Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Concussion Management in Orthopaedic Sport Medicine Ryan Martin, M.D., FRCSC Orthopaedic Trauma and Arthroscopic Knee Surgeon Calgary, AB
gest that exposure to RBT represents the greatest risk factor for CTE features3. However, quantifying the real risk of developing CTE is difficult and likely overestimated by media headlines due, in part, to sampling bias3. Brains donated to research centres are often from those who displayed behavioural disturbances after a history of RBT12. The only way of truly defining the actual prevalence of CTE would necessitate a study of those with and without a history of RBT, and with and without neuropsychiatric symptoms. These prospective studies are currently being performed (clinical trials NCT02191267 and NCT02798185)3.
oncussions are relatively common clinical entities that have gained increased media scrutiny and public attention of late. Orthopaedic surgeons, especially those subspecialized in sport medicine, should have a conceptual understanding of the clinical features of concussions as well as their recognition, assessment techniques, and principles of management5. Orthopaedic surgeons are often asked to perform recreational, elite or professional side-line coverage, which requires There are Canadian Guidelines on Concussion in Sport and a one to be comfortable in concussion assessments and return new International Consensus statement developed to help to sport decisions. Additionally, several studies have reported guide the diagnosis and management of concussions, espeon a potential post-concussion elevated cially in athletes11. They ensure athletes risk of musculoskeletal injury because of with a suspected concussion receive persistent deficits in postural control and appropriate sideline and offsite medical neural activation patterns2,8. Thus any assessment, proper concussion manageThese vignettes are a series of articles led surgeon caring for injured athletes will ment, and appropriate return to sport by experts and thought leaders who advise encounter patients with concussions. strategies. These guidelines employ tools on how to manage clinical controversies or Being educated on concussions will presuch as the Concussion Recognition Tool address emerging treatment trends, while pare orthopaedic surgeons to provide 5 and the Sport Concussion Assessment applying evidence-based principles. With coordinated care with other health-care Tool 5 (SCAT 5)4,7. Modified versions these vignettes, we aim to help provide the professionals such as sport medicine exist for paediatric children aged < 12. best evidence-based strategies to enable physicians, athletic trainers and physical Orthopaedic surgeons, especially sport clinicians to incorporate new treatment therapists5. medicine surgeons, should be familiar and diagnostic strategies into current with these guidelines and tools referConcussions are a form of traumatic enced in the suggested reading section. practice. Although no patient or condition brain injury induced by biomechanical fits into the proverbial “box,” we often need forces11. Debate exists as to where a Learning to identify concussion is importo solve problems in “real time” and these concussion fits on the traumatic brain tant, but once identified, orthopaedic comprehensive opinions will, hopefully, injury (TBI) spectrum. It is currently not surgeons should know where to refer to. provide some useful and applicable insights. fully understood whether they result in Many cities across Canada have multidispermanent structural changes as seen ciplinary concussion care clinics that are Femi Ayeni, M.D., FRCSC in severe TBI, or if the resulting neuromedically supervised by sports medicine Scientific Editor, COA Bulletin pathological changes represent reversiphysicians, neurologists, and/or rehable functional and structural disturbancbilitation physicians. Although referrals es5. The literature distinguishes between sports-related concusshould be made on an individual basis, Canadian Guidelines sions (SRC) and non-sporting mild traumatic brain (mTBI) injusuggest that those experiencing prolonged post-concussion ries10. The rational for separating the two entities make for ease symptoms (> four weeks for youth and two weeks for adult) of guideline development. Contact sporting athletes, unlike may benefit from a referral. Persistent symptoms beyond these regular patients, also expose themselves to repetitive trauma period is called post-concussion syndrome (PCS). Such clinics before and after single event mTBI. Since orthopaedic surgeons employ multimodal treatments involving active rehabilitation care for both patient populations, it is important to point out of targeted deficit and not rest alone. Employed rehabilitathat the separation is not rooted in pathology, and lessons tion therapies include aerobic, vestibular, vision and cognitive learned from mTBI can be extrapolated to SRC and vice versa10. behavioural therapy9. Therefore, guidelines for return to sport can be extrapolated to those who injured themselves outside a sporting environment, Although orthopaedic surgeons will never be the primary medand want to return to activity (i.e. school or work)1. ical experts responsible for managing concussions, we need to have a baseline understanding of the injury. This includes The media has drawn valuable attention towards concussions being familiar with its clinical features, consensus guidelines, with significant attention being focused on the long-term and clinical assessment tools. We need to understand how coneffects of repetitive brain trauma (RBT) and the link to a neucussions can influence the care of musculoskeletal problems, rodegenerative conditions called chronic traumatic encephaand when to refer. This understanding is all the more important lopathy (CTE)3. Medical experts should be aware of the gaps now because of the increased media scrutiny influencing our and controversies associated with CTE. The gaps largely exist patients understanding of the problem. because of the reliance on a postmortem diagnosis. Although complicated by selection criteria, the available data does sug-
COA Bulletin ACO - Summer / Été 2018
The Summer 2018 edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association