Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.

OBJECTIVE: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. METHODS: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. RESULTS: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement.

Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term "Team Physician" is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.

Meningitis in the athlete.

Infectious diseases among athletic teams commonly present challenges for team physicians and primary care doctors. There is some evidence to suggest that athletes are more susceptible to infection during an outbreak of the general population. The frequent physical contact and close travel arrangements associated with many team sports may put athletes at even greater risk. Viral meningitis is the most commonly reported central nervous system infection in the literature, and transmission seems to be increased among U.S. high school football teams. Septic meningitis is a life-threatening emergency that can occur in outbreaks affecting populations frequently involved in organized athletics (adolescents and young adults). The purpose of this review is to identify current medical literature on the epidemiology, diagnosis, treatment, and prevention of meningitis in the athletic population.

Sport-related concussion: factors associated with prolonged return to play.

OBJECTIVE: To assess predictive value of concussion signs and symptoms based on return-to-play timelines. DESIGN: Physician practice study without diagnosis that includes presentation, initial and subsequent treatment, and management of concussion. SETTING: National multisite primary care sports medicine provider locations. PARTICIPANTS: Twenty-two providers at 18 sites; 101 athletes (91 men, 10 women in the following sports: 73 football, 8 basketball, 8 soccer, 3 wrestling, 2 lacrosse, 2 skiing, 5 others; 51 college, 44 high school, 4 professional, and 2 recreational). MAIN OUTCOME MEASUREMENTS: Duration of symptoms, presence of clinical signs, and time to return to play following concussion. RESULTS: One hundred one concussions were analyzed. Pearson chi2 analysis of common early and late concussion symptoms revealed statistical significance (P < 0.05) of headache >3 hours, difficulty concentrating >3 hours, any retrograde amnesia or loss of consciousness, and return to play >7 days. There appeared to be a trend in patients with posttraumatic amnesia toward poor outcome, but this was not statistically significant. CONCLUSIONS: When evaluating concussion, symptoms of headache >3 hours, difficulty concentrating >3 hours, retrograde amnesia, or loss of consciousness may indicate a more severe injury or prolonged recovery; great caution should be exercised before returning these athletes to play.

Traumatic deep vein thrombosis in a soccer player: A case study.

A 42 year-old male former semi-professional soccer player sustained a right lower extremity popliteal contusion during a soccer game. He was clinically diagnosed with a possible traumatic deep vein thrombosis (DVT), and sent for confirmatory tests. A duplex doppler ultrasound was positive for DVT, and the patient was admitted to hospital for anticoagulation (unfractionated heparin, warfarin). Upon discharge from hospital the patient continued oral warfarin anticoagulation (six months), and the use of compression stockings (nine months). He followed up with his family doctor at regular intervals for serial coagulation measurements, and ultrasound examinations. The patient's only identified major thrombotic risk factor was the traumatic injury. One year after the initial deep vein thrombosis (DVT) the patient returned to contact sport, however he continued to have intermittent symptoms of right lower leg pain and right knee effusion.Athletes can develop vascular injuries in a variety of contact and non-contact sports. Trauma is one of the most common causes of lower extremity deep vein thrombosis (DVT), however athletic injuries involving lower extremity traumatic DVT are seldom reported. This diagnosis and the associated risk factors must be considered during the initial physical examination. The primary method of radiological diagnosis of lower extremity DVT is a complete bilateral duplex sonography, which can be augmented by other methods such as evidence-based risk factor analysis. Antithrombotic medication is the current standard of treatment for DVT. Acute thrombolytic treatment has demonstrated an improved therapeutic efficacy, and a decrease in post-DVT symptoms.There is a lack of scientific literature concerning the return to sport protocol following a DVT event. Athletic individuals who desire to return to sport after a DVT need to be fully informed about their treatment and risk of reoccurrence, so that appropriate decisions can be made.

Maxillofacial injuries in sport.

Maxillofacial injuries occur in contact and noncontact sports. Despite advancements in protective equipment and rule changes, there is still an unacceptably high rate of maxillofacial injuries. These injuries are clinically challenging. The significant morbidity, deformity, and disability associated with these injuries can be avoided by their prompt diagnosis and appropriate management. It is important for the sports medicine professional to be competent in the correct diagnosis and management of maxillofacial injuries. This article reviews some of the major maxillofacial injuries, along with their emergent examinations and treatments.

On-field predictors of neuropsychological and symptom deficit following sports-related concussion.

OBJECTIVE: Investigate the relationship between on-field markers of concussion severity and postinjury neuropsychological and symptom presentation in an athlete-specific population. DESIGN: Case control study. SETTING: Multicenter analysis of high school and college athletes. PARTICIPANTS: A total of 78 athletes sustaining sports-related concussion were selected from a larger sample of 139 concussed athletes. ASSESSMENT OF PREDICTOR VARIABLES: On-field presence of disorientation, posttraumatic amnesia, retrograde amnesia, and loss of consciousness. MAIN OUTCOME MEASURES: ImPACT, a computerized neuropsychological test battery, was administered pre-season and, on average, 2 days postinjury. Good postinjury presentation (n = 44) was defined as no measurable change, relative to baseline, in terms of both ImPACT memory and symptom composite scores. Poor presentation (n = 34) was defined as a 10-point increase in symptom reporting and 10-point decrease in memory functioning (exceeding the 80% confidence interval for measurement error on ImPACT). Athletes failing to meet good or poor selection criteria (n = 61) were not included in the analysis. RESULTS: Odds ratios revealed that athletes demonstrating poor presentation at 2 days postinjury were over 10 times more likely (P < 0.001) to have exhibited retrograde amnesia following concussive injury when compared with athletes exhibiting good presentation. Similarly, athletes with poor presentation were over 4 times more likely (P < 0.013) to have exhibited posttraumatic amnesia and at least 5 minutes of mental status change. There were no differences between good and poor presentation groups in terms of on-field loss of consciousness. CONCLUSIONS: The presence of amnesia, not loss of consciousness, appears predictive of symptom and neurocognitive deficits following concussion in athletes. Athletes presenting with on-field amnesia should undergo comprehensive and individualized assessment prior to returning to sport participation. Continued refinement of sports concussion grading scales is warranted in lieu of consistent findings that brief loss of consciousness is not predictive of concussion injury severity.

Kids' sports: a training ground for life...And for parents.

I'm a dad and proud of it! I'll defend my kids against all comers-opponents, coaches, refs, and sometimes even teammates. Anything wrong with that?

Medical students' experience with musculoskeletal diagnoses in a family medicine clerkship.

Many US medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses the students experience. This study examines patients encountered with musculoskeletal diagnoses using quantitative data collected by family practice clerkship students. Over a two-year period, 445 students completed 7,202 patient encounter forms for patients with a musculoskeletal diagnosis, noting their confidence level and responsibilities. Of the 78,854 diagnoses presented, 7,850 were for musculoskeletal conditions. Students reported a lower level of confidence in diagnosing and treating musculoskeletal patients when compared with their confidence level in dealing with non-musculoskeletal patients. They are generally more actively involved with musculoskeletal patients by observing, seeing the patient before the preceptor, taking a history, suggesting treatment and discussing the case with the preceptor. At the study school, this fact may reflect that formal curricular teaching in orthopedics occurs in the fourth year, after students have completed their family medicine clerkship. It is concluded that by using a relatively simple computerized database, areas of need for curricular change can be identified. Our study verifies that additional training is needed in the area of musculoskeletal diagnoses.

Athletes With Disabilities.

In brief For the most part, active people who are disabled require medical care for typical sports-related cuts, sprains, and strains. However, disability-related conditions such as bladder problems or pressure sores require specialized management to make activity safe.