Changing perceptions:

There is no such thing as

a minor concussion!

A partnership to

manage concussionBrought to you by:

American Academy of Neurology

& Brain Injury Association

Contents Defining concussion Anatomy of concussion Mechanisms of concussion Sideline evaluation Management recommendations Return to play Case study Prevention

Concussion

Definition– A concussion is an alteration of mental

status due to biomechanical forces affectingthe brain. A concussion may or may not cause loss of consciousness.

Facts About Concussion Centers for Disease Control and Prevention

(CDC) estimates 300,000 sports-related concussions occur per year– 100,000 in football alone

An estimated 900 sports-related traumatic brain injury deaths occur per year

Facts About Concussion

Concussion occurs most often in males and children, adolescents and young adults

Risk of concussion in football is 4-6 times higher in players with a previous concussion

Facts About Concussion Concussions per every 100,000 games and/or

practices at the collegiate level– Football: 27– Ice Hockey: 25– Men’s soccer: 25 – Women’s soccer: 24– Wrestling: 20– Women’s basketball: 15– Men’s basketball: 12

(Head and Neck Injury in Sports, R.W. Dick)

Anatomy of Concussion

The brain is a jello-like substance vulnerable to outside trauma. Skull protects the brain against trauma, but does not absorb impact forces. – During concussion, the

brain rotates and twists inside the skull, causing damage to brain tissue

Anatomy of Concussion

Cervical spine -- allows the head to rotate to avoid blunt trauma– However, rotational

forces can be the most damaging during concussion

Vulnerable Tissues

Gray Matter of the Brain– Neurons, residing in the gray matter, are single

cells that use chemical reactions to create electrical currents to carry out activities

– The gray matter is the site of processing, integration and memory

Vulnerable Tissues White Matter

of the Brain– Nerve cells are

connected by axons (long projections of nerve cells resembling insulated wiring) which connect neurons to other neurons

Two Primary Mechanisms of Concussion

Linear - Example: A quarterback falls to the ground and hits the back of his head. The falling motion propels the brain in a straight line downward.

Rotational- Example: When a football player is tackled, his head may strike an opponent’s knee; this contact to the head can cause arotational motion.

Immediate Signs of Concussion(occurring within seconds to minutes)

Impaired attention -- vacant stare, delayed responses, inability to focus

Slurred or incoherent speech Gross incoordination Disorientation Emotional reactions out of proportion Memory deficits Any loss of consciousness

Later Signs of Concussion(occurring within hours to days) Persistent headache Dizziness/vertigo Poor attention and concentration Memory dysfunction Nausea or vomiting Fatigue easily Irritability Intolerance of bright lights Intolerance of loud noises Anxiety and/or depression Sleep disturbances

Post Concussion Syndrome

Lingering symptoms and continuing cognitive deficit following a concussion injury– May occur for weeks or months after injury– Associated with concussion Grades 2 & 3

Second Impact Syndrome Second concussion occurs while still

symptomatic & healing from previous injury days or weeks earlier

Loss of consciousness not required Second impact more likely to cause brain

swelling and other widespread damage Can be fatal -- 50% mortality rate in most

severe cases Higher risk of long-term cognitive dysfunction

Related Brain Tissue Injuries Hematoma -- blood clot Contusion -- brain bruises Brain swelling and

diminished blood flow to sensitive brain tissues

How is Concussion Assessed?

AAN guidelines for sideline evaluation Standardized Assessment of Concussion

(SAC) for sideline use Standard neuropsychological tests Computerized reaction time tests

AAN Sideline Evaluation Mental status testing

- Orientation, concentration, memory

Exertional provocative tests - 40-yd. dash, push-ups, sit-ups, knee-bends

Neurological tests - Strength, coordination/agility, sensation

Neurology, March 1997

SACStandardized Assessment of Concussion

Assesses orientation, memory and concentration Developed for sideline use Developed for nonmedical personnel Easy to administer Can use for objective comparisons e.g. preseason

vs. post injury

(McCrea, et al Neurology, 1997)

Grade 1 Concussion

Transient confusion NO loss of consciousness Concussion symptoms or mental status

abnormalities resolve in less than 15 minutes

Management RecommendationsGrade 1

Remove from contest Examine immediately and at 5-minute

intervals for the development of mental status abnormalities or post-concussive syndrome at rest and with exertion

May return to contest if mental status abnormalities or post-concussive symptoms clear within 15 minutes

Grade 2 Concussion

Transient confusion NO loss of consciousness Concussion symptoms or mental status

abnormalities last more than 15 minutes

Management RecommendationsGrade 2

Remove from contest; disallow return that day Examine on-site frequently for signs of evolving

intracranial pathology A trained person should reexamine the athlete

the following day A physician should perform a neurologic exam to

clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion

Grade 3 Concussion

Any loss of consciousness, either brief (seconds) or prolonged (minutes)

Management RecommendationsGrade 3

Transport from the field to the nearest emergency department by ambulance if still unconscious or worrisome signs are detected (with cervical spine immobilization, if indicated)

A thorough neurologic evaluation should be performed emergently, including neuroimaging procedures when indicated

Admit to hospital if any signs of pathology are detected or if the mental status remains abnormal

When to Return to Play Grade of concussion Return to play only after

asymptomatic with normal neurologic assessment at rest and with

exercise Grade 1 15 minutes or less Multiple grade 1 1 week Grade 2 1 week Multiple grade 2 2 weeks Grade 3 2 weeks

– w/prolonged loss of consciousness

Multiple grade 3 1 month or longer

Treatment

The treating physician can utilize a variety of treatment options including:– Analgesics for pain – Sleeping medication – Muscle relaxants– Rehabilitation therapies

Case Study

17-year-old high school football player Suffered concussion without loss of

consciousness during a varsity game Complained of headache throughout the

next week Received no further injuries and did not

seek medical attention

Case Study

Next game– A week after first concussion

While carrying the ball, he was struck on the left side of his helmet by the helmet of his tackler

He was stunned, but mental functions appeared to clear quickly during a brief time out on the field

Case Study

He was given the ball during the next play His helmet made only slight contact with

one of several tacklers during the play He arose from the pile of players under his

own power then fell unconscious into the arms of a teammate

Case Study

He arrived at the local hospital unresponsive, pupils fixed and dilated

All treatment efforts were unsuccessful Brain pressure rose stopping blood flow to the

brain 15 hours after his loss of consciousness he

was pronounced dead (Kelly, et al, JAMA, November 27, 1991)

Prevention Goals Identification and education

It’s important to educate others about ways to prevent concussion before it happens

Implementing sideline evaluations & treatment recommendations– Recognize and treat post concussion syndrome– Prevent second impact syndrome– Prevent further morbidity– Prevent fatal injury

Prevention Tools

Rule changes– Play smart, keep the head safe by making

penalties tougher Use helmets and other protective equipment Design changes for protective equipment Ongoing research

– education, risk factors, early detection of concussion using SAC

Goals for the Future

Eliminate fatalities -- second impact syndrome Prevent morbidity -- post concussion syndrome Preserve brain function -- enable young players to

reach their full potential in life! Make sports safer Increase awareness about sports-related

concussions

A partnership to

manage concussionBrought to you by:

American Academy of Neurology

& Brain Injury Association