1. Put Me In Coach: I Want a Hat Trick
Understanding the Dynamics of Concussion
AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN,FAAN

2. HAT TRICK!!!!

5. Definitions
Trauma-induced alteration in mental status that may or may not be associated with Loss of Consciousness
AAN
Type of mild traumatic brain injury (TBI) caused by an impact or jolt to the head
AAP
A complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces
CISG
Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
Third International Conference

6. Consensus Statement on Concussions in Sports
2001
1st International Conference on Concussion in Sport, Vienna
2004
2nd International Conference on Concussion in Sport, Prague
2008
3rd International Conference on Concussion in Sport, Zurich
Sport Concussion Assessment Tool (SCAT2)

7. Consensus Statement Zurich, 2012
Centre for Health, Exercise and Sports Medicine, University of Melbourne, Australia
Sport Medicine Centre, Faculty of Kinesiology and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada
Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich, Switzerland
Ottawa Sport Medicine Centre, Ottawa, Canada
Huguenot House, Dublin, Ireland
Emerson Hospital, Concord, Massachusetts, USA

8. Purpose
Develop conceptual understanding of concussion in sport using a formal consensus-based approach
Develop guidelines for use by physicians, therapists, athletic trainers, health professionals, coaches and other individuals involved in the care of injured athletes, whether at the recreational, elite or professional level

9. Results
Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with impulsive force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.

10. More Results
Concussion may result in a graded set of clinical syndromes that may or may not involve LOC.
Resolution of the clinical and cognitive symptoms typically follows a sequential course.
Post-concussive symptoms may be prolonged in a small percentage of cases.
Concussion shows no abnormality on standard structural neuroimaging studies.

12. Traumatic Brain Injury
Caused by a blow to the head or a penetrating head injury that disrupts the normal function of the brain
A brief change in mental status or consciousness to “severe,” an extended period of unconsciousness or amnesia after injury”
Centers for Disease Control & Prevention

13. Mild TBIs are Concussions
Each year, more than 1.5 million people experience some form of traumatic brain injury (TBI)
85% of people with mild TBI have no long-term symptoms
15% of people with mild TBI have lingering or long-term symptoms
Many people don’t realize they have sustained a mild TBI

14. Common Signs of Mild TBI
Headaches
Nausea
Confusion
Length of time can vary, depending on the severity of the injury
Could last a few seconds, minutes, or even hours
Slow thinking
Sleep changes
Mood changes
May result in depression due to the dysfunction of the brain
Depression may go away, but some need help in counseling or medications
Dizziness

15. Common Causes of Mild TBI
Motor vehicle collisions
Falls
Toddlers learning to walk
Elderly who are beginning to experience coordination problems
Contact sports
More common amongst 15 – 25 year old males

20. Mechanism of Injury in Ice Hockey
Body checking 86% of all injuries in 9 – 15 year old
Contact leagues 4x injury rate, 12x fracture rate
45% legal body checks, 8% illegal body checks
Direct fatality and injury rates for football are half of hockey
Spinal cord injury and brain injury rate
2.6 per 100,000 high school hockey players
.7 per 100,000 high school football players

25. Challenges
Athletes may not report symptoms or head injury for fear of being excluded from participation
In a study of high-school football players with concussion:
47.3% reported their injury
52.7% did not report their injury because:
66% did think their injuries were serious enough to
36% did not realize their symptoms were consistent with concussion.
41% did not want to be held out of play.
Athletes who have ever had a concussion are at increased risk for another concussion.

26. Resources

27. Your Brain

29. What is Happening? Impact shakes the brain inside the skull
A wave through brain tissue causes discharge of damaging chemicals
Nerve cells can shear
Microscopic damage can affect the anatomy and function of brain cells

32. Management
. First Steps
If there is loss of consciousness – Initiate Emergency Action Plan. Call 911 to get an ambulance. Assume possible neck injury.
Assess ABCs: Airway, Breathing and Circulation
Important acute management principles

33. More Management
Remove the player from the current game or practice (if event occurred during sport)
Do not leave the player alone; monitor signs and symptoms
Do not administer medication
Inform parent or guardian
The player should be evaluated by a medical doctor
The player must not return to play in that game or practice

34. Later Management Later Management
The 6-step Graduated Return to Play Protocol
Step 1 - physical and mental rest.
No return to activity until all symptoms have resolved, and do not recur even after provocative exercise during Steps 2-5.
If any Symptoms or Signs Return, Stop the Process, and Return to Step 1 .

35. Continued
Step 2 - Light aerobic exercise, such as walking or stationary cycling. Monitor for symptoms and signs. No resistance training or weight lifting. 
Step 3 - Sport specific activities and training (e.g. skating).  
Step 4. Drills without body contact. May add light resistance training and progress to heavier weights. 
Step 5. Begin drills with body contact.  
Step 6. Game play.

36. Concussion Management: Return to Activity Guidelines
Step 1: No concentration, light aerobic exercise < 10 min
Step 2: Mild concentration, light aerobic exercise < 20 min
Step 3: Moderate concentration, add light strength training < 30 min

37. Concussion Management: Return to Activity Guidelines
Step 4: Sports performance training < 60 min, full concentration
Step 5: Progress to full activities including contact under observation
Full Return to Play

38. The time needed to progress from non-contact to contact exercise (45) will vary with the severity of the concussion and the player. Only go to step 5 after medical clearance. Again, go back to Step 1 if symptoms recur.

39. Recovery Most ‘recover’ in 1 – 2 weeks, 95% recover in 3 months
Longer in younger athletes and in female compared to male
Post-concussion syndrome is the presence of symptoms for at least 3 months post injury
Deficits in balance resolve in 5 days
Cognitive tests return to baseline in 5 – 10 days
Abnormalities in metabolic balance, oxygen consumption, and electrical responses persist for several months

40. Post Concussion Syndrome
Re-injury before complete recovery
Over-exertion early after injury
Significant stress
Unable to participate in sports
Medical uncertainty
Academic difficulties
Prior or comorbid condition
Migraine
Anxiety
ADHD, LD

41. Multiple Concussions Second Impact Syndrome
A concussion prior to recovery from a prior concussion
Athlete is still symptomatic
Mostly males < 21 years old
Rapid increase in intracranial pressure
Rare but almost always fatal

42. Multiple Concussions Cumulative effects
Risk of concussion is 4-6 times greater after one concussion
Risk is 8 times greater after sustaining two concussions
Prolonged or incomplete recovery
Increased risk of later depression or dementia

43. HOW MANY IS TOO MANY?

48. Diagnosis and Management
On-Field Diagnosis
“If In Doubt - Sit Them Out”
Then have the player assessed by a physician with expertise in concussions

50. Sideline Evaluation Rapid concussion evaluation
Brief neuropsychological test batteries that assess attention, concentration and short-term memory function – practical and effective
** worth noting that standard orientation questions (time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment

51. Sport Concussion Assessment Tool
SCAT: developed by combining existing tools into a new standardized tool for
Patient education
Physician assessment of sports concussion

54. Concussion Management: Acute Injury
ANY signs or symptoms of a concussion:
Should not be allowed to return to play in the current game or practice
Should not be left alone; regular monitoring for deterioration
Should be medically evaluated
Return to play must follow a medically supervised stepwise process
“When in doubt, sit them out!”
Acute injury

55. Neuroimaging Conventional modalities usually normal
Head CT (or MRI) contributes little to concussion evaluation except whenever suspicion of an intra-cerebral structural lesion exists:
Prolonged disturbance of conscious state
Focal neurologic deficit
Worsening symptoms
Newer structural MRI modalities (gradient echo, perfusion, and diffusion weighted) have greater sensitivity for structural abnormalities but limited use currently
Conventional structural neuroimaging is usually normal in concussive injury
Newer structural MRI modalities (gradient echo, perfusion, and diffusion weighted) have greater sensitivity for structural abnormalities but limited use current (due to lack of published studies and absent pre-injury data)

56. How Long do Cumulative Effects Last?
If there is another risk or exposure soon after a concussion, the likelihood of experiencing a repeated concussion is great
With athletes who have had at least two or three concussions, a decade, two, or even a lifetime of increased risk of concussion is possible
Statistically the risk is greater if people have a history of concussions

57. Ways to Make Sports Safer
Wear the proper helmet for each sport
Reduce risk of injury by changing some of the rules in certain sports
banning intentional hitting from football and ice hockey
Ban boxing entirely
Stop players from taking unnecessary risks in sports when it comes to repeat concussions

62. Conclusions
Repetitive concussions increase the risk of second impact syndrome and post-concussive syndromes
NO athlete should return to sport until all concussive symptoms have resolved at rest and with exertion
Goal: to prevent catastrophic outcomes of acute structural brain injury, second impact syndrome, and cumulative brain injury due to repetitive trauma.
All athletes suspected of having sustained concussions should undergo thorough evaluation, including neurologic screening exam, neuropsychological testing, and exertional provocative maneuvers.

63. Resources www.Parachutecanada.org www.aftertheinjury.org/concussions

65. Questions?