march 30, 2012 david cudmore tara sutherland angela wylie
TRANSCRIPT
ANTIGONISH CONCUSSION CLINIC
March 30, 2012David CudmoreTara Sutherland Angela Wylie
THE BEGINNING
September 1996 Dr David Cudmore MD Tara Sutherland CAT(C) Varsity Athletes Sports Injuries and Concussions
In January ----2009 – we added Dr Maureen Allen MD – Outpatients St Martha’s
Hospital Community Athletes and General Population and
Concussions
WHY ??
A 15 year old hockey player, a 40 year old construction worker and a 35 year old woman all received a hit to the head and report to the Emergency Room.
all leave with diagnosis of a concussion SO what is next for them , who and or
where is the follow up .. Their family Doctor ? Time issues , specialty issues other concerns , return to play supervision.
CONCUSSIONS ARE A HOT TOPIC!
Sport organizations, schools and employers are now realizing that this injury has a significant short and or long term impact on people.
There is a demand for medical assessment and active management of these patients.
Other Practitioner
s
Patient to ACC
Athletic Therapists
SCAT
Physician & AT
Decision Making
Referral
Referral
WHAT AND HOW WE WORK St Martha's ER DOC ‘sConcussion
form
Next Appointment
AFTER THE APPOINTMENT
The patient is usually sent home with specific instructions and a follow up appointment is booked for one or two week’s time. A handout is given if they have not yet received one .
The physician will often write medical notes for modified work and or school.
The ACC sees a patient regularly and continues until complete recovery whenever possible.
RETURN TO PLAY
When the individual becomes asymptomatic and is ready to return to a sport or activity the athletic therapists will have them perform a bike test at the Athletic Therapy Clinic at STFXU.
If the patient completes this bike test satisfactorily then we will have them return to activity according to the return to play guidelines set forth by McCrory et al., 2009.
Follow up visits are done with the physician and the athletic therapist until an athlete returns to play, especially if they participate in contact sports.
Similarly, non athletes are flowed until they resume normal activities, i.e. work, school etc
OTHER TESTING
Diagnostic – xrays – CAT scans MRIs
Often head and or neck xrays are done at the outpatients on the patients orginal visit. If not and problems persist we will send them for xrays .
We do limited MRI or CT scans since imaging is usually normal as reported by McCrory et al., 2009
SPECIALISTS
We do not refer many patients to medical specialists such as neurologists or neurosurgeons as we feel we are capable of handling most concussion cases . However if the patient is not improving and or have complicating issues such as persistent cognitive defects we refer to the specialist.
One of the most difficult parts of sending to a specialists is that they are over two hours away by car and the travelling can cause worsening of symptoms.
PHARMACOLOGICAL THERAPY
For prolonged sleep disturbances we have used amitriptyline. It helps restore a normal sleeping pattern and is useful for chronic pain.
Or other sleeping aids such as >>>>
OTHER
In addition for neck or other musculoskeletal problems we will refer to a Physiotherapist , Massage Therapy or Cranial Sacral Therapy as needed
OR We will occasionally send
patients to see a psychologist for treatment of depression or anxiety
STATS
ANTIGONISH CONCUSSION CLINIC
AGE Total Sports MVA FALLS Other
MALES < 16 years 15 8 5 0 2
17-80 yrs 40 0 6 2 6
FEMALES < 16 years 7 3 0 4 0
17-80 yrs 33 6 4 0 7
Jan 2010 to Dec 2011
total 95 patients
Aveage # visits 3.25 /patient
total visits 214
OUR GOAL
to enable our patients to return to a normal healthy active life
We consider our approach to be holistic and novel
We often call ourselves concussion coaches
Family doctors are kept informed of their patient’s progress through consultation letters sent by the physician
THE ANTIGONISH SET UP Multidiscipline collaboration practice with
athletic therapists and physicians It is sustainable in a medical fee for service
environment, requiring no new funding Athletic therapists have the expertise in the
area and can provided most of the care that the patient requires, with a small amount of medical supervision by the physician
Using this model we are able to efficiently and expertly look after a large number of patients every week
TESTIMONIAL
“The lingering aspect of this concussion is definitely the most difficult part. I sustained three concussions in a one year period, most recently 2½ months ago, and I am still not feeling 100%. I didn’t get hit by a rampaging hockey player at the speed of a train. You wouldn’t think that volleyball was a high-risk sport. All of my concussions were accidental, but they still add up nonetheless. The worst part is, I don’t know when it’s going to get better, and frankly, I’m scared of what another concussion might mean.” (Varsity University athlete)
“As an athlete having a concussion is hard to explain to your coaches and teammates. There's no visible evidence that you're hurt - like there is with an ankle or knee. I felt that my coaching staff didn't take my head injury seriously and pushed me to return to play earlier that I should. Without the care of our athletic therapists and doctors I probably would have returned to play too early and done further damage.” (Varsity University athlete)
QUESTIONS?
FORMS
Concussion Assessment Tool ( Antigonish) revised 2012
Name: Reporter Self
Date of Injury Age Parent
Activity/sport Other
Local Phone No. _____________
Signs: did you experience any of the following at the time of injury
Loss of consciousness YES NO
Seizures YES NO
Balance /Unsteadiness YES NO
Concussion History Headache History
Previous number Prior treatment for Headaches
1 2 3 4 other YES NO
Longest symptom duration History of Migraines
days weeks months years Personal Family
Symptom Check List
Please circle the number which describes your symptom best at this time
None Mild Moderate Severe
Headache 0 1 2 3 4 5 6
Pressure in Head 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred vision 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like in a fog 0 1 2 3 4 5 6
Don't feel right 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Trouble falling asleep 0 1 2 3 4 5 6
More emotional than usual 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or anixious 0 1 2 3 4 5 6
SYMPTOM SCORE TOTAL
132 max
TO BE COMPLETED BY PHYSICIAN
Cognitive Assessment
Word Recall Immediate Delayed
Word 1 Cat
word 2 Pen
word 3 Shoe
word 4 Book
word 5 Car
Months in Reverse
Jan -Feb - Mar -April - May - June - July - Aug - Sept - Oct - Nov - Dec
Neurological Screening Pass Fail
Speech
PEARL
Pronator Drift
Gait assessment
Antigonish Concussion Clinc Symptom Check List
Name:
Date of Injury
None Mild Moderate Severe
Headache 0 1 2 3 4 5 6
Pressure in Head 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred vision 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like in a fog 0 1 2 3 4 5 6
Don't feel right 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Trouble falling asleep 0 1 2 3 4 5 6
More emotional than usual 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or anixious 0 1 2 3 4 5 6
SYMPTOM SCORE
132
Please list any significant changes in how you are feeling?
Positive
Negative
Antigonish Concussion Clinic
First time visit
Name: Medications :
Date of Injury Allergies:
Activity/sport
Family Doctor
Concussion History
Previous number Prior treatment for Headaches
1 2 3 other YES NO
History of Migraines
date of concussions # of weeks to full recovery Personal Family
First
Second History of neck problems
Third YES NO
Symptom Check List
Please circle the number which describes your symptom best at this time
None Mild Moderate Severe
Headache 0 1 2 3 4 5 6
Pressure in Head 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred vision 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like in a fog 0 1 2 3 4 5 6
Don't feel right 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Trouble falling asleep 0 1 2 3 4 5 6
More emotional than usual 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or anixious 0 1 2 3 4 5 6
SYMPTOM SCORE TOTAL
132 max
Please include any other pertinent information re your concussion .