Saturday, July 14, 2012

Practical Concussion Management

The first job as a physician is "First, do no harm". Perhaps nowhere is this more important than in treating concussions in sport. If you are unsure what to do, always remember - don't make the situation worse.
If you're attending a game, on the sideline, in the stands, where ever, this is perhaps the best advice I can give you.

Having said that, here are a few practical things to consider if you witness a head injury at a game.

1. Principles of First Aid.
I try and start with the classic ABC's. Does the athlete have an adequate airway? Are they breathing? Do they have a pulse (circulation).  If you can ensure these things are happening, you're doing awfully well already. This can all be assessed within seconds.
Please take note: The "do no harm" part of here is, don't let the neck move until you,or someone who is qualified ensures that the neck has not been injured.

2. Assess The Athlete's Symptoms.
If the athlete is still breathing and conscious, then you're allowed to take a breath now too. The assessment tool I use on the sidelines is called the SCAT2. This stands for the "Sport Concussion Assessment Tool" and allows for a standardized means of assessing and following an athlete's symptoms. When I'm covering events I have a version of it with me on my iPad (there's an app for everything, right?).

The initial portion runs through possible concussion symptoms which can include:

  • headache
  • nausea
  • "not feeling right"
  • sensitive to light and or noise
  • anxiety
  • difficulty concentrating or remembering
  • etc.

I follow this with a modified Maddocks score, assessing the athlete's short term recall, using questions like:

  • Where are we playing today?
  • What period are we in?
  • What team did we play last week?
  • Did we win or lose the game last week?
  • Which team scored last?
Finally, I assess their concentration and recall with a number of short tests.

3. Assess Physical Symptoms.
Completing the SCAT assessment involves some balance and co-ordination exercises, and a standardized score is generated from the testing. This is useful as a baseline result, and for comparison as the athlete recovers over time.

Returning to Play
This is the million dollar question, whether you are a pro athlete, playing for your school, or just playing in a recreation league on weekends.
My answer is ALWAYS to err on the side of caution. Sport is a true love of mine, but your brain will always take priority for me.

Initially, on the sideline, if an athlete is displaying any signs or symptoms of a concussion, they need to be taken out of the game immediately.

If they have post concussive symptoms, such as headache, difficulty concentrating, noise/light sensitivity, I tell them they should have complete rest, until those symptoms clear. This means NO video games, NO TV, NO loud music. Once these symptoms have resolved entirely at rest, I allow a graduated return to activity.

  • Step 1 involves usual daily activity.
  • Step 2 involves increasing cardio output like riding a stationary bike.
  • Step 3 involves more sport specific activity, with NO contact. For example, shooting drills in soccer, running receiving routes in football, skating drills in hockey
  • Step 4 involves full contact practice with their own team.
  • Step 5 involves full game play.
At each stage, if any symptoms recur, they MUST stop and go back to the previous step until symptom free at that stage. 
Unfortunately, there are no hard and fast guidelines as to how quickly one can proceed through these stages, but I tend to be fairly aggressive, as long as symptoms do NOT recur.
I continue to repeat portions of  the SCAT assessment frequently throughout.

Final Thoughts.
This post is far from complete and far from all-encompassing, but more to serve as a starting point, and food for thought. The realm of concussions is still cloudy, and despite much more awareness and assessment, our ability as physicians, is still one of preventing further damage, rather than curing anything. I'd rather see my athletes live a long productive life off the field, than miss out on that potential by letting them back too soon.

Let me know what you think! This one's a big topic!

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