Berlin Consensus Statement October 27-28, 2017 Fifth International Consensus Conference on Concussion in Sport Kristian Goulet MD Medical Director: Children's Hospital of Eastern Ontario, Eastern Ontario Concussion Clinic, & the Pediatric Sports Medicine Clinic of Ottawa May 27, 2017

11 ‘Rs’ of Sport-Related Concussion Management Recognise Remove Re-evaluate Rest Rehabilitation Refer Recovery Return to Sport Reconsider Residual Effects Risk Reduction

Recognize: Definition “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Stateent on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich November 2008. Br J Sports Med. 2009 May;43 Suppl 1:i76-90.

Recognize: Symptoms Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability) Physical signs (eg, loss of consciousness, amnesia, neurolog­ical deficit) Balance impairment (eg, gait unsteadiness) Behavioural changes (eg, irritability) Cognitive impairment (eg, slowed reaction times) Sleep/wake disturbance (eg, somnolence, drowsiness)

SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body impulsive force transmitted to the head. SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. signs and symptoms may evolve over a number of minutes to hours. SRC largely reflect a functional disturbance rather than a structural injury no abnormality is seen on standard structural neuroimaging studies. SRC 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. The clinical signs and symptoms cannot be explained by other factors

Remove: With Any Suspicion The player should be evaluated by a physician or other li­censed healthcare provider on site using standard emergen­cy management principles particular attention to excluding a cervical spine injury and other “red flags” Must be done in a timely man­ner. If no healthcare provider is available, the player should be safely removed from play and urgent referral to a physician arranged. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.(CRT5) The player should not be left alone after the injury, se­rial monitoring for deterioration is essential over the initial few hours after injury. A player with diagnosed SRC should not return to play on the day of injury. If a non physician does the initial assessment, follow up with a physician is recommended

Re-evaluate: Post Injury Assessment (at the discretion of the physician) Comprehensive history and detailed neurological examination including A thorough assessment of mental status, cognitive functioning, sleep/ wake disturbance, ocular function, vestibular function, gait and balance. Determination of the clinical status of the patient, includ­ing whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewit­nesses to the injury. Determination of the need for emergent neuroimaging to exclude a more severe brain injury (eg, structural abnormal­ity) Physician (medically driven) makes diagnosis ASAP

Rest There is currently insufficient evidence that prescribing complete rest improves recovery. After a brief period of rest during the acute phase (24–48 hours) patients can gradually increase activity Needs to stay below their cognitive and physical symptom-ex­acerbation thresholds (ie, activity level should not bring on or worsen their symptoms). Avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined

Rehabilitation A variety of treatments may be required for ongoing symptoms The data support interventions including therapies for mood and physiotherapy. Closely monitored active rehabilitation programmes can be helpful Exercise that doesn’t produce symptoms or puts them at any risk of getting injured A collaborative approach to treatment is needed to: Control the amount of thinking Help them get back to school Possibly use medications Determining which therapies are needed. Should be overseen by a trained physician

Refer Persistent symptoms’ can be caused my many other things (not just the head injury) It takes a well experienced physician to determine which specialties/therapists need to be involved.

Recover Large majority of injured athletes recover, from a clinical perspective, within the first month of injury Having a low level of symptoms in the first day after injury is a favourable prognostic indicator. Development of subacute problems with migraine headaches or depression are likely risk factors for persistent symptoms There are a number of factors that have been identified that are associated with a longer recovery Physiological dysfunction may outlast current clinical measures of recovery, supporting a ‘buffer zone’ Students should have regular medical follow-up after an SRC May require TEMPORARY absence from school

Return To Learn

Return to Sport Return to sport; Graduated return-to-sport (RTS) strategy Return to Sport

Reconsider All athletes, regardless of level of participation, should be managed using the same management principles for athletes Age is an important consideration Clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression There is no accepted number of concussions that require retirement from sport. Each case is individualized The potential for developing chronic traumatic encephalopathy (CTE) must be a consideration There is till is a lot to be learned about the relationship between head injury and CTE

Risk Reduction The evidence for mouthguard use in preventing SRC is mixed meta-analysis suggests a non-significant trend towards a protective effect in collision sports, More research is needed Good evidence of the benefit of delaying body contact Zero tolerance for head checking and strict enforcement of rules Helmets work in skiing and snowboarding but not so far in ice hockey Headgear in rugby and soccer need more research Flexible boards and Glass has been show to decreased concussion risk Knowledge Translation is important

Neuropsychological Testing Baseline or pre-season NP testing was not felt to be required It may be helpful or add useful information to the overall interpretation of these tests. It provides an additional educative opportunity for the healthcare provider to discuss the significance of this injury. Post-injury NP testing is not required for all athletes. Should optimally be performed by a trained and accredited neuropsychologist

Other Discussion Points Biomarkers Brain Imaging Genetic Testing All require more research

Thank You Questions?