Concussion update the state of play
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Concussion Update The State of Play. Terry Coyne BrizBrain & Spine Sunshine Coast Brain & Spine. Aims. Identify concussion Appropriately advise players/other stakeholders re management, return to play Access resources. NFL, RETIRED PLAYERS RESOLVE CONCUSSION

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Concussion Update The State of Play

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Concussion update the state of play

Concussion UpdateThe State of Play

Terry Coyne

BrizBrain & Spine

Sunshine Coast Brain & Spine


Concussion update the state of play

Aims

  • Identify concussion

  • Appropriately advise players/other stakeholders re management, return to play

  • Access resources


Concussion update the state of play

NFL, RETIRED PLAYERS RESOLVE CONCUSSION

LITIGATION; COURT-APPOINTED MEDIATOR

HAILS “HISTORIC” AGREEMENT

Thousands of Retirees and Families to Benefit

Medical Testing; Research; Compensation and

Promotion of Safety All Part of Agreement

Former United States District Judge Layn Phillips, the court-appointed mediator in the consolidated concussion-related lawsuits brought by more than 4,500 retired football players against the National Football League and others, announced today that .


Concussion update the state of play

  • NFL would pay $765 million plus legal costs, but admits no wrongdoing.

  • Individual awards would be capped at $5 million for players suffering from Alzheimer’s disease.

  • Individual awards would be capped at $4 million for deaths from chronic traumatic encephalopathy (CTE).


Concussion update the state of play

  • Greg Williams has said that multiple concussions in his career resulted in permanent damage.

  • The Age, September 2013


Concussion update the state of play

NRL legend Mark Geyer set to have a brain examination and wants to other players who suffered concussion to be tested for potential trauma

James HooperThe Sunday TelegraphMarch 15, 2014


What is concussion

What is concussion?

  • Subset of mechanical brain injury

  • Can be direct or transmitted force to head

  • Typically rapid onset of neurological impairment which resolves spontaneously, but may evolve over minutes/hours

  • Acute symptoms usually due to functional disturbance rather than structural

  • May or may not involve LOC

  • Occasionally symptoms may be prolonged

BrizBrain & Spine St Andrews Education Meeting 2006


Concussion update the state of play

  • AFL – 5-6/1000 player hours

  • Equals 6-7/season per team on average

BrizBrain & Spine St Andrews Education Meeting 2006


Symptoms signs

Symptoms & Signs

  • Symptoms - somatic (eg headache)

    - cognitive (eg “feeling foggy”)

    - emotional (eg lability)

  • Signs eg loss of consciousness, amnesia

  • Behavioural change (eg irritability)

  • Cognitive impairment (eg slowed reaction times)

  • Sleep disturbance (eg insomnia)

BrizBrain & Spine St Andrews Education Meeting 2006


On field sideline evaluation

On field/Sideline evaluation

If ANY features of concussion:

  • Player requires evaluation; if none available, remove from play and arrange assessment

  • Standard emergency evaluation (ABC’s), Cx spine assessment

  • Assessment using appropriate tool (eg SCAT 3)

  • Player not left alone

  • If concussion – no return to play that day

BrizBrain & Spine St Andrews Education Meeting 2006


Concussion update the state of play

  • Diagnosis is a medical decision based on clinical judgement

  • Traditional questions to assess orientation (T,P, P) unreliable

  • Can be delayed

BrizBrain & Spine St Andrews Education Meeting 2006


In emergency room surgery

In Emergency Room/Surgery

  • Good history, detailed neuro exam (including mental status, cognition, gait, balance)

  • Improving or deteriorating?

  • Assess need for neuroimaging if need to exclude structural injury (prolonged disturbed LOC, focal deficit, deteriorating)

    (SCAT 3)

BrizBrain & Spine St Andrews Education Meeting 2006


Other investigations

Other Investigations

  • Balance Error Scoring System (BESS) – postural stability correlates well with overall neurological motor function

  • Biomarkers – genetic (eg Apo 4)

    - cytokines (eg IGF-1, S-100), in

    serum, CSF

  • Electrophysiological – EEG, evoked responses) - interesting, but significance

    unknown

BrizBrain & Spine St Andrews Education Meeting 2006


Neuropsychological assessment

Neuropsychological Assessment

  • Useful, but not practical except in professional setting

  • Symptoms usually resolve first, so when used usually after player asymptomatic

  • No evidence to support baseline neuropsych testing

BrizBrain & Spine St Andrews Education Meeting 2006


Concussion

Concussion


Management

Management

  • Key Points – physical and cognitive rest until

    acute symptoms resolve

    - then graduated exertion to

    normal play

  • No return to play on day of a concussion, esp school age, where cognitive deficits may not be present on the sideline, but may be delayed, more so than in adults

BrizBrain & Spine St Andrews Education Meeting 2006


Graduated rtp

Graduated RTP

  • Usually 24 hrs for each level, so 1 week to progress to RTP from when asymptomatic at rest

  • If symptoms recur, rest 24 hrs, and restart one level back, where was asymptomatic

  • Elite v non-elite – elite may have more resources, but their brains are the same, so management no different

BrizBrain & Spine St Andrews Education Meeting 2006


Persisting symptoms 10 days

Persisting symptoms (>10 days)

  • 10-15 % of concussions

  • Consider other pathologies (imaging)

  • Maybe multi-disciplinary approach – physio, psychologist, neuropsychologist, vestibular rehab etc

  • Pharmacology – specific symptoms (eg sleep disturbance, anxiety)

    - modify pathophysiology to shorten symptoms - methylphenidate (Ritalin), amantadine. But…….

BrizBrain & Spine St Andrews Education Meeting 2006


Children 13 yrs

Children (<13 yrs)

  • Ist step is successful return to school, prior to physical activity, even physical ADL’s

  • Increased risk of cerebral swelling

  • Need to be entirely symptom free before return to sport

  • May take longer to recover than adults

  • Child SCAT – neuropsych more difficult as brain not mature, so hard to standardise tests

  • Generally be more cautious

BrizBrain & Spine St Andrews Education Meeting 2006


Risks of too soon rtp

Risks of too soon RTP

  • Impaired performance, re-injury due to slower reaction times, for example

  • 2nd impact – acute severe cerebral swelling

    - ? disturbed auto regulation

    - case report level

  • ?CTE – seems to be greater risk of cognitive impairment, depression/other mental health issues amongst NFL players with multiple concussions; but we don’t know the type, number or severity of concussions required, and why a small # only get CTE. So, err on the side of caution

BrizBrain & Spine St Andrews Education Meeting 2006,


Chronic traumatic encephalopathy cte

Chronic traumatic encephalopathy (CTE)

  • Distinct tau-opathy

  • Incidence in athletes unknown

  • Cause and effect unknown

  • ?Genetic disposition

  • Other factors – age, mental health, alcohol/drug use, medical co-morbidities – largely not accounted for in studies to date

BrizBrain & Spine St Andrews Education Meeting 2006


Prevention

Prevention

  • Unfortunately, little evidence for protective gear. Mouthguards, football helmets good for dental, facial protection, but no evidence they decrease concussion. Also “risk compensation”, esp children, adolescents

  • Skiing, snowboarding – evidence, so recommended

  • Cycling, equestrian, motor sports - prob protect against falls against hard surfaces, less skull #’s

BrizBrain & Spine St Andrews Education Meeting 2006


Thank you

Thank you

Visit BBS Website to download:

  • Pocket Concussion Recognition Tool

  • SCAT 3

  • Child SCAT 3

  • Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012

BrizBrain & Spine St Andrews Education Meeting 2006


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