Recognizing and Managing Sports Concussion

1. Recognizing and Managing Sports Concussion June 2014 Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation SUNY Upstate Medical University Director, UPSTATE Concussion Center NYSPHSAA Concussion Team & Safety Committee NYS TBI Coordinating Council  Public Education Committee

2. Concussion – A Hot Topic • Growing concern about the effects of concussions and of repeated head trauma • Recognition of the need for more education, and to treat concussion more seriously • Proper management of concussion can make a difference • All 50 states have passed sports concussion laws

3. Concussion—What are the risks? Athletes who return to play while still symptomatic from a concussion are at increased risk of . . . Another concussion More severe symptoms Prolonged recovery, with associated medical, psychological, and academic difficulties

4. Concussion—What are the risks? Athletes who suffer multiple concussions are at increased risk of . . . Another concussion (increasing concussability) More severe symptoms or prolonged recovery Permanent problems Headache Cognitive problems Depression

5. What’s the big deal? “The hidden nature of the signs and symptoms of concussion often make detecting this injury challenging. Moreover, at younger competitive levels there is often limited medical coverage, which often places increased responsibility on coaches for addressing any medical issues that may arise. Therefore, it is important that individuals involved in youth sports, coaches in particular, be aware of the signs and symptoms of concussion and know how to respond if a concussion is suspected.” Covassin et al. 2012

6. Epidemiology 1.6 to 3.8 million sports concussions each year in the United States Football, hockey, and lacrosse are the riskiest male team sports Soccer and lacrosse are the riskiest female team sports In H.S. sports played by both sexes with the same rules, girls have a higher rate of concussion

7. Concussion in H.S. Sports Lincoln et al. 2011 Guerriero et al. 2012

8. Boys High School LacrosseConcussion Video Analysis 518 games ● 86 concussions ● 34 analyzed Player-to-player contact was the mechanism for all concussions Most often, injured players were unaware of the pending contact, and the striking player used his head to initiate contact Education of coaches and officials and enforcement of rules designed to prevent intentional head-to-head contact is warranted Lincoln et al. 2013

9. Concussion inMen’s Lacrosse NCAA data 1988 - 2004 8.6% of game injuries 3.6% of practice injuries 3% of severe injuries (10+ days out) 80% due to contact or collision with another player Dick et al. 2007

10. Concussion inWomen’s Lacrosse NCAA data 1988 - 2004 9.8 % of game injuries 4.6 % of practice injuries 5 times more likely in game vs. practice 56% of head and neck injuries due to stick, and 20% due to ball Dick et al. 2007

11. Pediatric ER Data Pediatric ER data 1990 - 2003 Young children (ages 2-9) were twice as likely to sustain an injury to the head and face than older children (10-18) Most facial injuries in female lacrosse occur away from the eye and mouth Yard & Comstock 2006

12. What is a concussion? Mild traumatic brain injury A disruption in normal brain function due to a blow or jolt to the head CT or MRI is almost always normal Invisible injury

13. Mechanisms of Injury • Complex physiological process • sudden chemical changes • traumatic axonal injury • altered cerebral blood flow

14. Common Physical Symptoms • Headache • Nausea and vomiting • Fatigue and lack of energy • Clumsiness and poor balance • Dizziness and lightheadedness • Blurred vision and light sensitivity • Sleep problems

15. Common Emotional Symptoms • Irritability • Anxiety or depression • Extreme moods • Easily overwhelmed • Personality change • Lack of motivation • Emotional outbursts

16. Common Cognitive Symptoms • Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ • Easily confused • Slowed processing • Easily distracted • Memory problems • Trouble reading • Poor mental stamina

17. Exertion effects • Symptoms are worsened by . . . • mental effort • environmental stimulation • emotional stress • physical activity

18. Zurich 2012 Guidelines • No grading of injury • Treat every concussion seriously 4th International Conference on Concussion in Sport FIFA IOC IIHF

19. Zurich Concussion Guidelines • Any athlete who show ANY symptoms or signs of a concussion: • athlete should not return-to-play in the current game or practice • Athlete should be monitored for deterioration for 24 hours • return-to-play must follow a medically supervised stepwise process • athlete must be symptom-free at rest and after exertion When in doubt – sit ‘em out

20. Medical Protocol • Any athlete who suffers a concussion should undergo medical evaluation within 24 hours • Anyone with loss of consciousness should be evaluated that day • If confused or not fully conscious, transport by EMS with immobilization • Follow athlete until asymptomatic • First medical clearance is to begin return- to-play progression • If no return of symptoms with exertion, then final clearance for game play

21. Zurich Return to Play Progression • No activity, complete rest • Light aerobic exercise but no resistance training • Sport specific exercise and progressive addition of resistance training • Non-contact training drills • Full contact training and scrimmage after medical clearance • Game play Also should be symptom-free after mental exertion and have normal neruocognitive test results

22. Sideline Evaluation • Standardized tools available • SCAT 3 • SAC • Signs & symptoms • Evaluation of cognition is an essential component • Standard orientation questions are unreliable • Postural stability testing is a valid addition to assessment • Serial testing recommended

23. NYSPHSAA Concussion Checklist • First completed by coach or trainer on the sideline • Follows athlete until cleared to RTP • Reviewed by trainer and school medical director after doctor clearance • Improves communication • Enforces proper protocol

24. Recovery from Concussion • Full recovery in 7-10 days. . .in most cases • Symptoms can last weeks or months • Symptoms can significantly disrupt academic abilities • Risk of depression and anxiety a ‘miserable minority’ experience persistent symptoms

25. Preventing Concussion • Don’t tolerate dangerous play • Late and unprotected hits • Checks to the head • Helmet properly fitted and worn

26. Recommendations for coaches • Educate players, parents and staff • Zero tolerance for hiding symptoms • If you’re suspicious of concussion, pull the player off the field for evaluation • Have a plan (e.g., who will evaluate the player, and how ?) • Clear communication with athlete, parents, other coaching staff, etc. • No return to play without proper clearance When in doubt – sit ‘em out

27. Heads Up High School Soccer Players With Concussion Education Are More Likely to Notify Their Coach of a Suspected Concussion Bramley et al. 2012 Clinical Pediatrics 72% of athletes who had acknowledged receiving concussion training responded that they would always notify their coach of concussion symptoms, as compared with 36% of the players who reported having no such training (P = .01)

28. Managing Complex Concussion • Consider referral to specialized provider or program if . . . • History of multiple concussions or other risk factors • Prolonged recovery (> 2 weeks) • Worsening symptoms

29. Guidelines for Return to School after Concussion • Out of school at first if necessary, and then gradual re-entry as tolerated • Avoid re-injury in sports, gym classs and crowded hallways or stairwells • Provide academic accommodations • Communicate and Educate

30. Academic Accommodations • Rest breaks during school in a quiet location (not always the nurse’s office) • Reduced course and work load • Decrease homework • Avoid over-stimulation, (e.g., cafeteria or noisy hallways) • Extra time and a quiet location for tests Provide reassurance and support

31. Resources • Free Educational Materials • Safe Kids USA www.safekids.org/sports • CDC Heads up in High School Sportskits • NFHS-CDC web-based training video for coaches • SUNY Upstate Concussion in the Classroom video and brochure on-line

32. Summary • CDC now recognizes sports concussion as a significant public health issue • Proper recognition and management of concussion can prevent serious problems • Avoid re-injury and over-exertion until recovered • No return to play until symptom-free and cleared by a trained professional • Everyone involved in sports needs to be educated about concussion

33. Thanks ! upstate.edu/concussion riegerb@upstate.edu