concussions 101

CONCUSSIONS 101

Michael J. Sileo, MDHayley Rintel-Queller, MD

Orthopedic Associates of Long Island (OALI)

Thanks!

Lisa M. Lally Hannah Kuemmel, ATC

Facts

10% of all contact athletes sustain concussions annually Approximately 300,000 sports related

concussions occur each year (reported) An athlete who sustains concussion is 4-6

times more likely to sustain a second concussion

Facts (con’t)

“Bell ringers”=concussion account for 75% of all concussive injuries

Concussions are cumulative in athletes who return to play prior to complete recovery

Dilemma

Concussions are more common and more serious than previously recognized Seasoned doctors, coaches and parents recall

treatments from the past and think that is still the standard of care

Seemingly mild initial symptoms may lead to long lasting symptoms

Youth athletes are more at risk for bad outcomes than their “professional counterparts” given their vulnerable/developing brains

Definition A concussion is a Mild Traumatic Brain

Injury. “Concussus” derived from the Latin “to shake

violently” Concussions may range from “bell

ringers” to prolonged loss of consciousness.

Definition

Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

Concussion result in a functional disturbance rather than a structural injury. No abnormality on standard structural

neuroimaging studies is seen in concussion.

Mechanism: Deceleration Injury

Mechanism: Rotational Injury

“Neurometabolic Imbalance”

On-field signs and symptoms

Symptoms Reported• Headache• Nausea• Balance problems• Double/fuzzy vision• Sensitivity to

noise/light• Feeling “foggy”• Change in sleep

pattern• Concentration/

memory issues

Signs Observed• Appears dazed• Confused about

play• Answers question

slowly• Forgets plays, score,

opponent• Personality/behavior

change• Forgets events

before and after hit• Loss of

consciousness

What kids might say…

“I just don’t feel right…” “My head feels heavy…” “I feel like I am under water…” “I got my bell rung…” “I feel like I am not really here right

now…”

Uh, he was hit… now what?

Concussion:The Return toPlayDilemma

Initial Management

Appropriate sideline evaluation by appropriately trained medical professional

Rule out more serious intracranial pathology If there is any focal neurologic deficit or

progressively worsening symptoms, further imaging is warranted (ie, MRI, CT scan)

Sideline Evaluation ORIENTATION

What is your name? Your coach’s name? What stadium/city is this? Who is the opponent? What color are their

jerseys? What day/date/month/year/season is it? What did you do in school today?

AMNESIA Anterograde

Girl, dog, green Retrograde

What happened prior to hit? What is score Concentration

Days of week backwards, number backward

Sideline Evaluation

Functional Testing Romberg Sway

20 seconds Heel-to-toe stance Oculomotor testing

Smooth vs. saccades 20 yard jog

No increase in symptoms

Appropriate Sideline Decisions

WHEN IN DOUBT, SIT THEM OUT! Take helmet away

If a player loses consciousness The player must be removed from play

If a player is removed from play for concussive symptoms Frequent reevaluation Deterioration of symptoms

Immediately to ER

Treatment

Priority #1: ** Avoid re-injury ** Evaluation by medical provider

Trained in concussion management REST

Cognitive and physical OALI Return to play protocol

5 step protocol to return to play is much more conservative in youth than in older athletes.

Cognitive Rest

May need to be out of school to start Reduced course and work load Extra time and a quiet location for tests Minimal TV, computers, texting, video

gaming, etc

Graduated Return to Play

1. Rest until asymptomatic (physical,mental) 2. Light aerobic exercise w no weight training.

No significant head movement 3. Moderate aerobic activities and weight

lifting. Minimal changes in head position 4. Increased weight training, aerobic activity

Add plyometrics,, proprioceptive challenge, head mvmt

5. Sport specific, non-contact training 6. Full contact training 7. Return to contact competition

Prognosis

Symptoms generally resolve in 7-10 days, but may be longer in adolescents and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of concussion)

If treated properly, the athlete will recover completely without any untoward effects.

If the athlete is not treated properly, they are at significantly increased risk of sustaining another concussion and having long term effects. Post Concussive Syndrome Second Impact Syndrome Chronic Traumatic Encephalopathy [CTE] Severe Emotional Problems ADHD/ Learning disability??

Second impact syndrome

A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event.

Can result in devastating/catastrophic increase in intracranial pressure This catastrophic demise is very rapid and carries a

50% mortality rate along with almost a 100% morbidity rate

Most common in the high school population secondary to poor autoregulatory control of intracranial blood flow

What happened to M. Ali?

Chronic Traumatic Encephalopathy

Recommendations for High School Athletes

EDUCATION, EDUCATION, EDUCATION All coaching staff, referees, parents, athletes,

and covering medical providers should be mandated to participate in an educational session on concussion recognition and initial management

Appropriate preventive measures No tolerance on poor technique (ie, spear

tackling) Appropriate sideline decisions

Orthopaedic Associates of Long Island (OALI) Concussion Management Program

Neurocognitive Testing/Evaluation Evaluates attention/concentration,

memory/recall, processing speed, and reaction time

Computerized models have simplified this ImPACT (others available) Testing done in 30 minutes or lessCurrently utilized by NCAA, NFL, MLB, NHL, WWE

Ideal to have baseline

Unique Contribution ofNeurocognitive Testing

Lovell, Collins et al., Am J Sports Med, 2006

Testing revealscognitive deficitsin asymptomaticathletes within 4days post-concussion

Continued…

St Charles/OALI Comprehensive Concussion Management Program

Working with many local high school sports teams

Baseline Neurocognitive testing (ImPACT) Appropriate sideline decision making Appropriate ER follow up Post injury testing combined with clinical

evaluation Treatment Decisions Return to play progression

Keys to Success

Education Coaches, athletes and parents, medical staff

Proper recognition and proper treatment results in full recovery for these athletes

Baseline and post-injury testing helps provide an objective measure for safe return to play

…

Michael J. Sileo, MDHayley Queller, MDPhil Schrank, MDGregg Jarit, MD

Orthopaedic Associates of Long Island(631) 689-6698www.oali .net