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Slide 2 Concussions range in severity but they all have one thing in common: They interfere with the way your brain works CONCUSSION Dr. Karen Barlow Acting Division Head, Pediatric Neurology Alberta Children's Hospital Foundation for Research Institute for Child and Maternal Health Dr. Kelly Brett Sports Medicine Physician University of Calgary, Sports Medicine Clinic Head physician, Calgary Flames Dr. Jeff Dunn Director, Experimental Imaging Centre Professor, Department of Radiology University of Calgary, Faculty of Medicine Dave Irwin Foundation for Brain Injury Slide 3 Steve Asmus, Ph.D Axonsthe fragile wires 0.001-0.01 mm in diameter SHEARING OF THE WIRESbreaking connections Slide 4 0.1mm BRAIN BRUISE: microbleeds Microvessels throughout the brainthe blood/brain barrier Slide 5 PAIN Only in the meninges, the thin surface covering of the brain There can be damage with little or no pain. Slide 6 Healing process Blood vessels heal- old blood and dead cells removed Healing of brain barrier Minutes to hours1-14 days Bleeding stops Remaking connections including new connections Weeks to months Slide 7 Challenges Detection MRI 20 patients with loss of consciousness, imaged at 1 day and 3 months after concussion---only 1 patient showed anything useful on MRI Schrader, et al. (2009) Magnetic resonance imaging after most common form of concussion. BMC Med Imaging 9, 11. Complexity 4524 scientific papers (140 in 2009) published on concussion. Reading 1 paper a day, it would take over 12 years to read the literature Management and outcome--- Slide 8 CONCUSSION Return to Sport and Risk of Reinjury Kelly Brett MD, Dip. Sport Med. (CASM) Faculty of Kinesiology, University of Calgary Head Physician, Calgary Flames Slide 9 Concussion Guidelines based on the 3 rd International Symposium on Concussion in Sport, Zurich 2008 1 st meeting in Vienna in 2001 2 nd meeting in Prague 2004 Organized by IIHF, FIFA, IOC, IRB Aim of symposium was for the improvement of safety and health of athletes who suffered sport- related concussion Slide 10 Concussion Guidelines Developed for use by doctors, therapists, health professionals, coaches and others involved in the care of injured athletes with sport-related concussion Protocol developed in an attempt to provide a comprehensive, systemic approach to concussion injury Protocol represents a work in progress Slide 11 Revised Definition of Concussion Concussion is defined as a complex process affecting the brain, induced by traumatic biomechanical forces. Common features that incorporate clinical, pathologic and biomechanical injury that may be used to define concussion include: Slide 12 Features of Concussion 1.Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the brain. 2.Concussion typically results in a rapid onset of short-lived impairment of brain function that resolves spontaneously 3. Concussion largely reflects a functional disturbance rather than structural injury to the brain Slide 13 Features of Concussion 4.Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness and resolution of the symptoms typically follows a sequential course. A small percentage of cases go on to Post-concussive Syndrome (PCS) 5.NO abnormality on standard structural neuroimaging studies is seen in concussion (normal MRI or CT) Slide 14 Grading Scales 25+ grading scales worldwide each with its own strengths and weaknesses and none scientifically validated The majority of concussions (80-90%) resolve in 7-10 days but may be longer in children and adolescents Slide 15 Symptoms and Signs of Acute Concussion The suspected diagnosis of concussion can include one or more of the following clinical domains: (a) Symptoms: (eg, headache etc next slide) (b) Physical signs (eg, loss of consciousness, amnesia, impact seizure, poor balance) (c) Behavioural changes (eg, irritability, emotional lability) (d) Cognitive impairment (eg, slowed reaction times, poor performance missing gates) (e) Sleep disturbance (eg, drowsiness) Slide 16 Common Symptoms: confusion, amnesia, unaware of time, date, place headache, dizziness, nausea, unsteadiness feeling dinged, not feeling right, dazed or stunned seeing stars or flashing lights, ringing in ears, double vision subjective feeling of slowness, fatigue Slide 17 Evaluation If any of symptoms or signs are present, a concussion should be suspected and appropriate management instituted An athlete does need to have loss of consciousness to have suffered a concussion) Slide 18 When a player shows ANY symptoms or signs of a concussion 1. The athlete should not be allowed to return to play in the current practice or competition 2. The athlete should not be left alone: regular monitoring for deterioration is essential 3. The athlete should be medically evaluated urgently following the injury including use of the SCAT2 or similar tool 4. Return to play must follow a medically supervised stepwise process Slide 19 Slide 20 Principles of Concussion Management Recommend a combined measure of recovery (hillside evaluation, recovery of symptoms and guided progression of activity while asymptomatic) Concussion symptoms and recovery time are highly individualized to each athlete Physicians/trainers/coach experience and knowledge of concussion is very important in evaluating an athletes return to play Slide 21 Concussion Management The cornerstone of concussion management is physical and cognitive rest until ALL symptoms and signs resolve completely Slide 22 What Constitutes Rest? Physical rest from any form of exercise other than normal activities of daily living Cognitive rest activities that require concentration and attention may exacerbate symptoms and prolong recovery (example: homework, video games, texting or on-line activities like Facebook) Slide 23 GOOD LUCK WITH THIS ONE!! Slide 24 SCAT2 Symptom Score a good way to track recovery Slide 25 Graduated Return to Play Protocol Slide 26 Return to Play Protocol Protocol only starts after completely symptomatic The athlete should continue to proceed to the next level only if asymptomatic at the current level. Generally, each step should take 24 hours so that an athlete would take approximately one week to proceed through the full rehabilitation protocol If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed. Slide 27 Role of Neuropsychological Testing: Cognitive Function Neuropsychological testing in concussion has been shown to be of clinical value Cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution suggesting that the assessment of cognitive function could be an important component in any return to play protocol Slide 28 Neuropsychological Testing (NP) When neuropsychologists are not available to administer NP tests, other medical professionals may perform or interpret NP screening tests. The ultimate return to play decision should remain a medical one Slide 29 Neuropsychological Testing (NP) In the majority of cases, NP testing will be used to assist return to play decisions and will not be done until the patient is symptom free There may be situations (eg, child and adolescent athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining management Slide 30 Neuropsychological Testing (NP) NP assessment should not be the sole basis of management decisions There may be a role in providing baseline testing for all athletes at high risk for concussion NP testing must also be age specific Slide 31 On-line Neuropsychological Testing Examples ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) U.S. CogState Sport Australia Slide 32 Potential Modifying Factors in Concussion Management Slide 33 Children and Adolescents Consensus panel in Zurich advised guidelines could be applied to adolescents down to the age of 10 years Below that age children report concussion symptoms differently from adults and would require age-appropriate symptom checklists as a component of assessment Because of the different physiological responses and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative return to play approach is recommended Slide 34 Thank you!!