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Update on Concussion Felicia Gliksman , DO, MPH Pediatric Neurology
Joseph M. Sanzari Children’s Hospital Hackensack University Medical Center Assistant Professor Seton Hall University-Hackensack Meridian SOM
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Objectives -Incidence of concussion -biomechanism of concussion
-signs and symptoms of concussion -sideline evaluation of concussion -possible short/long term effects -when is further specialist evaluation needed? -recommended testing/treatment/management AAN, CDC, Zurich guidelines and recommendations
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AKA: mild traumatic brain injury
Concussion Definition (5th International Consensus Conference on Concussion in Sport) AKA: mild traumatic brain injury clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness (LOC).
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Features of Concussion
May be caused by blow to head, face, neck, or elsewhere on body with an impulsive force transmitted to the head Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours. May result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies
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Features of Concussion
Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. Clinical signs and symptoms cannot be explained by drugs, alcohol, or medications, or other injuries such as: cervical injuries peripheral vestibular dysfunction other comorbidities: psych, co-existing medical conditions
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Biomechanics Possible mechanisms of injury include:
during trauma, the brain moves, twists, and experiences forces that cause movement of brain matter. This sudden movement or direct force applied to the head can set the brain tissue in motion even though the brain is well protected in the skull This motion squeezes, stretches and sometimes tears the neural cells. The stretching and squeezing of brain cells from these forces can change how the brain processes information.
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Biomechanics All of the different mechanisms may result in biochemical changes related to perfusion, energy demand, and utilization at the site of injury and are entirely well understood Although the stretching and swelling of the axons may seem relatively minor or microscopic, the impact on the brain’s neurological circuits can be significant. Even a “mild” injury can result in significant physiological damage and cognitive deficits.
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K+ Calcium Glucose Cerebral Blood Flow 2 6 12 20 30 24 3 10 minutes
(Giza & Hovda, 2001) 2 6 12 20 30 24 3 10 minutes hours days 500 400 300 200 50 100 % of normal Calcium K+ Glucose Glutamate Cerebral Blood Flow UCLA Brain Injury Research Center
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Physical forces disrupts brain function
Cascade for ionic, metabolic, and pathophysiological events Microscopic axonal injury Increased energy demand Decreased cerebral blood flow Mitochondrial dysfunction decreased energy supply
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Brain Metabolism following mTBI
Proton magnetic resonance spectroscopy Recovery of neuronal metabolism marker in 40 athletes following concussion N-acetylaspartate/creatine- containing compounds ratio Concussive head injury window of brain vulnerability from cellular energetic metabolism impairment Symptom recovering 3-15 days. Normalized metabolism by 30 days Brain 2010;133(11):
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Concussion Recovery
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Concussion Recovery Timeline
Typical Concussion Repeat Injury DYSFUNCTION Resolution Onset TIME
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Signs of concussion Features of concussion frequently observed
− Vacant stare − Delayed verbal and motor responses − Confusion and inability to focus attention − Disorientation − Slurred or incoherent speech − Gross observable incoordination − Emotions out of proportion to circumstances − Memory deficits − Any period of loss of consciousness
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Symptoms of concussion
− Early (minutes and hours) − Headache − Dizziness or vertigo − Lack of awareness of surroundings − Nausea or vomiting Late (days to weeks): − Persistent low grade headache − Light-headedness − Poor attention and concentration − Memory dysfunction − Easy fatigability − Irritability and low frustration tolerance − Intolerance of bright lights or difficulty focusing vision − Intolerance of loud noises, sometimes ringing in the ears − Anxiety and/or depressed mood − Sleep disturbance
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National TBI Estimates
In 2013, about 2.8 million emergency department (ED) visits, hospitalizations, or deaths were associated with TBI—either alone or in combination with other injuries—in the United States. TBI contributed to the deaths of more than 50,000 people. 30% of all injury deaths In 2012, an estimated 329,290 children (age 19 or younger) were treated in U.S. EDs for sports and recreation-related injuries that included a diagnosis of concussion or TBI. from rate of ED visits for sports and red-related injuries dx with concussion or TBI more than doubled
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TBI Concussions or other forms of mild TBI account for about 75% of TBIs that occur each year Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. From , TBI related ED visits increased by 47%, hospitalization rates decreased 2.5% and death rates decreased by 5%. CDC and Prevention estimates that 300,000 concussions are sustained during sports-related activity in the United States, and more than 62,000 concussions are sustained each year in high-school contact sports
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Increasing incidence of sports-related concussion
Due to increase number of young athletes Due to increase awareness and reporting of concussions Variability in care provider experience and training, coupled with an explosion of published reports related to sports concussion and mTBI, has led to some uncertainty and inconsistency in the management of these injuries.
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Epidemiology: Boys Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med ;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755
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Epidemiology: Girls Sports
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755
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Concussion Epidemiology
Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755
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Risk Factor for Sports Concussions
Increased Risk of Concussion Prolonged Recovery Past concussion Female athletes Certain sports, positions and individual playing styles Number, severity and duration of symptoms H/o migraines, depression, mood disorders, or anxiety, and developmental disorders (learning disabilities, ADHD) Youth Harmon KG, et al. Br J Sports Med 2013;47:15–26
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How to minimize the risk of concussion through primary prevention
Teach safe techniques in practice and play (coaches, AT) Encourage recognition and reporting of concussion symptoms Be aware that injuries are more common in younger athletes Use available assessment tools (sideline, office) Monitor developments at advanced levels of play and legislative efforts Head and spine injury prevention programs
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A PLAYER TAKES A HIT TO THE HEAD...
...ON SITE/SIDELINE EVALUATION WHEN A CONCUSSION IS SUSPECTED...
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Sideline testing Various tools
Sport Concussion Assessment Tool 5 ([SCAT5] includes SAC, BESS, others). Cannot be performed correctly under 10 minutes Standardized Assessment of Concussion (SAC) Symptom Assessment Balance Error Scoring System (BESS) Domains that may add to the clinical utility of the SCAT tool include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening.
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SCAT5 A standardized method of evaluating injured athletes for concussion and can be used in athletes aged from 10 years and older. Assessment Includes: Symptoms: 22 possible Cognitive & Physical Assessment LOC? Glasgow coma scale: eye, verbal, motor Orientation: Month, Date, Day of the week, year, time? Immediate Memory recall: 5 word recall: (elbow, apple, carpet, saddle, bubble) Concentration: Repeat Digits Backwards: , , Months of the year in reverse order Balance Coordination *Now available to download as an app onto a smart phone.
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Balance Error Scoring System (BESS)
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Medical Workup of concussion
Neurologic Examination Mental status Cranial nerves (EOM, pupillary response etc) Motor: strength/weakness DTRs Cerebellar/Balance (FNF, Romberg) Sensation
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Common with Concussion May Indicate more Serious injury
Mental Status: may be impaired Balance: Impaired tandem gait or single leg balance, abnormal BESS CN: nystagmus, saccades Strength: Normal, symmetric DTR: normal FTN: may be slightly abnormal GAIT: tandem gait my be ataxic, casual gait should be normal. Mental Status: significantly impaired Balance: Romberg, postural instability CN: unequal or fixed pupils, visual field deficit, abnormal EOM Strength: asymmetric, focal weakness DTR: hyper-reflexia, Babinski, clonus, FTN: uncoordination GAIT: ataxic
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Red Flags for ED referral / Urgent work up
Glascow Coma Score < 14 Concern for intracranial process Evidence of a skull fracture (bruising under eyes, behind ears, or swelling of the head) Concern symptoms are not related to recent minor head trauma Severe or progressively worsening headache Seizure activity Unusual behavior Lethargy Unsteady casual gait/ataxia Slurred speech Weakness or numbness in extremities Focal neurologic examination CLIN PEDIATR October 2015 vol. 54no. 11
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If abnormal neurological exam…
May include: CT or MRI scanning Recommended in all instances where headache or other associated symptoms worsen or persist longer than one week. should not be used to diagnose sport-related concussion but might be obtained to rule out more serious TBI such as an intracranial hemorrhage in athletes with a suspected concussion who have loss of consciousness, posttraumatic amnesia, persistently altered mental status (Glasgow Coma Scale <15), focal neurologic deficit, evidence of skull fracture on examination, or signs of clinical deterioration PECARN algorithm Terminating the season for player is mandated by any abnormality on CT or MRI scan (brain swelling, contusion, bleed etc) CT imaging and Neurosurgical evaluation or transfer to a trauma center Prolonged unconsciousness, persistent mental status alterations, worsening postconcussion symptoms, or abnormalities on neurologic examination
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NeuroImaging CT MRI Not recommended for routine concussion evaluation
Sensitive for skull fracture and intracranial hemorrhage Test of choice in first hours after injury Will not rule out chronic subdural or neurobehavioral dysfunction Not recommended for routine concussion evaluation More sensitive for cerebral contusion, petechial hemorrhage, white matter injury, posterior fossa abnormalities Gradient Echo and perfusion and diffusion tensor imaging may detect white matter injury better but clinical usefulness is not established. Ataxia is best evaluated with MRI even acutely.
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Secondary Conditions Associated with Concussions
Intracranial Hemorrhage Skull Fracture Epidural Hemorrhage Subdural Hemorrhage Intracerebral Hemorrhage Cerebral Hyperemia Cerebral Edema Seizures Migraine Headaches
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Intracranial Hemorrhage
Intracranial bleeding Venous bleeding Slow, insidious onset Arterial bleeding S/S apparent within a few hours
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Intracranial Hemorrhage
Early S/S Severe head pains Dizziness Nausea Unequal pupil sizes Sleepiness Severe S/S Deteriorating consciousness Neck rigidity Slow pulse Slow respiration Convulsions
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Epidural Hemorrhage A blow to the head causes a tear in one of the arteries of in the dural membrane that covers the brain Hematoma forms extremely fast Within 10 – 20 minutes after injury Requires surgery to relieve the pressure created by the hematoma Death or permanent disability may result
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Subdural Hemorrhage A blow to the head causes a tear in one of the veins located between the dura mater and the brain Hematoma forms slowly S/S may not be appear until hours after injury Commonly occurs following a contrecoup injury May or may not require surgery
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Cerebral Hyperemia Vasodilation of cerebral blood vessels following a head/brain injury Causes an increase in intracranial blood pressure Develops within minutes after the injury S/S: headache, vomiting, sleepiness S/S usually resolve within 12 hours after the injury
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Cerebral Edema Localized swelling of the brain at the injury site
Develops within 12 hours after the injury S/S: headache, seizures (occasionally) Cerebral edema may remain for as long as 2 weeks following the injury
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Intracerebral Hemorrhage
A blow to the head may cause bleeding within the brain itself Usually results due to a compressive force applied to the brain Rapid deterioration in neurological function Requires immediate hospitalization
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Axon Sports (playing cards test) Concussion vital signs
Neurocognitive testing ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) What is available? ImPACT (5-11yo, 12+) Axon Sports (playing cards test) Concussion vital signs Automated Neuropsychological Assessment Metrics ([ANAM] primarily military) HeadMinder Formal pencil and paper testing with neuropsychologists
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Issues with available tests
Standard for Assessment How often? Testing while symptomatic? “We suggest initial evaluation 24–72 hours after injury. Consult a physician for interpretation of ImPACT test results…second post-injury test should be administered 1–2 weeks after the initial post-injury test. We strongly discourage testing more than once a week.” Baseline vs No Baseline Cost Who will interpret?
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Neuropsychological testing
May be a part of a comprehensive concussion evaluation program May help identify the ‘not so forthcoming’ athlete For more concrete and specific neurocognitive evaluation, especially when considering significant or prolonged school adjustments → involve neuropsychologist for more formal testing can be used as a starting point for a plan of rehabilitation. It can assist brain injury professionals in identifying specific cognitive areas that have been damaged, as well as those areas still intact. Used as basis for CBT
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Other testing??? “Advanced neuroimaging, fluid biomarkers, and genetic testing are important research tools but require further validation to determine clinical utility in evaluation of SRC” “
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Assessments Predict length of recovery.
DO NOT- Predict length of recovery. Provide prognosis for future problems. Act as the sole determining factor for return to play. Act as a red light/green light.
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Putting it all together
Same assessments that are done on the field may not be as helpful in the office SCAT5―“S” is for “Sideline” Symptom score checklists Neurological examination Concussion history Balance assessments Most helpful first 3 days Vestibular system assessments School difficulties
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Outcomes TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions. Thinking (i.e., memory and reasoning); Sensation (i.e., touch, taste, and smell); Language (i.e., communication, expression, and understanding); and Emotion (i.e., depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).
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Outcomes TBI can also cause epilepsy
Increase the risk of Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age. Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.
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Outcomes A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death =second impact syndrome
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Outcomes Photo courtesy of Boston University, McKee Lab
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Preseason: concussion policy
Prevention in Sports Preseason: concussion policy players sign “concussion contract” trainers and coaches take mandatory concussion training course Action plan if concussion occurs: remove from play until evaluated by healthcare professional Inform the athlete’s parents or guardians about the possible concussion and give them the fact sheet on concussion. Educate coaches, athletes, parents Monitor the health of the athletes
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Prevention Safety first
Safe playing techniques, good sportsmanship, protective equipment Teach athletes it’s not smart to play with a concussion. Rest is key wrongly believe that it shows strength and courage to play injured. Discourage others from pressuring injured athletes to play. Don’t let the athlete convince you that they’re “just fine.”
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Prevention Prevent long-term problems.
If an athlete has a concussion, their brain needs time to heal. No return to play until cleared by health care professional Work closely with league or school officials. Be sure that appropriate individuals are available for injury assessment and referrals for further medical care
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Consensus Statement on Period of Rest
There is currently insufficient evidence that prescribing complete rest achieves outcome objectives. After a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms). It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study.
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Sleep Sleep is commonly disrupted with a concussion Naps are fine as long as it does not disrupt sleep Educate patient and family on sleep hygiene if not improving Education/Communication: Provide anticipatory guidance and concussion education Educate patient and family on avoiding symptom exacerbation Provide letter to school documenting injury, restrictions, and accommodations Close follow up until full recovery. Nutrition Encourage adequate fluid intake (athletes are often only used to drinking water during practice) Dehydration and poor nutrition can mimic many concussive symptoms. Mood Monitor for signs of depression (particularly in athletes with prolonged recovery) Encourage counseling/treatment if present
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Recovery May be slow!!! Majority (80-90%) resolve in short (7-10 day) period May take longer in children and adolescents (4 weeks!) Everyone “feels fine” Always ask: 1.“On a scale of 0 to 100%, how do you feel?” 2.“what makes you not 100%?” 3. Symptom Checklist – SCAT5 (only good for first few days)
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Recovery May need time away from school, untimed testing, less homework, modified school day Avoid doing anything that could cause another blow or jolt to the head. Reaction time slower Should not drive, ride a bike, etc Write things down if having a hard time remembering. May need help to re-learn skills that were lost. May need CBT (cognitive behavior therapy)
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Possible recommendations
No significant classroom or standardized testing at this time. Check for the return of symptoms when doing activities that require a lot of attention or concentration. Take rest breaks during the day as needed. Request meeting of 504 or School Management Team to discuss this plan and needed supports. Refer to: Neurosurgery/Neurology/Sports Medicine/Physiatrist/Psychiatrist/ Refer for neuropsychological testing
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RETURN TO LEARN BEFORE RETURN TO PLAY
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Return to Play Do not allow to return to game/practice if suspected or diagnosed concussion on day of injury (need to wait 24 hours) Do not allow return to play until asymptomatic at rest Not a defined, set time frame (ie, 7 days, 2 weeks, etc.) but need to be symptom-free from at least a week (and off meds!) Progressive, step-wise approach to return to play Full return to school first
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Criteria to Return to Play
Normal neurological function Normal vasomotor functions Normal balance Free of headaches Free of lightheadedness Free of dizziness Free of seizures
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Recovery SRCs can result in diverse symptoms and problems,
can be associated with concurrent injury to the cervical spine and peripheral vestibular system. The literature has not evaluated early interventions, as most individuals recover in 10–14 days. A variety of treatments may be required for ongoing or persistent symptoms and impairments following injury. The data support interventions including psychological, cervical and vestibular rehabilitation.
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Recovery Closely monitored active rehabilitation programs- involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery. A collaborative approach to treatment, including controlled cognitive stress, pharmacological treatment, and school accommodations, may be beneficial.
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Post-concussion syndrome
Failure of normal clinical recovery symptoms that persist beyond expected time frames >10–14 days in adults >4 weeks in children
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Treatment Treatment should be individualized and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of: a an individualized symptom-limited aerobic exercise program in patients with persistent post-concussive symptoms associated with autonomic instability or physical deconditioning, and b a targeted physical therapy program in patients with cervical spine or vestibular dysfunction c a collaborative approach including cognitive behavioral therapy to deal with any persistent mood or behavioral issues.
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Active Recovery- 4 Steps
Active treatment does not mean players immediately return to play. To ensure the best recovery, post-concussion, activity should be: Supervised. Activity should be guided by an expert. Low-level. The level of exertion should vary from person to person, but overall, activity should use less than 60 percent of the body's total exertion. Progressive. People should start recovery by engaging in a small amount of activity and increase activity as symptoms allow. Individually tailored. Adapt therapy to suit individual symptoms and needs. ex: person who has dizziness and vertigo after a concussion should engage in balance-based exercises. Patients who have trouble moving their eyes should be prescribed vision therapy, with exercises and tools designed to improve focusing and other eye functions. Although new research supports the benefit of this protocol, the experts say more research is needed, including clinical trials, to build on these findings.
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Management of Symptoms
No evidence for efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDs) or other medication in management of sport concussion May be helpful for symptoms of post-concussive symptoms (typically all off-label uses) Sleep aids, attention-deficit disorder (ADD) medications, non-conventional headache medications, antidepressives Athlete must be off medication and symptom-free before return to sports “Where pharmacological therapy may be begun during the management of an SRC, the decision to return to play while still on such medication must be considered carefully by the treating clinician.”
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Withdrawal from season/sport
No magic number Consider for prolonged symptoms, multiple concussions Involve someone experienced in sport concussion management
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Graded Return To Play Protocol
Rehabilitation Stage Functional Exercise at each stage 1. No activity Complete physical and cognitive rest (stage may be the longest 2. Light aerobic activity Walk, swim, stationary bike, keep intensity<70% of max HR, no resistance training 3.Sport- specific exercise Skating drill (ice hockey), running (soccer), no head impact activities 4. Non-contact training skills Progression to more complex training drills. May start resistance training 5. full-contact practice After medical clearance, participate in normal training activities 6. Return to play Normal game play
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Each stage is AT LEAST 24 HOURS
Therefore should take >5 days to complete
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“Modifiers” that can prolong recovery
Factors Modifiers Symptoms number, duration >10days, severity Signs LOC >1min, amnesia Sequelae Concussive convulsions Temporal Frequency (repeated conc), timing (close in time), “recency” Threshold Repeated conc. Occurring with progressively less impact or slower recovery after each successive conc Age <18yo Comorbidity/premorbity Migraine, depression, other, ADHD, LD, sleep disorder Medication Psychoactive drugs, anticoag Behavior Dangerous style of play Sport High-risk, contact/collision/high sporting level
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Where to get resources
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Available Tools
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Take home points for players
Don’t hide it Report it Take time to recover It’s best to miss one game than the whole season
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Facts on Helmets Only 40% of cyclists wear helmets
Bicycle helmets are 85% effective in reducing traumatic brain injuries Only 40% of cyclists wear helmets
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There is no such thing as a concussion proof helmet
“The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time”.
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Any Questions???
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