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Concussion:Updated Guidelines for a New Era ofSportsDouglas Comeau, DO, CAQSM, FAAFPMedical Director, Sports MedicineDirector, Primary Care Sports Medicine FellowshipRyan Center for Sports Medicine at Boston UniversityBoston Medical CenterHead Team Physician, Boston UniversityTeam Physician, Boston College

DisclosuresBoston University Slideshow Title Goes Here I, Douglas Comeau, nor any family members, haveany relevant financial relationships to be discussed,directly or indirectly, referred to or illustrated with orwithout recognition within the presentation

Learning ObjectivesBoston University Slideshow Title Goes Here Identify the warning signs of concussionKnow appropriate return to play progressionAttempts at preventionFuture research

Concussion can happen at any momentBoston University Slideshow Title Goes Here

With the Game on the LineBoston University Slideshow Title Goes Here

And it can be on the roadBoston University Slideshow Title Goes Here

Would you be ready as Team Physician?Boston University Slideshow Title Goes Here

The After Effects can change your outlookon life Boston University Slideshow Title Goes Here

StatisticsBoston University Slideshow Title Goes Here 300,000 mild traumatic brain injuries occur annually Can happen in any sport Much higher risk in game situation than in practice

History of concussion 40 years ago concussion tle Goes onHereHead Injury Nomenclature ofthe Congress of NeurologicalSurgeons “immediate and transientimpairment of neuralfunctions, such as analteration of consciousness,disturbance of vision andequilibrium due to brain steminvolvement” Over the next thirty years,over sixteen theories andreturn-to-play guidelines werepublished

Prior Grading ScalesGrade 1Grade 2Grade 3CantuNo LOCPTA 30 “LOC 5 “PTA 30” to24’LOC 5 “PTA 24 ‘ColoradoMedicalSocietyTransientconfusionNo PTA, no LOCTransientconfusion PTA , no LOCLOCAmericanAcademy No LOC, sx 15” No LOC, sx 15”Boston University Slideshow Title Goes HereLOC

Prior Grading Scale ReturnGrade 1Grade 2Grade 3CantuNo sx for 1weekNo sx for 2weeksOut 1 mos,No sx for 1weekColoradoMedicalSocietySx 20”No sx for 1weekOut 1 mos, nosx for 2 weeksAmericanAcademy ofNeurologistSx 15”No sx for 1weekBrief LOC: 1 weekLong LOC: 2 weekBoston University Slideshow Title Goes HereSame daySame day

Why didn’t it workBoston University Slideshow Title Goes Here Too many opinions Too many controversies Need for standard of care

Concussion Grading ScalesBoston University Slideshow Title Goes Here Abandoned with 2001 Vienna Conference Now combined measures of recovery Injury severity Injury prognosis Individual-specific return to play Severity graded once all symptoms resolved and athlete hasreturned to baseline Number of concussion signs does not correlate with severityof concussion

Vienna Conference: 2001Boston University Slideshow Title Goes Here First international symposium onconcussion Redefined “sports” concussion traumatically induced transientdisturbance of brain function causedby a complex pathophysiologicprocess. subset of mild traumatic brain injurywhich is generally self-limited and atthe less severe end of the braininjury spectrum.

Defining the Nature of Concussion Directblow to the head, face, neck with an “impulsive” forceBoston University Slideshow Title Goes Heretransmitted to the head Rapid onset of short-lived impairment of neurologicalfunction that resolves spontaneously Neuro-pathologic changes Acute symptoms are functional instead of structural Graded set of clinical syndromes May or may not involve loss of consciousness Resolution typically follows sequelae Typically associated with grossly normal structuralneuroimaging studies

Second International Conference onConcussion: Prague 2005Boston University Slideshow Title Goes Here Second International Conference on Concussion andSport IHF, FIFA, IOC Need to update grading system and management Definition unchanged Nature of Concussion unchanged except for thefollowing Post-concussive symptoms may be prolonged or persistent

Prague Concussion ClassificationBoston University Slideshow Title Goes Here New classificationsystem recommendedwith Prague Conference Simple versus complex Complex

Prague “Simple” Concussion: DefinedBoston University Slideshow Title Goes Here Most common form of concussion Injury that progressively resolves without complicationin 7-10 days Limit play and training while symptomatic No further intervention typically required Athlete resumes sport without problem Mental status screen at time of the injury No formal neuropsychological testing typically required

Prague “Simple” Concussion: TreatmentBoston University Slideshow Title Goes Here Rest until symptoms resolve Minimum 24 hours Graded program of exertion before return tosport BikeRunningFieldHelmet without padsReturnTypically seven days

Prague “Complex” Concussion: DefinedBoston University Slideshow Title Goes Here Athlete suffers persistentsymptoms Including recurrence withexertion Specific sequelae Concussive convulsions Prolonged LOC Greater than 1 minute Prolonged cognitiveimpairment after injury Multiple concussionsover time Repeated concussionswith progressively lessimpact Furtherneuropsychologicaltesting required prior toreturn to play in a multidisciplinary teamapproach

3rd International Conference on Concussion:Zurich 2008Boston University Slideshow Title Goes Here Simple vs. Complex does not work for all Treat each concussion individually Neuropsychiatric testing for all concussions could beideal Developed SCAT2 New Research on Exercise Testing for PCS

Concussion Zurich 2012:Boston University Slideshow Title Goes Here 4th international conference on concussion in sportHeld in November 2012Multi-specialty meetingPCSM, Neurosurgery, Neurology, Family Medicine, Pediatrics,Orthopedic Surgery all representedMultiple professional organizations worldwideEvaluate concussion diagnosis, management, and make anynecessary changesDeveloped SCAT3, including a child SCAT3Neuropsychologist recommended but not mandatedVestibular rehab for chronic symptomsAdded exercise from chronic symptoms

Pathophysiological Basis of ConcussionBoston University Slideshow Title Goes Here No animal or experimental model to date for sportsconcussion Trauma to neurons leads to temporary ionicdisequilibrium This leads to an “energy crisis” for the brain Some experimental studies in TBI show Biochemical Change Metabolic Change Gene Expression Change

Pathophysiology, subtypesBoston University Slideshow Title Goes Here Clinical Manifestations Confusion, Memory Problems, LOC Anatomic Localization Cerebral versus brainstem Biomechanical Impact Rotational versus linear force Genetic Phenotype Apo-lipoprotein epsilon 4 (ApoE4) positive Neuropathological change Structural injury versus none

PathophysiologyBoston University Slideshow Title Goes Here Post-concussive vulnerability, second blow before the brain has recovered results in worseningmetabolic changes within the cell. Concussed brain is less responsive to usual neuralactivation Premature cognitive or physical activity before full recovery hasoccurred Increased vulnerability to prolonged dysfunction

Risk FactorsConcussionBoston University Slideshow Title Goes HereProlonged Recovery Good Evidence Good Evidence Previous history Fair Evidence SportPositionPlaying StyleGender Weak Evidence Migraines Genetics Young age Greater number, severity,duration of symptoms Fair Evidence Pre-injury learningdisabilities, mooddisorders, ADD Migraine

Boston University Sports MedicineQuestions on History and Pathology?Boston University Slideshow Title Goes Here

Pre-participatory ExamBoston University Slideshow Title Goes Here Number of concussions Symptoms of each concussion Suspect undocumented concussion in history of cervicaland facial injuries Teammates and coaches unreliable Inquire about protective equipment at time of injury Baseline cognitive assessment (SCAT3) done prior tothe season If resources available, cognitive evaluation regardless ofage or level.

Concussion DefinedBoston University Slideshow Title Goes Here From Sport Concussion Assessment Tool 3rd Edition Disturbance in brain function caused by a direct orindirect force to the head. It results in a variety of nonspecific signs and/or symptoms and most often doesnot involve loss of consciousness. Concussion shouldbe expected in any one or more of the following: Symptoms (eg. Headache)Physical signs (eg. unsteadiness)Impaired brain function (eg. Confusion)Abnormal behavior (eg. change in personality)

Indications for Emergency ManagementBoston University Slideshow Title Goes Here Glascow Coma Scale 15Deteriorating mental statusPotential spinal injuryProgressive, worsening symptoms or new neurologicsigns

Sideline AssessmentBoston University Slideshow Title Goes Here The unconscious athlete ABCs Cervical spine Immediate referral?

Sideline AssessmentBoston University Slideshow Title Goes Here History Mechanism of InjuryAssess level of alertness, speechAmnesiaGraded Symptom Evaluation

Graded Symptom EvaluationBoston University Slideshow Title Goes Here Athlete scores themselves at the time of evaluation as how theycurrently feel (initial evaluation only) Scoring 0 6 NoneMildModerateSevere For follow-up visits, same scoring system over a period of time Never Sometimes Always

Graded Symptom EvaluationBoston University Slideshow Title Goes Here Headache“pressure in head”neck painnausea or vomitingDizzinessBlurred visionBalance problemsSensitivity to lightSensitivity to noiseFeeling slowed downFeeling like “in a fog“ “Don’t feel right”Difficulty concentratingDifficulty rememberingFatigue or low energyConfusionDrowsinesstrouble falling asleepmore emotionalirritabilitySadnessnervous or Anxious

Graded Symptom EvaluationBoston University Slideshow Title Goes Here Total number of symptoms (Maximum possible 22)Symptom severity score (Maximum possible 132)Do the symptoms get worse with physical activity?Do the symptoms get worse with mental activity?With or without parent input (in office)if you know the athlete well prior to the injury, howdifferent is the athlete acting compared to his / herusual self?

Sideline AssessmentBoston University Slideshow Title Goes Here Physical Exam Vital signs Cervical spine Neurological exam

Assessment ToolsBoston University Slideshow Title Goes Here Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS) Sport Concussion Assessment Tool 3 (SCAT3) Available online for free Smartphone app for free

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BESS: Live ExamplesBoston University Slideshow Title Goes Here BESS Double LegBESS Single LegBESS Single LegTandem Gait

Biodex Balance MachineBoston University Slideshow Title Goes Here

Biodex Report ComparisonBoston University Slideshow Title Goes Here

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Return to Play DecisionBoston University Slideshow Title Goes Here If a concussion is diagnosedthe athlete should not return toplay during that day Still unsure? Functional testing

Sideline 101Thereis NOsame dayreturnTitleto Goes HereBostonUniversitySlideshowplay for athletes diagnosed withconcussion

Monitoring and InstructionsBoston University Slideshow Title Goes Here Frequent assessments for changes in status Instructions for athletes/parents

Symptomatic TreatmentBoston University Slideshow Title Goes Here Early symptoms are generally best manage by cognitive andphysical rest OTC analgesics are commonly used for headache symptoms Other commonly used medications/supplements have an unclearrole in symptom management ADHD medicationsMigraine MedicationFish OilOthers Care should be taken not to cloud the return to play decision bymasking post-concussive symptoms