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Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines James W. Bryan IV, MD Little Rock, AR.

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Presentation on theme: "Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines James W. Bryan IV, MD Little Rock, AR."— Presentation transcript:

1 Concussion in Sports: A review of the AMSSM Position Statement and AAN Guidelines James W. Bryan IV, MD Little Rock, AR

2 Concussion is a brain injury and is defined a a complex pathophysiological process affection the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive injury include: Concussion defined Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

3 Caused by either 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 neurological function that resolves spontaneously Symptoms and signs may evolve over minutes to hours May result in neuropathological changes Reflect a functional disturbance rather than a structural injury No abnormalities are typically seen on standard neuroimaging studies Concussion defined: common features Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

4 Concussion defined: Neurometabolic cascade Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

5 Concussion defined: Neurometabolic cascade Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

6 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 In some cases the symptoms may be prolonged The majority of cases resolve in a 7-10 day period The recovery time frame may be longer in children and adolescents Concussion defined: common features Consensus Statement on Concussion in Sport: The 4th International Conference, Nov 2012, Zurich

7 *First concussion symposium: Vienna, International Ice Hockey Association, FIFA (soccer), and the International Olympic Committee *Second symposium: Prague, Sideline assessment tool (SCAT) *Third symposium: Zurich, SCAT revised (SCAT 2) -Designed to follow US NIH consensus criteria *Each produced a summary-and-agreement statement on concussion in sport. Background

8 The Fourth Conference: Zurich 2012 Used the same format as previously: 32 international experts 2 full days of new research presentations Extensive structured discussion Drafted a consensus paper, edited until all were in agreement Updated version of SCAT (SCAT 3)-with 3 distinct tools Final drafting of 12 critical review papers, co-published in multiple journals Background

9 British Journal of Sports Medicine April 2013; 47: Panel included Stanley Herring and Margot Patukian from AMSSM

10 Kimberly G Harmon, Jonathan A Drezner, Matthew Gammons, Kevin M Guskiewicz*, Mark Halstead, Stanley A Herring, Jeffrey S Kutcher*, Andrea Pana, Margot Putukian*, William O Roberts Endorsed by the National Trainers Athletic Association and the American College of Sports Medicine Press release December 13, 2012 British Journal of Sports Medicine April 2013, 47, Clinical Journal of Sport Medicine Jan 2013, 23 issue 1, 1-18 [Asterisk indicates Zurich 2012 participants] American Medical Society for Sports Medicine position statement: concussion in sport

11 To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion To establish the level of evidence, knowledge gaps and areas requiring additional research AMSSM Position Statement: concussion in sport --Purpose--

12 While directed toward sports physicians, it may help other health care providers in the care of concussed patients Care is ideally performed those with specific training and experiencenot dictated by specialty Sports physicians are trained to provide care from the time of injury to return-to-play AMSSM Position Statement: concussion in sport --Importance--

13 Both human and animal studies support the concept of postconcussion vulnerability A second blow sustained before recovery results in worsening metabolic changes within the neuron This concept is distinct from second impact syndrome The concussed brain is less responsive to usual neuron activation Prolonged dysfunction may result from premature cognitive activity or vigorous physical activity Pathophysiology AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

14 3.8 million sports related concussions annually in the USA Estimated that up to 50% are unreported or unrecognized Concussions occur in all sports Football, hockey, rugby, soccer, and basketball Incidence AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

15 History of previous concussion The greater the number, severity, and duration of symptoms predict a prolonged recovery In sports with similar rules, female athletes experience a higher incidence of concussion Certain positions within a sport present a greater exposure risk Risk factors for sports-related concussion AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

16 Pre-injury mental health conditions complicate the diagnosis and management of concussion Youth athletes have additional considerations More prolonged recovery Greater susceptibility to concussion accompanied by catastrophic injury Risk factors for sports-related concussion AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

17 Concussion is a clinical diagnosis Diagnosis is ideally made by a healthcare provider who is familiar with the athlete knowledgeable in the recognition and evaluation of concussion Graded symptoms checklists [e.g. SCAT3] Objective tool for assessing a variety of symptoms Useful in tracking the severity of symptoms over serial exams Diagnosis of concussion AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

18 Standardized assessment tools Can provide a helpful structure in evaluation Limited valuation of the assessment tools is available Examples include The Maddocks Questions Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS, modified BESS) SCAT2, SCAT3, SCAT3 Child, CRT (lay person) NFL Sideline Concussion Assessment Tool Glasgow Coma Score Diagnosis of concussion AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

19 Diagnosis of concussion SCAT3 SCAT3-CHILD Pocket Concussion Recognition Tool

20 NP testing is an objective measure of brain-behavior relationships More sensitive for subtle cognitive impairment than clinical exam Should be used as part of a comprehensive management strategy and not relied upon alone Ideal timing, frequency and type of NP testing is not established Unknown if NP testing helps prevent recurrent concussion, catastrophic injury, or long-term complications Neuropsychological testing AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

21 Paper and pencil NP tests Can be more comprehensive Can test different domains and assess for other conditions which may mask or complicate the assessment of concussion May provide added value to assess cognitive function and recovery Helpful in the management of patients with prolonged symptoms and complicated courses Neuropsychological testing AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

22 Computerized NP testing should be interpreted by providers trained and familiar with The type of the test The individual test limitations The reliable change index The baseline variability False-positive and false-negative rates Neuropsychological testing AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

23 96118 Neuropsychological testing, interpretation and reporting per hour by a psychologist ($92/unit) Neuropsychological testing per hour by a technician ($74/unit) Neuropsychological testing by a computer, including time for the psychologists interpretation and reporting ($103) Formal NP testing, scoring, interpretation and conference may require up to 4-8 hours Neuropsychological testing CPT ® codes accessed 5/14/13

24 Students will require a period of cognitive rest May require academic accommodations Reduced workload Extended time to complete tests Protections afforded under Section 504 / ADA Return to class AMSSM Position Statement: concussion in sport. Harmon KG, Drezner JA, Gammons M, et al. BJSM 2013,47, 15-26

25 Education Arkansas ACT 1435 Sen. David Sanders/SB1158 Rep. Gary Deffenbaugh Signed April 23, 2013 Requires the State Department of Health to develop concussion protocols to all youth athletes involved in youth athletic activities Based on existing AAA guidelines for sanctioned sports in grades 7-12 enacted in 2012 As of April 2013, 47 states have enacted legislation

26 Education Heads Up Tool Kit for Youth Sports CDC Coaches, athletes and parents Online videos Fact sheets, wallet cards NFLEvolution.com Promotion of the Lystedt Laws three tenets Inform and educate youth athletes, their parents and guardians and require them to sign a concussion information form Removal of a youth athlete who appears to have suffered a concussion from play or practice at the time of the suspected concussion Requiring a youth athlete to be cleared by a licensed health care professional trained the evaluation and management of concussions before returning to play or practice.

27 Education AMSSM 2014 AMSSM 23rd Annual Meeting April 5-9, 2014 Hyatt Regency New Orleans New Orleans, LA Advance Team Physicians Course Cosmopolitan Hotel Las Vegas, NV December 5-8, AAFP Scientific Assembly: Concussion and Minimal Brain Injury Thursday, September 26, 2013, San Diego Convention Center

28 Summary of evidence-based guideline update: Evaluation and management of concussion in sports Christopher C. Giza, MD, Jeffrey S. Kutcher, MD, Stephen Ashwal, MD, FAAN, Jeffrey Barth, PhD, Thomas S.D. Getchius, Gerard A. Gioia, PhD, Gary S. Gronseth, MD, FAAN, Kevin Guskiewicz, PhD, ATC, Steven Mandel, MD, FAAN, Geoffrey Manley, MD, PhD, Douglas B. McKeag, MD, MS, David J. Thurman, MD, FAAN and Ross Zafonte, DO Neurology; Published online before print March 18, 2013 Objective: To update the 1997 AAN practice parameter regarding sports concussion focusing on 4 questions

29 AAN Guideline Update: 4 questions 1. What factors affect risk? 2a.What diagnostic tools identify those with concussion and (2b)those at increased risk? 3.What clinical factors identify those at increased risk for severe/ prolonged early impairments, neurological catastrophe, recurrent concussion, or chronic impairment? 4.What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? Neurology, Mar 18, 2013

30 AAN Concussion Guidelines Preparticipation Counseling Number and type of previous concussions Symptoms and duration Other neurologic conditions (e.g. seizures) Assessment Post-Concussion Symptom Scale or Graded Symptom Checklist Standardized Assessment of Concussion Neuropsychological testing Balance Error Scoring System Sensory Organization Test Combination of measures Neurology, Mar 18, 2013

31 AAN Concussion Guidelines Management of suspected concussion Train inexperienced licensed HCPs to use a standardized assessment tool Use standardized assessment tools Warm handoff from sideline HCP and clinical HCP Obtain baseline scores Remove athlete from play No RTP without clearance by licensed HCP Dont perform imaging to make concussion diagnosis Do perform imaging to rule out suspected TBI Neurology, Mar 18, 2013

32 No RTP until resolved & asymptomatic Conservative approach for youth and high school Assessment tools specific for preteens Consider NP testing Individualize management plan No indication for absolute rest AAN Concussion Guidelines: DIAGNOSED CONCUSSION Neurology, Mar 18, 2013

33 AAN Concussion Guidelines: Multiple concussions Professional athletes: Refer for neurologic and neuropsychological evaluation Contact-sports with chronic impairment: RETIREMENT Amateur athletes: Formal neurologic/cognitive assessment Offer risk factor counseling Neurology, Mar 18, 2013

34 Numerous organizations have published guidelines regarding the management of sports-related concussions Emerging consensus that education is a key factor Treatment considerations differ slightly between youth, adolescent, and adult/professional athletes Inconclusive data regarding long-term risk Conclusions


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