Lecture 10 Concussions

Injury Definition: Sports concussion “Concussion is defined as a complex

pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…”

Aubry et. al. Br J Sports Med 36(1): 6-10, 2002

Definition Concussion may be caused either by a direct

blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.

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

Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However it is important to note that in a small percentage of cases, post-concussive symptoms may be prolonged.

No abnormality on standard structural neuro-imaging studies is seen in concussion.

May or may not involve loss of consciousness (only approximately 10 % result in LOC)

Concussion EffectsConcussions effect four areas of functionality The way the person feels How they think Changes in emotions How they sleep

Signs to watch for in athletes Appears dazed or stunned Confused about assignments Forgets plays Unsure of game score or opponentMoves clumsily Answers questions slowly Behaviour or personality changes Can’t recall events prior to or after injury LOC

Symptoms to watch for in Athletes

HeadacheNauseaBalance problems /dizzinessDouble or blurry visionSensitivity to light or noiseFeeling sluggish , foggy Concentration or memory problems confusion

Everyone “feels fine”Always ask:1.“On a scale of 0 to 100%, how do you feel?”2.“what makes you not 100%?”3. Checklist – SCAT2

Onfield or sideline evaluation of acute concussion The player should be medically evaluated onsite using

standard emergency management principles and particular attention should be given to excluding a cervical spine injury.

The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner.

An assessment of the concussive injury should be made using the SCAT3 or other similar tool.

The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.

A player with diagnosed concussion should not be allowed to return to play on the day of injury (see management section).

Investigations Balance assessment Balance error scoring

system (BESS)

Neuropsychological assessment Best done after symptom resolutionMost sensitive when compared to baseline

Management CORNERSTONE = rest until asymptomatic Rest from activity

No training, playing, exercise, weightsBeware of exertion with activities of daily

living

No television, extensive reading, video games, texting ?

Caution re: daytime sleep

Cognitive rest REST = ABSOLUTE REST!

Sports concussion Follow-up Management RestRestRestExpect gradual resolution in 7-10 daysStart graded exercise rehabilitation when

asymptomatic at rest and post-exercise challenge

Rest for a player with a concussion at school Stay at home or attend half days Take naps , need rest timeExtended time for assignments or testsWritten instructions for assignmentsRepeat and present new information slowly

Management Issues Consider role for psychological approachesPharmacotherapy Prolonged symptoms (sleep

disturbance, anxiety)Modify underlying pathophysiology

Upon return to play should not be on medication that could mask symptoms Antidepressants?

Management Issues Pre-participation Evaluation History:Type of sport?Number of prior concussions? Prior facial, dental injuries?Non-sporting head injuries?Type of player (“physical”?)Ability to “take a hit”Protective equipment (helmet age)

Second Impact Syndromethis occurs when an athlete ( generally

seen in children under 18) has sustained a head injury – usually a concussion and then sustains a second concussion before the symptoms associated with the first injury have totally resolved

the athlete may receive a relatively minor second blow to the head – the athlete often continues to compete and may be able to function fine for a short period of time

however the cranium becomes engorged with blood increasing the pressure on the brain

the athlete collapses , slips into a comatose state and respiratory failure ensues

the usual time from second impact to brainstem failure is rapid , 2 to 5 minute

Hence it is imperative any athlete who complains of headache, light headiness, visual disturbances or other neurologic symptoms should not be allowed to participate in any athletic event until they are totally asymptomatic

“When in doubt sit them out”

If S/S linger but appear minor an individual close to the injured person should be informed of the injury and told to watch for changes in behaviour, unsteady gait , slurred speech , progressive headache or nausea, restlessness , mental confusion or drowsiness.

These danger signs should be documented on a sheet to give out and given to the individual watching the injured person. If any S/S worsen then the injured person should be taken to the emergency room ASAP.

Must be checked by medical personal at some time

Must never be sent alone to the bus ,locker room, home etc.

When to call the ambulance ?A player with a witnessed LOC of any

duration A player who exhibits the one or more of the

following symptomsDecrease level of consciousnessUnusual drowsiness or the inability to be

awakenedDifficulty getting attention Breathing difficulty Severe or worsening headachesVomiting Seizures

Recovery How long asymptomatic before exercise?If rapid and full recovery, then 24-48 hoursOne approach is to require that they remain

asymptomatic (before starting exertion) for the same amount of time as it took for them to become asymptomatic.

Graded Exertion Protocol 24 hours per stepIf there is recurrence of symptoms at any

stage, return to previous stepReturn to Play / Sport Must pass graded exertion first=remain asymptomaticIs the athlete confident to go back?New helmet/head gear?Other “protective” equipment / behaviors /

factors?Consider implications of multiple/recent

injury

Modifiers May influence investigation and managementMay predict potential for prolonged or

persistent symptomsMultidisciplinary approach coordinated by a

physician with specific expertise in management of concussion.

FACTORSMODIFIER Symptoms Number

DurationSeverity

Signs Prolonged LOC (>1min)Amnesia

Abnormal condition Concussive convulsions Temporal Frequency –repeated concussion over time

Timing – injuries close together “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) Co and Pre-morbidities Migraine, depression or other mental health disorders,

attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders

Medication Psychoactive drugsAnticoagulants

Behaviour Dangerous style of play Sport High risk activity

Contact and collision sport

SCAT

See handout

Return to play guidelines

Special populations

Child and Adolescent Athlete Adult recommendations can apply down to

age 10Below 10 require age appropriate symptom

checklistsInclude both patient and parent, teacher, etc.Possibly use neuropsych testing before

symptoms resolve to assist planning school management

Child and Adolescent Athlete Consider age specific physical and cognitive

rest issuesSymptom resolution may take longerConsider extending symptom free period

before starting return to play protocolConsider extending length of the graded

exertion protocolDo not return to play same day

Elite vs non elite All athletes should be managed the same

regardless of level of participationHowever, available resources and expertise

may facilitate a more aggressive management approach