Concussions: An Overview of the Injury and the Return to Activity Process

2. Concussions:An Overview of the Injury and the Return to Activity Process Rusty McKune, ATC Sports Medicine Program Coordinator The Nebraska Medical Center

3. Concussion… • The term and therefore, definition, diagnosis, and treatment of concussion is very dynamic. • Consensus Statement on Concussion in Sport: the 4rdInternational Conference on Concussion in Sport (Zurich, 2012) • Concussion is a complicated injury that can present in a variety of ways.

4. Concussion- Defined • A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. (Zurich, 2012) - Concussion may be caused by a direct blow to the head, face, or neck or elsewhere on the body with an “impulsive” force transmitted to the head; - Typically results in the rapid onset of short lived impairment of neurological functioning that resolves spontaneously; - Results in a graded set of clinical syndromes that may or may not involve the loss of consciousness; - No abnormality on standard structural neuroimaging studies.

5. Characteristics of Concussions We now know that…. • “dings,” “bell-ringers” are concussions • Concussions do not have to involve LOC • Functional Disturbance (Software), Not a Structural Injury (Hardware); • Young athletes are at increased risk for serious problems (CDC 2012) • Less developed shoulder/cervical spine musculature • Poor technique • Brain is not as developed and less able to withstand the insult associated with a concussive injury.

6. AT THE END OF THE DAY… • A CONCUSSION IS A CONCUSSION • A CONCUSSION IS A BRAIN INJURY

7. What Does a Concussion Look Like?

8. Common Symptoms of Concussion • Headache • Feeling Slowed Down • Difficulty Concentrating • Dizziness • Fogginess • Fatigue • Blurred Vision • Sensitivity to Light/Noise • Memory Problems • Balance Problems “What they tell us.”

9. Common Signs of Concussion • Vacant Stare • Slow to Answer Questions or Follow Instructions • Easily Distracted • Disoriented; can’t focus attention • Disoriented; unaware of time, date, and place • Slurred or incoherent speech • Sensitivity to light/noise • Memory Deficits (can’t remember events prior to or after the injury) • Gross Incoordination • Emotions out of proportion to the situation • Loss of Consciousness • Seizures “What we see/observe”

10. Beyond the Field of Play • Personal/Home • Reduced Play/Activity • Difficulty completing chores • Depression • Irritability: • Parents • Siblings • Boyfriend/Girlfriend • Academic/School • Concentration/Focus • Remembering Assignments • Tolerance of Environment • Fatigue • Drop in Grades, Attendance

11. Concussion Management

12. How Do We Manage Concussions? • Best Treatment is Prevention • Is this possible? • So we do out best to: • Educate • Recognize, Remove, and Refer • Diagnose • Manage • Prevent further Injury

13. How Do We Manage a Concussion and Prevent Further Injury? Recognition relies on Education Preventing 2nd injury relies on Management Diagnosis relies on Recognition Management relies on Diagnosis

14. The concussion awareness act

15. Goals and Objectives of the Concussion Awareness Act • Consistent means to identify and manage concussions to ensure the safety of those involved in youth sports. • Contains the three tenets of model legislation • Education- Coaches, Parents and Student Athletes; • Removal from play if a concussion is reasonably suspected; • Clearance by a Licensed Health Care Provider.

16. Provisions of LB 260 • Who is does the bill apply to? • Sec. 4- Approved or accredited public, private, denominational or parochial schools (does not include higher education/college and university); • Sec. 5- Athletes 19 years of age or younger that participate in organized sports (“any city, village, business or nonprofit that organizes sports, charges a fee or is sponsored by a business or nonprofit organization”).

17. Provisions of LB 260- EDUCATION • Coaches • Training approved by the Chief Medical Officer must be made available to all Coaches • http://dhhs.ne.gov/publichealth/Pages/concussion.aspx • Parents and Student-Athletes and Athletes/Participants • Requires that information be provided on an annual basis prior to the start of practice or competition

18. Provisions of LB 260- REMOVAL FROM PLAY • Any student-athlete or athlete shall be removed from play when they are reasonably suspected of having a concussion by a coach or licensed health care professional ( for schools, this individual must be professionally affiliated with or contracted by the school). • Shall not be allowed to return to play until they are cleared by a licensed health care professional. • Parents or Guardian must be notified of the date and approximate time of the injury and the signs and symptoms that were observed, as well as any actions taken to treat.

19. Provisions of LB 260- RETURN TO PLAY • A student-athlete or athlete may be allowed to return to play when: • They have been evaluated by a licensed health care professional; • They have received written clearance from the licensed health care professional; • They have submitted the written and signed clearance to resume participation in athletic activities accompanied by written permission to resume participation from the student’s parent or guardian.

20. Thoughts on Return to Play • General Consensus that, beyond the limits of Concussion Awareness Act, return to play should not occur until: • The athlete is asymptomatic at rest AND exertion; • The athlete has returned to their baseline scores on any neurocognitive and/or balance examinations; • The athlete has completed a graduated return to play progression. Zurich, 2008

21. HOWEVER…. • At this age, not all students are athletes but ALL ATHLETES ARE STUDENTS. THEREFORE…. • We can’t just focus on athletics we need to include academics.

22. Return to Activity

23. Returning to Activity A return to activity plan is composed of two parts and should be considered a medical decision with input from all members of a schools concussion management team. • Return to Academics- a gradual return to school and academic requirements implemented by the teaching staff. • Return to Play- a gradual return to sports implemented by the athletic staff.

24. Returning to Activity

25. Return to Activity Return to Learn Step 1- Home- Relative Rest Step 2- Home- Light Mental Activity Step 3 School- Part Time Step 4 School Part Time Step 5 School Full Time Step 6 School Full Time Return to Play Step 1- No physical activity while there are symptoms Step 2- Light Aerobic Activity Step 3- Sport-specific exercise Step 4- Non-Contact Training Drills Step 5- Full Contact Practice Step 6- Return to Play Adapted from Oregon Concussion and Management Program and Slocum Sports Concussion Program

26. Academic Accommodations for Students • Excused Absence from Class • Rest Period During the School Day • Extension of Assignment Deadlines • Postponed or Staggered Exams • Excuse from Specific Tests and Assignments. • Extended Testing Time • Accommodation for Sensitivity to Light, Noise or Both • Excuse from Team Sport Practice and Gym Activities • Smaller, Quieter Exam Rooms to Reduce Stimulation and Distraction • Preferential Seating

27. Managing a Concussion at Home • Rest is a key component to the healing process of the brain. • Each concussion is different and will respond differently. • Must involve both physical and cognitive rest. • Means both sports and school may be affected. • Will need to communicate with AD’s, Coaches AND Teachers.

28. What is Rest? Physical Cognitive Limited concentration Modify/delay homework No prolonged classes and be aware of the class environment Shorten/modify days No Texting, e-mails or computers/video games. • No sports • No exercise • No weightlifting • ADL’s? REST MEANS REST!

29. What to do if a Concussion Occurs CDC Guidelines and the Concussion Awareness Act: • Remove from Play- do not allow them to return that day. • Ensure that athlete is evaluated by a health care professional experienced in evaluating concussions. • Inform Parents or Guardians • Keep out of play until symptom free and cleared by a licensed health care provider experienced in managing concussions

30. How Can we Prevent Concussions and/or Limit the Effects of Concussions? Education Coaches, Parents, Athletes, Officials Concussion Recognition and Management Rules Policies and Guidelines Regarding Concussions Safety Comes First Technique Rules Never “Play Through” a Concussion

31. ? NE High School Lacrosse Concussion Awareness

32. Closing Thoughts… • A CONCUSSION IS A CONCUSSION • Concussions don’t just happen in sports • NO SAME DAY RETURN TO PLAY • MANAGEMENT STARTS WITH EDUCATION • And in youth who are also students…ENDS WITH EDUCATION.

33. Resources http://www.cdc.gov/TraumaticBrainInjury/ http://www.nsata.org/ • http://dhhs.ne.gov/publichealth/Pages/concussion.aspx Rusty McKune, ATC Work Phone: 402- 552-3522 E-Mail: rmckune@nebraskamed.com http://www.biane.org/

34. References • Consensus Statement on Concussion in Sport, 4rd International Concussion in Sport, Zurich, November 2012. • Nebraska Brain Injury Resource Network- “Bridging the Gap From Concussion to Classroom.” • Nebraska Legislative Bill 260- The Concussion Awareness Act