Brain Injuries in Athletics

Objectives Define and explain these terms: ◦ Concussion ◦ MTBI ◦ Second-Impact Syndrome ◦ Post-Concussion Syndrome ◦ Intracranial hemorrhage ◦ Mortality ◦ Morbidity Continued….

Objectives Define and explain these terms: ◦ GSC ◦ SAC ◦ BESS ◦ IMPACT ◦ ISS ◦ HITS Be familiar with the incidence of head injury in sport Explain the various mechanisms of head injury Understand assessment procedures for head injuries Be familiar with current management practices for head injury

Cardinal Principles Treat every unconscious athlete as if she/he has a cervical spine injury until proven otherwise! No athlete should return to participation while symptomatic!

CONCUSSION/MTBI (MILD TRAUMATIC BRAIN INJURY) An injury of transient physiologic dysfunction resulting from biomechanical forces acting on the brain. It does not necessarily involve loss of consciousness (LOC)

Incidence of concussion Has been vastly underreported in the past, due to outdated definition. Fewer than 9% of collegiate concussions occurred with LOC (loss of consciousness). 47% of high school football concussions go unreported (McCrea, Hammeka, Olsen, Leo, Guskiewicz, 2004). BIG PROBLEM!!! Current estimate is million per year (Langlois, Rutlan-Brown, Wald, 2006) Accounts for 9% of all high school athletic injuries (Langlois, Rutlan-Brown, Wald) Long-term effects are just starting to become known

Why is the brain so susceptible to injury??

Mechanisms of MTBI Coup Contrecoup

MTBI Signs and Symptoms* *+ HEADACHE Possible nausea, tinnitis, photophobia

Amnesia Retrograde Anterograde

Signs vs. Symptoms?

Assessment of Concussion Immediate, on-field Follow-up Long-term All include both physical and neurocognitive testing

Immediate Assessment Note time of injury/initial assessment

MTBI Signs and Symptoms* *+ HEADACHE Possible nausea, tinnitis, photophobia

ASSESSMENT OF CONCUSSION Graded Symptom Checklist (GSC)

ASSESSMENT OF CONCUSSION Standardized Assessment of Concussion (SAC)

ASSESSMENT OF CONCUSSION Balance Error Scoring System (BESS)

ASSESSMENT OF CONCUSSION 1130 NATA 2005 CASE STUDIES 2[1].PDF 1130 NATA 2005 CASE STUDIES 2[1].PDF 1130 NATA 2005 CASE STUDIES 2[1].PDF Head Impact Telemetry System

3 Important Things for the Clinician Recognizing the injury and its severity Determining if the athlete requires additional attention and/or assessment Deciding when it is safe for the athlete to return to sports activity

Management of the Concussed Athlete

Play or no-play?? No LOC, no amnesia, other symptoms clear quickly (<15 minutes) – may return New NFL policy – any athlete demonstrating signs of concussion is out at least for the remainder of that day Out of collision activities at least 6 symptom-free days – WHY??

Second-Impact Syndrome (SIS) Estimates of 3-6x greater liklihood of sustaining a second concussion if returns too early (i.e. non-resolution of symptoms = NOT symptom-free) Brain is much more sensitive, and not as great an impact is required to cause substantial trauma 50% mortality rate/100% morbidity rate

Post-Concussion Syndrome Persistence of concussion symptoms ◦ May persist forever Must have continual follow-up to document signs and symptoms

Repeated MTBI Cumulative effect of multiple concussions over time ◦ Just beginning to see the effects of this

The Dangers of Concussion Second-Impact Syndrome Don’t yet know the effects of cumulative MTBI And…

Intracranial Hemorrhage Intracerebral hemorrhage (right) Cerebral hematoma Epidural hematoma Subdural hematoma

Intracranial Hemorrhage Signs and Symptoms* *+ HEADACHE Possible nausea, tinnitis, photophobia

Indicators that things are heading South Slowing pulse Slow increase in blood pressure Mental status changes (for the worse) Initiate Emergency Action Plan

Epidural Hematoma Occurs as a result of acceleration- deceleration mechanism Rapidly developing ◦ Deteriorating status begins 10 minutes to 2 hours post-ictal ◦ “Lucid Interval” Phenomenon Always check for associated skull fracture (common) Immediate surgery required

Subdural Hematoma Blow to the head Much more insidious onset ◦ Why?

3 Important Things for the Clinician Recognizing the injury and its severity ◦ Sideline evaluation ◦ Serial follow-up evaluations ◦ Patient and family education Determining if the athlete requires additional attention and/or assessment ◦ Progression of symptoms Deciding when it is safe for the athlete to return to sports activity ◦ Symptom-free! ◦ Neurocognitive testing within baseline limits

References Corvassin, T, Elbin, R., Stiller-Ostrowski, J. and Kontos, A. (2009). Immediate post- concussion assessment and cognitive testing (ImPACT) practices of sports medicine professionals. Journal of Athletic Training, 44(6), Broglio, SP and Guskiewicz, KM (2009). Concussion in sports: the sideline assessment. Sports Health, 1(5), Kutcher, J. (2010). Management of the complicated sports concussion patient. Sports Health, 2(3),

Questions?