Introduction to Concussions: Recognition and Management of Concussion in Sport David B. Gealt, D.O. Cooper Bone and Joint Institute Cooper University Hospital Asst Professor UMDNJ-RWJ Asst Professor UMDNJ-SOM Palmyra-Riverton Soccer Club August 24, 2011

Many changes in the last few yrs and still evolving.

Estimates: Concussions in New Jersey The previous slide was based on actual emergency room discharge data. At this time we do not have actual numbers of concussions related to sports and recreation traumatic brain injuries. The causes as they are currently reported do not pull out sports related injuries as a separate category. So, This slide shows estimates of the numbers of individuals in New Jersey who sustain sports and recreation-related traumatic brain injuries each year. These estimates are reported by the by the Centers for Disease Control and are based on extrapolations from national data. The interesting thing about this slide is the estimate of the number of unidentified sports-related concussions every year - 25,000 to 75,000. It is believed that most individuals who sustain a concussion never go to the emergency room at all. What we can conclude from this slide and the previous one is that the statistics definitely do not tell the whole story about concussions. (UPDATE WHEN CDC RELEASES NEW STATS)

Athletic Trainers Report: 5.1% of football players sustained a concussion during a season 0.7% sustained a second concussion during the same season BUT…… Here is an example of of why brain injury statistics do not tell the whole story. This slide shows the result of a study done by athletic trainers who were researching the number of concussions sustained by high school and college football players during a football season. The study showed that when Athletic Trainers were asked “how many of your players had sustained a concussion”, their answer was approximately 5.1%. (NOTE- it is important to understand that in this study, the question asked specifically about “concussion,” and not the symptoms of concussion.) Of that 5.1%, .7 percent were also reported as having sustained a second concussion. (Guskiewicz et al.2000)

Player’s Report Symptoms of Concussion 47% had at least one concussion during the season. 35% had multiple concussions during the season. (Langburt et al.2001) In a separate study done with a a different group of players, the players were asked if they had suffered the SYMPTOMS of concussion. Remember on the previous slide the Athletic Trainers were asked how many concussions the players had sustained. In this study, the players were asked specifically about their symptoms. 47% of the football players reported symptoms of concussion. Of the 47%, 35% reported having symptoms multiple times throughout the season. The discrepancy between the results of these two studies may be attributed to the fact that….

STAY IN THE GAME!! Athletes Want to… Create dramatic scenario –insert video-player falls and with a cheering crowd goes back into the game. This raises the issue How much do we really understand about the seriousness of concussions.

Education is #1 Healthcare Personnel Certified Athletic Trainers Coaches Parents Athletes Everyone needs to be on the same page to avoid the potential dangers of repetitive concussive head injury

Concussion Facts A direct blow to the head, face, and neck can cause a concussion An indirect blow elsewhere on the body can transmit an “impulsive” force to the head, causing a concussion Most concussions do NOT involve loss of consciousness Every blow to the head region is a potentional concussion Here are three key facts that everyone should know about concussions, “Most concussions do not involve loss of consciousness.” This is probably the biggest misconception about concussions. YOU DO NOT NEED TO LOSE CONSCIOUSNESS TO HAVE SUSTAINED A CONCUSSION! A direct blow to the head, face and neck can cause a concussion. An example would be when two athletes collide head-to-head. Take the example of a student athlete who takes an elbow to the chin. In this instance the immediate concern would be a possible broken jaw or missing teeth, and the possibility of a concussion may not be considered. An indirect blow elsewhere on the body can transmit an “impulsive” force to the head, causing a concussion. When a lineman hits a quarterback, body slamming him to the ground, the force of the impact is transmitted throughout the body, including the brain. Think about throwing a rock into a calm body of water. The ripples expand far beyond the point of initial impact.

Concussion Facts Typically results in rapid onset of short-lived impairment of neuro function that spontaneously resolves Majority of concussions resolve within 7-10 days

Physical Signs and Symptoms Headaches Dizzy or Lightheaded Blurry Vision Ringing in the Ears Loss of Balance Numbness or Tingling Sensations Loss of consciousness Nausea/Vomiting Fatigue,Exhaustion Difficulty Sleeping Sensitivity to Light and Sound Dilated Pupils Slurred Speech Glassy eyed/foggy Pupils do not have to be blown!These are the physical signs and symptoms. Read through the signs and symptom for review. Some of these symptoms are more obvious then others and that is why understanding the range of symptoms following a concussion is so important in making decisions on when it is safe to return the concussed athlete to active play.

Cognitive and Emotional Signs & Symptoms Confusion Difficulty Focusing or Concentrating Disorientation of Time & Place Slower Rate to Processing Information Memory Loss* Irritability/mood changes Anxiety Easily Saddened or Upset Sadness,Depression The previous slide addressed the physical signs following a concussion. Now, lets review the cognitive and emotional signs and symptoms of concussion. GO THROUGH THE LIST Just as we know that a concussion immediately disrupts brain function we also know that most concussions resolve over a period of days or weeks. However, it is important to state that Over the next couple of days following the injury, if the symptoms are actually getting worse, this is a sign that a more serious brain injury has occurred, and should be considered an emergency. MEDICAL CARE SHOULD BE SOUGHT IMMEDIATELY. May not see some until later

Consequences can Affect: Academics Social Relationships Behavior Emotions GOES BEYOND THE PLAYING FIELD! What becomes clear is that although a concussion is called a mild traumatic brain injury, this does not mean that the consequences of the injury will be mild. If the consequences of a concussion can affect academics, relationships, behavior and emotions then you can see how return to play decisions become critical decisions. Now imagine that each of these consequences affecting grades, friendships, family life, and self-esteem would have on an adolescent who is already going through the most stressful developmental time of his/her life. The wide ranges of consequences that can result following a concussion stress the importance of why information about the concussed athlete must go beyond the playing field to the teacher, parents, school nurse and to any individual who may be involved with that student, including his friends. They may be the first to notice that something is not quite right.

Evaluation/Management Basic Life Support to assure ABC’s Determine if LOC has occurred If LOC and/or ? Cervical spine injury MUST STABILIZE and BOARD and TRANSPORT. Do not remove helmet and shoulder pads. Ask teammates involved in play if LOC * Once ruled out can move to sidelines

Evaluation Sideline Assessment SCAT 2 Reassess q 5-10 minutes Remove helmet Deterioration of Neuro fcn—SEND TO ED ASAP! Follow up with complete eval in office Computer Neuropsychological Testing-ImPACT If not rtp removed helmet for ind may be confused and not remember instructions and run back on field

Baseline Testing- A Cutting Edge Technology-ImPACT Immediate Post-Concussion Assessment and Cognitive Testing Provides comparison based on pre and post concussion scores Provides clinicians with a tool to help determine safe return to play Documents an athletes concussion history All concussions are not the same and therefore should not be treated the same. We need to treat each individual concussion until it is resolved. There are a tools available to help in the decision making process. One such tool is computerized baseline testing. Pre-season baseline assessment is cutting edge technology that is used to help ensure the safety and recovery of our young athletes who sustain a concussion. Utilizing a baseline test on student athletes can change the way concussions are measured, monitored, and managed. The pre and post scores help the physician and athletic trainer determine when the athlete's brain functions have returned to baseline and when it is safe for the athlete to return to sports or activity. There are several computerize software packages available that can be researched on line. However, if baseline testing is not available there are other methods used for helping to make safe return to play decisions. 15

2010 NJ State Law N.J.S.A 18A:40-41.3 was passed on 12/7/2010 by Gov Christie Development of interscholastic athletic head injury safety training program NJ Dept of Ed (NJDOE) “Model Policy and Guidance for Prevention and Treatment of Sports-Related Concussions and Head Injuries” http://www.njleg.state.nj.us/legislativepub/ldoa/ldoa.pdf, February 28, 2011 Bill originally made by assemblymen Patrick Diegnan and Sen Cooley bill 2743 16

2010 NJ Law Immediate removal from sports competition or practice Unable to RTP: Medical Evaluation and written clearance by a physician or other licensed health care provider trained in the evaluation and management of concussion. Removal even if suspected of sustaining a concussion

NJ State Law All coaches, school nurses, school/team physicians and ATCs must complete a Concussion Head Injury Training Program Head Injury Fact sheet signed by each student/guardian annually before activity Each school needs a written concussion policy implemented by 2011-2012 year Ex National Fed of State high Schools Assoc “Concussion in Sports” prgm. CDC coming out with a program

How to manage concussions?

Management Acute Response (All newest literature data supports) -Any signs/symptoms of concussion = No RTP, Out of Activity -Not to be left alone: to ck for deterioration -Medical evaluated ASAP -RTP by stepwise process with trained supervision Supported by both symposiums Any individual suspected of concussion or w/ concussion taken out of activity. And not to return that day

Other Factors to Consider Age of the child…younger is not always better in fact may be worse (Field et al 2003) Symptoms that persist for longer than 3-6 weeks (PCS) Cumulative effects of multiple concussions Other factors to consider before making return to play decisions would be the age of the child. There are developmental issues that need to be considered more closely and could result in more serious long term consequences if the concussion isn’t measured, monitored and managed properly. If symptoms occur for longer then 6-8 weeks then more extensive testing should be considered. Seeking medical advice is imperative. Sometimes a neuropsychologist, who is a specialist in the relationship between brain functions and behaviors may be recommended. Something we did not touch upon but, you need to be aware of is that there are cumulative effects of multiple concussions and this needs to be considered when making return to play decisions about a player. Field et al 2003 J Peds

RTP too soon—Serious Consequences Post Concussion Syndrome Second Impact Syndrome Loss of cerebrovascular autoregulation causing brain swelling, herniation, death

Management No Cookbook Guidelines Individualized Treatment Multi-Discipline Approach Physicians ATC School Nurse Neurocognitive Testing Neuropsychologists/Psychologist Cognitive Therapist Guidance Counselors Teachers Family Support

In simplest terms think of a concussion as a “sprained brain” Physical Rest “Cognitive Rest”– limit ADLs, exertion and scholastic activities while symptomatic (INCLUDING VIDEO GAMES, TEXTING, FACEBOOK, INTERNET, ETC.) With a sprained ankle you don’t go play on it. RICE and rehab

Management Consider Modifications @ school during recovery Extensions/Breaks/Testing/Time in School Gym and athletics When we send someone out of the office have a plan to give to school re tests/hrs in school/gym/extended time

RTP Protocol Must by ASYMPTOMATIC w/ normal neuro/cognitive fcn No activity, asymptomatic for 24 hours Light aerobic exercise Sport specific training Noncontact drills Full contact Game play If become symptomatic, return to prior level and wait 24 hours Get into it later

“When in Doubt - Sit Them Out!” Proper management of concussion is the best form of prevention of serious injury Not worth the risk of playing with a concussion Only 1 Brain: Protect It! “When in Doubt - Sit Them Out!” Only given one brain protect it

Heads Up Concussion Kits http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm First step in fixing this epidemic It’s Free! Videos, posters, handouts, fact sheets etc. to help fight this epidemic

Thank You