1. Evaluation and Management of Head Injuries in Sports
George S. Wham Jr., M.S., A.T.,C., S.C.A.T.

2. NATA Competencies concerning Head Injuries
Recognize signs and symptoms of head trauma, including loss of consciousness, changes in neurological function, cranial nerve assessment, and other symptoms that indicate brain injury
Explain and interpret signs and symptoms associated with intracranial pressure
Define cerebral concussion and lists the signs and symptoms used to classify cerebral concussion to accepted grading scales: Cantu, Colorado, ANA
Assess a patient for possible closed-head trauma

3. Mechanisms of Injury Coup
a forceful blow to resting head, producing maximal injury beneath the point of impact
example: being hit with a baseball or hockey puck

4. Mechanisms of Injury Contrecoup
moving head hits an unyielding object, producing maximal brain injury opposite the site of impact as the brain bounces within the cranium
Example: head hits ground when being tackled

5. Mechanisms of Injury Repeated Sub-concussive Blows
Many nontraumatic blows overtime
Example: Soccer players who head the ball frequently

6. Types of Head Injuries in Sports
Cerebral Concussion
Cerebral Contusion
Cerebral Hematoma

7. Cerebral Concussion
Head trauma-induced alteration in mental status that may or may not involve a loss of consciousness

8. Cerebral Contusion
A bruise of the brain resulting from an impact of the skull and an object causing bleeding from injured vessels
May be associated with partial paralysis, one sided pupil dilation, and altered vital signs
Progressive edema may further compromise brain tissue not injured in original trauma
If basic life support, proper transport techniques, and prompt expert evaluation are delivered, no surgery is needed and prognosis is good

9. Cerebral Hematoma
Blood clot in the tissue surrounding the brain causes pressure on the brain
3 Types
Epidural
Subdural
Intercerebral

10. Epidural Hematoma
Results from a severe blow to the head that produces a skull fracture in the temporoparietal region
Neurological status may not be evident for 10 to 20 minutes after the injury
Immediate surgery needed to decompress the hematoma and control the bleeding artery

11. Subdural Hematoma
A blow to the skull that causes subdural blood vessels to tear resulting in venous bleeding and the slow formation of a clot
Symptoms may not appear for hours, days, or even weeks
Surgery is needed to drain the hematoma and decompress the brain

12. Intracerebral Hematoma
Bleeding from a torn artery collects within the brain itself
Often results from a depressed fracture or penetrating wound
No lucid interval after the injury
Hematoma progresses rapidly
Death occurs before the athlete can be moved to an emergency facility

13. Second Impact Syndrome
An athlete sustains a second concussion before an earlier one has resolved
Potential for occurrence with mild head injuries
Often the first concussion goes unreported or unrecognized
A major consideration when making return to play decisions

14. Second Impact Syndrome (con’t)
Occurs within 1 week of initial injury
Involves rapid brain swelling and herniation
Brain stem failure develops within 2-5 minutes
Causes rapid dilation of pupils, loss of eye movement, respiratory failure, and coma
Athlete must be intubated
Mortality rate 50%

15. Frequency of Concussions
1 in 5 (250,000) high school football players per year (Cantu 1986)
300,000 sport-related concussions per year (Thurman et al., 1998)
Player is 3 times more likely to sustain a 2nd concussion after the 1st (Guskiewicz 2000)
Only 1 in 100,000 high school football players suffer catastrophic injuries (Cantu 1999)

16. Who’s at Greatest Risk?
(Mueller, F.O. 2001).

17. Frequency of Head-Related Fatalities
(Mueller, F.O. 2001).

18. Cause of Death?
(Mueller, F.O. 2001).

19. It’s Getting Better …..
(Mueller, F.O., 2001).

20. OK, but isn’t it just football?.…
(Mueller, F.O., 2001).

21. Mouth Guards Decrease Concussions? How?
(Winters, J.E., 2001)

22. Grading Scales Cantu (1984) Colorado Medical Society (1991)
American Academy of Neurology (1997)

23. Cantu’s Scale (1984) Grade 1 – no loss of consciousness
Grade 2 – loss of consciousness < 5 minutes
Grade 3 – loss of consciousness > 5 minutes
Revised in 1992
(Shultz et al., 2000)

24. Colorado Medical Society’s Scale
Grade 1 – confusion; no amnesia; no loss of consciousness
Grade 2 – confusion; amnesia; no loss of consciousness
Grade 3 – any loss of consciousness

25. American Academy of Neurology’s Scale
Grade 1 – confusion less than 15 minutes, no loss of consciousness
Grade 2 – confusion greater than 15 minutes, no loss of consciousness
Grade 3 – any loss of consciousness

26. A.A.N.’s Recommendations for Management of Concussions in Sports
For a grade 1
Remove from activity
Examine immediately and at 5 minute intervals
Allow to return only if post-concussive symptoms resolve within 15 minutes
If a 2nd grade 1 concussion occurs on the same day then remove until asymptomatic for 1 week

27. A.A.N.’s Recommendations for Management of Concussions in Sports
For a Grade 2
Remove from activity
Examine frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if symptoms worsen or persist for more than 1 week
Athlete may return to play after 1 week asymptomatic

28. A.A.N.’s Recommendations for Management of Concussions in Sports
For a Grade 3
Remove from activity for 1 week if loss of consciousness is brief, or for 2 weeks if prolonged
If unconscious at time of initial evaluation or if neurological signs are abnormal, the athlete should be transported by ambulance to ER
If a 2nd grade 3 occurs, the athlete should not return to sport until asymptomatic for 1month

29. If any abnormality exists on the MRI or CT scan the athlete should be removed from activity for the season and discouraged from a future return to contact sports

30. Another Classification Scale to Consider?
(Oliaro, S., et al. 2001).

31. More Return to Play Guidelines
(Oliaro, S., et al. 2001).

32. Evaluation

33. Signs of Severe Brain Damage
Damage below brain stem
Rigid extension of all 4 extremities with arms internally rotated and pronated
Damage above brain stem.
Rigid extension of legs and flexion of the arms, wrist, and hands towards the chest
Babinski Sign

34. Thorough Evaluation Before an Athlete Is Allowed to Return to Play
On-field Assessment
Primary Survey
Secondary Survey
Off –field Assessment

35. On-field Assessment Primary survey check ABC’s Secondary survey
H.O.P.S. protocol
determine if the athlete can go to the sideline for further evaluation or needs an ambulance
**Often there is no “player down” assessment**

36. Check for Signs of Skull Fracture
Battle’s Sign – posterior auricular hematoma
Ottorrhea – CSF draining from ears
Rhinorrhea – CSF draining from nose
Raccoon Eyes – periorbital ecchymosis resulting from blood leaking from anterior fossa of skull

37. Symptoms of a Concussion
Headache, nausea, vomiting, dizziness, poor balance, sensitivity to noise or light, ringing in the ears, blurred vision, poor concentration, memory problems, trouble sleeping, sleepiness, depression, irritability
Only 8.9% result in a loss of consciousness (Guskiewicz et al., 2000)

38. Method to Rate Severity of Signs & Sx
(Oliaro, S., et al. 2001).

39. Initial Assessment
Obtain information about mental confusion, any loss of consciousness, and amnesia
Confusion: dazed, stunned, or glassy-eyed facial expression; behaviors like running to the wrong huddle
Unconscious: assume a cervical spine injury exists, athlete spine boarded sent to ER; If conscious ask if he has any tingling, numbness, or neck pain. Also, can he move his fingers and toes?
Amnesia: test for post-traumatic amnesia by asking what he remember about the last play; test for retrograde amnesia by asking name, date, place

40. Initial Assessment (con’t)
Ask athlete if “his ears’ are ringing”, he has blurry vision, or nausea
Check for any facial abnormalities
While asking questions, observe speech patterns, respirations, and movement of the extremities
Palpate the athlete’s cervical spine and skull to rule out fracture, assuming neck injury has been ruled out
Walk to sideline for further assessment

41. Glasgow Coma Scale Used to assess level of consciousness
(Shultz et al., 2000)

42. Cranial Nerve Assessment
Rule out problems with II, III, IV, VI first
II – check vision by read scoreboard and fingers
III, IV, VI – check eye movement by asking athlete to track a moving object, check pupils for equal size and light reactivity with a penlight
** problems indicate increased intracranial pressure**
(Shultz et al., 2000)

43. Further Cranial Nerve Assessment
I – check smell
V – check by clinching jaw
VII – check by raising eyebrows, smiling
VIII – check balance and hearing
IX and X – check by swallowing
XII – check by sticking out tongue
XI – check by neck rotation/extension and shoulder shrug

44. (Shultz et al., 2000)

45. Test Sensory/Motor Function
Dermatome Testing
Myotome Testing
ROM Testing
Strength Testing

46. Upper Extremity Dermatome Testing
C6: Lateral forearm, thumb, fore finger
C7: posterior forearm, middle finger
C8: Lower medial forearm, 4th and 5th fingers
T1: Medial forearm
C1: Top of head
C2: Temporal, Occipital
C3: Neck, Posterior Check
C4: Superior Shoulder
C5: Deltoid patch

47. Upper Extremity Myotome Testing
C1/C2: Cervical flexion
C3: Lateral neck flexion
C4: Shoulder Shrug
C5: Shoulder Abduction
C6: Elbow flexion, wrist extension
C7: Elbow extension, wrist flexion
C8: Ulnar deviation, thumb extension, finger flexion & abduction
T1: Finger abduction/adduction

48. Check Vital Signs
Increased pulse, increased systolic blood pressure, and a decreasing diastolic blood pressure indicates increasing intracranial pressure
A decrease in systolic bp denotes shock

49. Check for Post-traumatic Amnesia (Anterograde)
Give the athlete 3 unassociated words to remember, and periodically ask for recall
Example: Red, Explorer, Clemson

50. Check for Retrograde Amnesia
Ask questions like
Where are we playing?
Which quarter is it?
What did we have for pre-game meal?
Who did we play last week?

51. Check for Concentration
Have athlete
Recite days of the week or months of the year backward
Count backward from 100 by 7’s (Serial 7’s)
Multiple/Addition facts

52. SAC (Standardized Assessment of Concussion)
Designed to detect impaired concentration
Sideline or follow-up evaluation tool
Takes 5 minutes to assess:
Orientation
Immediate memory
Neurological fxn
Concentration
Delayed recall
Sx during exertional testing
(McCrea et al., 1997)

54. Neurocognitive Assessments
Trail-Making Test B: (working memory and rapid visual processing) Connect circles containing letters (A-L) to numbers (1-13) in alternating numeric fashion as fast as possible.
Wechsier Digit Span Test: (concentration and memory recall) Subjects presented w/ a series of numbers and must repeat digits in same order or reverse order.
(Guskiewicz, K. M. et al., 2001)

55. Check Balance, Coordination, and Depth Perception
Romberg’s Test
Finger-to-Nose Test
Finger-to-Finger Test
Heel-to-Toe Walking
Supine Heel-to-Knee Test

56. Nerurocom Smart Balance Master System
SOT (Sensory Organization Test)
Forceplate system measures postural sway by quantifying balance deficits and sensory organization problems resulting from a concussion
Expensive and immobile
(Guskiewicz, K. M. et al., 2001)

57. NeuroCom Smart Balance Master vs BESS
(Guskiewicz, K. M. et al., 2001)
Strong Correlation between the two tests!

58. Balance Error Scoring System (BESS)
Quantifiable modified Rhomberg
3 tests lasting 20s each
Double-leg
Single-leg
Heel-toe
Eyes Closed
Perform once on ground and once on foam
Tally number of errors
(Guskiewicz, K. M. et al., 2001)

59. 6 Types of Errors in BESS
(Guskiewicz, K. M. et al., 2001)

60. Test Equilibrium and Balance
(Oliaro, S., et al. 2001).

61. (Shultz et al., 2000)

62. How long do symptoms linger?
Post Concussion Syndrome
(Guskiewicz, K. M. et al., 2001)

63. Functional Testing Must be asymptomatic
Designed to see if activity will cause symptoms
Sit-ups
Push-ups
Jogging
Running
Sports Specific Tasks

64. Return to Play Protocol
95% of baseline on cognitive and balance tests
(Oliaro, S., et al. 2001).

65. Return to Play
Assuming the athlete passes the complete exam he/she may return to play

66. Take Home Message
While experts argue over specifics of the guidelines all agree –
NO ATHLETE EXPERIENCING SYMPTOMS SHOULD PARTICIPATE!

67. References
Guskiewicz, K.M., Weaver, N.L., Padua, D.A., Garrett, W.E. (2000). Epidemiology of concussion in collegiate and high school football players. American Journal of Sports Medicine, 28,
Guskiewicz, K.M., Ross S.E., Marshall, S. W. (2001). Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training. 36 (3),
McCrea, M, Kelly, J.P., Kluge, J., Ackley, B., and Randolph, C. (1997). Standardized assessment of concussion in football players. Neurology, 48, (3),
Mueller, F.O. (2001). Catastrophic head injuries in high school and collegiate sports. Journal of Athletic Training 36, (3),
Oliaro, S., Anderson S., and Hooker, D. (2001). Management of cerebral concussion in sports: the athletic trainer’s perspective. Journal of Athletic Training, 36, (3),
Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1st Ed., pp ). Human Kinetics. Champaign IL.
Thurman, J.D., Branche C.M., Sniezek, J.E. (1998). The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. Journal of Head Trauma Rehabilitation, 13, 1-8.
Winters, J.E. (2001). Commentary: Role of properly fitted mouthguards in prevention of sport-related concussion. Journal of Athletic Training, 36 (3),