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Concussions on Campus

Concussions on Campus. Christina Smith Paul MD, CAQSM Primary Care & Sports Medicine Student Health Service University of Pennsylvania. Overview. Definitions Diagnosis & Clinical Course Cognitive tests Treatment Prevention (EDUCATION , gear ) Clearance: Academics, Sports Referrals?

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Concussions on Campus

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  1. Concussions on Campus Christina Smith Paul MD, CAQSM Primary Care & Sports Medicine Student Health Service University of Pennsylvania

  2. Overview • Definitions • Diagnosis & Clinical Course • Cognitive tests • Treatment • Prevention (EDUCATION, gear) • Clearance: Academics, Sports • Referrals? • Ongoing research

  3. Concussions in the News: ESPN, NYTimes • “SEC concerned about concussions” • “New concussion law suit filed by 100 ex-players” • “Concussions affecting women more often than men” • “More retired players sue NFL over concussion effects” • “Trying to Reduce Head Injuries, Youth Football Limits Practices”

  4. NFL, players reach concussion dealAugust 2013 • Landmark decision • 4500 plaintiffs (former players) • $765 million dollars • $75 million - health exams • $675 million – compensation • $10 million - research

  5. DP • 19 yo M, plays ultimate Frisbee, collided w another player 2 d ago. • No LOC • Tried to get back in the game but “didn’t feel right” • HA, + photophobia, + difficulty concentrating ever since. • Has a test tomorrow • Wants to play in tournament this weekend • Wants to know what he can take/do to get better

  6. Concussion • Concussion = Traumatic Brain Injury • Loss of consciousness = Rare (and not predictive) • Causes: blow to head or body • Symptoms vary • Grading systems obsolete

  7. Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

  8. Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

  9. Evidence-Based Medicine?

  10. Consensus Statement on Concussion in Sport: International Conference(s) • 1st (Prague) 2001 • 2nd (Vienna) 2004 • Produced SCAT • 3rd (Zurich) November 2008 • Produced SCAT 2 • Designed to follow US NIH consensus criteria • And…..

  11. British Journal of Sports Medicine April 2013; 47: 250-258 Panel included Stanley Herring and Margot Putukian from AMSSM

  12. The Fourth Conference: Zurich 2012 Used the same format as previously: • 32 international experts • 2 full days of new research presentations • Extensive structured discussion • Drafted a consensus paper, edited until all were in agreement • Updated version of SCAT (SCAT 3)-with 3 distinct tools • Final drafting of 12 critical review papers, co-published in multiple journals

  13. AMSSM Position Statement: Concussion in sport--Purpose-- • To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion • To establish the level of evidence, knowledge gaps and areas requiring additional research

  14. What we know • Numbers are increasing. 3.8 million in US/yr • More so in females • Theories on why: Anatomy • heads are smaller • necks are smaller/less muscle mass • Theories on why: Culture • Girls more likely to self-report? • Girls get more attention?

  15. What we know • Equipment does not PREVENT concussion “Absence of Proof is not Proof of Absence” www.sportsdentristy.com

  16. What we know • Each subsequent concussion - requires less force • Post Concussion Vulnerability • A second blow sustained before recovery results in worsening metabolic changes within the neuron • This concept is distinct from “second impact syndrome” • The concussed brain is less responsive to usual neuron activation • Prolonged dysfunction may result from premature cognitive activity or vigorous physical activity Is a functional, not structural issue

  17. What we don’t know (but are working on) • How to predict duration of recovery • Why some people are more susceptible • Genetic component (APOE ε4 genotype) • How many is “too many” • How to speed recovery • Supplements • Medications • Physical therapy

  18. DP • 19 yo M, plays ultimate Frisbee, collided w another player 2 d ago. • No LOC • Tried to get back in the game but “didn’t feel right” • HA, + photophobia, + difficulty concentrating ever since. • Has a test tomorrow • Wants to play in tournament this weekend • Wants to know what he can take/do to get better

  19. Concussion Symptoms • Headache • Nausea • Dizziness • Blurry vision • Sensitivity to light or noise • Feeling sluggish, foggy, “out of it” • Confusion • Difficulty with concentration, memory

  20. Emotional • Irritability, sadness, more emotional, nervousness • If positive, screen further (PHQ-9) • Compounding factors: • Loss of time from sport • Falling behind in school • Lack of physical activity/release as coping skill

  21. Concussion Diagnosis • You can’t SEE it • Sings/symptoms usually follow the injury but there can be a delay • Awareness/education of coaches, parents, athletes is VITAL

  22. Concussion Evaluation • HEENT • Pupils • Ocular movement • Nystagmus • hemotympanum • Neck • C-spine tenderness • Neuro • Cranial Nerves • Short term memory • Concentration • Balance (BESS testing if baselined)

  23. Balance Error Scoring System (BESS)

  24. Concussion Treatment • Initial Treatment: • Need for immediate/ED evaluation? • Imaging (ie Head CT?) • Education (student; family; professors, etc.) • HIPPA • COGNITIVE AND PHYSICAL REST

  25. Treatment, continued • Ongoing: • Wake up at night? • Attendance in class? • homework, watch TV, email? • Return to athletics? • ibuprofen? • Role of other meds or physical therapy? • Melatonin • Amantadine • Amitriptyline • Vestibular therapy

  26. Concussion Investigations • Neuroimaging • CT scan • MRI (structural and functional: studies emerging) • Neuropsychological assessment

  27. Neurocognitive Testing • Computer-based • ImPACT, CogSport, HeadMinder • Added tool for use in return-to-play decisions • Avoidance of returning an athlete too soon • Baseline testing • Timing of testing • Pros/cons of testing • Formal “paper and pencil” testing • Several hours • Comprehensive • Reserved for chronic/difficult cases

  28. Management in College • Student/Family education • Health Center • Dean’s Office • Disability Services • Professors • Athletics • Coaches • ATCs

  29. Accommodations • Rest from class • Frequent breaks • Extra time for assignments • Postpone tests/exams • Note taking service • Quiet environment

  30. DP • Returns 48 hours later after complete cognitive and physical rest • Symptom score goes from 35 to 10 • Can he go to school? • Can he go for a run? • When would you expect all symptoms to clear?

  31. Return To School Guidelines (CHOP) • Step 1 • Complete cognitive rest: No TV, computer, text, etc. • Step 2 • Light cognitive activity, 5-15 min increments, frequent breaks, stop if symptomatic • Step 3 • Schoolwork at home, 30 min increments • Step 4 • if tolerating 1-2 hrs at home, can go half day *advance to next step if symptom-free x 24 hrs

  32. Graded Return to Play

  33. Recurrent Concussions • Second impact syndrome: • Brain swells rapidly, death near certain • repeat injury w/o proper healing time • Young people more vulnerable • Few cases • Post concussive syndrome • Chronic Traumatic Encephalopathy

  34. Sports Legacy Institute • Chris Nowinski

  35. Concussions and mental health:In the news Chronic Traumatic Encephalopathy (Tau Protein)

  36. Prevention? • EDUCATION (Coaches, parents, administrators) • Gear limitations (Head gear, Mouth guards) • Gear Changes (Softer balls - Soccer) • Exercises: • Strengthen neck • Learn proper techniques • Tackletechniques • Heading techniques

  37. Prevention • Rule Changes: • NFL and NCAA Football • Kickoffs moved up to 35 yd line (from 30 yd line) • NCAA Football • Post-game video review “targeted hits” • Impose suspension if intentional or reckless • Pop Warner Football • No hitting in 2/3 of practice • Additional precautions (3 yards or less, etc) • USA Hockey • Raise checking age (11 to 13) • Education (coaches, trainers, athletes, parents)

  38. What we are doing at Penn • Concussion policy (NCAA requires) • Baseline ImPACT testing • All Varsity contact sports • All varsity and club athletes must be evaluated and cleared by SHS physician • Referral resources: • Neurology & Neuropsychiatry • Weingarten Learning Resource Center • CAPS (Counseling) • Physical Therapy (Vestibular Rehabilitation)

  39. SHS visits for concussions2012-2013

  40. 2012-13 SHS Data

  41. 2012-13 SHS Data

  42. 2012-13 SHS Data

  43. 2012-13 SHS Data

  44. DP • Symptom score 0 • ImPact back to baseline • Tolerating full academics • 5 day graded return to sport completed • Cleared for ultimate frisbee tournament play

  45. Summary • Suspect concussion? NO return to play same day, regardless of resolution of symptoms Education – most important tool in preventing bad outcomes • Return to academics before athletics • Stepwise approach for both

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