1. Sport Medicine Centre Dr. Victor Lun, MD, CCFP, Dip Sport Med Concussions in Sport

2. Sport Medicine Centre Outline Mechanism of Injury Mechanism of Injury Concussion Guidelines Concussion Guidelines Clinical Evaluation Clinical Evaluation Return to Play Management Return to Play Management Concussion Prevention Concussion Prevention Recurrent Concussions Recurrent Concussions

3. Sport Medicine Centre Concussion - Mechanisms Rapid deceleration Rapid deceleration Extension-flexion movement Extension-flexion movement Rotation Rotation Snowboarding – fall on the back of the head Snowboarding – fall on the back of the head

4. Sport Medicine Centre Concussion - Mechanisms The brain floats in cerebrospinal fluid and is protected by the skull. The brain floats in cerebrospinal fluid and is protected by the skull. The brain will rotate and twist inside the skull which can result in localized and diffuse damage The brain will rotate and twist inside the skull which can result in localized and diffuse damage

5. Sport Medicine Centre Concussion - Mechanisms Mod Mild Severe Severe (Coma) GCS < 8 Moderate GCS 9 - 12 Mild GCS 13 - 15 Teasdale et al Lancet 1974; ii: 81-4 Concussion ? GCS “ Minimal ”

6. Sport Medicine Centre 27+ different grading systems in literature !! 27+ different grading systems in literature !! No universal agreement with regards to injury definition and return to play guidelines No universal agreement with regards to injury definition and return to play guidelines Old Concussion Guidelines

7. Sport Medicine Centre Common elements: memory, loss of consciousness, and symptoms Common elements: memory, loss of consciousness, and symptoms Used to assess severity of a concussion Used to assess severity of a concussion Poor prognostic value Poor prognostic value Varying return to play timelines Varying return to play timelines Old Concussion Guidelines

8. Sport Medicine Centre New Concussion Guidelines, Vienna, 2001 1 st International Symposium on Concussion in Sport, Vienna, 2001, Prague, 2004 2 nd International Symposium on Concussion in Sport, Prague, 2004 NIH consensus format NIH consensus format World’s experts in concussion World’s experts in concussion

9. Sport Medicine Centre New Concussion Classification Simple Simple Complex Complex Summary and Agreement Statement of the 2nd International Symposium on Concussion in Sport. Clin J Sports Med 15(2): 48-56, 2005

10. Sport Medicine Centre What is a Simple Concussion? Symptoms? Symptoms? Pattern of gradual resolution Pattern of gradual resolution Without complication Without complication Resolution over 7-10 days Resolution over 7-10 days Memory dysfunction? Memory dysfunction? Transient Transient Loss of Consciousness? Loss of Consciousness? Transient / “blacked out” Transient / “blacked out”

11. Sport Medicine Centre What is a Complex Concussion? Symptoms? Symptoms? Convulsions Convulsions > 10 days > 10 days Loss of Consciousness? Loss of Consciousness? > 1 minute > 1 minute Referral to sports concussion specialist recommended Referral to sports concussion specialist recommended

12. Sport Medicine Centre Simple or Complex?? Simple or Complex?? History History Physical exam Physical exam Serial assessment Serial assessment Retrospective Diagnosis Retrospective Diagnosis

13. Sport Medicine Centre Evaluation - History Circumstances of injury Circumstances of injury Symptoms immediate post injury Symptoms immediate post injury Current symptoms Current symptoms Ask patient, family member, coach etc. to corroborate Ask patient, family member, coach etc. to corroborate Check video if available Check video if available

14. Sport Medicine Centre > 90% of sport-related concussion have no L.O.C. > 90% of sport-related concussion have no L.O.C. Any sport Any sport Evaluation – Symptoms

15. Sport Medicine Centre Symptoms often minimized by athlete Symptoms often minimized by athlete Everyone “feels fine” Everyone “feels fine” Better to ask: Better to ask: 1. “On a scale of 0 to 100%, how do you feel?” 2. “What makes you not 100%” or “What’s missing” Evaluation – Symptoms

16. Sport Medicine Centre Sport Concussion Assessment Tool (SCAT)

17. Sport Medicine Centre Sport Concussion Assessment Tool (SCAT) Standardized tool Patient education and physician assessment of sport concussion Combination of existing tools

18. Sport Medicine Centre SCAT – Symptom Scale

19. Sport Medicine Centre Evaluation – Symptoms Headaches67% Confusion29% Dizziness29% Nausea21% Neck Pain 20% Blurred Vision 20% Fatigue15% Light sensitivity 7% FrequencySymptom

20. Sport Medicine Centre SCAT - Assessment

21. Sport Medicine Centre Evaluation - Examination Neurocognitive Neurocognitive Modified Maddocks questions Modified Maddocks questions 5 word recall (immediate & delayed) 5 word recall (immediate & delayed) months of year in reverse months of year in reverse reverse digits (string of 5 or 6) reverse digits (string of 5 or 6) Neurological exam Neurological exam Speech Speech Eye motion Eye motion Pronator Drift Pronator Drift Gait/ Balance Assessment Gait/ Balance Assessment

22. Sport Medicine Centre If concussion is suspected: Remove from activity and observe Remove from activity and observe If prolonged LOC or neurological concerns, C-spine precautions and hospital assessment If prolonged LOC or neurological concerns, C-spine precautions and hospital assessment Return-to-Play Management

23. Sport Medicine Centre Rest Rest Physical Rest No “light” exercise or cross trainingNo “light” exercise or cross training No weight trainingNo weight training No physical activity!!!No physical activity!!! Return-to-Play Management

24. Sport Medicine Centre Rest Rest Cognitive rest School, computer work, video games Return-to-Play Management

25. Sport Medicine Centre Return-to-Play Management Rest for how long? If rapid and full recovery, then 24-48 hours If rapid and full recovery, then 24-48 hours For the same amount of time as it took to become asymptomatic (especially in the pediatric age group) For the same amount of time as it took to become asymptomatic (especially in the pediatric age group)

26. Sport Medicine Centre Neuropsychological Testing Neuropsychological Testing Detecting cognitive abnormalities Detecting cognitive abnormalities Memory, concentration, “information processing” Memory, concentration, “information processing” Best when compared to baseline data Best when compared to baseline data Return-to-Play Management

27. Sport Medicine Centre Neuropsychological Testing Neuropsychological Testing Types: Traditional 6 hour battery, Web-based programs Types: Traditional 6 hour battery, Web-based programs www.cogsport.com Return-to-Play Management www.impacttest.com

28. Sport Medicine Centre Return-to-Play Management Graded Exercise Challenge Exercise ●Aerobic x 10 min HR<130 bpm ●Aerobic x 30 min with intervals ●Protected sport-specific practice ●Full sport-specific practice ●Return to sport Goal Increase HR Increase HR Max. HR Max. HR Add movement Add movement HR + movement HR + movement Exercise + coordination + thinking Exercise + coordination + thinking

29. Sport Medicine Centre 24 hours per step If there is recurrence of symptoms at any stage, return to step 1 Return-to-Play Management Graded Exercise Challenge

30. Sport Medicine Centre Return to Play Management Other factors Other factors Ready to return (confidence) Ready to return (confidence) Equipment Equipment Helmet and mouthguard Helmet and mouthguard

31. Sport Medicine Centre How Many Is Too Many? Lack of agreement on number of concussions “allowed” before termination of season or career Lack of agreement on number of concussions “allowed” before termination of season or career Evidence of cumulative effect Evidence of cumulative effect With each successive concussion: With each successive concussion: Lower threshold for injury Lower threshold for injury More severe symptoms More severe symptoms Longer lasting symptoms Longer lasting symptoms Risk of subsequent injury higher Risk of subsequent injury higher

32. Sport Medicine Centre ● Longer period of asymptomatic rest before starting graded exercise challenge ● Extend the time for each stage of exertional protocol ● Take period of time/season off if showing lower threshold / longer recovery ● More conservative with younger patient (“susceptibility”?) Managing Recurrent Concussion

33. Sport Medicine Centre QUESTIONS?