evaluation, management and RTP decision very challenging Take home message: must individualize management and RTP decision Emerg Med Pract. 2012;14(9):1-24.
    13. 13.   Zurich Guidelines 2012 Complex pathophysiological process affecting brain due to traumatic biomechanical forces. Consensus statement, 4th International Conference, Zurich, 2012.
    14. 14.    Direct blow to head, face, neck or elsewhere with an “impulsive” force transmitted to head Rapid onset of short-lived neurological functional impairment May/may not LOC  LOC occurs in fewer than 10% with sports-related concussion.* Consensus Statement on Concussion, Vienna, 2001 Emergency Emerg Med Pract. 2012;14(9):1-24. Consensus statement, 4th International Conference, Zurich, 2012
    15. 15.       Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow, which is reduced Activation of immune inflammatory response* Possible shear injury to vessels and neurons May create immediate neuronal depolarization followed by refractory period of no neural transmission J. Athl Train. 2001 Jul-Sep; 36(3): 228-235 *Phys Sportsmed. 2012 Nov;40(4):73-87
    16. 16.   Jordan et al found Apolipoprotein E (ApoE) E4 assoc w/ increased severity of chronic TBI (cTBI) in high-exposure boxers.* College athletes w/ ApoE promoter G-219T TT genotype may be at increased risk for having h/o concussions.** *JAMA. 1997;278(2):136-140. **Clin J Sport Med. 2008 Jan;18(1):10-7.
    17. 17.    National High School Federation Data, 20082010: 2.50 injuries/10,000 athlete exposures. CDC: During 2001-2005, an estimated 207,830 ED visits annually for concussions and other TBIs related to sports and recreational activities, with 65% of TBIs among children aged 5-18 years Increase in incidence  CDC: From 2001 to 2009, annual TBI-related ED visits increased significantly, from 153,375 to 248,418, with highest rates among males aged 10-19 years MMWR Morb Mortal Wkly Rep. 2011;60(39):1337-42. AJSM January 27, 2012 as doi:10
    18. 18.    Somatic: headache, nausea, vomiting, motor problems, fatigue, dizziness, visual disturbance, photophobia, phonophobia Affective: Irritability, depression, emotional lability, sleep disturbance, personality disturbances Cognitive: Confusion, disorientation, RTA, PTA, LOC, feeling “in a fog”, “zoned out”, vacant stare, inability to focus, decreased processing speed, drowsiness Modified from Herring et al, TPCC ’06
    19. 19.    ABCD, sideline tests (e.g., SCAT 2), rule out structural intracranial lesions Monitor for initial few hours following injury, or send emergently if change in behavior, worsening headache, vomiting, seizure, double vision, excessive drowsiness, or worsening symptoms No RTP on day of injury
    20. 20.      Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions King-Devick Test
    21. 21.     Basic neurological scale that quantifies level of consciousness Score ranges from 3 (unconscious) to 15 (alert and oriented) Most EMS protocols: GCS score < 14 should be transported to Level I or II trauma center Inverse relationship between GCS score and positive findings on CT
    22. 22.     Tests for eye saccade (quick, simultaneous movements of eyes in same direction) Uses charts of numbers Charts become increasingly difficult to read as space between numbers increases Patient’s speed and fluidity of reading used to derive score K-D Test
    23. 23.    Postural stability testing, assesses cognitive motor function Quantifiable, modified Romberg test – three 20second balance tests performed on firm and foam surfaces Postural instability: communication between three sensory systems either at central or peripheral level is lost Clinical J. Sports Med. 2001;11:182-190.
    24. 24.     Calculated for athlete>10 y/o Preseason baseline testing can be helpful. Calculated based on symptoms, physical signs, GCS, balance examination, coordination, orientation, immediate memory, concentration, delayed recall scores No cut-off value on SCAT 2 score Clin J Sport Med. 2005;15(2):48-55.
    25. 25.      At what venue are we today? Which half is it now? Who scored last in this match? What did you play last week? Did your team win the last game?
    26. 26.      Comprehensive history, physical assessment (e.g., cspine, obvious skull depressions, CSF rhinorrhea/otorrhea) Detailed neurological exam including Glasgow Coma Scale (GCS), mental status, cognitive functioning, gait and balance, pupillary reflex, cranial nerve testing Progression since time of injury (improvement or deterioration?) Is emergent neuroimaging indicated? Rule out/treat hypoxia, hypercarbia and hypotension (associated with poorer outcomes in TBI)
    27. 27.    1) Avoid CT scans in low risk patients based on validated decision rules 2) Avoid placing indwelling catheters in stable pts who can urinate on there own 3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first Choosing Wisely”® campaign during the ACEP13 annual meeting, Oct. 14-17
    28. 28.    Related to the burden, nature and duration of symptoms Modifiers (Zurich ’09) 1. Age 2. Prior h/o concussion 3. Learning disability 4. Headache/migraine history Other risk factors, h/o: neurosurgery, drug/alcohol use, anticoagulant/antiplatelet use, hemophilia
    29. 29.       Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a “lucid” interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine Arch Intern Med. 1998;158(15):1617-1624.
    30. 30.         Cervical spine injury Skull fracture Intracranial hemorrhage Seizures Post-concussion Syndrome (PCS) Second Impact Syndrome (SIS) Cognitive decline Dementia pugilistica* *Neurosurg Focus. 2012. 33(6):E5: 1-9.
    31. 31.     Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury J. Neurotrauma, 2006; 23:1201-1210.
    32. 32. CT/MRI     Whenever suspicion of intracerebral structural lesion exists 1. Prolonged disturbance of conscious state 2. Focal neurological deficit 3. Worsening symptoms CT/MRI typically interpreted as normal; symptoms more often reflect functional rather than structural disturbance Role of fMRI/PET
    33. 33.       Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of “concussion plan” evolving Neurosurgery. 2004; 54:1073-1078; discussion, 8-80.
    34. 34.     Endorsed as a "cornerstone" of concussion management by Vienna and Prague Consensuses. imPACT (Immediate Post-concussion Assessment and Cognitive Testing) Computer-based Compare baseline and post-injury scores
    35. 35.   Physical and cognitive rest until symptoms resolve, then graded program of exertion prior to medical clearance and RTP. Activities that require concentration and attention may delay recovery. Curr Sports Med Rep. 2004; 3:316-323 Consensus statement, 4th International Conference, Zurich, 2012
    36. 36.   All but one U.S. states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events. Refer to specialist for follow-up care and graduated RTP plan.
    37. 37. Rehabilitation Stage 1. Functional Exercise No activity Complete rest •imPACT testing 2. Light aerobic exercise No resistance 3. Sport-specific exercise No head impact 4. Non-contact Progressive resistance 5. Full contact Normal training 6. RTP Normal game play Consensus statement, 4th International Conference, Zurich, 2012.
    38. 38.    Management of sleep disturbance, anxiety, depression Management of headache, vomiting, dizziness Before RTP, the concussed athlete should not only be symptom free but avoiding any medications that may mask or modify the symptoms of concussion.
    39. 39.  May need additional management considerations  Symptoms, signs, sequelae, temporal, threshold  Age, co- and premorbidities, medication, behavior, type of sports Consensus statement 4th International Conference, Zurich, Nov. 2012.
    40. 40.  Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions  Monitors sports related cognitive sequelae  Takes 25 minutes to administer  Consists of six subtests measuring reaction time, object recognition, recall
    41. 41.    College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided 436 Columbia U football players over 11 seasons (2000-2011) 148 had at least one concussion prior to entering college Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013
    42. 42.  All 436 received baseline CRI’s before football started  Total of 647 CRI obtained  70 of the 436 athletes had a concussion Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013
    43. 43.  Median time between concussions and RTP was 10 days.  28 of the 70 concussed cleared to RTP had a decline in their CRI assessment by 0.5 units  This is clinically significant impairment identified by cognitive testing  Key Point- DON’T RUSH your players back, learn how to test for concussions appropriately, and follow the guidelines Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013
    44. 44.       Designed to incorporate and expand principles in previous consensuses (Vienna and Prague) Simple vs. complex eliminated Individualized RTP Differentiation of elite vs. non-elite RTP Modifiers Same-day RTP only in very specific situations for adult athlete Consensus statement, 4th International Conference, Zurich, 2012.
    45. 45.    Symptomatic athlete should not return to play, same-day RTP controversial, safest course of action: hold an athlete Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience. Additional considerations in RTP: 1. Severity of injury 2. Previous injury (no, severity, proximity) 3. Significant injury to minor blow 4. Age, sport, learning disabilities *Collaboration of ACSM, AMSSM, AOSSM, AAOS, AAFP, AOASM.
    46. 46.  Helmets and mouth guards 1. Injury rates similar between helmeted and nonhelmeted sports. 2. No helmet in any sports prevents concussion. 3. Mouth guards do not prevent concussion but prevent dental injury. BMJ. 2005; 330:281-283
    47. 47.           How many is too many? Influence of gender and genetics on injury risk, severity and outcome Pediatric injury and management paradigms Novel technique: testing for biochemical serum and CSF markers of brain injury Rehabilitation strategies (e.g., exercise therapy) Novel imaging modality: role of fMRI/DTI Long term outcomes (e.g., depression/suicide) On-field injury severity outcomes Concussion surveillance Protective factors
    48. 48. Source CSHB 15(JUD)
    49. 49.   Definition, epidemiology, causation, risks, and RTP guidelines All covered earlier
    50. 50.  Guidelines established by ASAA along with governing body of each school district to educate    Coaches Athletes Parents Guidelines include risks and standards of RTP
    51. 51.   School provides this information to parent/guardian of athletes under 18 Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
    52. 52.   Athlete removed from sporting event May not return to play w/o being cleared in writing by qualified person (QP) with certified training
    53. 53.    Health care provider licensed in the state or exempt from licensure Person acting under supervision who is licensed in the state Unpaid QP may not be held liable for civil damages resulting from act or emission of eval. unless found negligent or reckless in care
    54. 54.  School district not liable for injury or death caused by concussion by actions of QP if Action/inaction occurred during delivery of service by district or organization in compliance with AS 14.30.142  The organization is under contract to provide services  Before services the organization provided written verification of   a valid insurance policy  Compliance with protocol o prevention and reporting of concussions required in AS 14.30.142
    55. 55.   Previous slide can not be construed to impair or modify ability of a person to recover damages Youth organization means public/private organization that provides service to youth 18 years of age or younger
    56. 56. 62
    57. 57.   Roughly 12,000 new cases of SCI a year Sports-related events causing approximately 7.6% Semin Spine Surg 22:173-180 63
    58. 58.  Catastrophic injury- Sport injury that resulted in a brain or spinal cord injury or skull or spinal fracture  Classification    Fatal Serious Complete and incomplete neurological recovery National Center for Catastrophic Sport Injury Research
    59. 59. 65
    60. 60. 66
    61. 61. 67
    62. 62.     Buffalo Bills TE Fractured C3 and C4 on Sept. 9th 2007 Everett could fill nothing below his neck following impact He was told he would never walk again 68
    63. 63.  He started walking again on December 7th, 2007
    64. 64. 70
    65. 65. 71
    66. 66. Recall the hit by Jadeveon Clowney  How much time do you thinkCoaches spennt preparing and teaching him  He spent practicing basic fundamentals and situational football  Scouting teams spent studying their upcoming opponent and their style of play  ITS ALL ABOUT PREPAREDNESS
    67. 67.    Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher, more is on the line then just sporting events The will to win is important, but the will to prepare is vital. Joe Paterno
    68. 68. 74
    69. 69. J Athl Train. 2005;40(3):155–161 75
    70. 70.      Burners/Stringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease 76
    71. 71.    Transient sensory and/or motor loss involving arms and/or legs 2 mechanisms of injury Traction and compression Severity determined by amount of time that passes between loss of function and restoration of function Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 77
    72. 72. Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29 78
    73. 73.  Physical Exam      Test for muscle weakness: C4-C5 deltoids, C5-C6 triceps, C6-C7 triceps. Test for sensory loss: over biceps (C5), thumb (C 6), and long fingers (C7). Check reflexs and Spurling’s sign Tx- Rest until strength and sensation returns RTP: Allowed to return when they have normal neuro exam and full cervical ROM Netters Sports Med, copyright 2010
    74. 74.   The most common cervical injury seen in sports are stingers and burners. True or False 81
    75. 75.     Most common injury No neurological or osseous injury Cervical xray needed to r/o possible fracture Pts return to play when pain is gone, ROM is full, and strength is normal Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 82
    76. 76.  C1-Jefferson fracture Traumatic burst fracture from axial load  Presents with neck pain and likely neurologic injury  Palpate for tendeness, check ROM  Plain films/CT are diagnostic  Tx: unstable injury, see spine surgeon  RTP: not likely  Netters Sports Med, copyright 2010 84
    77. 77.  C2: Hangman’s Fracture Traumatic spondy from axial load and extension  Presents with neck pain, instability  Palpate for tendeness, check ROM  Lateral films/CT are diagnostic  Tx: immobilize head, see spine specialists  RTP: not likely  Netters Sports Med, copyright 2010
    78. 78.  Burst fractures Traumatic fractures of vertebral body from axial load with possible retropulsion of fragments into the cord  Presentation is similar  Palpate for tenderness but loss of sensation or paralysis requires trauma management which is to be discussed  Tx: immobilize head, ABC’s, spine board, transport to nearest ER  RTP: to be discussed  Netters Sports Med, copyright 2010
    79. 79.      Loss of Lordosis Cervical Stenosis Narrowing of disc space Preexisting bony or ligamentous injury seen on studies Player should not be allowed to RTP Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
    80. 80.   Measuring canal width accurately and taken in all factors that may change canal width is difficult Torg Ratio: midsagittal diameter to the AP diameter of corresponding vertebral body -1.0 is normal, 0.8 consider stenotic, most use 0.7  General consensus is that normal width from C3C7 be above 15mm and anything below 13mm AP dimension is stenotic Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29 Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 88
    81. 81. X-ray MRI
    82. 82.   Herzog* found that many athletes had larger than normal vertebral body width Blackley** demonstrated that measurement of the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account:     the size and shape of the spinal cord, the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy Spine. 1991 Jun;16(6 Suppl):S178-86.* Spine. 2003 Jun;28(12):1263-8. **
    83. 83. NFL football players with stenosis  Jermichael Finley  Jarvis Jones  David Wilson  Chris Berman  Archie Manning
    84. 84.   Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation Best determined with CT, MRI, or myelography Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 92
    85. 85.    Far less common than lumbar herniation Usually only affects older athletes Two types: hard and soft Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29 94
    86. 86.    Tx: nonoperative unless myelopathy or progressive neurolgic deficit present Nonoperative tx includes rest, ice, NSAIDS, immobilization, cervical traction, and therapeutic injections as needed RTP: when pt regains full function without signs of neurologic complications Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29 95
    87. 87. 96
    88. 88. 97
    89. 89.    Every patient suspected of cervical spine injury needs complete physical examination Immobilize head and neck Assess ABC’s Semin Spine Surg 22:173-180 98
    90. 90.  Careful attention should be directed towards -neurological complaints -head trauma -headaches -mental status changes -midline spinal pain/tenderness Semin Spine Surg 22:173-180 99
    91. 91.  Following head and neck examination, careful motor and sensory exam of extremities should be performed Semin Spine Surg 22:173-180 100
    92. 92. Semin Spine Surg 22:173-180 101
    93. 93.    Lift and slide maneuver used Causes less motion of C-spine then rolling pt DOCTOR should be head of injured athlete Journal of Athletic Training 2009;44(3):306–331
    94. 94. 103
    95. 95.      Team physician should use multiple assistants to position pt DOC at head Minimum of 4 with doc controlling CS, one the torso, one the hips, and one the legs Log rolling is initiated by team doc controlling head and cervical spine Pt should be rolled directly onto spine board Journal of Athletic Training 2009;44(3):306–331
    96. 96.   Key to successfully maneuvering the injured pt…. Practice, practice, practice. Don’t let the injury be the first time you try to attempt this
    97. 97.     Only remove equipment that may obstruct breathing Tools and techniques that cause least amount of torque should be used Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually Journal of Athletic Training 2009;44(3):306–331
    98. 98.    Helmeted pts are difficult to collar Once on spine board, pt can have sandbags or foam blocks taped to board for immobilization of c-spine Vacuum immobilizer can also be used Journal of Athletic Training 2009;44(3):306–331 107
    99. 99.     Team physician should accompany the injured athlete Provides Continuity of care Provides ED doc accurate clinical information regarding pt and injury Allows the sports medicine professional to assist emergency department personnel during equipment removal Journal of Athletic Training 2009;44(3):306–331
    100. 100.  Once pt is stable and transferred to the hospital, standard diagnostic evaluation of the C-spine should be performed  AP, lateral, and odontoid radiographs of entire cervical spine including occiput/C1 and C7/T1 junctions should be obtained Semin Spine Surg 22:173-180 109
    101. 101.   CT use continues to expand with cervical neck injuries A diagnostic study showed that CT had higher sensitivity, higher specificity, and higher positive predictive value over plain films in viewing injury Semin Spine Surg 22:173-180 110
    102. 102.  MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present Semin Spine Surg 22:173-180 111
    103. 103. EBMedicine.net • April 2009
    104. 104.      Dependent of context of injury Known risk factors Number of previous injuries Pressure from player, coaches, and family members Dependent on each individual pt Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 113
    105. 105.  Generally speaking, athletes can RTP when they are: asymptomatic,  have full ROM,  regain preinjury strength,  imaging shows no evidence of functional stenosis of spinal column  Normal lordotic curve with no evidence of instability  Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 114
    106. 106.      Neurological findings of cervical myelopathy Continued discomfort, decreased ROM Following C1-C2 fusion, cervical laminectomy, or three level anterior or posterior cervical fusion Increased ligamentous laxiety (>11degrees) Spear Tackler’s spine Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 115
    107. 107.      RTP following injury is complicated and pt specific No universally accepted RTP criteria Communication is essential from time of injury to recovery Begins with staff who have educated themselves on what to do when they encounter these types of injuries Rehearse correct protocol Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7 116
    108. 108.      USA football was established in 2002 by the NFL and the NFL Players Association It’s a nonprofit program The program was developed to change the culture of the sport and the way it has been played with an emphasis on safety There is a direct correlation between proper technique and decreased injury (this goes for all sports) Millions of dollars have been donated Headsupfootball.com 117
    109. 109. 118
    110. 110. David Carfagno, D.O., C.A.Q.S.M.    Board Certifications: Internal Medicine, Sports Medicine (CAQ), Ringside Medicine (ABRM) Medical Director, Ironman Arizona Team physician, USA Boxing and ATP/WTA professional tennis 10133 N. 92nd Street, Suite 102 Scottsdale, AZ 85258 Office – 480.664.4615 Email – david.carfagno@gmail.com

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