Concussion in Sport: A Primary Care Perspective

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Concussion in SportA Primary Care Perspective

• Dr. Mark Lees
• Department of Family Medicine
• University of Saskatchewan
• July 20th, 2006

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Overview

• Background
• Case 1
• Clinical review
• On-field management
• Case 2
• In-office follow-up / management
• Summary take home messages

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What Exactly is a Concussion?

• Traumatic biomechanical force (direct or
  indirect)
• Complex pathophysiological process
• Acute symptoms a result of functional
  disturbance, not a structural injury

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Concussion Background

• Neurologic impairment
• Rapid onset
• Short lived
• Spontaneous resolution
• Graded set of clinical syndromes
• Typically associated with grossly normal
  structural neuroimaging studies

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Concussions Classification

• Complex
• Persistent symptoms or cognitive impairment
• Seizures
• Prolonged LOC (gt 1 minute)
• Multiple concussions requiring progressively less
  impact

• Simple
• Most common form
• Resolves over 7-10 days
• No intervention except complete REST and graded
  return to play

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Concussion Facts

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

Source Ontario Brain Injury Web Site
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More Concussion Facts

• Minor league hockey players (ages 9-17) in
  Canada
• 10 of players per season
• 2.8 concussions per 1000 player hours

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Case 1

• Spectator at 12 y.o nieces playoff Pee Wee
  hockey game in Tisdale
• Star player caught with her head down and checked
  hard hitting head on the ice
• Gets 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

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What would you like to do now?
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Assessment Acute Injury

• ABCs
• C-spine precautions
• Canadian C-Spine Rule

Sensitivity 100 Specificity 42.5
The Canadian C-spine rule for radiography in
alert and stable trauma patients. JAMA 2001 Oct
17286(15)1841-8
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Canadian CT Head Rule

• Any (adult) patient with a mild TBI any of
• GCS lt15 two hours after injury
• Suspected open or depressed skull fracture
• Any sign of basilar skull fracture
• 2 episodes of emesis
• 65 years of age or older
• Retrograde amnesia gt 30 minutes
• Dangerous mechanism
• pedestrian struck by motor vehicle
• occupant ejected from motor vehicle
• Fall from 3 feet or 5 stairs

• Excluded from study
• Neuro deficit
• Anti-coagulation
• Bleeding disorder
• Hx of Seizure

Sensitivity 100 Specificity 88
Comparison of the Canadian CT Head Rule and the
New Orleans Criteria in patients with minor head
injury. JAMA 2005 Sep 28294(12)1511-8
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Now that youre happy youve ruled out the really
worrisome stuff
How do we best assess her for a concussion?
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Assessment Signs and Symptoms

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

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Concussion Signs and Symptoms

• Immediate Symptoms
• Headache
• Dizziness
• Nausea

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Assessment Acute Injury
Sport Concussion Assessment Tool
(SCAT) www.thinksmart.ca

• Cognition
• Memory
• What venue are we at?
• What period is it?
• Who scored last?
• Did we win our last game? Who did we play?
• 5 word recall (immediate delayed)
• Concentration
• Months in reverse, digits backwards

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Assessment Acute Injury

• Neurologic screening
• Speech
• Eye motion pupils
• Pronator drift
• Gait

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Management Acute Injury

• When in doubt, sit them out
• No player should be allowed to play if symptomatic

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Management Acute Injury

• Player should not be allowed back into current
  game or practice
• Player should be monitored and observed for
  several hours post injury
• Medical evaluation
• Dont let player drive
• Not to be left alone for 24-48 hours
• RTP should be a medically supervised process

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Management ER Transfer?

• Worsening headache
• Development of focal neurologic deficits
• Youre worrying about not already having done so

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Case 2

• 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 says she is worried that he might have blood
  on the brain and wants an MRI done (today)

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Case 2 Continued

• Detention last week at school as didnt 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

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Case 2 continued

• 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

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History

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

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Concussion Signs and Symptoms

• Delayed Signs
• Dizziness, vertigo
• Persistent headache
• Poor attention and concentration
• Memory dysfunction
• Nausea/vomiting
• Photophobia
• Anxiety or depression
• Sleep disturbances
• Irritability

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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
• What do you tell him?

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Return to Play Protocol

• NO activity complete physical AND cognitive
  rest
• Light aerobic exercise
• Sport specific exercise
• Non-contact training drills
• Full contact training after medical clearance
• Game play

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Why wont you let me play?!?

• If playing while symptomatic
• Greater risk for another injury
• Another concussion
• Symptoms more severe and long lasting
• Second-Impact syndrome (rare)
• Cumulative neuropsychological impairment?
  (punch-drunk)
• Other injury
• Longer time to recovery

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So I have a concussion

• Mom doesnt think this is very cool at all and
  starts lecturing Tony about not wearing a helmet
• What do you tell them?

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In Office Management

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

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Neuropsychological Assessment

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

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ImPACT Computerized Testing

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

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The Easy to Remember Take Home Message(s)

• Concussions are common and often unrecognized by
  the patient
• When in doubt, sit them out
• No player should be allowed to play if symptomatic

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