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

A partnership to manage concussion Brought to you by: American Academy of Neurology & Brain Injury Association

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

Concussion u Definition –A concussion is an alteration of mental status due to biomechanical forces affecting the brain. A concussion may or may not cause loss of consciousness.

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

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

Facts About Concussion u 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)

Anatomy of Concussion u 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

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

Vulnerable Tissues u 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

Vulnerable Tissues u 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

Two Primary Mechanisms of Concussion u 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. u Rotational - Example: When a football player is tackled, his head may strike an opponent’s knee; this contact to the head can cause a rotational motion.

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

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

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

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

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

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

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

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

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

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

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

Management Recommendations Grade 2 u Remove from contest; disallow return that day u Examine on-site frequently for signs of evolving intracranial pathology u A trained person should reexamine the athlete the following day u 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

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

Management Recommendations Grade 3 u 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) u A thorough neurologic evaluation should be performed emergently, including neuroimaging procedures when indicated u Admit to hospital if any signs of pathology are detected or if the mental status remains abnormal

When to Return to Play Grade of concussion Return to play only after asymptomatic with normal neurologic assessment at rest and with exercise u Grade 1 15 minutes or less u Multiple grade 11 week u Grade 21 week u Multiple grade 22 weeks u Grade 3 2 weeks –w/prolonged loss of consciousness u Multiple grade 31 month or longer

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

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

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

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

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

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

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

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

A partnership to manage concussion Brought to you by: American Academy of Neurology & Brain Injury Association