RETURN TO PLAY AFTER CONCUSSION
RETURN TO PLAY AFTERCONCUSSIONTHOMAS A. KINGMAN, M.D.Financial DisclosureDr. Thomas Kingman has no relevantfinancial relationships with commercialinterests to disclose.ConcussionLatin concussus meaning “to shakeviolently” Immediate & transient alteration of mentalstatus & level of consciousness resultingfrom mechanical force or trauma Confusion is the hallmark of concussion This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Things to Remember: High school and younger athletes are morevulnerable to concussion and longer to recoverfrom concussion than older athletes.They should NOT return to play thesame day of injury.Girls are more vulnerable than boys.Return to play should be individualized.Concussions are cumulative.Total number of sports relatedhead impacts – 354,000,000/yr40,000 concussions/yr in H.S. football 5-20% of players get concussions 90% mild – no loss of consciousness 30% return to play same day 60% athletes claim they made the decisionto return to play independent of trainer orteam physician ANY SPORT HAS AN INHERENTRISK OF INJURY.This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Unique to athletic injuries is thatthe player is intentionallysubjected to repetitive cranialtrauma Tackling Headingthe ballNature of concussive head injury Concussion may be caused by a direct blowto the head, face, neck, or elsewhere on thebody with an “impulsive” force transmittedto the head.Nature of concussive head injury Concussion typically results in the rapidonset of short lived impairment ofneurological function that resolvesspontaneouslyThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Nature of concussive head injuryConcussion results in a graded set ofclinical syndromes that may or may notinvolve loss of consciousness Resolution of the clinical and cognitivesymptoms typically follows a sequentialcourse Only 9.3% of NFL players whosustain a concussion had a loss ofconsciousness. Now 11 lawsuitsagainst the NFL for repeatedconcussions and resultant longterm consequences.Nature of concussive head injuryConcussion is typically associated withgrossly normal structural neuroimagingstudies Functional MRI may be abnormal MRI Spectroscopy may be abnormal for amonth This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
The risk of concussion is 4 times higher in apreviously concussed player than in a playerwho has never sustained a concussion.Concussion (Mild TraumaticBrain Injury)Structural damage with loss of brain cellsdoes occur with some concussions Repeated concussions additive – slower/less complete recovery Second Impact Syndrome – 100%morbidity, 50% mortality (only occurs inyouth) CLOSE OBSERVATION ANDASSESSMENT OF THE INJUREDATHLETE COULD BE CRITICALTO THE PREVENTION OFCATASTROPHIC BRAIN INJURYAND CUMULATIVENEUROPSYCHOLOGICALDEFICITS.This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
THE CONFUSIONAL EPISODE ANDAMNESIA MAY OCCURIMMEDIATELY AFTER THE BLOW TOTHE HEAD OR SEVERAL MINUTESLATER. CLOSE OBSERVATION ANDASSESSMENT OF THE ATHLETEOVER SOME PERIOD OF TIME ISNECESSARY TO DETERMINEWHETHER EVOLVINGNEUROPATHOLOGIC CHANGEASSOCIATED WITH CONCUSSIONWILL LEAD TO A CONFUSIONALSTATE OR TO THE DEVELOPMENTOF MEMORY DYSFUNCTION.ConfusionDisturbance of vigilance/heighteneddistractibility Inability to maintain a coherent stream ofthought Inability to carry out a sequence of goaldirected movements Disorientation may be present butsubtle mental statusabnormalities more commonProblems with new learning memoryProblems attention and concentration Problems of cognitive processing speed Problems of complex operations related toworking memory This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
EARLY (minutes and hours) SYMPTOMSOF CONCUSSIONHEADACHEDIZZINESS OR VERTIGOLACK OF AWARENESS OF SURROUNDINGSNAUSEA OR VOMITINGLATE (days to weeks) SYMPTOMS OFCONCUSSIONPERSISTENT LOW GRADE HEADACHELIGHT-HEADEDNESSPOOR ATTENTION AND CONCENTRATIONMEMORY DYSFUNCTIONEASY FATIGUABILITYIRRITABILITY AND LOW TOLERANCEINTOLERANCE OF BRIGHTLIGHTS ORDIFFICULTY FOCUSING VISIONINTOLERANCE OF LOUD NOISES, SOMETIMESRINGING IN THE EARSANXIETY AND/OR DEPRESSED MOODSLEEP DISTURBANCETABLE 1: FEATURES OF CONCUSSIONFREQUENTLY OBSERVED VACANT STARE (BEFUDDLED FACIALEXPRESSION)DELAYED VERBAL AND MOTORRESPONSES (SLOW TO ANSWERQUESTIONS OR FOLLOW INSTRUCTIONS)CONFUSION AND INABILITY TO FOCUSATTENTION (EASILY DISTRACTED ANDUNABLE TO FOLLOW THROUGH WITHNORMAL ACTIVITIES)This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
TABLE 1: FEATURES OF CONCUSSIONFREQUENTLY OBSERVED DISORIENTATION (WALKING IN THEWRONG DIRECTION, UNAWARE OF TIME,DATE , AND PLACE)SLURRED OR INCOHERENT SPEECHGROSS OBSERVABLE INCOORDINATIONEMOTIONS OUT OF PROPORTION TOCIRCUMSTANCESMEMORY DEFICITSANY PERIOD OF LOSS OF .pdfhttp://www.cces.ca/files/pdfs/SCAT2[1].pdfThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
TABLE 3 SIDELINE EVALUATIONMENTAL STATUS TESTINGORIENTATIONTIME, PLACE, AND SITUATIONCONCENTRATIONDIGITS BACKWARDMONTHS OF THE YEAR INREVERSE ORDERMEMORYNAMES OF TEAMS IN PRIORCONTEST;RECALL OF 3 WORDS AND 3OBJECTS AT ZERO AND 5MINUTES;RECENT NEWSWORTHY EVENTS;DETAILS OF THE CONTESTSideline assessmentSerial sevens Immediate recall – Digit span test Days of the week/ Months of the year inreverse order Spelling words backwards TABLE 3 SIDELINE EVALUATIONNEUROLOGIC TESTSPUPILSSYMMETRY AND REACTIONCOORDINATIONFINGER-NOSE-FINGER,TANDEM GAITSENSATIONFINGER-NOSE (EYES CLOSED)AND ROMBERGThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Balance Error Scoring System(UNC) Six 20 second testsBoth legs, single non-dominant leg, tandem stanceFirm surface/foam surface10 cm thick medium density foam Hands on iliac crestsEyes closedMaximum error score of 10Balance Error Scoring SystemErrors hands lifted off iliac crest opening eyes step, stumble or fall moving hip into more than 30% of flexion orabduction lifting forefoot or heel remaining out of testing position for more than5 secondsTABLE 3 SIDELINE EVALUATIONEXTERNAL PROVOCATIVE TESTS40 YARD SPRINT;5 PUSHUPS;5 SIT UPS;5 KNEEBENDSThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
SAC better if have preinjury baseline.Also allows for followingrecovery.Contraindications to return to sportNo one plays the same day Persistent post-concussive symptoms Abnormal neurologic exam Symptoms on exertion Abnormalities on cognitive testing Abnormalities on imaging In place of a single grading scale andin the absence of any scientificallyvalidated return-to-play guidelines,the participants recommended theuse of a clinical construct based onan assessment of recovery frominjury and graded return to play.This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
The number, duration and severity oftotal postconcussion symptoms weremost important in determiningconcussion severity and that thecombination of symptoms weremore important than the singlesymptom of amnesia.Simple concussion One in which the neurological symptomsresolves within 7 to 10 daysComplex concussionOne in which the symptoms persistedlonger than 10 days Patient had loss of consciousness for longerthan a minute Patient had a convulsive concussion Patient had repeated concussions involvingdiminishing force This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Consequently, concussionseverity cannot be determined onthe day of the concussion, butrather only after all symptomshave resolved.As a result, no guideline is givenfor return to play.1 FULLASYMPTOMATICWEEKThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Vestibular testing/PosturographyClearly abnormal in concussionCan use to follow recovery Need equipment , i.e. cost Pre-injury testing helpful Recovery follows same timeline as recoverymeasured by neuropsychological testing Computerized ConcussionManagement?Programs increasingly available CogState Headminder- CRE ImPACT AutomatedNeuropsychologicalAssessment Metric (ANAM)This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
How they workBaseline test usually taking 20 minutes,testing brain processing speed, memory, andvisual motor skills Repeat testing at regular intervals after headinjury occurs Goal is to gauge when athlete has returnedto his/her baseline Shortcomings of testing Does not supplant clinical evaluationComputerized testing has to be validated againstthe full battery of neuropsychological tests thathave traditionally been usedProblem arises when a psychological test ismarketed to non-psychologists who may not havethe training to make an independent judgmentReturn to Play Decisions regarding concussionmanagement and return to play lie largely inthe realm of clinical judgment and must bemade on an individual basisThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Return to playNo athlete returns to play until they areasymptomatic at rest and exertion and mustremain asymptomatic with exertion Ideally, neuropsychological testing wouldhave been done and returned to normal Postural stability is normal Return to play Severity of the current injury is documentedprimarily by the number and duration ofpostconcussion symptomsReturn to playThe number, severity and proximity ofprevious concussions Whether a severe injury had occurred inresponse to what appeared to be a minorblow Age of athlete Gender of athlete This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Return to playSport involvedAthlete had a pre-existing learningdisability Neurologic examination Neuropsychological testing Table 3Vienna concussion conference: return to playrecommendations. Athletes should complete the followingstepwise process before return to play following concussion1.2.3.Removal from contest following sign/symptomsof concussionNo return to play in current gameMedical evaluation following injurya. Rule out more serious intracranial pathologyb. Neuropsychological testing considered“cornerstone” of proper post injury assessmentTable 3, continued4. Stepwise return to playa. No activity and rest until asymptomaticb. Light aerobic exercisec. Sport-specific trainingd. Non-contact drillse. Full-contact drillsf. Game playThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
THE LOSS OF OBJECTIVITY ONTHE PART OF THE ATHLETE,FAMILY, COACHES, SPORTSMEDIA, AND SPECTATORS ISAN UNFORTUNATE ANDPOTENTIALLY HARMFUL BIAS.Use of new helmetscreates a 20% decreasein concussions.No effect onsubconcussive forces.ResourcesNeurosurgical Focus/Volume 21/October,2006 – An overview of concussionconsensus statements since 2000 (Cantu) Clinics in Sports Medicine/Volume28/January, 2009 – The Management ofSports-Related Concussion: Current Statusand Future Trends (Lovell) This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Things to Remember:High school and younger athletes are morevulnerable to concussion and longer torecover from concussion than older athletes.They should NOT return to play thesame day of injury. Girls are more vulnerable than boys. Stepwise return to play should beindividualized. Concussions are cumulative. Recognition, technique and properequipment are critical. Lystedt Laws - Coaches Coaches are required to sign a statement indicating that they havebeen educated as to the nature and risk of head injuries.If a coach suspects that a player has a head injury, (s)heis required to immediately remove that player from the practice orgame: "When it doubt, sit them out.”A player that has been removed from competition cannot returnto play until (s)he has been evaluated by a licensed health careprovider trained in the evaluation and management of concussionand has received written clearance to return to play from thathealth care provider.Finally, coaches are responsible for educating their athletesregarding the nature and risk of head injuries, and encouragingathletes to notify a coach if they notice signs of a head injury inthemselves or their teammates.Lystedt Laws –Parents/Guardians Parents/Guardiansare required toreview and sign an annualconcussion and head injuryinformation sheet prior to theirchildren's participation in athleticevents.This presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
Lystedt Laws - Athletes Athletes are required to review and signan annual concussion and head injuryinformation sheet prior to theirparticipation in athletic events. If theysuspect a head injury in themselves or ateammate, they are encouraged to telltheir coachFuture Directions Newgame rules? New return to play directives? New equipment? Genetic and biomarkers?All concussions are serious Don’thide it Report it Take time to recover It’s better to miss one game thanthe whole seasonThis presentation is the intellectual property of the author. Contact them at tkingman@satx.rr.com forpermission to reprint and/or distribute.
The risk of concussion is 4 times higher in a previously concussed player than in a player who has never sustained a concussion. Concussion (Mild Traumatic Brain Injury) Structural damage with loss of brain cells does occur with some concussions Repeated concussions additive – slower/ less complete recovery Second Impact Syndrome – 100%
concussion test is a tool or device used to check a What is a concussion test? person's level of functioning after a suspected concussion. There are several types of concussion tests, including neurocognitive, balance, vestibular ocular, motion sensors, and more. These tests do not diagnose concussion, but rather note deficits in
A Guide for Teachers and School Professionals . specific protocols for returning a student to learning after a concussion is essential. Because students typically appear well physically after a concussion, educators, school administrators, and peers may not fully appreciate the extent of symptoms and . A concussion is a type of brain injury .
3. onsite medical assessment 14 4. medical assessment 16 5. concussion management 17 6. multidisciplinary concussion care 20 7. return to sport 21. canadian sport concussion pathway 23 guideline development process . evidence stakeholder consultation updates to this guideline. appendix: documen
This policy is aligned with the Canadian Guideline on Concussion in Sport. . the 5th International conference on concussion in sport held in Berlin, Oct 2016. British Journal of Sports Medicine 2017 0:1-10. This policy is aligned with the Canadian Guideline on Concussion in Sport. . medical
Consensus Statement on Concussion in Sport . The detailed clinical assessment of concussion is outlined in the SCAT2 form, which is an appendix to this document. The suspected diagnosis of concussion can include one . psychological test batteries that assess attention and memory
used in the evaluation of concussion; however, none is specifically validated for such use.31–41 SCAT2 includes one such symptom evaluation scheme.7 Increasing evidence suggests that concussion rating scales based on athlete self-report of multiple symptoms are a more reliable and practical way of detecting concussion
Furthermore, a detailed concussion his-tory is an important part of the evalua-tion both in the injured athlete and when conducting a pre-participation examina-tion. The detailed clinical assessment of concussion is outlined in the SCAT2 form (see p 85). The suspected diagnosis of concussion can include one or more of the following clinical .
small-group learning that incorporates a wide range of formal and informal instructional methods in which students interactively work together in small groups toward a common goal (Roseth, Garfield, and Ben-Zvi 2008; Springer, et al. 1999).
