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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

Concussion UpdateThe 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

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 .




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? wants to other players who suffered concussion to be tested for potential trauma

  • 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


  • AFL – 5-6/1000 player hours wants to other players who suffered concussion to be tested for potential trauma

  • Equals 6-7/season per team on average

BrizBrain & Spine St Andrews Education Meeting 2006


Symptoms signs
Symptoms & Signs wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

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


BrizBrain & Spine St Andrews Education Meeting 2006


In emergency room surgery
In Emergency Room/Surgery wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma


Management
Management wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

  • 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) wants to other players who suffered concussion to be tested for potential trauma

  • 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) wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

  • 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) wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

  • 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 wants to other players who suffered concussion to be tested for potential trauma

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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