Transcript Document

Ahead of the Game:
Keeping Up with Sports Concussion
Matthew S. Reeves, DO, CAQSM
Scott Schroeder, MSPT, LAT, ATC
August 13, 2013
Ahead of the
Game: Keeping
Up with Sports
Concussion
Matthew S. Reeves, DO, CAQSM
Scott Schroeder, MSPT, LAT, ATC
August 13, 2013
Housekeeping
• Thank you for being here!
• Disclosure
Tonight’s speakers have no financial or other
conflicts of interest to disclose in regards to the
topic presented today
Remember these three words (but do not write
down!!)
Speaker Background
Matthew S. Reeves, DO, CAQSM
• Board Certified and
Licensed Primary Care
Physician
• Fellowship trained in
Sports Medicine
• 20+ years experience
working with sports-related
concussion and other
sports related injuries and
illnesses
Scott Schroeder, MSPT, LAT, ATC
• Certified and Licensed
Athletic Trainer
• Licensed Physical
Therapist
• 20+ years experience
working with sports-related
concussion and other
sports related injuries and
illnesses
Objectives
• Differentiate between fundamental concussion related fact
and fiction
• Discuss the current Indiana state law related to sports
concussion and its proposed amendments
• Discuss the process for diagnosing a concussion
• Discuss the most up to date treatment options for
concussion
• Explain the currently accepted best practice process for
return to school, sports and/or work after concussion
• Answer questions related to concussion
• Get audience feedback related to community understanding
of sports related concussion its management
Introduction
“I’m a big football fan,
but I have to tell you, if I
had a son, I’d have to
think long and hard
before I let him play
football.”
Barack Obama
President of the United States
Interview with New Republic
January 27, 2013
“Interesting. I do have
boys and I’m thinking
long and hard about
them getting near
politics. No problem
them playing football.”
Tony Boselli
Former NFL Player
Twitter
January 28, 2013
Concussion vs. Head Injury
• Square vs. Rectangle
• Concussion is one of many types of head injury
• Head injuries
– Lacerations, fractures, bleeds, aneurysm, etc.
What is a concussion?
• A brain injury caused by a
traumatic force
• May be caused by a blow
to the head, face, neck,
or elsewhere on the body
with force transmitted to
head
• May also be a result of
hitting a hard surface,
player collisions or being
hit by equipment
What is a concussion?
Getting “dinged”
or having your
“bell rung”
IS
a concussion!
“Common Knowledge”
• Many misconceptions about concussion
– Examples from 2003 study:
•42% of respondents believed that sometimes a
second blow to the head can help a person
remember things that were forgotten
•66% of respondents believed that the only sure
way to tell if someone has suffered brain damage
from a head injury is by an x-ray of the brain
•28% of respondents believed that a concussion
is harmless and never results in long term
problems or brain damage
Concussions Facts
• ALL concussions are serious
• Often occur without loss of consciousness
(<10% of cases) or obvious signs
• Can occur in ANY sport
• Can occur in game, practice or outside of sports
• Can occur in athletes of any age
Concussions Facts
• Athletes can get a concussion even when
wearing proper equipment (including a helmet)
• Athletes often don’t report symptoms due to
sense of responsibility to their team, peer
pressure or fear of losing playing time
• Identification and proper, early response can
help prevent additional injury or even death
(second impact syndrome)
Second Impact Syndrome
• Results from a “second blow” when athlete is still
recovering from initial concussion
• Often times is NOT a hard impact
• Causes rapid onset of brain swelling, increased
intracranial pressure, ischemia (oxygen loss) and
permanent brain injury
• Can lead to death or permanent
disability
• Most common in immature brain
– High School age and younger
Concussion Facts
• Data suggests 1.5 to 3.8 million traumatic brain
injuries occur each year
• Concussion characterized the majority of these
– about 75%
Concussion Facts
• The pediatric (18 and younger) brain vs. the
adult brain
– More vulnerable to concussions
– Longer recovery from concussion
– More vulnerable to repeated concussions
– More susceptible to second impact syndrome
Concussion Facts
• At risk populations
– Female gender
– Pediatric (age 18 and younger)
– Mood Disordered
– Learning Disorders
– Migraine Sufferers
– Family History
– Fatigue
– Apolipoprotein E Promoter Gene (G-219T TT
subtype)
– Those Recovering from Recent Concussion
Concussion Facts
• Risk factors for prolonged recovery
– ADD/ADHD
– Learning disabilities
– Anxiety disorder
– Depression
– Emotional/behavioral/conduct disorders
– Seizure disorders
– Previous concussion
– History of headaches (migraines especially)
Recognizing a Concussion
• Watch for these things
– A forceful blow to the head
or body leading to rapid
movement of the head
– Any change in the studentathlete’s behavior,
thinking or physical
function
Signs observed by others
• Dazed/confused
appearance
• Clumsy movement or
balance problems
• Slurred speech/slow
response
• Loss of consciousness
(even brief)
• Memory loss
• Behavior/personality
change
Symptoms reported by Athlete
• Headache
• Nausea/vomiting
• Dizziness/balance problems
• Vision problems
• Light/noise sensitivity
• Concentration/memory problems
• Confusion
• Feel foggy/groggy/hazy/sluggish
• Doesn’t “feel right”
Preparation/Prevention
** Can’t absolutely prevent concussion – can minimize risk
• What you can do
– Know concussion signs and symptoms
– Recognize potential for harm specific to the activity
– Use the proper protective equipment, check for
proper fit of equipment, understand safe sports
technique
– Know and follow the process for return to activity
•Don’t return too early!
• Safety First
– Athletes should use safe-play techniques and follow
the rules
– Athlete should immediately report symptoms of
concussion either in themselves or a teammate
Avalanche of State Legislation
• Since 2009, 44 states and the District of
Columbia have passed legislation designed to
reduce the overall impact of
concussion/traumatic brain injuries in young
athletes
• Most revolve around 3 core elements
– Annual education for athletes and parents
– Mandatory removal from play if concussion
suspected
– Clearance by a designated health professional
before able to return to play
Zack Lystedt
• In large part because of his case, the first
concussion law was passed in the state of
Washington
– 2006 suffered a concussion playing football
– Returned pre-maturely to play
– Collapsed after the game and had emergency
surgery
– Suffered numerous strokes, spent 7 days on
ventilator and 3 months in a coma; then spent 4
weeks in a nursing home followed by 2 months
in children’s rehab hospital
Zack Lystedt
• Life changed irrevocably
– 13 months before he moved an arm or leg
– Spent 20 months on a feeding tube
– Nearly 3 years before Zack would stand (with
assistance) on his own 2 feet
Indiana’s Law
• IC 20-34-7
– Athletes and parents/guardians must be
provided with concussion information then sign
and return a form acknowledging receipt of the
information
– Athletes will be removed from play (practice or
game) if suspected of having a concussion
– To return to play, require written clearance from
a licensed healthcare provider trained in the
management of concussions and head injuries
– Addresses high school age athletes
Indiana’s Law
• Proposed Amendments
– Expand to include all athletes less than 20 years
of age
– Mandate annual coach education
– Organizing entity defined as any school that
sponsors athletic activity or any non-profit or forprofit entity that uses school property for an
athletic activity
Knowing What We Don’t Know
• There are many things we still don’t know
• Some questions answered, but many new
questions have been identified
• The practice of concussion care continues to
evolve
• In the absence of definitive evidence, we use
the best evidence available and err on the side
of conservative care (especially in young
athletes)
Concussion Publications by Decade:
1970s to Current
826
323
113
195
5
7
2
60
1
248
23
Modified from: Philip Schatz PhD, St. Joseph’s University
130
Concussion Publications by Decade:
1970s to 2010s Projected
2478
962
57
2
60
1
69
23
Modified from: Philip Schatz PhD, St. Joseph’s University
195
130
323
745
248
1970 to 2009: 796 Publications
2010 to June 2013: 826 Publications
2010 to 2019 projected: 2478 Publications
Preparation, Identification
and
Medical Management
Concussion Pathway
Preparation / Initial
Assessment
Emergency Action
Plan
Athlete/Parent
Education
Concussion
& Clinical
Assessment
Treatment Pathways
Vestibular
Ocular
Coach Education
Baseline Testing
Sideline
Examination
Cognitive /
Fatigue
Migraine
Anxiety /
Mood
Cervical
Emergency Action Plan (EAP)
• A written blueprint for how to handle emergency
situations
• Establishes a situation based plan, identifies
who carries out duties
• Helps to ensure efficient and appropriate care
is delivered
Athlete/Parent Education
• Helps parties understand what concussions are
and what the course of care might be
Coach Education
• Helps coaches understand what to look for,
especially when no medical personnel are
available
• Clarifies the standards for removal from and
return to play
Baseline Testing
• Used to determine pre-injury status; can be
compared with testing after injury to determine
severity of injury and track progress
• Components include:
– Pre-participation screen
– Symptom checklist
– Neurocognitive testing
– Balance testing
Baseline Testing:
Pre-Participation Screen
• Commonly called “physicals”
• Not as involved or thorough as a true “physical”
and should not be used as a replacement for one
• Identifies medical conditions that may indicate
increased risk of concussion
• History of previous concussions
• List of current medications
Baseline Testing:
Symptom Type and Severity Measure
• To determine the type and nature of pre-injury
symptoms if present
• Included in neurocognitive testing as well as
pencil and paper test
Baseline Testing:
Neurocognitive Testing
• We use ImPACT™ Test
– Computer based
– This is currently done for contact
intensive sports; parents can request
baseline testing for other sports
– Re-test if concussion occurs
– Measures symptoms and scores
severity
– Measures attention, memory,
processing speed and reaction time.
– Assists healthcare providers with
return to play decisions (not the only
factor in determining when to return
to full activity)
– Automatically compares to “norms”
and individual “baseline”
Baseline Testing:
Balance
• Recent research has indicated that this an
important component to consider with baseline
testing
• Working to add this component to what we are
doing with baseline testing
• Multiple ways to assess; we are working on
finding the best test for the circumstances
Sideline Examination
• Goal: To identify signs or symptoms that
indicate the possibility of concussion or more
serious injury
• Multiple standardized examination forms
available
– ACE, SCAT2, SCAT3, SAC, MACE
• Should consider physical, cognitive and
emotional symptoms and impairments
If a concussion is suspected:
• Remove from activity
– “When in doubt, sit them out”
• Educate on immediate concussion
management
– Take home sheet
• Early evaluation by licensed healthcare
professional with training in the identification
and management of head injuries
– Rule out other serious head injuries
Who are the “appropriate health care
professionals”?
Appropriate healthcare professionals are those
with specialized backgrounds in the management
of sports injury/concussion
• Sports medicine physicians
• Licensed athletic trainers
• Healthcare providers (Physicians, physician
assistants, nurse practitioners, etc.) with
concussion management training
Clinical Examination
• Symptoms
• Cranial nerve function
• General musculoskeletal examination
• Neurocognitive performance (ImPACT™ test)
• Balance
• Vestibular/Ocular function
• Imaging tests?
Symptoms
• First thing addressed in clinical examination
• Typically are divided in to 4 categories
– Physical Symptoms
– Cognitive Symptoms
– Emotional Symptoms (frontal impact
concussions)
– Sleep
Physical Symptoms
• Headache
• Dizziness
• Nausea
• Impaired Balance
• Tinnitus
• Fatigue
• Light Sensitivity
• Blurred or Double Vision
Emotional Symptoms and Sleep
Dysfunction
• Depression or Anxiety
• Mood Changes (degree
and speed)
• Irritability
• Sadness
• Nervousness
• Sleep Pattern Changes
Cognitive Symptoms
• Amnesia
• Disorientation
• Confusion
• Impaired
Concentration
• Impaired Reasoning
• Impaired memory
Cranial Nerve Function
• Tests motor functions throughout the body and
gives us a window to see what is going on in the
brain
• Helps to rule out other significant injuries
• Tests might include -
General Musculoskeletal
Examination
• Screen for associated injuries, initially
unrecognized due to focus on head
• Neck – headache and pain may be from here,
not concussion
• Other brain injuries may affect musculoskeletal
function throughout the body
Neurocognitive Function
• Compare to baseline or normative data if
available
• ImPACT™
• Used to assess memory, reaction time,
processing of information, judgment
• Tests might include: serial 7, months in reverse
Balance
• Helps identify what part of brain may have been
injured
• Examples: 1 leg stand, tandem stance
Vestibular/Ocular Function
• Helps more clearly define the nature of the
deficit or lesion
• Helps to clarify the course of treatment
Imaging Tests
• Used to rule out certain life threating or other
severe injuries
• Identify structural lesions
• Structural vs metabolic injury
• If you are told you don’t have a concussion
because the your standard CT, CAT scan or MRI
is normal …
Immediate Medical Treatment
• Cognitive rest
• Reduced school work
• Physical rest
• Limit TV, computer, video games, texting, phone
• Confer when safe to drive, ride bike
• Tylenol ONLY – Not ibuprofen type drugs
• NO alcohol
• NO narcotics, blood thinners, drugs that cause
drowsiness
School Considerations
• May need to be excused from school initially or
until symptoms are very mild
• Consider postponing exams
• Consider a reduced school day
• Allowances for reduced/no homework
• Ask teachers to notify parent if athlete can’t
reasonably focus in class or has change in
behavior or reported symptoms
Post Concussive Syndrome
• Ill-defined term
• Ambiguity leads to imprecision and variability in
study
• Characterized by persistence of symptoms
longer than would be expected
– Typically defined as symptoms greater than 3
months after injury
– In athletes or very active may consider the
threshold of 3-6 weeks
Medication Interventions
• Used for prolonged or severe symptoms
(usually begin 3-6 weeks after injury)
• Based on categorization of symptoms
– Physical: Lexapro, Zoloft, Amytriptyline
– Emotional: Lexapro, Zoloft
– Cognitive: Amantadine, Methylphenidate
– Sleep: Melatonin, Trazodone
• Recommend being off medications prior to
return to activity
When OK to return to
sports/activity?
• Return to baseline symptoms at rest
AND
• Physical examination is normal
AND
• Satisfactory results of brain function with
neurocognitive testing (ImPACT™ test)
AND
• Successfully completes structured exertion
reintegration program
AND
• When cleared by a licensed healthcare
professional trained in the evaluation and
management of concussion
Rehabilitation
Concussion Pathway
Preparation / Initial
Assessment
Emergency Action
Plan
Athlete/Parent
Education
Concussion
& Clinical
Assessment
Treatment Pathways
Vestibular
Ocular
Coach Education
Baseline Testing
Sideline
Examination
Cognitive /
Fatigue
Migraine
Anxiety /
Mood
Cervical
Vestibular
• Exercise and manual techniques to stimulate or
“reset” components of the vestibular system
Ocular
• Exercises to aid with resolution of identified
deficits
• Incorporate functional activities
• If not responding consider referral to
optometrist or ophthalmologist
Cognitive
• Tasks to stimulate cognitive function with:
– Attention/concentration, memory, organizational
skills, reasoning, problem solving, decision
making, executive stills
• Goal is to incorporate with relevant functional
activities
Headaches and Migraine
• Identify the “trigger(s)”
• Treat the appropriate triggers as well as the
symptoms
• Often treated in conjunction with the neck
• Relaxation, soft tissue mobilization, joint
mobilization, relaxation, cranio-sacral therapy
Cervical
• Rule out significant cervical issues (fractures,
etc.)
• Identify involved structure(s)
• Soft tissue mobilization, joint mobilization,
stretching, strengthening
Reintegration of Exertion
Return to Activity Guidelines
• Step 1: Physical and Cognitive Rest
• Step 2: Light Aerobic Based Activity
• Step 3: Higher Intensity / Function Specific Activities
• Step 4: Non-contact Training Activities
• Step 5: Full-contact Activities
• Step 6: Return to Full Participation
• May alter this slightly based on nature of dysfunction
When OK to return to
sports/activity?
• Return to baseline symptoms at rest
AND
• Physical examination is normal
AND
• Satisfactory results of brain function with
neurocognitive testing (ImPACT™ test)
AND
• Successfully completes structured exertion
reintegration program
AND
• When cleared by a licensed healthcare
professional trained in the evaluation and
management of concussion
Summary
The Plan – Step by Step
• Evaluation/re-evaluation
• Very limited daily activities until return to
baseline symptoms at rest
• When returned to baseline symptoms at rest,
begin re-integration of exertional activity
– Sport specific drills
– Non-contact drills
– Full-contact drills
Take Home Points
• Education is a key facor!
• Early recognition and start of and appropriate
treatment plan is essential
• EARLY REST - physical and cognitive is the
hallmark of initial treatment
• Return to activity in a graduated fashion and
not before symptoms have returned to baseline
levels
• Multiple criteria must be met prior to
unrestricted return to activity
What Does the Future Bring?
• More research
• Improved imaging tests for diagnosis of
concussion
• Improved equipment to help minimize the risk
of concussion
• Improved techniques for the treatment of
concussion
Important to Remember
• Many people play a role in ensuring the health and
safety of athletes; all need to communicate and act
as a team
– Concussion sufferer
– Family (parent, spouse, etc.)
– Coach
– Teachers
– Employers
– Athletic Trainer
– Physician/PA/NP
– Nurse
– Friends/teammates/co-workers
??QUESTIONS??
Anyone, Anyone
THANK
YOU!