1. Mild Traumatic Brain Injuries Stephanie T. Leive, ATC Certified Athletic Trainer UPMC Sports Medicine Winchester Thurston School

2. MTBI Overview What is a concussion? Signs and Symptoms External Factors Post concussion syndrome Secondary Impact Syndrome Prognosis/Recovery Treatments Medications Return to Play ImPACT ImPACT team

3. What is a concussion? A Mild Traumatic Brain Injury (MTBI) or concussion is a disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head Disturbance of brain function is related to neurometabolic dysfunction, rather than structural injury, and is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI).  In the United States, the annual incidence of sports-related concussion is estimated between 1.6 – 3.8 million. MTBI may or may not involve a loss of consciousness (LOC). Recent research suggests that up to 90% of concussions do not involve an LOC. MTBI results in a constellation of physical, cognitive, emotional and sleep-related symptoms. Duration of symptoms are highly variable

4. Facts and Statistics  10% of all contact sport athletes sustain concussions yearly  63% of all concussions occur in football  Estimated that up to 20% of football players will sustain a concussion per season.  An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion  ”Bell ringers” or mild concussions account for 75% of all concussive injuries  Effects of concussion are cumulative in athletes who return to play prior to complete recovery  The best way to prevent problems with concussion is to manage them effectively when they occur  No athlete should return to play while experiencing symptoms of concussion.

5. Signs Signs are what are what can be observed… Balance Problems Dizziness Fatigue Sensitivity to light Sensitivity to noise Numbness/Tingling Appears to be dazed or stunned Is confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even temporarily) Shows behavior or personality change Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia)

6. Symptoms Feeling mentally "foggy“ Feeling slowed down Headache Difficulty concentrating Difficulty remembering Nausea Vomiting Visual problems 71% of athletes complain of headaches More importantly, 29% report no headaches after a concussion You do not have to be symptomatic to have a concussion Symptoms are what can be reported by the athlete…

7. External Factors Play a Role in Concussions Ailments Does the athlete get migraines? Is the athlete under a lot of stress? Previous history of a concussion? Prescriptions Some medications can have little or no effect initially. ADD ADHD

8. Post Concussion Syndrome (PCS) Although the majority of athletes who experience a concussion are likely to recover, an as yet unknown number of these individuals may experience chronic cognitive and neurobehavioral difficulties related to recurrent injury. Symptoms may include: – chronic headaches, fatigue, sleep difficulties, personality change (e.g. increased irritability, emotionality), sensitivity to light/noise, dizziness when standing quickly, and deficits in short-term memory, problem solving and general academic functioning. This collection of symptoms is referred to "Post-Concussion Syndrome" and can be disabling for an athlete. In some cases, such difficulties can be permanent and disabling.

9. Secondary Impact Syndrome In addition to Post-Concussion Syndrome, suffering a second blow to the head while recovering from an initial concussion can have catastrophic consequences as in the case of "Second Impact Syndrome," which has led to approximately 30-40 deaths over the past decade.

10. RECOVERY Athletes that are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussive injury. Such difficulties are prevented if the athlete is allowed time to recover from concussion and return to play decisions are carefully made. No athlete should return to sport or other at-risk participation when symptoms of concussion are present and recovery is ongoing.

11. I mPACT MEMORY COMPOSITE SCORES Brief versus Prolonged On-field Mental Status Changes ImPACT Memory-Percent Correct N = 64 High School Athletes P<.003 P<.02 P<.004 P<.01 P<.03 NS Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; March 2004

12. TREATMENTS Traditional neurological and radiologic procedures, such as CT, MRI, and EEG, although helpful in identifying more serious concerns (e.g. skull fracture, hematoma, contusion), are not useful in identifying the effects of concussion. Such tests are typically unremarkable or normal, even in athletes sustaining a severe concussion. implementation of baseline and/or post- injury neurocognitive testing.

13. Medications Aspirin should be avoided after a suspected concussion OTC drugs should be avoided initially to prevent “masking” of symptoms In the event of chronic prolonged symptoms some medications can be prescribed to help control symptoms of a concussion.

14. Return To Play No activity - rest until asymptomatic Light aerobic exercise Sport-specific training Non-contact drills Full-contact drills – Football, Hockey…etc. Game play Cognitive exertion (thinking) as well as physical exertion can increase symptoms It is important to consider classes through the duration of a concussion

15. Final Notes & Questions? Education and awareness is key to safety of athletes and prevention of returning too soon Symptoms – Day to day management and observation is necessary Communication – Parents, Coaches, Athletic Trainer, Athlete

16. (Immediate Post-Concussion Assessment and Cognitive Testing) If Used Correctly, ImPACT will… -Help determine severity of concussion -Provide valuable information to the athlete, parents, athletic trainers, physicians -Provide information on academic deficits associated with concussion -Promote safe return to play - Reduce liability for school districts Test Section 1: Subject Profile and Health History Questionnaire Test Section 2: Current Symptoms and Conditions Test Section 3: Neuropsychological Tests (Baseline and Post-Concussion) – Module 1 (Word Discrimination) – Module 2 (Design Memory) – Module 3 (X's and O's) – Module 4x (Visual Attention Span) ImPACT 1.0 only-This module has been removed for version 2.0. – Module 4 (Symbol Matching) – Module 5 (Color Match) – Module 6 (Three letters) IV. Injury Description V. Graphic Display of Data

17. THANK YOU

18. Refrences www.impacttest.com www.impacttestoffice.com http://www.cdc.gov/NCIPC/tbi/Coaches_Tool _Kit.htm http://www.cdc.gov/NCIPC/tbi/Coaches_Tool _Kit.htm Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; March 2004