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Sports Sports Concussion Concussion Update Update 10 10 th th Annual Steadman Hawkins Sports Annual Steadman Hawkins Sports Medicine Symposium Medicine Symposium June 7 2013 June 7 2013 Chae Ko, MD Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow Primary Care Sports Medicine Fellow
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Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Dec 14, 2015

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Page 1: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Sports Sports Concussion Concussion

UpdateUpdate1010thth Annual Steadman Hawkins Sports Annual Steadman Hawkins Sports

Medicine SymposiumMedicine SymposiumJune 7 2013June 7 2013

Chae Ko, MDChae Ko, MDSteadman Hawkins Clinic of the CarolinasSteadman Hawkins Clinic of the Carolinas

Primary Care Sports Medicine FellowPrimary Care Sports Medicine Fellow

Page 2: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

ActionAction

Page 3: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

What Is Concussion?What Is Concussion?

It’s pretty simple…It’s pretty simple…

Page 4: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 5: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 6: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

DefinitionDefinition

““Concussion Concussion is a brain injury is a brain injury and is and is defined as a complex defined as a complex pathophysiological process affecting pathophysiological process affecting the brain, induced by biomechanical the brain, induced by biomechanical forces”forces”

Page 7: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

DefinitionDefinition

Concussion may be caused by a direct blow to the Concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body with an head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head“impulsive” force transmitted to the head

Concussion typically results in the rapid onset of Concussion typically results in the rapid onset of short-lived impairment of neurologic function that short-lived impairment of neurologic function that resolves spontaneously. resolves spontaneously. However, in some cases However, in some cases symptoms and signs may evolve over a number of symptoms and signs may evolve over a number of minutes to hours.minutes to hours.

Concussion may result in neuropathological Concussion may result in neuropathological changes but the acute clinical symptoms largely changes but the acute clinical symptoms largely reflect a functional disturbance rather than a reflect a functional disturbance rather than a structural structural injury and as such, no abnormality is injury and as such, no abnormality is seen on standard structural neuroimaging studies.seen on standard structural neuroimaging studies.

Page 8: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 9: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 10: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 11: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

• HeadachesHeadaches• DizzinessDizziness• Insomnia Insomnia • FatigueFatigue• Gait Gait • NauseaNausea• Vision Vision • SeizuresSeizures

• Attention Attention difficultiesdifficulties

• ConcentratiConcentrationon

• Memory Memory problemsproblems

• OrientationOrientation

• Irritability• Depression• Anxiety• Sleep Disorders• Emotional Control• Relationships, marriage, school and employment

Page 12: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Sideline EvaluationSideline Evaluation The player should be evaluated The player should be evaluated by a physician or other by a physician or other

licensed healthcare providerlicensed healthcare provider onsite using standard onsite using standard emergency management principles and particular emergency management principles and particular attention should be given to excluding a cervical spine attention should be given to excluding a cervical spine injuryinjury

The appropriate disposition of the player must be The appropriate disposition of the player must be determined by the treating healthcare provider in a determined by the treating healthcare provider in a timely manner. timely manner. If no healthcare provider is available, If no healthcare provider is available, the player should be safely removed from practice or the player should be safely removed from practice or play and urgent referral to a physician is arrangedplay and urgent referral to a physician is arranged

Once the first aid issues are addressed Once the first aid issues are addressed an assessment an assessment of the concussive injury should be made using the of the concussive injury should be made using the SCAT 3 or other sideline assessment toolsSCAT 3 or other sideline assessment tools

The player should not be left alone following the injury The player should not be left alone following the injury and serial monitoring for deterioration is essential over and serial monitoring for deterioration is essential over the initial few hours following injurythe initial few hours following injury

A player with diagnosed concussion should not be A player with diagnosed concussion should not be allowed to return to play on the day of injuryallowed to return to play on the day of injury

Page 13: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

“OLD”

Page 14: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

“NEW”

Page 15: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 16: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 17: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Grading / Grading / Classification of Classification of

ConcussionConcussion•Many different guidelines and classification systems in the past

•There has been nearly one new guideline every year for the past 20 years

•As of the 4th International Symposia on Concussion in Sport (Zurich), concussion is no longer graded or classified

Page 18: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Neuropsychological Neuropsychological EvaluationEvaluation

Important in overall assessment and RTPImportant in overall assessment and RTP Should not be sole basis of management Should not be sole basis of management

decisionsdecisions Aid to clinical decision makingAid to clinical decision making

Formal NP testing not required for allFormal NP testing not required for all Best done when asymptomatic but may Best done when asymptomatic but may

be beneficial at other stages in certain be beneficial at other stages in certain situationssituations

Baseline testing is not mandatory Baseline testing is not mandatory

Page 19: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 20: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Cognitive Adjust academic

workload and school attendance

Adjust non-academic activities

Leisure reading Video games Texting and

computers

Page 21: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

ManagementManagement

Cornerstone Cornerstone initial period of rest until initial period of rest until acute symptoms resolveacute symptoms resolve

80 – 90% resolve in short period80 – 90% resolve in short period 7 – 10 days7 – 10 days

Children and adolescentsChildren and adolescents May take longerMay take longer

Expect gradual resolutionExpect gradual resolution Gradual return to school and social Gradual return to school and social

activities that does not significantly activities that does not significantly exacerbate symptomsexacerbate symptoms

Page 22: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 23: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 24: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Graduated RTP ProtocolGraduated RTP Protocol

Page 25: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 26: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Same Day Return To Same Day Return To Play?Play?

NO!NO!

Page 27: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Postconcussive Postconcussive SymptomsSymptoms

Persistent symptoms > 10 daysPersistent symptoms > 10 days 10-15%10-15%

Consider other issuesConsider other issues DepressionDepression AnxietyAnxiety

Should be managed in Should be managed in multidisciplinary mannermultidisciplinary manner

Pharmacotherapy Pharmacotherapy

Page 28: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Child And Adolescent Child And Adolescent AthleteAthlete

Child SCAT3Child SCAT3 Adult recommendation may apply down to Adult recommendation may apply down to

age 13age 13 Modify school attendance and activitiesModify school attendance and activities No return to sport or activity until No return to sport or activity until

successful return to school successful return to school More conservative RTP approach More conservative RTP approach

recommendedrecommended Extend symptom free period before RTP Extend symptom free period before RTP

protocol protocol Consider extended graded exertion steps Consider extended graded exertion steps

Page 29: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Elite AthletesElite Athletes

Managed the same Managed the same regardless of level of regardless of level of

participation participation

Page 30: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

PreventionPrevention

Protective equipmentProtective equipment MouthguardsMouthguards

No evidence of concussion reductionNo evidence of concussion reduction HelmetsHelmets

Reduction in biomechanical forces but no Reduction in biomechanical forces but no evidence in reducing concussion incidence evidence in reducing concussion incidence

Page 31: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 32: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
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Page 34: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 35: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 36: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.
Page 37: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Chae Ko, [email protected]

Thank You

Page 38: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Barkhoudarian G, Hovda DA, Giza CC. The Molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011 Jan; 30 (1): 33-48, vii-iiii.

Campbell A, Ocampo C, DeShawn Rorie K, Lewis S, Combs S, Ford-Booker P, Briscoe J, Lewis-Jack O, Brown A, Wood D, Dennis G, Weir R, Hastings A. Caveats in the neuropsychological assessment of African Americans. J Natl Med Assoc. 2002 Jul;94(7):591-601.

Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Heads up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). www.cdc.gov/NCIPC/pub-res/tbi_toolkit/physicians/mtbi/mtbi.pdf. Accessed 2012 September 21.

Charles, JD, Bejan A. The Evolution of Speed, Size, and Shape in Modern Athletics. J Experimental Bio. 2009 May; 212: 2419-25.

Iverson G. Predicting Slow Recovery From Sport-Related Concussion: The new Simple-Complex Distinction. Clin J Sport Med. 2007 Jan;17(1): 31-7.

Ma R, Miller C, Hogan M, Diduch B, Carson E, Miller M,. Sports-Related Concussion: Assessment and Management. J Bone Joint Surg Am. 2012 September; 94(17): 1618 – 1627.

Mills JD, Bailes JE, Sedney CL, Hutchins H, Sears B. Omega-3 Fatty Acid Supplementation and Reduction of Traumatic Axonal Injury in a Rodent Head Injury Model. J Neurosurg. 2011 Jan; 114(1):77-84.

McCrory P, Meeuwisse W, Aubry M, Cantu B, Dvorak J, et al. Consensus statement on Concussion in Sport 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med 2013;23:89–117.

Putukian M. The Acute Symmptoms of Sport-related Concussion: Diagnosis and On-Field Management. Clin Sports Med. 2011 Jan;30(1):49-61, viii.

Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006 Oct;34(10):1630-5.

Page 39: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Child SCAT3 DifferencesChild SCAT3 Differences

Child Maddocks questionsChild Maddocks questions Symptom scale Symptom scale

Child specificChild specific 4 point rating scale4 point rating scale

Parent rating of child’s symptomsParent rating of child’s symptoms OrientationOrientation

No time of dayNo time of day Reverse days of the weekReverse days of the week No single leg stanceNo single leg stance

Page 40: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Canadian Head CT RuleCanadian Head CT Rule

Applies to patients with GCS=13-15 following minor head Applies to patients with GCS=13-15 following minor head trauma with witnessed LOC.trauma with witnessed LOC.

Patients with any of the below need a CT:Patients with any of the below need a CT:

1.GCS<15 after 2hrs.

2.Suspected open or depressed skull fracture.

3.Any sign of basilar skull fracture.

4.Two or more episodes of vomiting.

5.Age 65 or older.

Page 41: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

New Orleans CriteriaNew Orleans Criteria

Applies to patients with GCS=15 following minor head Applies to patients with GCS=15 following minor head trauma.trauma.

Patients with any of the below need a CT:Patients with any of the below need a CT:

1.Headache

2.Vomiting

3.Age > 60

4.Intoxication

5.Persistent anterograde amnesia

6.Visible trauma above the clavicle

7.Seizure

Page 42: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

NEXUS II CriteriaNEXUS II Criteria

““BEAN BASH” CriteriaBEAN BASH” Criteria

Behavioral Abnormality

Emesis (intractable)

Age >65

Neurological Deficit

Bleeding Disorder

Altered Mental Status

Skull Fracture

Hematoma of the Scalp

Page 43: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Age and Age and Developmental LevelDevelopmental Level

Younger athletes take longer Younger athletes take longer to recoverto recover High school versus collegeHigh school versus college High school versus professionalHigh school versus professional

Children undergo more Children undergo more cerebral swelling with more cerebral swelling with more severe mild TBI, which may severe mild TBI, which may account for delayed recovery account for delayed recovery compared to older athletescompared to older athletes

Immature brain is up to 60x Immature brain is up to 60x more sensitive to glutamate more sensitive to glutamate (part of the metabolic cascade (part of the metabolic cascade that follows concussion)that follows concussion) All this may account for SIS All this may account for SIS

only occurring in children.only occurring in children.

Page 44: Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary.

Gender DifferencesGender Differences

Females have a higher Females have a higher rate of concussionrate of concussion

Females are Females are cognitively impaired cognitively impaired 1.7x more frequently 1.7x more frequently than malesthan males

Females had Females had significantly more significantly more post-concussive post-concussive symptoms as well as symptoms as well as poorer performance poorer performance on follow-up testing on follow-up testing (ImPACT)(ImPACT)