1. Concussions in Sport Information and Presentation Materials Courtesy Of Dr. Victor Lun, CCFP, DIP Sport Med, Dr. Connie Lebrun, Medical Director – CSF Dr. Bob Morell, Member FIS Medical Committee, Tara Fontenot – USSA ATC/PT

2. Outline All Sports are subject to Concussion Exposure Mechanism of Injury Concussion Guidelines Clinical Evaluation Return to Play Management Concussion Prevention Recurrent Concussions

3. Concussion - Mechanisms Rapid deceleration Extension-flexion movement Rotation Skiing – fall on the back of the head

4. Concussion - Mechanisms “Minimal” “Mild” “Moderate” General Area of Involvement “Minimal “ To “Mid-Mild” Severe = Coma

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

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

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

8. What is a Simple Concussion? Symptoms? Pattern of gradual resolution Without complication Resolution over 7-10 days Memory dysfunction? Transient Loss of Consciousness? Transient / “blacked out” < 15 Sec.

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

10. Simple or Complex?? History Physical exam Serial assessment-SCAT Retrospective Diagnosis

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

12. Evaluation – Symptoms Note: > 90% of sport-related concussion have no L.O.C. Any sports

13. Sport Concussion Assessment Tool (SCAT) Provides an easy to use tool Standardized tool Patient education and physician assessment of sport concussion Combination of existing tools

14. Sport Concussion Assessment Tool (SCAT)

15. SCAT – Symptom Scale

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

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

18. Return-to-Play Management Physical Rest Physical Rest No “light” exercise or cross training No weight training No physical activity until symptom free! Rest - Rest - Rest Rest - Rest - Rest

19. Return-to-Play Management Cognitive Rest Cognitive Rest Limited School, computer work, No !!! - Video games Rest - Rest - Rest Rest - Rest - Rest

20. Return-to-Play Management Rest for how long? If rapid and full recovery, then 24-48 hours – this is not the return to physical activity time frame. For the same amount of time as it took to become asymptomatic ( no symptoms i.e headaches etc.)

21. Return-to-Play Management Neuropsychological Testing Detecting cognitive abnormalities Memory, concentration, “information processing” Best when compared to baseline data – many teams are now doing baseline testing to establish a norm for each competitor

22. Return-to-Play Management Neuropsychological Testing Web-based Types: Traditional 6 hour battery programs www.cogsport.com www.impacttest.com

23. 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

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

25. Return to Play Management Other factors Ready to return (confidence) Equipment Helmet and Mouthguard

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

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

28. Operative Words For Technical Delegates When In Doubt Keep The Athlete Out Of Competition Utilize The Medical Release Form

29. -HELMETS- All Helmets Are Not Created Equal No Matter How They May Look