1. Concussion in Sport: A Primary Care Perspective Dr. Mark Lees Department of Family Medicine University of Saskatchewan July 20 th, 2006

2. Overview Background Background Case #1 Case #1 Clinical review Clinical review “On-field” management “On-field” management Case #2 Case #2 In-office follow-up / management In-office follow-up / management Summary & take home messages Summary & take home messages

3. What Exactly is a Concussion? Traumatic biomechanical force (direct or indirect) Traumatic biomechanical force (direct or indirect) Complex pathophysiological process Complex pathophysiological process Acute symptoms a result of functional disturbance, not a structural injury Acute symptoms a result of functional disturbance, not a structural injury

4. Concussion: Background Neurologic impairment Neurologic impairment Rapid onset Rapid onset Short lived Short lived Spontaneous resolution Spontaneous resolution Graded set of clinical syndromes Graded set of clinical syndromes Typically associated with grossly normal structural neuroimaging studies Typically associated with grossly normal structural neuroimaging studies

5. Concussions: Classification Simple Simple Most common form Most common form Resolves over 7- 10 days Resolves over 7- 10 days No intervention except complete REST and graded return to play No intervention except complete REST and graded return to play Complex: Complex: Persistent symptoms or cognitive impairment Persistent symptoms or cognitive impairment Seizures Seizures Prolonged LOC (> 1 minute) Prolonged LOC (> 1 minute) Multiple concussions requiring progressively less impact Multiple concussions requiring progressively less impact

6. Concussion Facts Occurs every 4 minutes in Canada Occurs every 4 minutes in Canada We only see a miniscule fraction of them We only see a miniscule fraction of them Average age for a first concussion is 10 years Average age for a first concussion is 10 years 1/3 rd of those graduating from high school 1/3 rd of those graduating from high school Most common in young adult males Most common in young adult males RR of 2 nd concussion = 4.0 RR of 2 nd concussion = 4.0 20% concussions from organized sports (remainder from MVA, playground, work) 20% concussions from organized sports (remainder from MVA, playground, work) 80 percent of individuals with a past concussion did not recognize it as such 80 percent of individuals with a past concussion did not recognize it as such Source: Ontario Brain Injury Web Site

7. More Concussion Facts Minor league hockey players (ages 9-17) in Canada: Minor league hockey players (ages 9-17) in Canada: 10 % of players per season 10 % of players per season 2.8 concussions per 1000 player hours 2.8 concussions per 1000 player hours

8. Case #1 Spectator at 12 y.o niece’s playoff Pee Wee hockey game in Tisdale Spectator at 12 y.o niece’s playoff Pee Wee hockey game in Tisdale Star player caught with her head down and checked hard hitting head on the ice Star player caught with her head down and checked hard hitting head on the ice Get’s up about 5 seconds later, skating away from the play and looking a little wobbly Get’s up about 5 seconds later, skating away from the play and looking a little wobbly The coach, who somehow knows you are a family medicine resident, calls you over to the bench and asks you to have a look at her to make sure she is ok to keep playing The coach, who somehow knows you are a family medicine resident, calls you over to the bench and asks you to have a look at her to make sure she is ok to keep playing

9. What would you like to do now?

10. Assessment: Acute Injury ABC’s ABC’s C-spine precautions: C-spine precautions: Canadian C-Spine Rule Canadian C-Spine Rule The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001 Oct 17;286(15):1841-8 Sensitivity = 100% Specificity = 42.5%

11. Canadian CT Head Rule Any (adult) patient with a mild TBI & any of … Any (adult) patient with a mild TBI & any of … GCS <15 two hours after injury GCS <15 two hours after injury Suspected open or depressed skull fracture Suspected open or depressed skull fracture Any sign of basilar skull fracture Any sign of basilar skull fracture 2+ episodes of emesis 2+ episodes of emesis 65 years of age or older 65 years of age or older Retrograde amnesia > 30 minutes Retrograde amnesia > 30 minutes Dangerous mechanism Dangerous mechanism pedestrian struck by motor vehicle pedestrian struck by motor vehicle occupant ejected from motor vehicle occupant ejected from motor vehicle Fall from 3 feet or 5 stairs Fall from 3 feet or 5 stairs Sensitivity = 100% Specificity = 88% Excluded from study: Neuro deficit Anti-coagulation Bleeding disorder Hx of Seizure Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005 Sep 28;294(12):1511-8

12. Now that you’re happy you’ve ruled out the really worrisome stuff … How do we best assess her for a concussion?

14. Assessment: Signs and Symptoms Immediate Signs: Immediate Signs: Altered consciousness (LOC, disorientation) Altered consciousness (LOC, disorientation) Impaired attention: Impaired attention: Vacant stare, delayed responsiveness, inability to focus Vacant stare, delayed responsiveness, inability to focus Slurred speech Slurred speech Poor co-ordination / balance Poor co-ordination / balance Personality changes (emotionally labile) Personality changes (emotionally labile) Memory deficits Memory deficits Decreased playing ability Decreased playing ability Tonic posturing / convulsive movements Tonic posturing / convulsive movements

15. Concussion: Signs and Symptoms Immediate Symptoms: Immediate Symptoms: Headache Headache Dizziness Dizziness Nausea Nausea

16. Assessment: Acute Injury Cognition: Cognition: Memory: Memory: What venue are we at? What venue are we at? What period is it? What period is it? Who scored last? Who scored last? Did we win our last game? Who did we play? Did we win our last game? Who did we play? 5 word recall (immediate + delayed) 5 word recall (immediate + delayed) Concentration Concentration Months in reverse, digits backwards Months in reverse, digits backwards Sport Concussion Assessment Tool (SCAT) www.thinksmart.ca

17. Assessment: Acute Injury Neurologic screening: Neurologic screening: Speech Speech Eye motion & pupils Eye motion & pupils Pronator drift Pronator drift Gait Gait

18. Management: Acute Injury “When in doubt, sit them out” “When in doubt, sit them out” No player should be allowed to play if symptomatic No player should be allowed to play if symptomatic

19. Management: Acute Injury 1. Player should not be allowed back into current game or practice 2. Player should be monitored and observed for several hours post injury 3. Medical evaluation 4. Don’t let player drive 5. Not to be left alone for 24-48 hours 6. RTP should be a medically supervised process

20. Management: ER Transfer? Worsening headache Worsening headache Development of focal neurologic deficits Development of focal neurologic deficits You’re worrying about not already having done so You’re worrying about not already having done so

22. Case #2 16 y.o Tony seen with his mom 16 y.o Tony seen with his mom Mom concerned regarding persistent headaches over the last 2 weeks after hitting his head while skateboarding Mom concerned regarding persistent headaches over the last 2 weeks after hitting his head while skateboarding Mom says she is worried that he might have “blood on the brain” and wants an MRI done (today) Mom says she is worried that he might have “blood on the brain” and wants an MRI done (today)

23. Case #2 Continued Detention last week at school as didn’t finish home work – says was too tired to get it done as he has had trouble falling asleep at night Detention last week at school as didn’t finish home work – says was too tired to get it done as he has had trouble falling asleep at night Mom states Tony is more moody than usual, yelling at his younger sister a lot. Tony says she is intentionally trying to bother him Mom states Tony is more moody than usual, yelling at his younger sister a lot. Tony says she is intentionally trying to bother him

24. Case # 2 continued Tony feels his mom is “stupid and overreacting” and wants to go home Tony feels his mom is “stupid and overreacting” and wants to go home Says he has felt like this several times before and it eventually gets better Says he has felt like this several times before and it eventually gets better

26. History Accident details Accident details LOC? LOC? Amnesia? Amnesia? Thorough headache history Thorough headache history Constant occipital pain, not progressive Constant occipital pain, not progressive Worse during gym class and playing video games Worse during gym class and playing video games Concussion history Concussion history Unrecognized? Unrecognized?

27. Concussion: Signs and Symptoms Delayed Signs: Delayed Signs: Dizziness, vertigo Dizziness, vertigo Persistent headache Persistent headache Poor attention and concentration Poor attention and concentration Memory dysfunction Memory dysfunction Nausea/vomiting Nausea/vomiting Photophobia Photophobia Anxiety or depression Anxiety or depression Sleep disturbances Sleep disturbances Irritability Irritability

28. So I have a concussion … Tony thinks this is really cool and wonders if maybe he should stay home for a week from school and recover Tony thinks this is really cool and wonders if maybe he should stay home for a week from school and recover What do you tell him? What do you tell him?

29. Return to Play Protocol 1. NO activity – complete physical AND cognitive rest 2. Light aerobic exercise 3. Sport specific exercise 4. Non-contact training drills 5. Full contact training after medical clearance 6. Game play

30. Why won’t you let me play?!? If playing while symptomatic … If playing while symptomatic … Greater risk for another injury: Greater risk for another injury: Another concussion Another concussion Symptoms more severe and long lasting Symptoms more severe and long lasting Second-Impact syndrome (rare) Second-Impact syndrome (rare) Cumulative neuropsychological impairment? (punch-drunk) Cumulative neuropsychological impairment? (punch-drunk) Other injury Other injury Longer time to recovery Longer time to recovery

31. So I have a concussion … Mom doesn’t think this is very cool at all and starts lecturing Tony about not wearing a helmet Mom doesn’t think this is very cool at all and starts lecturing Tony about not wearing a helmet What do you tell them? What do you tell them?

32. In Office Management Concussion history Concussion history Prevention Prevention Protective equipment Protective equipment No clinical evidence No clinical evidence Risk compensation? Risk compensation? Throw bike helmets out after impact Throw bike helmets out after impact Promotion of fair play Promotion of fair play Education (signs, symptoms, risks) Education (signs, symptoms, risks) Coaches, parents, kids Coaches, parents, kids www.thinkfirst.ca www.thinkfirst.ca Supervised return to play Supervised return to play Baseline / pre-participation cognitive assessment Baseline / pre-participation cognitive assessment

33. Neuropsychological Assessment Useful in complex concussions Useful in complex concussions Cognitive recovery may precede or follow clinical symptom resolution Cognitive recovery may precede or follow clinical symptom resolution Can be used as a part of RTP decision making Can be used as a part of RTP decision making Should be performed only after asymptomatic Should be performed only after asymptomatic Web based computerized testing available Web based computerized testing available

34. ImPACT Computerized Testing Neurocognitive test instrument: Neurocognitive test instrument: attention, memory, processing speed, and reaction time attention, memory, processing speed, and reaction time Takes 20 minutes to complete Takes 20 minutes to complete Computer or web based Computer or web based Costs: Costs: High school $500 / year High school $500 / year University $600 / year University $600 / year Teams & clubs $700 / year Teams & clubs $700 / year Clinics $600 for 10 baseline tests and 15 post injury tests Clinics $600 for 10 baseline tests and 15 post injury tests Used in Canada by OHL, York University, UNB, U of Waterloo, SFU, Laurentian Used in Canada by OHL, York University, UNB, U of Waterloo, SFU, Laurentian

35. The Easy to Remember Take Home Message(s) Concussions are common and often unrecognized by the patient Concussions are common and often unrecognized by the patient “When in doubt, sit them out” “When in doubt, sit them out” No player should be allowed to play if symptomatic No player should be allowed to play if symptomatic