ConcussionsCurrent Concepts and Future Directions

Objectives

• Be able to identify signs and symptoms of concussive and post concussive injuries

• Understand role for neurocognitive testing in concussion management

• Be able to follow current concussion legislation and latest guidelines

• Develop an appropriate treatment plan for youth with concussions

Statistics

• 10% of all contact sport athletes sustain concussions yearly

• 63% of all concussions occur in football• Up to 20% of football players will sustain a

concussion per season• An athlete that who sustains a concussion is 4-6 times

more likely to sustain a second concussion• “Bell ringers” or mild concussions account for 75%

of all concussive injuries• Effects of concussion injuries are cumulative

Signs/Symptoms of Concussion

• How do you know?– Historically

• On field/sideline evaluation

• Follow post concussive symptoms

– Imaging Studies (Study structure not function)• Do not detect subtle physiological changes in the concussed brain

Signs/Symptoms of Concussion

• Dazed• Confused about play• Answers questions

slowly• Personality/Behavior

change• Anterograde amnesia• Loss of consciousness

• Headache• Nausea• Balance problems• Double vision• Photosensitivity• Feeling Sluggish• Feeling foggy• Change in sleep pattern• Cognitive changes

Sideline Evaluation

• SCAT-2– Physical Signs

– Glasgow Coma Scale

– Maddock’s Questions

– Cognitive Assessment

– Balance Examination

– Coordination Examination

Risks of Premature Return To Play

• No athlete should return to play while experiencing symptoms of concussion!

• Why? – risk of Second Impact Syndrome

Second Impact Syndrome

• Occurs in athletes with history of a prior concussion– Second impact can be relatively minor– Can occur up to 14 days after injury– Athlete return to play before resolution of 1st concussion

symptoms

• Catastrophic increase in intracranial pressure– Vasomotor paralysis, edema, massive swelling, herniation,

death

• Most often occurs in athletes < 21 yrs old– Appears to be due to neuro-chemical processes in the

developing brain

Post Concussive Syndrome

• Decreased Processing Speed• Short Term Memory Impairment• Concentration Deficit• Irritability/Depression• Fatigue/Sleep Disturbance• General Feeling of “Fogginess”• Academic Difficulties

How Do We Know When An Athlete Can Return?

• Physical Exam– Balance– Cranial Nerves– Coordination

• Neurocognitive Exam– ImPACT

Clinical Assessment Tool

• Neurocognitive testing– Pre-season Baseline– Post Injury Testing

• ImPACT Test – clinically validated objective measure

Impact Test

• Computer Test – Developed by clinical researchers at the University of Pittsburgh Medical Center (UPMC)

• Developed to allow for an objective assessment of concussion and recovery

• Baseline testing allows for individual differences in cognitive ability and symptom reporting

• Provides a test that allows for collaboration between athletic trainers, coaches, physicians, and neuropsychologists

Current Users

• NFL• NHL• MLB• MLS• CHL• Rapid City Rush• Many colleges (SDSU)• Many high schools (STM, RC Stevens, RC Central,

Sturgis Brown)

What Does Impact Measure?

What Does Impact Measure?

• Demographic/Concussion Questionaire• Concussion Symptom Scale (21 item scale)• Neurocognitive Measures

– Memory, working memory, attention, reaction time, mental speed, verbal memory, visual memory, reaction time, processing speed

• Detailed clinical report

ImPACT Test Examples

ImPACT Test Report

Frequently Asked Questions

• Data is confidential• Athletes baseline screens performed in schools

computer lab• Data stored online – no server/equipment needed at

the school • Sideline assessment by trainer, post concussion test

with 24-48 hours, then tested once a week until score normalizes

• Return to play after evaluation by physician

If Used Correctly, ImPACT will …

• Help determine severity of concussion• Provide valuable information to the athlete, parents,

athletic trainers, and physicians• Provide information on academic deficits associated

with concussion• Promote safe return to play• Reduce liability for school districts• Impact will not

– Prevent a concussion from happening

– Eliminate the risk of concussion

Return to Play

Return to Play• Remove from play/practice/event• Sideline Evaluation – SCAT2• If indicated – physician/Emergency Room• Monitor post-concussive symptoms• Once symptoms resolved –

– Begin gradual return to play ladder– Follow ImPACT test Scores

• Step-wise return to play– No activity - rest until asymptomatic– Light aerobic exercise– Sport-specific training– Non-contact drills– Full-contact drills– Game play

How Many Concussions Per Year?

• Cantu rules – 2 severe or 3 total concussions in a calendar year

• If 3 concussions = sit out x 1 year or longer

How Many Concussions Per Career?

• Chronic Traumatic Encephalopathy (CTE)– Degenerative Process

– Deposition of Tau Protein (stains dark)

• Boston University Center for the Study of Traumatic Encephalopathy

Future Directions

New Diagnostic Tests• U.S. Army, in partnership with the Alachua, Fla.based company

Banyan Biomarker• Preliminary test (34 subjects), second phase 1200 patients

•  Test identifies substances that spill into the blood from injured brain tissue– SBDP145 and SBDP120 proteins appear to enter the blood as a result of

damage to brain cell

• Severe brain injury patients had levels of a biomarker called UCH-L1 that were 16 times the level found in patients without brain injury

Neuroproteomics: A Biochemical Means to Discriminate the Extent and Modality of Brain Injury.   Ottens AK, Bustamante L,  Golden EC, Yao C, Hayes RL, Wang

KK, Tortella FC, Dave JR.  J Neurotrauma. 2010 Aug 10. 

Functional MRI

• Purdue engineering students• Collecting control data for concussion project• During season/multiple hits to head lead to decline in

activity in the dorsolateral prefrontal cortex – area responsible for visual memory

Helmets

• Studies looking at biomechanical properties of concussions

• Accelerometers in helmets to detect g-forces in athletes when they sustain concussion

• Inconsistent findings– Occasionally expected threshold reached and no

concussion occurs

– Linear vs rotational forces

– Expect that hits causing greater than 80Gs would cause concussion (heading soccer ball 20Gs)

Helmets

- Helmets intended to prevent skull fractures- No independent evidence based study showing any helmet type can prevent concussions

Helmets

Riddell - $419.99Xenith - $319.00

Cascade M11 Hockey Helmet$149.00

Coaching

• Eliminate Hitting with head down• Change in “toughness culture”• Emphasis on proper technique

South Dakota Senate Bill 149• Included are South Dakota State Activities Association

Coaches/Athletes• A concussion information sheet will need to be signed and

returned prior to participation• Education and training for coaches/parents/athletes• Key Safety Components:

– Athlete is removed from play/practice as soon as they show signs of concussion

– All signs/symptoms of concussion must have resolved– Evaluation by licensed/certified health care provider– Written clearance provided by health care provider

Rule Changes

Rule Changes

• NHL – Rule 48 – Illegal check to the Head -  A lateral or blind side hit to an opponent where the head is targeted and/or the principal point of contact is not permitted.

- NFL -  New rules prohibit a player from launching himself off the ground and using his helmet to strike a player in a defenseless posture in the head or neck.  When a player loses his helmet, the play is immediately whistled dead.

Education

• National Federation of High Schools• Web based training program:

– Free

– 20 min training program

– www.nfhslearn.com/electiveDetail.aspx?courseID=15000

Return to Play• Remove from play/practice/event• Sideline Evaluation – SCAT2• If indicated – physician/Emergency Room• Monitor post-concussive symptoms• Once symptoms resolved –

– Begin gradual return to play ladder– Follow ImPACT test Scores

• Step-wise return to play– No activity - rest until asymptomatic– Light aerobic exercise– Sport-specific training– Non-contact drills– Full-contact drills– Game play