concussions 101
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Concussions 101. Michael J. Sileo , MD Hayley 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 - PowerPoint PPT PresentationTRANSCRIPT
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