1. Concussions: Should Richie play football? Christina Smith Paul MD, FAQSM Primary Care & Sports Medicine Student Health Service University of Pennsylvania

2. Concussions are not a new phenomenon, but they certainly have been getting a lot of attention in the news in the past few years. High profile professional athletes and former athletes have started to come forward and speak about their experiences with this injury and its (sometimes) prolonged and profound effect on their respective futures. The heightened awareness about this important injury has led to a boom in marketing efforts: both from an injury prevention standpoint and a diagnosis standpoint, with inconsistent evidence that these efforts are successful. Education about the injury remains the most important tool in preventing bad outcomes. Come learn a bit more about concussion, help clarify some myths, and hear how we take care of our concussed students here at Penn

3. Concussions in the News: ESPN, NYTimes SEC concerned about concussions New concussion law suit filed by 100 ex- players Concussions affecting women more often than men More retired players sue NFL over concussion effects Trying to Reduce Head Injuries, Youth Football Limits Practices

4. Overview Definitions Diagnosis Cognitive tests Treatment Prevention Return to school, return to athletics/clearance Ongoing research Systems at Penn

5. Headgames http://vimeo.com/headgames/trailer

6. Concussion Concussion = Traumatic Brain Injury Loss of consciousness = Rare (and not predictive) Causes: blow to head or body http://www.youtube.com/watch?feature=player_ detailpage&v=fY7J7bccNoU http://www.youtube.com/watch?feature=player_ detailpage&v=fY7J7bccNoU Symptoms vary Grading systems obsolete – Simple vs Complex (Prague, abandoned Zurich) – Avoid slang terms as well (bell rung etc.)

7. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008

8. What we know Numbers are increasing – More so in females Each subsequent concussion seems to require less force Balance testing is an objective measure (BESS: Balance Error Scoring System) Is a functional, not structural issue

9. What we know Equipment does not PREVENT concussion Absence of Proof is not Proof of Absence www.sportsdentristy.com

10. What we dont know (but are working on) How to predict duration of recovery Why some people are more susceptible http://www.youtube.com/watch?v=O8R1x6Co 6OY&feature=player_detailpage http://www.youtube.com/watch?v=O8R1x6Co 6OY&feature=player_detailpage How many is too many How to speed recovery – Supplements – Medications – Physical therapy

11. Concussion Symptoms Headache Nausea Dizziness Blurry vision Sensitivity to light or noise Feeling sluggish, foggy, out of it Confusion Difficulty with concentration, memory

13. Concussion Facts High risk activities: Bicycling, Football, Playground Activities, Basketball, Soccer – Numbers and rates are highest in: football (55,007; 0.47 per 1000 athlete exposures) girls soccer (29,167; 0.36 per 1000 athlete exposures) ED visits: – 1.37 million per year (790k male/575k female)

14. Concussion Diagnosis You cant SEE it Sings/symptoms usually follow the injury but there can be a delay Awareness/education of coaches, parents, athletes is VITAL http://www.nfl.com/videos/nfl-network-around- the-league/09000d5d814d2543/Concussion- safety http://www.nfl.com/videos/nfl-network-around- the-league/09000d5d814d2543/Concussion- safety

15. Concussion Treatment Initial Treatment: – Do I need to take Richie to the ED? – Should Richie get a head CT? COGNITIVE AND PHYSICAL REST

16. Treatment, continued Ongoing: – Do I need to wake Richie up at night? – Can Richie go to school? – Can Richie do homework, watch TV, email? – Can Richie play in his game tomorrow? – Can Richie take ibuprofen? – Role of meds or physical therapy?

17. Concussion Investigations Neuroimaging – CT scan – MRI (structural and functional: studies emerging) Objective balance assessment (BESS) Neuropsychological assessment

18. Neurocognitive Testing Computer-based – ImPACT, CogSport, HeadMinder – Added tool for use in return-to-play decisions – Avoidance of returning an athlete too soon – Baseline testing – Timing of testing – Pros/cons of testing Formal paper and pencil testing Several hours Comprehensive Reserved for chronic/difficult cases

19. Return To School Guidelines (CHOP) Step 1 – Complete cognitive rest: No TV, computer, text, etc. Step 2 – Light cognitive activity, 5-15 min increments, frequent breaks, stop if symptomatic Step 3 – Schoolwork at home, 30 min increments Step 4 – if tolerating 1-2 hrs at home, can go half day *advance to next step if symptom-free x 24 hrs

20. Graded Return to Play Rehab StageFunctional ExercisesObjective at each stage 1. No activityPhysical and Cognitive RestRecovery 2. Light aerobic exercisesWalking, swimming, stationary bike; intensity <70% maximum HR Increase HR 3. Sport-specific exercisesSkating drills, running drills etc. No head impact. Add movement 4. Non-contact training drills Progression to more complex training (passing, etc.); May start resistance training Exercise, coordination, and cognitive load 5. Full contact practiceFollowing medical clearance participate in normal training/practice Restore confidence and assess functional skills 6. Return to playNormal game play

21. Recurrent Concussions Second impact syndrome: – Brain swells rapidly, death near certain – repeat injury w/o proper healing time – Young people more vulnerable – Few cases Post concussive syndrome Chronic Traumatic Encephalopathy

22. Sports Legacy Institute Chris Nowinski

23. Concussions and mental health: In the news Chronic Traumatic Encephalopathy (Tau Protein)

24. Prevention? Gear – Head gear Helmet Other head gear – Mouth guards – Softer balls (soccer) Exercises: – Strengthen neck – Learn proper techniques Tackle techniques Heading techniques

25. Prevention Rule Changes: – NFL and College Football Kickoffs moved up to 35 yd line (from 30 yd line) – Pop Warner Football No hitting in 2/3 of practice Additional precautions (3 yards or less, etc) – USA Hockey Raise checking age (11 to 13) – Education (coaches, trainers, athletes, parents)

26. What we are doing at Penn Concussion policy (NCAA requires) All varsity and club athletes must be evaluated and cleared by SHS physician Baseline ImPACT testing done on all Varsity athletes involved in contact sport Referral resources: – Neurology and Neuropsychiatry – Weingarten – CAPS – Physical Therapy (Vestibular Rehabilitation)

27. SHS visits for concussions

28. 2010 SHS Data

31. summary http://www.youtube.com/watch?v=yyRBlSAfb _k&feature=player_detailpage http://www.youtube.com/watch?v=yyRBlSAfb _k&feature=player_detailpage

32. Should Richie play football? Should Finley play Soccer??

33. References www.cdc.gov/concussion/sports McCrory P, Meeuwisse W, Johnston K, et al.Consensus Statement on Concussion in Sport: the 3 rd International Conference on Concussion in Sport, Zurich 2008. Br J Sports Med 2009;43:i76-i84. New York Times, June 13 2012 Internet resources (ESPN, Youtube, Vimeo, google,etc.)

34. More video, if time… Sudden Impact Syndrome http://www.youtube.com/watch?v=dqlDOH45xWM &feature=relmfu