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Concussion in Sport

Concussion in Sport. Heather Sloan, RN, BSN Washburn University Graduate Nursing Student. Who am I?. Washburn University Graduate Nursing Student (Family Nurse Practitioner focus) Thesis project on Concussion New topic surfacing in 1999 2004 OHS Graduate

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Concussion in Sport

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  1. Concussion in Sport Heather Sloan, RN, BSN Washburn University Graduate Nursing Student

  2. Who am I? Washburn University Graduate Nursing Student (Family Nurse Practitioner focus) Thesis project on Concussion New topic surfacing in 1999 2004 OHS Graduate 2008 Emporia State University Graduate Registered Nurse at St. Luke’s, Stormont-Vail, and Mercy Regional

  3. Topic Significance • 3.8 million sport related concussions occur annually • Adolescents are of particular risk • Three times more likely to experience a catastrophic head injury • Second Impact Syndrome: (occurring only in individuals <20 years old) • 90% of fatal sports related head injuries occur in high school age or younger athletes. • Life long debilitating injuries • Few safety measures to protect adolescents (AAP, 2010; Theye & Mueller, 2004; Langlois, Rutland-Grown, & Wald, 2006; Boden, Tacchetti, Cantu, Knowles, & Mueller, 2007; Mueller, 2001; McCrory, 2001)

  4. Topic History • Concussion in sport became a hot topic in the 1990s • 2001 the First International conference on concussion in Sport and Concussion in Sport Group (CISG) emerged . • CISG sets the standard for concussion management • Every 3 years a new conference is held and a resulting statement is issued to update evidence-based concussion management approaches. • 2012 will be the next conference

  5. Concussive Injury

  6. Defining Concussion “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” (McCroy et al., 2009, p. 37) Direct blow to the head, face, neck or body Rapid onset of short-lived neurologic impairment that may occasionally be prolonged Symptoms largely affect function rather than a structural injury Once an athlete has sustained a concussion, he or she is 6 times more likely to sustain a second.

  7. Signs and Symptoms (APA, 2010; McCroy et al., 2001; McCroy et al. 2004; McCroy et al. 2009; Theye & Mueller, 2004)

  8. Second Impact Syndrome • Special injury reported only in individuals less than 20 years • Catastrophic fatal injury following two or more concussions within a short period of time (hours, days, weeks) when the athlete has not had a chance for complete recovery between injuries • Causes rapid brain swelling from disrupted autoregulation and cerebrovascular congestion. Results in brain herniation and death in 2 to 5 minutes. • Risk with any concussion • Highest risk sports include football and women’s soccer. • Females experience a higher rate of concussion than males in similar sports • ( APA, 2010; Guskiewicz et al. 2004; Cobb & Battin, 2004; Theye & Mueller, 2004, McCroy, 2001)

  9. Long term consequences • It is well established in research that cumulative effects occur if repeat concussions take place. • Diffuse Axonal Injury: • results from shearing forces impacting neuronal axons and small vessels.

  10. Long term consequences • Chronic Traumatic Encephalopathy: • Result of repeat head trauma • Symptoms similar to Alzheimer’s and progressing into symptoms similar to Parkinson’s disease.

  11. Additional injuries

  12. Concussion Management

  13. Management Principles 1. Legislative changes HB 2095 passed in 2011 2. Front line management ImPACT 3. Medical Management Return to play guidelines

  14. Legislative changes • HB 2095 • Education per state board of education and Kansas state high school activities association for school districts, coaches, athletes, and guardians. • Immediate removal from competition or practice should occur if concussion is suspected. • Athletes will not return to competition or practice until evaluated by a licensed health care provider trained in the evaluation and management of concussion. Athletes must also receive final clearance by a MD or DO to return to play.

  15. Front Line Management • Baseline Assessments • comparison of functioning if injured during play • ImPACT • Top of the line neuropsychological testing • Return to Play guideline adherence • Allows for complete recovery of injury

  16. Medical Management

  17. Medical Management • Return to Play guidelines (McCroy et al., 2009)

  18. Medical Management • 1. To begin return to play process the athlete must be asymptomatic at rest and with cognitive stress. • 2. If asymptomatic at the current level of activity the athlete may precede to the next level of activity every 24 hours. • 3. If any symptoms occur the athlete returns to the last stage without symptoms and resumes progression following 24 hours rest. • 4. The average time required for complete recovery is 7-10 days but may be prolonged in adolescents and children due to their developing brains.

  19. Home Management • Monitor for new or worsening concussion symptoms. • Encourage your teen to report any and all symptoms. • Remind your teen the priority is their health which is more valuable than sitting out a game or practice. • Avoid taking medications except for Acetaminophen/Tylenol. • Avoid alcohol or drug ingestion • Avoid activities that increase symptoms • Strive for physical and cognitive rest (including texting, school work, and video games) • Awakening at night is only necessary for athletes who had a loss of consciousness, prolonged amnesia, or is still experiencing significant symptoms at bedtime. • Follow the step wise return to play approach as prescribed by the trainer/health care provider.

  20. What is ImPACT? • Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) • Neurocognitive testing has been identified as the “cornerstone” in proper concussion management by the international consensus statement on concussion management. • Has emerged as the leader in computerized neurocognitive testing tools for athletes and was designed for detection and management of concussion in sport. • ImPACT is a scientifically validated tool that is intended to be used as a baseline tool to appraise an athlete’s neurocognitive functioning that can later be compared back to if the athlete sustains a concussive injury. • Assesses 5 key areas: verbal memory, visual memory, reaction time, processing speed, and a symptom scale.

  21. ImPACT Application • Baseline assessment tool • Currently administered every two years. • Post injury, the tool is readministered and compared to baseline findings to detect injury and track recovery progress. • The test is readministered approximately every 24-72 hours post injury by the athletic trainer to track recovery progress and determine return to play guideline application. • In practice this information is important when considering beginning the return to play process and final release to game play. • Additional Resources for ImPACT: • www.impacttest.com • - Pay close attention to the “Concussion Management “ tab and be sure to review the “management” link under this tab. • http://impacttest.com/pdf/improtocol.pdf (ImPACT algorithm of best practices)

  22. Evidence base for ImPACT • ImPACT baseline testing has been found to be a stable measure of neurocognitive performance in high school athletes (Elbin, Schatz, Covassin, 2011) • Schatz’s study in 2010 supported ImPACT’s test-retest reliability . • 64% of concussed athletes reported an increase in symptoms with a symptom only based approach (Van Kampen et al., 2006, p. 1633). • With ImPACT only, 83% of concussed athletes were detected or a net increase in sensitivity of 19% occurred (Van Kampen et al., 2006, p. 1633). • When ImPACT is combined with postconcussion symptom (PCS) presentation, 93% of concussed athletes are appropriately identified (Van Kampen et al., 2006, p. 1634). • 0% of the control group presented with both complaints of symptoms and a change in their ImPACT score compared to their preseason baseline.

  23. Prevention

  24. Remember… When in doubt, sit them out!

  25. Miscellaneous Information • Additonal References • www.kansasconcussion.org • www.impacttest.com • See attachments for the American Academy of Pediatricians 2010 statement on pediatric concussion management and the latest CSIG statement on concussion management. • Please e-mail the attached consent form electronically signed, brief survey, and any additional questions to heather.sloan@washburn.edu Thank you for your time and dedication to concussion management!

  26. References American Academy of Pediatrics (2010). Clinical report- Sport-related concussion in children and adolescents. Pediatrics, 126 (3), 596-616. Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Johnston, K., Kelly, J. … Schamasch, P. ( 2002). Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Br J Sports Med, 36, 6-10. Borowski, L.A., Yard, E.E. Fields, S.K., Comstock, R.D. (2008). The epidemiology of high school basketball injuries. American Journal of Sports Medicine, 36(12),2328-2325. Calvin A.C., Mullen, J., Lovell, M.R., West, R.V., Collins, M.W., Groh, M. (2009). The role of concussion history and gender in recovery from soccer-related concussion. American Journal of Sports Medicine, 37(9), 1699-1704. Dick, R.W. (2009). Is there a gender difference in concussion incidence and outcomes? British Journal of Sports Medicine, 37(1), i46-i50. Elbin, R.J., Schatz, P., Covassin, T. (2011). One-year test-retest reliability of the online version of ImPACT in high school athletes. The American Hournal of Sports Medicine, 39 (11), 2319-2324.

  27. References Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., Comstock, R.D. (2007). Concussions among United States high school and collegiate athletes. Journal of Athletic Training, 42 (4), 495-503. Guskiewicz, K. M., Bruce, S. L., Cantu, R. C., Ferrara, M. S., Kelly, J. P., McCrea, M. … McLeod, T. C. (2004). National athletic trainers’ association position statement: management of sport-related concussion. Journal of Athletic Training, 39 (3), 280-297. Langlois, J.A., Rutland-Brown, W., & Wald, M.M. (2006). The epidemiology and impact of traumatic brain injury: a brief review. Journal of Head Trauma Rehabilitation, 21(5), 375-378. Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. PlexusPress: Bordentown, New Jersey. McCroy, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J. … Schamasch, P. (2005). Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med, 39, 196-204.

  28. References McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Malloy, M., & Cantu, R. (2009). Consensus statement on concussion in sport – The 3rd International Conference on Concussion in Sport held in Zurich, November 2008. SAJSM, 21 (2), 36-46. House Bill NO. 2095 (2011). Retrieved from http://www.kslegislature.org/li/b2011_12/measures/documents/hb2095_00_0000.pdf Schatz, P. (2010). Long-term test-retest reliability of baseline cognitive assessments using ImPACT. The American Journal of Sports Medicine, 38 (1), 47-53. Sitzman, K. & Eichelberger, L.W. (2004). Understanding the work of nurse theorists: A creative beginning. Jones and Bartlett Publishers: Sudbury, Massachusetts.

  29. References Theye, F. & Mueller, K. A. (2004). “Heads up”: Concussions in high school sports. Clinical Medicine & Research, 2 (3), 165-171. Tucker, A.L. & Edmondson, A.C. (2002). Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. Harvard Business School. Retrieved from http://www.hbs.edu/research/facpubs/workingpapers/papers2/0203/03-059.pdf Van Kampen, D.A., Lovell, M.R., Pardini, J.E., Collins, M.W., & Creddie, H.F. (2006). The “Value Added” of neurocognitive testing after sports-related concussion. The American Journal of Sports Medicine, 34 (10), 1630-1635.

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