Download Sports concussion management in the South African environment

Sports concussion management in the
South African environment
Dr Jon Patricios
Sports Physician, Johannesburg
Director of Sports Concussion South Africa
IRB, SA Rugby and BokSmart Concussion Consultant
Introduction
Together with the rest of the sporting world, South Africa has followed a decade-long evolution in clinical
evaluation and care of the concussed athletes. Moreover, with the collision sport of rugby union accounting
for by far the largest number of cases of concussion, we have adapted our protocols to reach the diverse
populations playing this sport, intertwine clinical know-how with grassroots education of the public, coaches
and referees and make the clinical assessment template more comprehensive.
Definition
The modern expanded definition of concussion as “a trauma-induced, complex patho-physiological alteration
in brain function” that emphasises a wide array of possible clinical manifestations and highlights microscopic
and physiological brain changes rather than gross structural abnormality, has remained intact since the first
international conference on concussion in sport in Vienna, 2001. Indeed it is this broad descriptive terminology
that dictates a multifaceted and serial clinical approach to the concussed athlete. The South African approach
to concussion management takes its lead from the consensus documents that have emerged since then, most
recently from the 2008 Zurich meeting and can be classified into the following categories:
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Education
Fieldside care
Initial clinical assessment
Follow-up clinical assessments
Return-to-play
Education
There is a drive internationally to better educate the sports-participating public as well as clinicians as to the
significance of recognising concussion and the importance of following best clinical practice guidelines.
Public education programmes make use of media campaigns (e.g. “Sports Concussion Awareness Week” on
radio), public and school lectures and the internet (www.sportsconcussion.co.za). Most importantly
educational drives are closely linked with the South African Rugby Union’s BokSmart injury-prevention
campaign that aims to limit all but especially serious and catastrophic rugby injuries by targeting rugby
referees and coaches. Educational posters, pocket concussion cards and pamphlets that summarise best
concussion practice are freely available to schools and clubs and all protocols are fully described on the
BokSmart website pages applying to concussion (www.boksmart.com).
In addition free advice and emergency transport for head and spine-injured athletes is available from the 24
hour Spineline 0800-678678, as well as training for first aiders through the “Rugby Medics” programme. All
rugby referees and coaches at any level from Springbok to primary school have to undergo a 2-yearly
BokSmart certification course. The purpose of this multifaceted educational and intervention process is the
early identification and appropriate referral of concussed players so as to prevent the potentially serious
sequelae of head injury including intra-cranial haemorrhage, diffuse cerebral oedema or “second impact
syndrome” which most often occur with mismanagement in the early stages of injury.
Fieldside care
Any player that loses consciousness, has neck pain or associated neurological symptoms should be treated as a
neck injury, implying head and neck stabilisation and stretchering off the field. Facilitation of appropriate field
side care medical or paramedical care is guided by the Pocket Field side Sports Concussion Assessment Tool
(SCAT) card. The South African version of the field side card that emerged from the Zurich consensus meeting
contains the following information:
1.
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Identification of concussion using
Simple memory function testing in the form of modified Maddock’s questions (on-field questions devised
by a neuropsychologist to distinguish significant concussion)
Common early symptoms and signs of concussion;
“Do’s and don’ts” for the concussed athlete
Identification of “Red Flags” that may indicate more serious or rapidly progressing pathology.
Contact details for local emergency departments and sports concussion clinics
Athletes identified as having possibly suffered a concussion should be removed from the field and receive
further evaluation as soon as possible.
Initial clinical evaluation
The Sports Concussion Assessment Tool version 3 (SCAT3) emerged from the Zurich consensus meeting as the
template
best-suited
to
evaluate
the
concussed
athlete.
The
SCAT3
(http://www.sportsconcussion.co.za/Pharos/Protocols.php) is designed for use by medical and paramedical
personnel and includes the following important information:
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Educational information on the definition and significance of concussion
Epidemiological information
A symptom analysis and score
Scores for:
Glasgow Coma Scale
Physical signs
Verbal cognitive assessment
Balance
Athlete “Red Flag” information
Athlete advice
More recently (2011) the SCAT has become available as an iPad and iPhone application improving fieldside
functionality. The South African experience is that the SCAT3 is appropriate for acute concussion assessment
but that a more comprehensive tool is needed to facilitate record and guide complete concussion care.
Serial follow-up clinical evaluation
Following acute assessment and management of the concussed athlete, the next phase is the most essential in
facilitating timely return-to-play for which the following criteria must be met:
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The athlete must be asymptomatic
The neurological (including verbal cognitive and balance) examination must be normal
Computerised cognitive tests must have returned to baseline or be equivalent to age-appropriate norms.
An asymptomatic exercise stress test must have been completed.
In our experience, the SCAT3 is inadequate to be used as a template for this more extensive assessment phase
and there is a trend away from over-reliance on computerised cognitive tools which are most-appropriately
interpreted as part of a thorough clinical evaluation. This has led to the creation of the Sports Concussion Office
Assessment Tool (SCOAT) designed to facilitate continuity with SCAT3 but provide a more comprehensive
template to serially monitor the resolution of sports concussion. In essence this template is designed to:
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Be used serially by clinicians in a consulting room environment
Evolve from the SCAT3 by retaining the important features relevant to acute, subacute and subsequent
presentations
Exclude those aspects of SCAT3 only relevant to the field side assessment of concussion
Follow the Zurich consensus guidelines as closely as possible
Simplify the scoring system to one that tends towards zero before returning to play
Aid as a tool for further research.
SCOAT excludes those aspects of the SCAT3 only relevant to the most acute phase of concussion, duplicates the
parts relevant in ongoing serial assessments, incorporates more features of significance to the concussed athlete
and simplifies the scoring system.
Instructions
It is assumed that clinicians using the SCOAT are familiar with modern concussion management and many of
the detailed instructions included in SCAT3 have been omitted.
Epidemiological data
These are expanded upon from the SCAT3 with the addition of “position played” and the “mechanism of
injury” both of which may be relevant in epidemiological data capture. Loss of consciousness (LOC) and, in
particular, amnesia are specifically recorded. Rather than an emphasis on the presence and duration of LOC
which heavily influenced previous grading scales and RTP, amnesia is now acknowledged as the more
significant acute marker of injury severity and duration.
“Red Flags”
As a reminder to clinicians that more serious intra-cranial pathology may mimic concussion particularly in the
early stages of presentation, those symptoms that may indicate a need for neuroimaging and neurosurgical
referral are afforded more prominence than in the SCAT3.
Compliance record
We have found that patient recovery is often influenced by compliance to the advice given. For example:
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Was a concussed child kept from school?
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Did he/she avoid unnecessary forms of cognitive stress (computer games; texting etc.)?
Were all forms of physical exertion avoided?
Failure to adequately comply may explain slower progress and is therefore recorded; similarly, claims of
good compliance in the face of a failure to clinically improve may be a poor prognostic sign.
Modifying factors
Several associations have been described in the literature between predisposition and prognosis and their
influences on recovery and prognosis. It is most beneficial to document such features as a qualitative record
that may significantly influence player management.
Symptom analysis
One of the most influential determinants of clinical progress is the progression of symptom resolution. The
SCOAT retains the same 22 symptoms as SCAT3 and the 7-point Likert scale form common to most concussion
symptom scales but divides them into clusters to enable the clinician to more efficiently monitor trends in
both presentation (i.e. are the manifestations of injury more physical, cognitive, emotional or sleep-related?)
and resolution.
Verbal Cognitive Assessment
The clinical cognitive assessment (cognitive assessment, immediate memory, concentration and delayed recall) as
described and validated in the Standardised Assessment Concussion is left almost unchanged from SCAT3. Of note
however, is that SCOAT uses a modified scoring system where incorrect answers are awarded 1 point. The purpose
of this is to again create a “norm” of zero mistakes, the aggregate score in the recovering patient trending towards
zero.
Balance Assessment
The validated Balance Error Scoring System (BESS) is left unchanged as is the awarding of a point for each error
scored, again aiming for a “normal” score of zero.
Examination
As the SCOAT is designed as a clinical evaluation form, space is afforded to clinical examination findings both
general and neurological. Again a score of 1 point for any adverse finding is awarded as an acknowledgement
that players should have a normal neurological examination before returning to sport.
Computerised Cognitive Screening
The trend in concussion evaluation is towards thorough and serial clinical assessments. However, the
emergence of computerised cognitive test batteries has provided an additional validated tool enabling the
clinician to evaluate changes in brain function particularly where a pre-injury baseline score is available.
Neuroimaging
Because the manifestations of concussion are largely functional rather than structural, brain scans (CT or MRI)
have specific indications. In those cases where imaging is warranted, the indication, type of scan and result are
recorded on the SCOAT.
Scoring system
The maximum aggregate score is 200 and before returning to play the patient should ideally score zero meaning
there are no symptoms, the examination is normal and the verbal cognitive, co-ordination and balance tasks
were perfectly completed. In a fully recovered patient this may still not be possible where baseline measures of
these parameters are not perfect, but we feel that zero provides a benchmark towards which all recovering
concussed athletes should trend.
Recommended Management
The SCOAT provides a record of medications prescribed, referrals to colleagues and paperwork dispensed.
Checklist
The final block is a checklist of those factors most highlighted in the consensus statements and essential for
ensuring that the athlete is recovered before returning to sport namely that they are asymptomatic, have a
normal examination, the computerised cognitive screen has normalised and the return-to-play exercise
protocol has been followed whilst acknowledging the influence of modifying factors.
Conclusion
South African sports concussion management guidelines follow international consensus whilst also
customising both educational programmes and clinical protocols to strive for appropriate standardised best
clinical practice in this country. The integration of best practice guidelines into the BokSmart injury prevention
programme has facilitated a national footprint, whilst the dividing of the clinical approach into field side, acute
and follow-up protocols has streamlined medical management. The SCOAT is a clinical tool designed to
integrate all aspects of concussion care deemed to be essential.
References available on request.
All protocols referred to are available at:
www.sportsconcussion.co.za and www.boksmart.com
Pocket Fieldside Sports Concussion Assessment Tool (SCAT)
Concussion should be suspected in the presence of any one or more of the following:
symptoms (such as headache) or
physical signs (such as unsteadiness) or
impaired brain function (e.g. confusion, memory loss) or
abnormal behaviour.
1. Memory function
Failure to answer all questions correctly may suggest a concussion.
“At what venue are we at today?”
“Which half is it now?”
“Who scored last in this game?”
“Did your team win the last game?”
2. Symptoms
Presence of any of the following signs & symptoms may suggest a concussion.
Loss of consciousness
Blurred vision
Difficulty remembering
Seizure or convulsion
Balance problems
Fatigue or low energy
Amnesia
Sensitivity to light
Confusion
Headache
Sensitivity to noise
Drowsiness
“Pressure in head”
Feeling slowed down
More emotional
Neck Pain
Feeling like “in a fog“
Irritability
Nausea or vomiting
“Don’t feel right”
Sadness
Dizziness
Difficulty concentrating
Nervous or anxious
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY,
urgently assessed medically and should not be left alone.
Important Advice:
A doctor must assess you after suffering a suspected concussion. If concerned about the player’s
condition, transfer immediately to an Emergency Department; if the player is lucid and stable,
he/she may be monitored at home and should attend the Sports Concussion Clinic in the coming
days. Note: a normal X-ray, CT or MRI brain scan does NOT exclude concussion.
If referred home:
Always make sure that you are in the presence of a responsible adult for 48 hours.
Record and monitor the symptoms of concussion including headache, nausea, dizziness, fatigue,
sleep disturbances, memory lapses, mood swings, poor concentration or any other feeling that
concerns you.
Complete rest & sleep will help recovery.
Use only mild painkillers (e.g. Panado) for headaches
DO NOT:
Consume alcohol
Study
Take excessive amounts of painkillers(follow doctor’s
Work at the computer
orders)
Place yourself in an environment of loud noise and
excessive light
Drive for 48 hours
Exercise until re-evaluation by a doctor