2013 Sports Concussion Management Jim Chesnutt, M.D. OHSU Sports Medicine Orthopaedics and Rehabilitation and Family Medicine Recognize: Remove: Refer : Return

Concussions: The Problem We now realize concussions occur more often than previously thought Young athletes are at risk for serious short-term and long- term problems There is much variation in the knowledge of Health Care Providers managing concussed athletes New and emerging technologies will lead to a continuing evolution of care

What is a Concussion? A concussion is a mild traumatic brain injury that interferes with normal function of the brain Evolving knowledge- “dings” and “bell ringers” are brain injuries- no such thing as a mild concussion Loss of consciousness is not common in concussion( 30 minutes

Concussions Estimated 300, mil sports-related head injuries in athletes yearly 9% of all sports injuries ? head-injuries in Oregon HS athletes based on OSAA participation #s Pros: lower incidence possibly 10x lower

Newer Data High School RIO Injury rate per 100,000 player exposures Football52 Girls’ Lacrosse39 Girls’ soccer35 Boys’ Lacrosse32 Wrestling22 Girls basketball20 Boys’ soccer17 Softball15 Boys basketball 7

Concussion Symptoms are variable for each individual in terms of type, intensity and duration Classified into three main areas: – physical ( HA, dizzy) –emotional ( agitated, quiet, depressed), –cognitive ( memory, processing) Cumulative impairment can occur 3x more likely to get a second concussion

Second Impact Syndrome Injury before recovery from the previous head injury May cause brain swelling from loss of normal control of brain blood flow –Rare but deadly, more common in teenagers Prevention is the key……. –Do not return to play too early

The Goal of Appropriate Treatment Minimize the duration of symptoms Return to play as soon as safely possible Avoid entirely the risk of second impact syndrome Minimize the rate of chronic post concussion syndrome

Recovery from concussion 80% of concussion recover well if managed actively in the first 3 weeks. Average recovery time for youth with concussion is about 3 weeks Loss of consciousness is not a prognostic factor for recovery unless >30 min Imaging is not usually helpful ( mostly done in first 48 hrs if decline mental status increased HA or neurologic deficit)

Landmark Guidelines Clin J. Sports Med 2009,19: ( balance testing, SCAT2 and new science )

New Guidelines just published!

New in Oregon in State-wide concussion management program involving all high schools –Establish state-wide physician network –Uniform evaluation and management protocol –Consultation service for coaches, athletes, parents, and physicians –ImPACT baseline suggested for contact and collision sport athletes:

Concussions: The Oregon Plan Identified Regional Leaders Portland: OHSU Eugene: Slocum Bend: The Center Each provides oversite of schools in their regions and help local doctors/trainers care for their own athletes

Oregon Concussion Awareness and Management Program (OCAMP) The Oregon Concussion Assessment and Management Program (OCAMP) is a group made up of physicians, neuropsychologists, athletic directors, certified athletic trainers, educators and representatives from OSAA, ODE and OADA. We are working with OSAA and ODE to develop a model to support students as they return safely to full participation in athletics and academics.

Oregon Concussion Awareness and Management Program (OCAMP) Slocum Orthopaedic and Sports Medicine Center Mick Koester,M.D. OHSU Sports Medicine Jim Chesnutt, M.D Charles Webb, The Center/ St Charles Sondra Marshall,PhD Leah Schock, PhD. Contact us for questions or to sign up!

Max’s Law: Sports Concussion (SB 348- April 2009) Max Condradt is an OR brain- injured athlete hurt in football Law focused on no return-to- play the same day as concussion Medical release needed to return to play Yearly coach concussion education required Effective: July 2009

New Concussion Guidelines 1. No Same Day Return to Play 2. Return to Play Recommendations * approximately one week out* Symptoms fully resolved -and- Complete a structured, graded exertion protocol over approximately 5-7 days without symptoms

Concussions: Return to Play A Step-wise symptom limited program 1. Rest until asymptomatic ( physical,mental) 2. Light aerobic exercise ( exercise bike) 3. Sport- specific exercise 4. Non-contact training drills ( wt lifting or sleds) 5. Full contact training (after medical clearance) 6. Return to competition( game play) Each stage is about 24 hrs or longer and return to stage one if symptoms reoccur

Module 1: Word Discrimination Module 2: Design Memory Module 3: X's and O’s

Purpose of Care Plan: Guide recovery, Educate, Manage exertional and school activity Educational resources: State TBI Teams Develop concussion education programs and return to academic programs, and assist with 504 plans if needed. Call : or

Return to School 50 60

OSAA Concussion Return to Play Form

Keys to Recovery Resting the brain & getting good sleep No additional forces to head/ brain Managing/ facilitating physiological recovery –Avoid activities that produce symptoms –Not over-exerting body or brain Ways to over-exert Physical Emotional Cognitive! (concentration, learning, memory)

Return to Play considerations All symptoms need to resolve –This includes HA, especially –Follow symptom log Neurocognitive scores usually normalize after symptoms resolve If symptoms recur with exercise, school, work or play: remove from activity/ modify RTP plan

When Return to Play? ….to full shedule at school? No longer have symptoms –No longer need medicine to control symptoms. Neuro-cognitive function & balance back to “normal.” –After rest and gradual activity (exertion) Cleared by medical professional. Zurich: Recognition that the child/ adolescent student-athlete may take longer, and we should proceed more cautiously

Comprehensive/ Team- Based Treatment Modalities Rest from school and activities School modifications Rehabilitation, cognitive and visual therapy Medications Neuropsycholgy testing Psychiatry/ Neurology as needed Educational counselling

OHSU Concussion Management or Pre-season Impact baseline testing –Can do whole team or individuals Athletic trainers on- field and in injury clinic Post –concussion evaluations –Physician and ATC evaluations & Impact testing Concussion Rehabilitation Team – PT, Vestibular/ENT, SLP/ cognitive,OT/vision Pediatric Neuropsychology testing if chronic Sport Concussion Support Group (student/family)

OHSU Concussion Rehab Team A. Speech -language pathologist: for evaluation and treatment to address cognitive and executive function issues B. Physical therapy: for vestibular therapy and neck and associated orthopaedic issues. C. Occupational Therapy: for visual and functional therapy. This is on the 1st floor of OHSU Center for Health and Healing. Please call to schedule an appointment but this will likely need to be approved by your insurance

Concussion Medication Management Fish oil and tylenol early, NSAID after 72 hrs Amitriptyline 10 mg pills. Take10-50mg ( 1-5 pills) at night at bedtime as directed for Headache/nerve pain and to help with sleep. Amantadine 100 mg BID is used for concussion symptoms.Please take one pill in Am then after one week consider adding one more at noon. Continue for about 2-4 weeks to see if this helps with your concussion- related symptoms. Topimax: 50 mg BID start 25 HS, increase q3-7 Antidpressants, aleve, anti-seizure meds, Bblocker,triptan

When Return to Play? Criteria for RTP No longer have symptoms –No longer need medicine to control symptoms. Neurocognitive function & balance back to “normal.” –After rest and gradual activity (exertion) Cleared by medical professional. Zurich: Recognition that the child/ adolescent student-athlete may take longer, and we should proceed more cautiously

Summary Must improve early identification & diagnosis Coach, athlete, parent, medical education Careful individualized clinical assessment and tracking from time of injury SCAT2 Neuropsychological Testing ( Impact, Axon, or full) Implement active treatment in home & school school accommodations, 504 plan, OCAMP.org Free coaches education: on.aspwww.osaa.org/healthandsafety/concussi on.asp

Concussion Final thoughts…. Be alert for subtle symptoms Adhere to guidelines to limit contact for about one week and transition back to play Consider use of neuropsych testing –Document baseline, deficits and improvement Be aware of cumulative trauma and risk for permanent damage Be more conservative with younger athletes

Sports Concussion Management Contact our sports medicine team for questions: Jim Chesnutt, M.D. Charles Webb, D.O. Ryan Petering, M.D. Melissa Novak D.O. Rachel Bengtzen M.D. or