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Page 1 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats New In Concussions: Prevention and Management ACHA Annual Meeting, San Francisco.

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Presentation on theme: "Page 1 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats New In Concussions: Prevention and Management ACHA Annual Meeting, San Francisco."— Presentation transcript:

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2 Page 1 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats New In Concussions: Prevention and Management ACHA Annual Meeting, San Francisco May 2009

3 Page 2 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Presenters Dr. James MacDonald, MD, FAAFP University of California – Santa Cruz Santa Cruz, CA Dr. Lori Dewald, EdD, ATC, CHES, F-AAHE Salisbury University Salisbury, MD

4 Page 3 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Background….UCSC Our clinic Our student population Mostly Young Mostly Healthy Very Active!

5 Page 4 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury UCSC Division III Sports mens tennis womens tennis mens basketball womens basketball mens soccer womens soccer mens volleyball womens volleyball mens water polo womens water polo womens cross-country womens golf mens and womens swimming and diving

6 Page 5 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury …..And More Club Sports Rugby, Ultimate, Baseball, Lacrosse, Cheerleading, Dance and more Activities and Classes Jiu Jitsu, Capoeira, Biking, Lifting, Swimming, Skating, Snowboarding, Surfing………. Our Campus!

7 Page 6 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury 8000 students. One of the most successful Division III athletic departments in the country. Multiple national championships in multiple sports annually. Background….Salisbury University

8 Page 7 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Salisbury University* NCAA Division III Our sports Womens Field HockeyMens Football Womens SoccerMens Soccer Womens Cross Country Mens Cross Country Womens Basketball Mens Basketball Womens LacrosseMens Lacrosse Womens Softball Mens Baseball Womens Track/Field Mens Track/Field Womens TennisMens Tennis Womens SwimmingMens Swimming Womens Volleyball

9 Page 8 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Athletics does not deal with… Club sports Other activities (i.e. dancers, theatre, etc.) These are dealt with by the student health center!

10 Page 9 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats New In Concussion A move away from consensus grading to a binary diagnosis scheme: simple vs. complex A move away from arbitrary days, and a move toward symptom-based protocol for return to play A move toward more objective assessment of recovery (quantifying symptoms, neuropsychological performance, balance) Increasing research!

11 Page 10 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Ever Increasing Research and Awareness

12 Page 11 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Brain Anatomy

13 Page 12 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury ConcussionA Definition Diffuse, reversible brain injury associated with trauma. Functional not structural!! Caused by inertial forces from trauma that lead to shear strain. Concussion is a metabolic injury: injury results in increased energy demands as repair begins. Hallmark: Mental Status changes, including confusion, amnesia, even loss of consciousness.

14 Page 13 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Epidemiology CDC estimate: more than 1.6 million/year/USA. 300,000+ are sports related. This means that 1.3 million occur in other ways….such as alcohol-related stunts, etc. 92% of repeat concussions occur within 10 days of the first! Kevin Guskierwicz 2000

15 Page 14 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury YouTube Video This is the way your students might get this in a non athletic way

16 Page 15 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Concussiona metabolic injury Increased demand for glucose coupled with decreased cerebral blood flow. Can be seen on PET, fMRI imaging (not clinically useful). Vasoconstrictive effects are due to local accumulations of calcium in endothelium of cerebral vasculature. /sports/other/concussion.swf

17 Page 16 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury

18 Page 17 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury How lay people understand it A Ding. Getting Your Bell Rung. Just shake it off and get back in the game. The difference between injury and pain.

19 Page 18 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury The reality…. ConcussusLatin:to shake violently. Traumatic functional brain injury. With rapid onset of short lived neurological deficits!!!!!! No two concussions have the same signs or symptoms. Student health centers see more concussions than athletic trainers, because you have the entire student body as your patients. Intramural sports, accidents, general student body, physical education classes, and weekend warriors experience more concussions annually.

20 Page 19 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury What its not! Epidural hematoma Subdural hematoma Brain contusion Cervical Spine injury Transient quadriplegia Facial fracture

21 Page 20 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Concussion--Signs Appears dazed and confused. Forgets Plays. Unsure of game, score, opponent. Moves clumsily. Answers questions slowly. Loss of consciousness. Personality changes. Amnesiaboth retrograde and antegrade. No localizing signs on neurological exam. Imbalance. Seizure. Inappropriate emotions.

22 Page 21 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Concussion--Symptoms Headache, nausea., vomiting Dizziness. Blurry Vision. Light, sound sensitivity. Feels sluggish or slow. Feels groggy or foggy. Concentration problems. Difficulty balancing Tinnitus Sadness or finding everything funny Hallucinations

23 Page 22 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury SCAT 2

24 Page 23 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Testing Monitoring of the following critical domains Neuropsychological (Standardized Assessment of Concussion, SAC) Balance (Balance Error Scoring System, BESS) Symptoms (Graded Symptom Checklist) These can all be found in the newly released SCAT2 widely distributed now on the internet

25 Page 24 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury ConcussionAssociated Sports All sports have the potential for concussions! Football Soccer Rugby Wrestling Boxing Martial Arts Skiing Snowboarding Lacrosse I like to believe that my best hits border on felonious assault. ~Jack Tatum Float like a butterfly, sting like a bee. ~Muhammad Ali

26 Page 25 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Concussion--diagnosis Best done on the field or shortly thereafter. Neurological examination, including mental status testing. Grade I (Mild): <30 min. amnesia, no LOC. Grade II (Moderate): 30 min to 24 hours of amnesia, and/or < 5 min. of LOC. Grade III (Severe): >24hr amnesia and/or >5 min LOC. LOC means loss of consciousness NO!!!!!

27 Page 26 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury On field mental status Orientation and evaluation of retrograde amnesia. Who are we playing? Which goal is ours? Who is winning? Who scored last? Who did we play last week? Did we win last week? Are your parents at this game?

28 Page 27 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Mental Status--continued Concentration. Months backwards. Digits or Name backwards. Evaluate antegrade amnesia: three to five word recall.

29 Page 28 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Additional considerations Brains appear normal on CAT scans, x-rays, and MRIs. PET, SPECT, and functional MRIs are the preferred imaging. Especially to be used immediately after the injury and then as a comparative tool for determining concussion recovery. Difficult to find though. The effects of concussions are cumulative! The adolescents and teens are more vulnerable to concussions than adults…but researchers still do not know exactly why this is. Girls possibly, too.

30 Page 29 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Recent research Study by Collins et al. revealed that the presence of amnesia and not LOC was most predictive of post injury difficulties at three days post injury. Studies by Erlanger et al. found that LOC was not predictive of deficits following sports related concussion. Women appear at higher risk for concussions: why?

31 Page 30 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Cantus Guidelines for return to play First Concussion Second Concussion Third Concussion Grade I Return to play if asymptomatic for one week Return to play in two weeks if asymptomatic at that time for one week Terminate season; may return to play next season if asymptomatic Grade II Return to play if asymptomatic for one week Return to play if asymptomatic one month; consider terminating season Terminate season; may return to play next season if asymptomatic Grade III Return to play if asymptomatic one month Terminate season; may return to play next season if asymptomatic NO!!!!!

32 Page 31 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Step Wise Return to Play Protocol 1. No activity; complete rest. Once asymptomatic, proceed to level (2), and so on… 2. Light aerobic exercise such as walking/cycling. 3. Sports specific traininge.g. running in rugby or skating in hockey. 4. Non-contact training drills. 5. Full contact training. 6. Game play. With this stepwise progression, athlete should continue to next level if asymptomatic at current level. If symptoms develop, drop back to previous asymptomatic level and try to progress again after 24 hours.

33 Page 32 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Disqualifying considerations Disqualifying for a game or practice. Disqualifying for the season. Disqualifying for a career.

34 Page 33 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Second Impact Syndrome This dreaded complication occurs when athlete is still symptomatic from initial head injury and sustains a second head injury. Second injury shear force causes enough damage to result in cerebral edema leading to brain stem herniation. Signs: fixed, dilated pupils; slowing and then stopping of respiration; a rigid, abnormal posture. Rare, but becoming more common!

35 Page 34 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Post-concussion Syndrome By definition what is seen in a complex concussion Prolonged Inattention Affective symptoms Difficulty Concentrating Headaches

36 Page 35 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Long term complications Long term deficits have been observed from a single concussive event. More events = higher risk of long term deficits; but how much is too many? Dementia pugilisticais this secondary to concussion or multiple lower level traumatic events to the brain?

37 Page 36 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Chris Nowinski

38 Page 37 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Encephalopathy Increasingly researched. Anecdotal information mounting.

39 Page 38 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Athletes to donate brains for concussion study

40 Page 39 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Long Term Complications, Cont. Center for the Study of Retired Athletes, Univ. of North Carolina

41 Page 40 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Retirement? No evidence based recommendations guide practitioner. Anecdotal cases of athletes with poor outcomes dictate many decisions. Some evidence that certain preconditions (ApoE gene; associated learning disabilities) are associated with higher risk. Having a frank discussion with the athlete about risks/benefits seems appropriate course at this current juncture.

42 Page 41 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury ConcussionHow to avoid it Customized mouthguard is a must…..for teeth protection! Head protection. Avoiding sports at risk. Pre-season neck strengthening? Wearing appropriate/advanced, sport specific head gear. Not wearing head gear???? Minding your manners if youve had a concussion. Correct tackling, etc. Turf?

43 Page 42 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats New? Grading of concussions is simplified: there are simple and complex concussions. Return to play/work decisions are simplified: functional assessment as opposed to old criteria. Increasing recognition of impact in the school room and not just the playing field. Increasing recognition of longer term consequences. Increasing Awareness!

44 Page 43 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Whats new continued Neuropsychometric testing preseason, after trauma, and postseason. Genetic testing for apolipoprotein E (ApoE) gene. Sport specific differences. Gender specific differences. Females more susceptible than males. Age specific differences. Handheld device that is taped to the forehead and reads the brains electrical activity immediately after the possible concussion and compares it immediately to normal brain function.

45 Page 44 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Increasing Awareness CDC Heads Up Program

46 Page 45 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury National Athletic Trainers Association Position Statement on Sport-Related Concussions

47 Page 46 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Another Video! This time from the CDC

48 Page 47 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Suggestions QI In service Readings Track Diagnosis code Chart Review Feedback

49 Page 48 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Summary A functional, not a structural injury. Be comfortable with return to play/work progression. Consider additional injuries and rule out/treat as indicated. Consider referral for complex concussions. Students will present just as likely as athletes Practice Pearl!!!

50 Page 49 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Resources NATA Position Statement on Concussions (available at Pediatrics Vol. 123 No. 1 January 2009, pp Review Article on Concussions British Journal of Sports Medicine (the entire May 2009 issue). CDCs Heads Up program, at The 3 rd International Conference on Concussion in Sport, Zurich, 2008 (being widely distributed)

51 Page 50 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Thanks, From UCSC and Salisbury!

52 Page 51 UCSC Lori Dewald, ATC, ED.D. James MacDonald, MD Salisbury Questions?


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