2013 sports concussion management
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2013 Sports Concussion Management. Jim Chesnutt, M.D. OHSU Sports Medicine Orthopaedics and Rehabilitation and Family Medicine. Recognize: Remove: Refer : Return. Concussions: The Problem. - PowerPoint PPT PresentationTRANSCRIPT
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. [email protected] OHSU Sports MedicineJim Chesnutt, M.D [email protected] Webb, D.O. [email protected] Center/ St CharlesSondra Marshall,PhD [email protected] Schock, PhD.
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: [email protected]
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. [email protected] Charles Webb, D.O. [email protected] Ryan Petering, M.D. [email protected] Melissa Novak D.O. [email protected]
Rachel Bengtzen M.D. [email protected] www.ohsusportsmedicine.com or 503-494-4000