Concussion in Athletes

1. Stacy Camou, ATC ROP-Sport Medicine Rowland High School Concussion in Athletes

2. DEFINITION • A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. • May be caused either by a direct blow to the head, face or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head. • Rapid onset of short-lived impairment of neurologic function that resolves spontaneously. • A functional disturbance rather than a structural injury (TBI) • Results in a graded set of clinical symptoms that may or may not involve loss of consciousness. • No abnormality on standard structural neuroimaging studies (MRI/CT)

3. BASIC BRAIN ANATOMY 1. Dura – The outer most layer of the meninges(membrane surr.brain& sp. cord) that consists of three distinct layers: a) Dura Mater- is the outer most layer of the meninges & is made of strong white Fibrous tissue b) Arachnoid membrane- delicate & weblike layer, is the innermost layer c) Pia mater- transparent adheres to the outer surface of the brain & contains blood vessels 2. Dural Spaces- Spaces among the dura • Epidural space • Subdural space • Subarachnoid space

4. BASIC BRAIN ANATOMY 1. Four Major Areas: a) Cerebral Hemisphere- major portion of the brain (83%) 1) Divisions: • LEFT • RIGHT 2) SUB DIVISIONS: “LOBES” • Frontal • Parietal • Occipital • Temporal

5. THE BRAIN CONT. 1. Four Major Areas: a) Cerebral Hemisphere- major portion of the brain (83%) 1) Divisions: • LEFT • RIGHT 2) SUB DIVISIONS: “LOBES” • Frontal:thinking, problem solving, planning, emotions, behavioral control, decision making. • Parietal: perception, object identification, spelling, knowledge of numbers, depth perception • Occipital: vision, visual processing, color identification • Temporal: memory, understanding language, facial recognition, hearing, vision, speech, emotion. • Brain Stem: the control center of the brain. Regulates body temperature, heart rate, breathing, swallowing • Cerebellum– beneath the occipital lobe control balance, hand-eye coordination, gross and fine motor skills

7. BRAIN LOBES & FUNCTIONS

8. EPIDEMIOLOGY • There are between an estimated 1.6 and 3.8 million sports-related concussions in the United States every year • A 2011 study of U.S. high schools with at least one athletic trainer on staff found that concussions accounted for nearly 15% of all sports-related injuries reported to ATs. • During 2001-2009, annual sports-related ER visits for children and youth ages 5-18 increased 62% to a total of 2.6 million. (CDC) • For young people ages 15 to 24 years, sports are the second leading cause of traumatic brain injury behind only motor vehicle crashes.

9. EPIDEMIOLOGY • Those at increased risk • Prior history of concussion • Symptoms last longer • Gender • Women more likely than males • Age • Younger more susceptible – developing brains • Musculature • Larger neck muscles control head movement better

10. EPIDEMIOLOGY • Football: Between 60and 76.8 • At least one player sustains a mild concussion in nearly every American football game • Girl's soccer: Between 33 and 35 • Boys' lacrosse: Between 30and 46.6 • Girls' lacrosse: Between 20and 31 • Boys' soccer: Between 17 and 19.2 • Boys' wrestling: Between 17and 23.9 • Girls' basketball: Between 16and 18.6 • Boxing ??? • Greater than 5000 at the professional level • A KO is a concussion *Per 100,000 athletic exposures (one athlete participating in one organized high school athletic practice or competition, regardless of the amount of time played)

11. HITTING HEAD DOWN vs HEAD UP • Lordotic curve of cervical spine absorbs pressure, like the shocks on a car • Lowering head, PREVENTS c/s ability to absorb shock

12. assessment

13. REVIEW:ON THE FIELD ASSESSMENT • Appropriate acute care cannot be provided without a systematic assessment occurring on the playing field first • On-field assessment • Determine nature of injury • Provides information regarding direction of treatment • Divided into primary and secondary survey

14. REVIEW:ON THE FIELD ASSESSMENT • Primary survey • Performed initially to establish presence of life-threatening condition • Airway, breathing, circulation (ABCs), shock and severe bleeding • Used to correct life-threatening conditions • Secondary survey • Life-threatening condition ruled out • Gather specific information about injury • Assess vital signs and perform more detailed evaluation of conditions that do not pose life-threatening consequences

15. REVIEW:ON THE FIELD ASSESSME NT • Establish Unresponsiveness • Gently tap shoulder and ask athlete “Are you okay?” • If no response, EMS should be activated • Must be considered to have life-threatening condition- call EMS • Check and establish ABC’s • Assume neck and spine injury • Remove helmet only after neck and spine injury is ruled out (facemask removal)

16. REVIEW:ON THE FIELD ASSESSMENT • With athlete supine and not breathing, ABC’s should be established immediately • If athlete unconscious and breathing, nothing should be done until consciousness resumes • If prone and not breathing, log roll and establish ABC’s • If prone and breathing, nothing should be done until consciousness resumes—then carefully log roll and continue to monitor ABC’s • Life support should be monitored and maintained until emergency personnel arrive • Once stabilized, a secondary survey should be performed

17. REVIEW:ON THE FIELD ASSESSMENT • Equipment Considerations • Equipment may compromise lifesaving efforts but removal may compromise situation further • Facemask should be removed with appropriate clip cutters (Anvil Pruner, Trainer’s Angel, FM Extractor) • Use of pocket mask/barrier mandated by OSHA during CPR to avoid exposure to bloodborne pathogens

19. PHYSICAL EXAM • Unconscious athlete • Call EMS • Stabilize head and neck-DO NOT MOVE if vitals are intact • Examine rest of body for possible broken bones and/or bleeding

20. Compound Problems • A skull fracture is a broken bone of the skull, not a per se, injury to the brain. The probability of serious injury does go up with a skull fracture. SIGNS • Raccoon eye/eyes- peri orbital ecchymosis • Battle's sign- ecchymosis behind the ear • Cerebrospinal Rhinorrhea: Discharge of cerebrospinal fluid through the nose, usually due to skull fracture. • Cerebrospinal Otorrhea:Leakageof cerebrospinal fluid from the ear structures

21. PHYSICAL EXAM • Conscious patient • Palpate head and neck (c-spine) • Ask if any neurological symptoms in head, neck, or extremities • Palpate facial bones • Open and close the mouth • Inspect the nose for deformity • Eye ROM, pupillary response (PEARL), visual fields

22. PHYSICAL EXAM • Once neck injury has cleared: • Check symptoms • Check cranial nerves • Perform neurocognitive testing: • Orientation • Immediate memory • Concentration • Delayed memory • Balance

23. SYMPTOMS • Headache • “Pressure in head” • Neck Pain • Nausea or vomiting • Dizziness • Blurred vision • Balance problems • Sensitivity to light • Sensitivity to noise • Feeling slowed down • Feeling like “in a fog“ • “Don’t feel right” • Difficulty concentrating • Difficulty remembering • Fatigue or low energy • Confusion • Drowsiness • Trouble falling asleep (if applicable) • More emotional • Irritability • Sadness • Nervous or Anxious If any one or more of these symptoms are present, a concussion should be suspected and the appropriate concussion management strategy instituted.

24. CRANIAL NERVES- increased intracranial pressure CRANIAL NERVEACTIONTO TEST • Olfactory smell smelling • Optic vision read something • Oculomotor pearl, eye movment PEARL • Trochlear eye movement H-pattern • Trigmeinal chewing bite down • Abducens eye movement H-pattern • Facial expressing smile • Vestibulocochlear hearing snapping • Glossopharyngeal swallowing swallow • Vagus pharynx and larynx say “ahhhhh” • Accessory trapezius and SCM shrug shoulders • Hypoglossal tongue movement stick out tongue

25. SCAT3-Sideline Concussion Assessment Tool • Symptoms (one point for each negative symptom) • List of 22 symptoms • Graded on a scale of 0-6 • Physical Signs Score (1 point for each negative response) • LOC/length • Balance problems • Glasgow Coma Scale (15 points total) • Eye response (out of 4) • Verbal response (out of 5) • Motor response (out of 6)

26. SCAT3 • Cognitive assessment (SAC test) • Orientation (1 point each) • Month, Date, Day, Year, Time • Immediate Memory (1 point for each correct) • Five words, three trials • 15 pts possible • Concentration (5 points total) • Reverse digits, 4 strings, 3,4,5,6 numbers long (one point per level) • Months of the year in reverse (one point) • Delayed Recall (5 points total • Same words from immediate memory approximately five min after.

27. SCAT3 • Balance Assessment (Total out of 30) • 20 second timed trial per stance • Double leg stance • Single leg stance • Tandem stance • One point off for each error • Coordination • Index finger to nose and back out 5 times (one point) • Total Score • SAC Test- 30 points • All other tests- 70 points

30. IMPACT Immediate Post-Concussion Assessment and Cognitive Testing • Baseline testing prior to season • Compares baseline to post-injury tests • Gives a more objective idea of athlete’s status • Test takes 20 minutes to complete • 13 different languages • Measures: • Attention span • Working memory • Sustained and selective attention time • Problem solving • Reaction time

31. IMPACT • Section 1: Demographic Information & Health History • Section 2: Current Symptoms and Conditions • Section 3: Neuropsychological Tests (baseline testing and post-injury testing) • Module 1: Word Memory • Module 2: Design Memory • Module 3: X's and O's • Module 4: Symbol Matching • Module 5: Color Match • Module 6: Three Letter Memory

32. CLASSIFICATION OF CONCUSSIONS • Prior- • 3 grades • LOC • Number of concussions • Present- • No grading scales • Concussions managed by symptoms only • General assumption that most concussions will resolve in 7-10 days • Adolescents longer

33. CONCUSSION CARE • Player should never be left alone following the injury • Monitoring for deterioration is essential over the first few hours after injury • If there is a cranial hemorrhage, symptoms will occur within that period of time • A player with suspected concussion should not be allowed to return to play on the day of injury. • No medicine for first day • Need to be able to know severity of symptoms

34. CONCUSSION CARE • Full physical and MENTAL rest • Depending on severity of symptoms, absence from school may be recommended • Once athlete is no longer symptomatic, they may begin a gradual return to play protocol • PROBLEM: • Reliance on athletes to report symptoms • SOLUTION: • Formal neurological testing • Tests mental capacities affected with concussion • Takes athlete’s honesty out of it

36. RETURN TO PLAY PROTOCOL • Each step takes place at a 24-hour interval • If concussion symptoms occur during, stop immediately and repeat previous asymptomatic step the following day • If concussion symptoms occur after activity (same afternoon/evening), repeat previous asymptomatic step the following day

37. MODIFYING FACTORS IN RTP • LOC >1 minute • Symptoms: number, duration (>10 days), severity • Convulsions: • Timing: frequency – repeated concussions over time, injuries close together in time, recency– recent concussion or TBI • Threshold- repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion • Age: child and adolescent (<18 years old) • Migraine, depression or other mental health disorders, ADHD, LD, sleep disorders • Behavior: dangerous style of play • Sport: high-risk activity, contact and collision sport, high sporting level

38. CONCUSSION LEGISLATION • AB 25 • Requires immediately remove , an athlete who is suspected of sustaining a concussion or head injury from activity, for the remainder of the day • Prohibits the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from, a licensed health care provider, as specified • On a yearly basis, a concussion and head injury information sheet needs to be signed and returned by the athlete and the athlete's parent/guardian before the athlete initiates practice or competition • CIF Bylaw 313 • Requires a athlete who is suspected of sustaining a concussion or head injury in a practice or game to be removed from competition at that time for the remainder of the day • Any athlete who has been removed from play is prohibited from returning to play until the athlete is evaluated by a licensed health care provider trained in education and management of concussion (MD or DO) and receives written clearance to return to play from that health care provider

39. SECOND IMPACT SYNDROME • Intracranial pressure increases rapidly causing brain death in as little as three to five minutes • Occurs when an athlete returns to sport too early after suffering from an initial concussion, • under 23 years of age • Brain is more vulnerable and susceptible to injury after an initial brain injury • It only takes a minimal force to cause irreversible damage • Brain’s ability to regulate the amount of blood flow to the brain is damaged • increased cerebral blood volume—can result in brainstem herniation and death.

40. CHRONIC TRAUMATIC ENCEPHALOPATHY • CTE is a progressive neurodegeneration • memory disturbances, behavioral and personality change, Parkinsonism, and speech and gait abnormalities • By instituting and following proper guidelines for RTP after a concussion or mTBI and reducing amount of collisions (such as in football) , it is possible that the frequency of sports-related CTE could be dramatically reduced or perhaps, entirely prevented