Introduction to Concussions Introduction to Concussions

NPR Story – March 2007 Billy’s story Billy’s story Newspaper piece Newspaper piece lacrosse-athletic-directors-and-coaches-must-be-held- accountable-for-enforcing-no-play-or-practice-rules/ lacrosse-athletic-directors-and-coaches-must-be-held- accountable-for-enforcing-no-play-or-practice-rules/ lacrosse-athletic-directors-and-coaches-must-be-held- accountable-for-enforcing-no-play-or-practice-rules/ lacrosse-athletic-directors-and-coaches-must-be-held- accountable-for-enforcing-no-play-or-practice-rules/ Listen to this later – 30 minute piece Listen to this later – 30 minute piece tes/story/story.php? storyId= tes/story/story.php? storyId= tes/story/story.php? storyId= tes/story/story.php? storyId=

Statistics 300,000 a year in sports 300,000 a year in sports 19% or 1 in 5 chance that you can get a concussion in a contact/collision sport 19% or 1 in 5 chance that you can get a concussion in a contact/collision sport Collegiate Stats ( season, per 1,000 athletes) Collegiate Stats ( season, per 1,000 athletes) Football: 3.52 per game/practice; Ice Hockey: 2 per game/practice; Men’s Soccer: 1.13 per game/practice; Women’s Soccer: 1.8 per game/practice Football: 3.52 per game/practice; Ice Hockey: 2 per game/practice; Men’s Soccer: 1.13 per game/practice; Women’s Soccer: 1.8 per game/practice million youth will suffer a concussion during football play million youth will suffer a concussion during football play After 1 st concussion After 1 st concussion 4X more likely to receive a 2 nd one 4X more likely to receive a 2 nd one Takes less of a blow to the head Takes less of a blow to the head

Videos he_lines_second_impact_syndrome.htm he_lines_second_impact_syndrome.htm he_lines_second_impact_syndrome.htm he_lines_second_impact_syndrome.htm ng_for_trouble.htm ng_for_trouble.htm ng_for_trouble.htm ng_for_trouble.htm

Anatomy Scalp Scalp Skull Skull Cerebrum Cerebrum Cerebellum Cerebellum Diencephalon Diencephalon Thalamus Thalamus Hypthalamus Hypthalamus Brain Stem Brain Stem

Anatomy Meninges and Spaces Dura mater – “hard mother” Dura mater – “hard mother” Meningeal arteries Meningeal arteries Subdural space Subdural space Venous drainage Venous drainage Arachnoid mater Arachnoid mater Subarachnoid space Subarachnoid space CSF fluid CSF fluid Pia mater – “tender mother” Pia mater – “tender mother”

Check out the Meningeal Layers in a REAL brain! Image from outreach.mcb.harvard.edu/teachers/Summer05/JenniferJunkins/Brain_sportsconcussion.ppt

Head Injury Terminology Mild Traumatic Brain Injury (MTBI) Mild Traumatic Brain Injury (MTBI) Concussions Concussions Subdural hematoma Subdural hematoma Epidural hematoma Epidural hematoma Brain Edema Brain Edema Post-concussion Syndrome Post-concussion Syndrome Second Impact Syndrome Second Impact Syndrome

Concussions A clinical syndrome characterized by immediate and transient post-traumatic impairment of neural functions. A clinical syndrome characterized by immediate and transient post-traumatic impairment of neural functions. = contusion to the brain which messes up your normal brain function = contusion to the brain which messes up your normal brain function Concussions occur as a result of a direct blow, or sudden snapping of the head forward, backward, or rotating to the side Concussions occur as a result of a direct blow, or sudden snapping of the head forward, backward, or rotating to the side result in loss of consciousness, disorientation or amnesia; motor coordination or balance deficits and cognitive deficits May or may not result in loss of consciousness, disorientation or amnesia; motor coordination or balance deficits and cognitive deficits

Neurometabolic Cascade Giza and Hovda, JAT, 2001

Mechanisms

…and we cannot tape up a damaged brain…

Clinical Evaluation Signs and Symptoms are your clues… Signs and Symptoms are your clues… …but they are not always obvious …but they are not always obvious Be aware of the… Be aware of the… easily seen signs easily seen signs the self-reported (subtle) symptoms the self-reported (subtle) symptoms and the delayed symptoms and the delayed symptoms Need a timeline to record symptoms Need a timeline to record symptoms

Signs observed Appears to be dazed Appears to be dazed Is confused about assignment Is confused about assignment Forgets plays Forgets plays Is unsure of game, score, or opponent Is unsure of game, score, or opponent Moves clumsily Moves clumsily Answers questions slowly Answers questions slowly Loses consciousness (even temporarily) Loses consciousness (even temporarily) Shows behavior or personality change Shows behavior or personality change Forgets events prior to hit (retrograde amnesia) Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia) Forgets events after hit (anterograde amnesia) Symptoms reported by athlete Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling "foggy" Change in sleep pattern Concentration or memory problems

Signs and Symptoms Are there any signs and symptoms that are more important? Are there any signs and symptoms that are more important? What signs or symptoms seem to matter most? What signs or symptoms seem to matter most?

Sign and Symptoms Take home message: Take home message: Athlete doesn’t have to have any certain number of signs and symptoms Athlete doesn’t have to have any certain number of signs and symptoms Definition of concussion: Definition of concussion: 1 or more of S/S 1 or more of S/S Recent evidence suggests that Neuropsychological testing plus symptom scoring is the gold standard Allows for post concussion assessment - CHANGES ImPACT Testing

What can an athletic trainer do to prevent and treat concussions? Understand mechanisms of injury Understand mechanisms of injury Monitor equipment and technique Monitor equipment and technique Be thorough in your evaluation Be thorough in your evaluation Use team physician Use team physician Recognize injury severity Recognize injury severity Collaborate with physician on return to play decisions Collaborate with physician on return to play decisions Use concussion assessment tools Use concussion assessment tools Understand the potential negative consequences of concussions Understand the potential negative consequences of concussions

Concussions and Athletic Trainers Recognition and Treatment Recognition and Treatment 50% of all those who suffer permanent neurological consequences from head trauma are the result of inappropriate first aid, NOT the actual injury 50% of all those who suffer permanent neurological consequences from head trauma are the result of inappropriate first aid, NOT the actual injury Often catastrophic head injuries have few outward signs and symptoms. Often catastrophic head injuries have few outward signs and symptoms. Work as a sports medicine team Work as a sports medicine team Athletic trainer, physician, and athlete Athletic trainer, physician, and athlete Athlete should understand consequences Athlete should understand consequences The ability to identify and properly manage patients with head injuries may determine life, death, or disability. The ability to identify and properly manage patients with head injuries may determine life, death, or disability.

Equipment Issues Protective Equipment and Proper Technique Protective Equipment and Proper Technique Helmets/Facemasks Helmets/Facemasks Properly fitted and maintained Properly fitted and maintained Will not prevent all head injuries but may reduce risk Will not prevent all head injuries but may reduce risk National Operating Committee on Standards for Athletic Equipment (NOCSAE) or American Society for Testing and Materials (ASTM) National Operating Committee on Standards for Athletic Equipment (NOCSAE) or American Society for Testing and Materials (ASTM) Mouthguards Mouthguards No concrete evidence that reduces head injury but provides protection of mouth No concrete evidence that reduces head injury but provides protection of mouth No spearing or butt blocking – Heads Up Video No spearing or butt blocking – Heads Up Video Reduction of full contact practices Reduction of full contact practices

Be thorough in your evaluation BE COMPLETE BE COMPLETE History – i.e., previous injury History – i.e., previous injury Observation – i.e., response of the eyes, balance, symptoms over time Observation – i.e., response of the eyes, balance, symptoms over time Palpation – i.e., rule out C-spine and Skull Fracture Palpation – i.e., rule out C-spine and Skull Fracture Special Tests – i.e., memory and concentration Special Tests – i.e., memory and concentration