1. Hayley Rintel-Queller, MD Orthopedic Associates of Long Island (OALI)
Concussions 101
Michael J. Sileo, MD
Hayley Rintel-Queller, MD
Orthopedic Associates of Long Island (OALI)

2. Thanks!
Lisa M. Lally
Hannah Kuemmel, ATC

3. Facts 10% of all contact athletes sustain concussions annually
Approximately 300,000 sports related concussions occur each year (reported)
An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion

4. Facts (con’t) “Bell ringers”=concussion
account for 75% of all concussive injuries
Concussions are cumulative in athletes who return to play prior to complete recovery

5. Dilemma
Concussions are more common and more serious than previously recognized
Seasoned doctors, coaches and parents recall treatments from the past and think that is still the standard of care
Seemingly mild initial symptoms may lead to long lasting symptoms
Youth athletes are more at risk for bad outcomes than their “professional counterparts” given their vulnerable/developing brains

6. Definition A concussion is a Mild Traumatic Brain Injury.
“Concussus” derived from the Latin “to shake violently”
Concussions may range from “bell ringers” to prolonged loss of consciousness.

7. Definition
Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
Concussion result in a functional disturbance rather than a structural injury.
No abnormality on standard structural neuroimaging studies is seen in concussion.

8. Mechanism: Deceleration Injury

9. Mechanism: Rotational Injury

10. “Neurometabolic Imbalance”

11. On-field signs and symptoms
Signs Observed
Appears dazed
Confused about play
Answers question slowly
Forgets plays, score, opponent
Personality/behavior change
Forgets events before and after hit
Loss of consciousness
Symptoms Reported
Headache
Nausea
Balance problems
Double/fuzzy vision
Sensitivity to noise/light
Feeling “foggy”
Change in sleep pattern
Concentration/memory issues

12. What kids might say… “I just don’t feel right…” “My head feels heavy…”
“I feel like I am under water…”
“I got my bell rung…”
“I feel like I am not really here right now…”

13. Uh, he was hit… now what?
Concussion:
The Return to
Play
Dilemma

14. Initial Management
Appropriate sideline evaluation by appropriately trained medical professional
Rule out more serious intracranial pathology
If there is any focal neurologic deficit or progressively worsening symptoms, further imaging is warranted (ie, MRI, CT scan)

15. Sideline Evaluation ORIENTATION AMNESIA
What is your name? Your coach’s name?
What stadium/city is this?
Who is the opponent? What color are their jerseys?
What day/date/month/year/season is it?
What did you do in school today?
AMNESIA
Anterograde
Girl, dog, green
Retrograde
What happened prior to hit? What is score
Concentration
Days of week backwards, number backward

16. Sideline Evaluation Functional Testing Romberg Sway Heel-to-toe stance
20 seconds
Heel-to-toe stance
Oculomotor testing
Smooth vs. saccades
20 yard jog
No increase in symptoms

17. Appropriate Sideline Decisions
WHEN IN DOUBT, SIT THEM OUT!
Take helmet away
If a player loses consciousness
The player must be removed from play
If a player is removed from play for concussive symptoms
Frequent reevaluation
Deterioration of symptoms
Immediately to ER

18. Treatment Priority #1: ** Avoid re-injury **
Evaluation by medical provider
Trained in concussion management
REST
Cognitive and physical
OALI Return to play protocol
5 step protocol to return to play is much more conservative in youth than in older athletes.

19. Cognitive Rest May need to be out of school to start
Reduced course and work load
Extra time and a quiet location for tests
Minimal TV, computers, texting, video gaming, etc

20. Graduated Return to Play
1. Rest until asymptomatic (physical,mental)
2. Light aerobic exercise w no weight training.
No significant head movement
3. Moderate aerobic activities and weight lifting. Minimal changes in head position
4. Increased weight training, aerobic activity
Add plyometrics,, proprioceptive challenge, head mvmt
5. Sport specific, non-contact training
6. Full contact training
7. Return to contact competition

21. Prognosis
Symptoms generally resolve in 7-10 days, but may be longer in adolescents and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of concussion)
If treated properly, the athlete will recover completely without any untoward effects.
If the athlete is not treated properly, they are at significantly increased risk of sustaining another concussion and having long term effects.
Post Concussive Syndrome
Second Impact Syndrome
Chronic Traumatic Encephalopathy [CTE]
Severe Emotional Problems
ADHD/ Learning disability??

22. Second impact syndrome
A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event.
Can result in devastating/catastrophic increase in intracranial pressure
This catastrophic demise is very rapid and carries a 50% mortality rate along with almost a 100% morbidity rate
Most common in the high school population secondary to poor autoregulatory control of intracranial blood flow

23. Chronic Traumatic Encephalopathy
What happened to M. Ali?
Chronic Traumatic Encephalopathy

24. Recommendations for High School Athletes
EDUCATION, EDUCATION, EDUCATION
All coaching staff, referees, parents, athletes, and covering medical providers should be mandated to participate in an educational session on concussion recognition and initial management
Appropriate preventive measures
No tolerance on poor technique (ie, spear tackling)
Appropriate sideline decisions

25. Orthopaedic Associates of Long Island (OALI) Concussion Management Program
Neurocognitive Testing/Evaluation
Evaluates attention/concentration, memory/recall, processing speed, and reaction time
Computerized models have simplified this
ImPACT (others available)
Testing done in 30 minutes or less
Currently utilized by NCAA, NFL, MLB, NHL, WWE
Ideal to have baseline

26. Unique Contribution of Neurocognitive Testing
Testing reveals
cognitive deficits
in asymptomatic
athletes within 4
days post-concussion
Lovell, Collins et al., Am J Sports Med, 2006

27. Continued…

28. St Charles/OALI Comprehensive Concussion Management Program
Working with many local high school sports teams
Baseline Neurocognitive testing (ImPACT)
Appropriate sideline decision making
Appropriate ER follow up
Post injury testing combined with clinical evaluation
Treatment Decisions
Return to play progression

29. Keys to Success Education
Coaches, athletes and parents, medical staff
Proper recognition and proper treatment results in full recovery for these athletes
Baseline and post-injury testing helps provide an objective measure for safe return to play

30. Michael J. Sileo, MD Hayley Queller, MD Phil Schrank, MD…
Michael J. Sileo, MD
Hayley Queller, MD
Phil Schrank, MD
Gregg Jarit, MD
Orthopaedic Associates of Long Island
(631)
.net