2013 Sports Concussion Management

Jim Chesnutt, M.D. OHSU Sports Medicine

Orthopaedics and Rehabilitation

and Family Medicine

Recognize: Remove: Refer : Return

Concussions: The Problem

• We now realize concussions occur more often than previously thought

• Young athletes are at risk for serious short-term and long-term problems

• There is much variation in the knowledge of Health Care Providers managing concussed athletes

• New and emerging technologies will lead to a continuing evolution of care

What is a Concussion?• A concussion is a mild

traumatic brain injury that interferes with normal function of the brain

• Evolving knowledge- “dings” and “bell ringers” are brain injuries- no such thing as a mild concussion

• Loss of consciousness is not common in concussion(<90%) and is not prognostic factor unless >30 minutes

Concussions• Estimated 300,000- 3 mil

sports-related head injuries in athletes yearly

• 9% of all sports injuries• 700-2000? head-injuries

in Oregon HS athletes based on OSAA participation #s

• Pros: lower incidence possibly 10x lower

Newer Data High School RIO 08-09Injury rate per 100,000 player exposures• Football 52 • Girls’ Lacrosse 39 • Girls’ soccer 35• Boys’ Lacrosse 32 • Wrestling 22 • Girls basketball 20 • Boys’ soccer 17 • Softball 15• Boys basketball 7

Concussion

• Symptoms are variable for each individual in terms of type, intensity and duration

• Classified into three main areas: – physical ( HA, dizzy)– emotional ( agitated, quiet, depressed), – cognitive ( memory, processing)

• Cumulative impairment can occur• 3x more likely to get a second concussion

Second Impact Syndrome

• Injury before recovery from the previous head injury

• May cause brain swelling from loss of normal control of brain blood flow– Rare but deadly, more common in teenagers

• Prevention is the key…….– Do not return to play too early

The Goal of Appropriate Treatment

• Minimize the duration of symptoms• Return to play as soon as safely

possible• Avoid entirely the risk of second impact

syndrome• Minimize the rate of chronic post

concussion syndrome

Recovery from concussion• 80% of concussion recover well if managed

actively in the first 3 weeks.• Average recovery time for youth with

concussion is about 3 weeks• Loss of consciousness is not a prognostic

factor for recovery unless >30 min• Imaging is not usually helpful ( mostly done

in first 48 hrs if decline mental status increased HA or neurologic deficit)

Landmark Guidelines 2008-9 Clin J. Sports Med 2009,19:185-200

( balance testing, SCAT2 and new science )

New Guidelines just published!

New in Oregonin 2008-9

• State-wide concussion management program involving all high schools– Establish state-wide physician

network – Uniform evaluation and

management protocol– Consultation service for

coaches, athletes, parents, and physicians

– ImPACT baseline suggested for contact and collision sport athletes: www.impacttest.com

Concussions: The Oregon Plan

Identified Regional Leaders • Portland: OHSU• Eugene: Slocum• Bend: The Center

• Each provides oversite of schools in their regions and help local doctors/trainers care for their own athletes

Oregon Concussion Awareness and Management Program

(OCAMP) The Oregon Concussion Assessment and

Management Program (OCAMP) is a group made up of physicians, neuropsychologists, athletic directors, certified athletic trainers, educators and representatives from OSAA, ODE and OADA. We are working with OSAA and ODE to develop a model to support students as they return safely to full participation in athletics and academics.

Oregon Concussion Awareness and Management Program (OCAMP)

Slocum Orthopaedic and Sports Medicine CenterMick Koester,M.D. mkoester@slocumcenter.com OHSU Sports MedicineJim Chesnutt, M.D chesnutt@ohsu.eduCharles Webb, D.O. webbch@ohsu.eduThe Center/ St CharlesSondra Marshall,PhD sbmarshall@stcharleshealthcare.orgLeah Schock, PhD.

lschock@stcharleshealthcare.org

Contact us for questions or to sign up!

Max’s Law: Sports Concussion (SB 348- April 2009)

• Max Condradt is an OR brain- injured athlete hurt in football

• Law focused on no return-to- play the same day as concussion

• Medical release needed to return to play• Yearly coach concussion education required• Effective: July 2009

New Concussion Guidelines

1. No Same Day Return to Play

2. Return to Play Recommendations *approximately one week out*

Symptoms fully resolved -and-Complete a structured, graded exertion protocol over

approximately 5-7 days without symptoms

Concussions: Return to PlayA Step-wise symptom limited program

1. Rest until asymptomatic ( physical,mental)2. Light aerobic exercise ( exercise bike)3. Sport- specific exercise4. Non-contact training drills ( wt lifting or sleds)5. Full contact training (after medical clearance)6. Return to competition( game play)

Each stage is about 24 hrs or longer and return to stage one if symptoms reoccur

Module 1: Word Discrimination

Module 2: Design Memory

Module 3: X's and O’s

Purpose of Care Plan: Guide recovery , Educate, Manage exertional and school activity Educational resources: State TBI Teams Develop concussion education programs and return to academic programs, and assist with 504 plans if needed.

Call : 877.872.7246 or Email: tbi@wou.edu

Return to School

50 60

OSAA Concussion Return to Play Form

Keys to Recovery• Resting the brain & getting good sleep• No additional forces to head/ brain• Managing/ facilitating physiological recovery

– Avoid activities that produce symptoms– Not over-exerting body or brain

Ways to over-exert• Physical• Emotional• Cognitive! (concentration, learning, memory)

Return to Play considerations• All symptoms need to resolve

–This includes HA, especially–Follow symptom log

• Neurocognitive scores usually normalize after symptoms resolve

• If symptoms recur with exercise, school, work or play: remove from activity/ modify RTP plan

When Return to Play?….to full shedule at school?

• No longer have symptoms– No longer need medicine to control symptoms.

• Neuro-cognitive function & balance back to “normal.”– After rest and gradual activity (exertion)

• Cleared by medical professional.Zurich: Recognition that the child/ adolescent

student-athlete may take longer, and we should proceed more cautiously

Comprehensive/ Team- Based Treatment Modalities

• Rest from school and activities• School modifications• Rehabilitation, cognitive and visual therapy• Medications• Neuropsycholgy testing• Psychiatry/ Neurology as needed• Educational counselling

OHSU Concussion Managementwww.ohsusportsmedicine.com or 503-494-4000

• Pre-season Impact baseline testing– Can do whole team or individuals

• Athletic trainers on- field and in injury clinic• Post –concussion evaluations

– Physician and ATC evaluations & Impact testing• Concussion Rehabilitation Team

– PT, Vestibular/ENT, SLP/ cognitive,OT/vision• Pediatric Neuropsychology testing if chronic• Sport Concussion Support Group (student/family)

OHSU Concussion Rehab TeamA. Speech -language pathologist: for evaluation and treatment to address cognitive and executive function issues

B. Physical therapy: for vestibular therapy and neck and associated orthopaedic issues.

C. Occupational Therapy: for visual and functional therapy.

This is on the 1st floor of OHSU Center for Health and Healing.Please call 503-494-3151 to schedule an appointment but this will likely

need to be approved by your insurance

Concussion Medication Management• Fish oil and tylenol early, NSAID after 72 hrs

• Amitriptyline 10 mg pills. Take10-50mg ( 1-5 pills) at night at bedtime as directed for Headache/nerve pain and to help with sleep.

• Amantadine 100 mg BID is used for concussion symptoms.Please take one pill in Am then after one week consider adding one more at noon. Continue for about 2-4 weeks to see if this helps with your concussion- related symptoms.

• Topimax: 50 mg BID start 25 HS, increase q3-7• Antidpressants, aleve, anti-seizure meds, Bblocker,triptan

When Return to Play?Criteria for RTP

• No longer have symptoms– No longer need medicine to control symptoms.

• Neurocognitive function & balance back to “normal.”– After rest and gradual activity (exertion)

• Cleared by medical professional.Zurich: Recognition that the child/ adolescent

student-athlete may take longer, and we should proceed more cautiously

Summary• Must improve early identification & diagnosis

• Coach, athlete, parent, medical education

• Careful individualized clinical assessment and tracking from time of injury• SCAT2• Neuropsychological Testing ( Impact, Axon, or full)

• Implement active treatment in home & school school accommodations, 504 plan,

OCAMP.org• Free coaches education:

www.osaa.org/healthandsafety/concussion.asp

ConcussionFinal thoughts….

• Be alert for subtle symptoms• Adhere to guidelines to limit contact for

about one week and transition back to play• Consider use of neuropsych testing

– Document baseline, deficits and improvement• Be aware of cumulative trauma and risk for

permanent damage• Be more conservative with younger

athletes

Sports Concussion ManagementContact our sports medicine team for questions:

Jim Chesnutt, M.D. chesnutt@ohsu.edu Charles Webb, D.O. webbch@ohsu.edu Ryan Petering, M.D. petering@ohsu.edu Melissa Novak D.O. novakm@ohsu.edu

Rachel Bengtzen M.D. bengtzen@ohsu.edu www.ohsusportsmedicine.com or 503-494-4000