CONCUSSION IN ATHLETES

Stacy Camou, ATC ROP-Sport Medicine Rowland High School

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)

BASIC BRAIN ANATOMY1. 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 tissueb) Arachnoid membrane- delicate & weblike layer, is the innermost layerc) 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

BASIC BRAIN ANATOMY1. Four Major Areas: a) Cerebral Hemisphere- major portion

of the brain (83%)1) Divisions:

○ LEFT○ RIGHT

2) SUB DIVISIONS: “LOBES”○ Frontal○ Parietal ○ Occipital○ Temporal

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

BRAIN LOBES & FUNCTIONS

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.

EPIDEMIOLOGY

Those at increased riskPrior history of concussion○ Symptoms last longer

Gender○ Women more likely than males

Age○ Younger more susceptible – developing

brainsMusculature○ Larger neck muscles control head

movement better

EPIDEMIOLOGY Football: Between 60 and 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 30 and 46.6 Girls' lacrosse: Between 20 and 31 Boys' soccer: Between 17 and 19.2 Boys' wrestling: Between 17 and 23.9 Girls' basketball: Between 16 and 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)

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

ASSESSMENT

REVIEW:ON THE FIELD ASSESSMENT Appropriate acute care cannot be

provided without a systematic assessment occurring on the playing field first

On-field assessmentDetermine nature of injury○ Provides information regarding direction

of treatmentDivided into primary and secondary

survey

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 outGather specific information about injuryAssess vital signs and perform more

detailed evaluation of conditions that do not pose life-threatening consequences

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 EMSCheck and establish ABC’sAssume neck and spine injuryRemove helmet only after neck and spine

injury is ruled out (facemask removal)

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

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

PHYSICAL EXAM Unconscious athlete

Call EMSStabilize head and neck-DO NOT MOVE if vitals

are intactExamine rest of body for

possible broken bones and/or bleeding

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:Leakage of cerebrospinal fluid

from the ear structures

PHYSICAL EXAM

Conscious patientPalpate head and

neck (c-spine)Ask if any

neurological symptoms in head, neck, or extremities

Palpate facial bonesOpen and close the

mouthInspect the nose for

deformityEye ROM, pupillary

response (PEARL), visual fields

PHYSICAL EXAM

Once neck injury has cleared:Check symptomsCheck cranial nervesPerform neurocognitive testing:○ Orientation○ Immediate memory○ Concentration○ Delayed memory○ Balance

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.

CRANIAL NERVES- increased intracranial pressure

CRANIAL NERVE ACTION TO TEST1. Olfactory smellsmelling2. Opticvision read something3. Oculomotor pearl, eye movment PEARL4. Trochlear eye movement H-pattern5. Trigmeinal chewing bite down6. Abducens eye movement H-pattern7. Facial expressingsmile8. Vestibulocochlear hearing snapping9. Glossopharyngeal swallowingswallow10. Vagus pharynx and larynx say “ahhhhh”11. Accessory trapezius and SCM shrug shoulders12. Hypoglossal tongue movement stick out tongue

SCAT3- Sideline Concussion Assessment Tool

Symptoms (one point for each negative symptom)List of 22 symptomsGraded on a scale of 0-6

Physical Signs Score (1 point for each negative response)LOC/lengthBalance problems

Glasgow Coma Scale (15 points total)Eye response (out of 4)Verbal response (out of 5)Motor response (out of 6)

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.

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 ScoreSAC Test- 30 pointsAll other tests- 70 points

IMPACTImmediate 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 spanWorking memorySustained and selective attention timeProblem solvingReaction time

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 MemoryModule 2: Design Memory Module 3: X's and O's Module 4: Symbol Matching Module 5: Color Match Module 6: Three Letter Memory

CLASSIFICATION OF CONCUSSIONS Prior-

3 gradesLOCNumber of concussions

Present-No grading scalesConcussions managed by symptoms

onlyGeneral assumption that most

concussions will resolve in 7-10 days○ Adolescents longer

CONCUSSION CARE Player should never be left alone

following the injuryMonitoring for deterioration is essential over

the first few hours after injuryIf 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 dayNeed to be able to know severity of symptoms

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

GRADUATED RETURN TO PLAY PROTOCOLSTAGE ACTIVITY PURPOSE

No activity Complete physical and cognitive rest

Recovery

Light aerobic exercise Walking, swimming, or stationary cycling keeping intensity at 70% MHR, no resistance training

Increase HR

Sport-Specific Exercise Skating drills in ice hockey, running drills in soccer, no head impact activities

Add movement

Non-contact training drills

Progression to more complex training drills like passing drills in football and ice hockey; may start progressive resistance training

Exercise, coordination, and cognitive load

Full Contact Practice Following medical clearance, participate in normal training activities

Restore confidence and assess functional skills by coaching staff

Return To Play Normal game play

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

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

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

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 injuryIt only takes a minimal force to cause irreversible

damage Brain’s ability to regulate the amount of blood

flow to the brain is damagedincreased cerebral blood volume—can result in

brainstem herniation and death.

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