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1. Concussion Assessment: A Standardized Approach
3. Although the athlete depicted here suffered a severe laceration to the face and gums, he did not sustain a concussion
Although concussions obviously cannot be graded or judged simply by the viciousness of the hit, they can be judged and graded using a few simple tools
Your athletes lives just may depend upon it Introduction
4. Is there a time efficient, easy, and economical means through which we can determine when an athlete has sustained a traumatic brain injury? Introduction
5. Rationale for using a standardized approach:
Startling facts about concussions
Anatomy of concussions
Signs and symptoms of concussions
Common concussion sequelae Overview: Concussion Assessment: A Standardized Approach
6. Administration of the Standardized Assessment for Concussion (SAC)
Administration of the Balance Error Scoring System (BESS)
Considerations for implementation Overview: Concussion Assessment: A Standardized Approach
7. Definitions
A violent shaking or jarring action that can result in immediate or transient impairment of neurological function (Anderson & Hall, 1995).
A traumatically induced alteration in brain function resulting from a direct blow to the head or a whipping force, which can jar the brain against the skull (Sugarman & Roche, 2000). Concussion
8. Facts About Concussion Centers for Disease Control and Prevention (CDC) estimates 300,000 sports-related concussions occur per year
100,000 in football alone
Over 63% of certified athletic trainers report not using any objective criteria in their concussion protocol (Ferrara, et al., 2001)
9. Concussions occur most often in males and are most prevalent among adolescents and young adults
Risk of concussion in football is 4-6 times higher in players with a previous concussion Facts About Concussion
10. Significant relationship noted between diagnosed learning disabilities and incidence of concussion Facts About Concussion
11. Concussions per every 100,000 games and/or practices at the collegiate level
Football: 27
Ice Hockey: 25
Mens soccer: 25
Womens soccer: 24
Wrestling: 20
Womens basketball: 15
Mens basketball: 12 (Head and Neck Injury in Sports, R.W. Dick) Facts About Concussion
12. Skull
bony casing around brain
Brain
approximately 1/4 space between skull and brain in sub-arachnoid space Anatomy
13. Anatomy The brain is a jello-like substance vulnerable to outside trauma.
The skull protects the brain against trauma, but does not absorb impact forces.
14. Anatomy Cervical spine allows the head to rotate to avoid blunt trauma, however, rotational forces can be the most damaging during concussion
15. 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: As a football player is tackled, his head strikes an opponents knee; This contact to the head can cause arotational motion.
16. Impaired attention -- vacant stare, delayed responses, inability to focus
Slurred or incoherent speech
Gross incoordination Immediate Signs of Concussion(Occurring Within Seconds to Minutes)
17. Disorientation
Emotional reactions out of proportion
Memory deficits
Any loss of consciousness Immediate Signs of Concussion(Occurring Within Seconds to Minutes)
18. Persistent headache
Dizziness/vertigo
Poor attention and concentration
Memory dysfunction
Nausea or vomiting Later Signs of Concussion(Occurring Within Hours to Days)
19. Fatigue easily
Irritability
Intolerance of bright lights (photophobia)
Intolerance of loud noises
Anxiety and/or depression
Sleep disturbances Later Signs of Concussion(Occurring Within Hours to Days)
20. Post Concussion Syndrome
Lingering symptoms and continuing cognitive deficit following a concussion injury
May occur weeks or months after injury
Associated with concussion grades II & III Common Concussion Sequelae
21. Subdural Hematoma
Epidural Hematoma
Generalized brain swelling and diminished blood flow to sensitive brain tissues Common Concussion Sequelae
22. Second Impact Syndrome
Second concussion occurs while still symptomatic & healing from previousinjury days or weeks earlier
Athlete may or may not lose consciousness
Second impact more likely to cause brain swelling and other widespread damage
Loss of cerebral blood flow autoregulation results in massive vasodilation and 100% mortality (Snoek, et al., 1984) Common Concussion Sequelae
23. Primary survey to rule out immediate threats to life
Trending vital signs
Secondary survey to identify potential threats to life or limb
C-spine
Neuro exam How Are Concussions Assessed?
24. Neurological exam should include:
Cranial nerve check
Myotome testing
Dermatome testing
Reflexes
Cognition How Are Concussions Assessed?
25. At least 14 concussion grading systems now exist, with three being pre-eminent
Cantu guidelines (1988)
Colorado Medical Society (CMS) guidelines (1991)
American Academy of Neurology guidelines (1997) How Are Concussions Assessed?
26. Problems with Cantu, CMS, and AAN guidelines include:
Inconsistency of criteria to determine severity
Controversy regarding the importance of loss of consciousness, post-traumatic amnesia, and post-concussive symptoms How Are Concussions Assessed?
27. No scientific basis for return to play guidelines
No consensus within sports medicine for any of the established guidelines
Most do not use objective, repeatable measures How Are Concussions Assessed?
28. Neuropsychological baseline testing considered the gold standard but not frequently used
Too costly ($500-2000 per athlete)
Too time consuming (4-8 hours per athlete)
Standardized Assessment for Concussion (SAC) developed as a time-efficient and cost-effective alternative How Are Concussions Assessed?
29. Standardized Assessment for Concussion (SAC) (McCrea, Kelly, Randolph, et al.)
Relatively quick and easy
Norms being established, but key is comparison to athletes own pre-participation baseline How Are Concussions Assessed?
30. NeuroCom Smart Balance Master considered gold standard
Again, not cost efficient and cannot be used on the sideline
Balance Error Scoring System (BESS) (Guskiewicz, McCrae, et al.)
Whereas SAC assesses cognitive function, BESS assesses balance and equilibrium function
Relatively quick and easy How Are Concussions Assessed?
31. Orientation (5 points)
Ask athlete a series of questions regarding time, day, date, etc
Aimed at establishing athletes awareness
Five questions scored (1 point for correct answer, 0 points for incorrect answer) Administration of the SAC
32. Immediate recall/learning (15 points)
Recite list of words and ask athlete to repeat
Recite list additional times to see if recall improves
Do NOT inform athlete of delayed recall of same list later during the administration of the test Administration of the SAC
33. Concentration (5 points)
Recite increasingly long series of numbers and ask athlete to recite list in reverse order
Ask athlete to recite months of the year in reverse order
Administration of the SAC
34. Delayed recall (5 points)
Ask athlete to recite word list from immediate memory portion of SAC
Administration of the SAC
35. Scoring system
compare subjects test score(s) to his/her baseline, not to other subjects scores
Norms not yet established, but differences of 2-3 points considered significant Administration of the SAC
36. Total of six stances with eyes closed and hands on iliac crests
Firm surface two-feet, non-dominant one foot, and tandem (heel to toe)
Soft surface (AirEx Balance Pad) two-feet, non-dominant one foot, and tandem (heel to toe) Administration of the BESS
37. Stance held for 20 seconds and errors counted
Errors consist of any of the following:
Lifting hand(s) from iliac crest(s)
Step, stumble, or fall
Lifting forefoot or heel
Moving hip more than 30 degrees from starting position
Staying out of testing area > 5 seconds Administration of the BESS
38. Maximum number of errors per position is 10
Errors for each position added together for final BESS score out of 60
Test valid and reliable (Riemann, et al., 1999)
Considerations for implementation include distraction, taping/bracing, pads, fatigue, and inter-rater reliability Administration of the BESS
39. Objective measure of cognitive function
Identifies signs and symptoms that may be too subtle to otherwise detect
Difficult to cheat
Athletes who should not return easily identified What SAC/BESS testing CAN Tell You
40. No way to determine grade of concussion from SAC/BESS data alonemust use other criteria
Return to play guidelines utilize SAC/BESS data as a portion of the overall picture to be considered
What SAC/BESS testing CANNOT Tell You
41. Baselines should be completed BEFORE contact begins
Maintain list of baselines and keep them handy
Sometimes helpful to keep with insurance documentation Considerations for Implementation
42. Mimic the surroundings of a competition/sideline while administering baseline test to ensure validity
Keep a small, laminated version of the SAC and BESS in your fanny pack or kit for ease of use during game situations Considerations for Implementation
43. Objectives of RTP guidelines
Prevent missed concussions and the complications that may potentially arise
Improve awareness and identification of concussions among medical and coaching staff
Reduce subjectivity
Discontinue arbitrary decision making for RTP duration Return to Play Guidelines
44. Utah State University (USU) Model (Finnoff & Mildenberger)
Utilizes SAC, BESS, and functional testing data to determine RTP
Athlete may not return to play until 5 days AFTER SAC & BESS normalization and asymptomatic functional testing Return to Play Guidelines
46. Return to Play Guidelines: USU Model
47. By using the SAC and the BESS, you can be better prepared to objectively evaluate athletes with concussion-like symptoms quickly, easily, and consistently
Along with a functional progression, such information can help determine without question when an athlete may safely return to play