Changing perceptions: There is no such thing as a minor concussion!

1. Changing perceptions: There is no such thing as a minor concussion!

2. Sports and Concussion A partnership to manage concussion Brought to you by: American Academy of Neurology & Brain Injury Association

3. Contents • Defining concussion • Anatomy of concussion • Mechanisms of concussion • Sideline evaluation • Management recommendations • Return to play • Case study • Prevention

4. Concussion • Definition • A concussion is an alteration of mental status due to biomechanical forces affectingthe brain. A concussion may or may not cause loss of consciousness.

5. Facts About Concussion • Centers for Disease Control and Prevention (CDC) estimates 300,000 sports-related concussions occur per year • 100,000 in football alone • An estimated 900 sports-related traumatic brain injury deaths occur per year

6. Facts About Concussion • Concussion occurs most often in males and children, adolescents and young adults • Risk of concussion in football is 4-6 times higher in players with a previous concussion

7. Facts About Concussion • Concussions per every 100,000 games and/or practices at the collegiate level • Football: 27 • Ice Hockey: 25 • Men’s soccer: 25 • Women’s soccer: 24 • Wrestling: 20 • Women’s basketball: 15 • Men’s basketball: 12(Head and Neck Injury in Sports, R.W. Dick)

8. Anatomy of Concussion • The brain is a jello-like substance vulnerable to outside trauma. Skull protects the brain against trauma, but does not absorb impact forces. • During concussion, the brain rotates and twists inside the skull, causing damage to brain tissue

9. Anatomy of Concussion • Cervical spine -- allows the head to rotate to avoid blunt trauma • However, rotational forces can be the most damaging during concussion

10. Vulnerable Tissues • Gray Matter of the Brain • Neurons, residing in the gray matter, are single cells that use chemical reactions to create electrical currents to carry out activities • The gray matter is the site of processing, integration and memory

11. Vulnerable Tissues • White Matter of the Brain • Nerve cells are connected by axons (long projections of nerve cells resembling insulated wiring) which connect neurons to other neurons

12. 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: When a football player is tackled, his head may strike an opponent’s knee; this contact to the head can cause arotational motion.

13. Immediate Signs of Concussion(occurring within seconds to minutes) • Impaired attention -- vacant stare, delayed responses, inability to focus • Slurred or incoherent speech • Gross incoordination • Disorientation • Emotional reactions out of proportion • Memory deficits • Any loss of consciousness

14. Later Signs of Concussion(occurring within hours to days) • Persistent headache • Dizziness/vertigo • Poor attention and concentration • Memory dysfunction • Nausea or vomiting • Fatigue easily • Irritability • Intolerance of bright lights • Intolerance of loud noises • Anxiety and/or depression • Sleep disturbances

15. Post Concussion Syndrome • Lingering symptoms and continuing cognitive deficit following a concussion injury • May occur for weeks or months after injury • Associated with concussion Grades 2 & 3

16. Second Impact Syndrome • Second concussion occurs while still symptomatic & healing from previous injury days or weeks earlier • Loss of consciousness not required • Second impact more likely to cause brain swelling and other widespread damage • Can be fatal -- 50% mortality rate in most severe cases • Higher risk of long-term cognitive dysfunction

17. Related Brain Tissue Injuries • Hematoma -- blood clot • Contusion -- brain bruises • Brain swelling and diminished blood flow to sensitive brain tissues

18. How is Concussion Assessed? • AAN guidelines for sideline evaluation • Standardized Assessment of Concussion (SAC) for sideline use • Standard neuropsychological tests • Computerized reaction time tests

19. AAN Sideline Evaluation • Mental status testing- Orientation, concentration, memory • Exertional provocative tests - 40-yd. dash, push-ups, sit-ups, knee-bends • Neurological tests - Strength, coordination/agility, sensationNeurology, March 1997

20. SACStandardized Assessment of Concussion • Assesses orientation, memory and concentration • Developed for sideline use • Developed for nonmedical personnel • Easy to administer • Can use for objective comparisons e.g. preseason vs. post injury (McCrea, et al Neurology, 1997)

21. Grade 1 Concussion • Transient confusion • NO loss of consciousness • Concussion symptoms or mental status abnormalities resolve in less than 15 minutes

22. Management RecommendationsGrade 1 • Remove from contest • Examine immediately and at 5-minute intervals for the development of mental status abnormalities or post-concussive syndrome at rest and with exertion • May return to contest if mental status abnormalities or post-concussive symptoms clear within 15 minutes

23. Grade 2 Concussion • Transient confusion • NO loss of consciousness • Concussion symptoms or mental status abnormalities last more than 15 minutes

24. Management RecommendationsGrade 2 • Remove from contest; disallow return that day • Examine on-site frequently for signs of evolving intracranial pathology • A trained person should reexamine the athletethe following day • A physician should perform a neurologic exam to clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion

25. Grade 3 Concussion • Any loss of consciousness, either brief (seconds) or prolonged (minutes)

26. Management RecommendationsGrade 3 • Transport from the field to the nearest emergency department by ambulance if still unconscious or worrisome signs are detected (with cervical spine immobilization, if indicated) • A thorough neurologic evaluation should be performed emergently, including neuroimaging procedures when indicated • Admit to hospital if any signs of pathology are detected or if the mental status remains abnormal

27. When to Return to Play • Grade of concussion Return to play only after asymptomatic with normal neurologic assessment at rest and with exercise • Grade 1 15 minutes or less • Multiple grade 1 1 week • Grade 2 1 week • Multiple grade 2 2 weeks • Grade 3 2 weeks • w/prolonged loss of consciousness • Multiple grade 3 1 month or longer

28. Treatment • The treating physician can utilize a variety of treatment options including: • Analgesics for pain • Sleeping medication • Muscle relaxants • Rehabilitation therapies

29. Case Study • 17-year-old high school football player • Suffered concussion without loss of consciousness during a varsity game • Complained of headache throughout the next week • Received no further injuries and did not seek medical attention

30. Case Study • Next game • A week after first concussion • While carrying the ball, he was struck on the left side of his helmet by the helmet of his tackler • He was stunned, but mental functions appeared to clear quickly during a brief time out on the field

31. Case Study • He was given the ball during the next play • His helmet made only slight contact with one of several tacklers during the play • He arose from the pile of players under his own power then fell unconscious into the arms of a teammate

32. Case Study • He arrived at the local hospital unresponsive, pupils fixed and dilated • All treatment efforts were unsuccessful • Brain pressure rose stopping blood flow to the brain • 15 hours after his loss of consciousness he was pronounced dead(Kelly, et al, JAMA, November 27, 1991)

33. Prevention Goals • Identification and educationIt’s important to educate others about ways to prevent concussion before it happens • Implementing sideline evaluations & treatment recommendations • Recognize and treat post concussion syndrome • Prevent second impact syndrome • Prevent further morbidity • Prevent fatal injury

34. Prevention Tools • Rule changes • Play smart, keep the head safe by making penalties tougher • Use helmets and other protective equipment • Design changes for protective equipment • Ongoing research • education, risk factors, early detection of concussion using SAC

35. Goals for the Future • Eliminate fatalities -- second impact syndrome • Prevent morbidity -- post concussion syndrome • Preserve brain function -- enable young players to reach their full potential in life! • Make sports safer • Increase awareness about sports-related concussions

36. Sports and Concussion A partnership to manage concussion Brought to you by: American Academy of Neurology & Brain Injury Association