Understanding Sports related Head Injuries and Concussions Anthony - PDF document

7/23/2015 Understanding Sports ‐ related Head Injuries and Concussions Anthony Luke MD, MPH Credit: Carlin Senter, MD and Elise Hammond, ATC UCSF Department of Orthopaedics Bay Area Concussion and Brain Injury Program at UCSF A collaboration between UCSF Medical Center, Benioff Children’s Hospital, and San Francisco General Hospital 1

7/23/2015 Concussions are common Concussions are common 2

7/23/2015 Concussion Numbers Increasing Marin JR et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014 May 14;311(18):1917 ‐ 9. We Miss Concussions 3

7/23/2015 Objectives: 1. Use the return to learn protocol. 2. Use the return to play protocol. 3. Discuss tough ?s with patients 1. Preventive gear? 2. How many concussions is too many? 3. What are the long term consequences of concussion? Concussion Definition • Type of mild traumatic brain injury • Blow to head, neck, body  force to head. • Neurologic impairment within 48 hours of trauma. • Symptoms usually resolve in 1 ‐ 2 weeks spontaneously but in some cases can be prolonged. • May or may not include loss of consciousness. 4

7/23/2015 Concussion Symptoms Physical Sleep Cognitive Emotional http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. Pathophysiology: Acute neurometabolic cascade Ion Need Energy Force to fluxes; glucose but brain vasocon ‐ less blood crisis striction flow Giza CC and Hovda DA, J of Athletic Training, 2001. Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. 5

7/23/2015 Concussion clinic evaluation: symptom checklist SYMPTOMS s/p 6d SYMPTOMS s/p 6d Headache 5 “ Don ’ t Feel Right ” 5 “ Pressure in Head ” 3 3 Difficulty Concentrating Neck Pain 0 Difficulty Remembering 3 Nausea / Vomiting 0 Fatigue / Low Energy 2 Dizziness 2 Confusion 0 Blurred Vision 0 Drowsiness 2 Balance Problems 2 0 Trouble Falling Asleep Sensitivity to Light 2 More Emotional 0 1 Sensitivity to Noise 2 Irritability Feeling Slowed Down 3 Sadness 0 Feeling like “ in a Fog ” 0 0 Nervous / Anxious TOTAL 35 Concussion evaluation: physical exam • Normal neck exam • Normal neurologic exam 6

7/23/2015 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250 ‐ 8 Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250 ‐ 8 7

7/23/2015 Concussion Treatment • Cognitive rest • Physical rest • Medication – Tylenol – Ibuprofen after first 72 hours • No driving • No Etoh Case 1 17 y/o high school lacrosse player presents to your office with a concussion. He is a senior and his last high school game is in 4 weeks. He has no history of concussion, depression, or anxiety. 8

7/23/2015 What is the likelihood that he will be back to play in his last game? A. High: 90% of sports concussion patients are better within 3 weeks of injury. B. Moderate: 65% of sports concussion patients are better within 3 weeks of injury. C. Low: 25% of sports concussion patients are better within 3 weeks of injury. D. Zero: sports concussion patients should rest from contact for at least 4 weeks post injury. How Severe is my Concussion? • Concussion grading is retrospective – Historically concussions were graded on the sideline based on amnesia and LOC at time of injury. – American Academy of Neurology, 1997 – Cantu, 2001 – Studies have shown these factors not to be predictive of recovery. • Only when the athlete recovers can you tell how severe the concussion was 9

7/23/2015 Symptom Resolution after Sport Concussion • 50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.) • 7 ‐ 10 days avg. symptom resolution . (3rd International Conference on Concussion in Sport (2008). Clin J Sport Med, 2009.) • High schoolers take longer to recover based on neuropsychological testing compared to college athletes . (Field et al, J Pediatr, 2003.) Case 2 16 y/o high school student presents to your office with concussion sustained 3 days ago during football. He reports headache, fogginess, and dizziness that is mild to moderate intensity at home but moderately severe at school. He is resting from sports. 10

7/23/2015 What do you recommend he do with respect to school? A. Continue school without adjustments. B. Continue school but no test ‐ taking. C. Attend ½ days of school for a week, no test ‐ taking. D. Rest from school until can tolerate 1 ‐ 2 hours of work at home. E. Rest completely from school for a week. Return to Learn Progression Return to full day of school. Return to ½ day of school. 30 min schoolwork at 15 min a time until cognitive can do 1 ‐ 2 No school. activity at a hours. time. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html 11

7/23/2015 UCSF concussion clinic school note Case 3 16 y/o high school student presents to your office Monday morning with concussion sustained playing soccer 3 days ago (Friday). She initially had headache, dizziness, and fogginess, but those symptoms resolved yesterday. She is now asymptomatic with a normal neurologic exam. She has no deficits on balance testing. She has no deficits on memory testing. 12

7/23/2015 Assuming she remains asymptomatic, when would you clear her to return to full contact soccer games? A. Today (Monday) B. Tomorrow (Tuesday) C. In 2 days (Thursday) D. 1 week post injury (Saturday) E. 2 weeks post injury Concussion Legislation • 50 states have adopted youth concussion laws • California: education code 49475 (effective 1/2012) 1. Athletes and guardians sign a concussion information form yearly 2. Athlete suspected of having concussion removed at time of injury for the rest of the day 3. Athlete can return only after cleared by healthcare professional trained in evaluation and management of concussion 13

7/23/2015 Concussion legislation • California Assembly Bill 2127 (in effect 1/2015) – Adds to AB 25 • FB full ‐ contact practice limits: – No more than 2/week during preseason and season – These practices cannot exceed 90 minutes – No full ‐ contact in off ‐ season • Once clear must follow gradual return to play protocol of at least 7 days under supervision of licensed provider Return to Play Progression Clinician clearance Game play Full contact practice Non ‐ Asymptomatic Saturday contact Sport training specific Light Friday activity aerobic Thursday activity Wednesday Tuesday 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196 . 14

7/23/2015 Return to play activity examples Step Objective Activities 1 Recovery No activity 2 Increase heart rate Walking, swimming, or stationary bike. < 70% max heart rate. No weights. 3 Add movement Skating drills in hockey, running drills in soccer. No head impact activities. 4 Add coordination and More complex drills (passing). Can start cognitive load weights. 5 Restore confidence and Full ‐ contact practice assess functional skills by coaching staff 6 Normal game play Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250 ‐ 8 UCSF concussion clinic sports note 15

7/23/2015 Case 3 The student athlete follows up with you as scheduled in the office on Thursday to consider full contact clearance for Friday. She did 1 hour of high intensity non contact training earlier Thursday afternoon. She felt good except for a very mild headache during the sprinting workouts. The headache is now gone. Her neurologic exam, balance testing, and memory testing is normal. Return to Play Progression Clinician clearance Game play Full contact practice Non ‐ Asymptomatic contact Sport training specific Light activity aerobic Thursday activity Wednesday Tuesday 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196 . 16

7/23/2015 What do you do next? A. Clear her for full contact practice on Friday followed by full contact game on Saturday. B. Have her return to sport specific activity on Friday, then do non contact training Saturday and see you next week to consider full clearance. C. Recommend rest from sports over the weekend, follow up with you next week. D. Recommend rest from sports for one week, follow up with you in 2 weeks. Return to Play Progression Clinician clearance Game play Full contact practice Non ‐ Asymptomatic contact Sport training specific Light activity aerobic Thursday activity Wednesday Tuesday 2 nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196 . 17