1. Concussion: Definition, Demographics, Signs & Symptoms Andrew Gregory, MD, FAAP, FACSM Associate Professor Orthopedics & Pediatrics Team Physician, Vanderbilt & Belmont Universities

2. Objectives Definition of concussion Discuss common signs & symptoms Review demographics – Who, what, when and how

3. Is this a concussion? 11 yo was swinging on a tree limb, fell 5-6’ and hit the back of his head on the ground Loses consciousness for one min according to other kids Then has headaches and blurry vision Vomits twice

4. Is this a concussion? Seen at the Emergency Room - “normal exam”, CT Scan negative Goes back to school with headaches needing Ibuprofen Headaches get worse with physical activity (including practicing with his travel baseball team)

5. Self Reported Symptoms Headache – 3/6 Trouble Sleeping – 3/6 Drowsiness – 2/6 Sensitivity to light – 2/6 Feeling like “in a fog” – 1/6 Difficulty concentrating – 1/6 All others - 0/6

6. Did this child have a concussion?

7. What is a Concussion? Lots of terms – Ding, bell rung, shaking off the cobwebs, closed head injury, mild traumatic brain injury (mTBI) “A trauma induced alteration in mental status that may or may not involve loss of consciousness” —AAN 1997 Headache plus… Transient Neurological Phenomenon

8. Definition of Concussion 1. Caused either by a direct blow to the head, face, neck or elsewhere on the body with a resultant force transmitted to the brain. 2. Typically results in the rapid onset of short-lived changes in neurological function that resolves spontaneously. 3. May result in structural brain changes, but the symptoms largely reflect a functional disturbance rather than a structural injury. 4. Usually follows a progressive course of improvement 5. Imaging studies (brain CT/MRI) are usually normal.

9. Signs and Symptoms of Concussion Signs Appears dazed or stunned Confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness Shows behavior or personality change Forgets events prior to play (retrograde) Forgets events after hit (posttraumatic) Symptoms Headache Nausea Balance problems or dizziness Double vision Sensitivity to light or noise Feeling sluggish Feeling “foggy” Concentration or memory problems Change in sleep pattern (appears later) Feeling fatigued

10. Common symptoms of concussion from a series of injured high school athletes Three most common symptoms: 1.Headaches (55%) 2.Dizziness (42%) 3.Blurred vision (16%) 46% experienced either cognitive or memory problems 9% had loss of consciousness (“knocked out”)

11. Do you have to be “knocked out” to have a concussion? NO!!!!! In fact, only a SMALL number of concussed athletes were “knocked out” Many studies have now shown that amnesia (inability to remember) is a much more common sign of concussion and ALWAYS indicates that a brain injury has occurred

12. What are the “Grades” of a concussion? In the past concussions were often classified into grade 1, 2, or 3 based on the severity and duration of symptoms at the time of injury Many research studies have showed that these grading scales were useless in predicting the severity of injury or how long to recover Grading scales are no longer used

13. If you have a history of a previous concussion are you more likely to have a longer duration of symptoms? Available research says “yes”

14. Does having a concussion increase your chances for a future concussion? Some research says “yes” 92% of the in-season repeat concussions occurred within 7-10 days of first

15. Epidemiology of Concussion 1.5-3.8 million reported cases of brain injury per year in the US (CDC) 20% (300,000-760,000) are sports-related 53,000 deaths each year 70-90,000 permanently disabled Highest sports incidence: ages 15- 24 Cost estimated at > $60 billion annually

16. HS RIO™ Injury Surveillance System Internet-based high school sports-related injury surveillance system Weekly data capture 2005 - 2010 academic years Representative sample of 100 US high schools – Geography (4 US census regions) – Size (≤1,000 vs >1,000 students) 20 sports – Boys’ - football, soccer, basketball, wrestling, baseball, lacrosse, ice hockey, swimming & diving, track & field, volleyball – Girls’ - volleyball, soccer, basketball, softball, lacrosse, field hockey, gymnastics, swimming & diving, track & field, cheerleading 16

17. Rates per 1,000 Athletic Exposures Sport # of Concussion s National Estimate s Practice Competition Overall Football1392357,114 1.311.42.9 B Soccer18289,237 0.33.01.1 G Soccer243132,062 0.34.61.6 G Vball5417,326 0.20.60.3 B Bball11127,404 0.21.30.6 G Bball18447,439 0.42.71.1 Wrestling15233,979 0.61.91.0 Baseball329,569 0.10.40.2 Softball6623,692 0.40.80.5 Concussion Rates, 2005- 2010 17 Includes concussions resulting in <1 day time loss (non time loss = 2% of all concussions)

18. Concussion Severity 2005-2010 Time lost (days) 18 Time lost means days missed from sport due to concussion

19. Concussion Mechanisms 2005-2010 19 Includes only time loss concussions

20. Activity Associated with Concussions, Soccer 2005-2010 Activity Boys’ soccerGirls’ soccer Heading ball36%30% Goaltending17%13% General play10%11% Defending9%17% Chasing loose ball11%15% Ball handling/dribbling 6%5% Receiving pass6%3% 20 Includes only time loss concussions

21. Activity Associations Basketball 20 05 - 2010 21 Activity Boys’ basketballGirls’ Basketball Rebounding30%21% Chasing loose ball17% Defending20%27% General play14%7% Shooting10%6% Ball handling/dribbling 6%10% Receiving pass1%7% Includes only time loss concussions

22. Activity Associations Baseball/Softball 2005 -2010 Activity BaseballSoftball Batting37%8% Running bases 22%4% Fielding15%25% Pitching6%5% Catching6%33% Sliding12%5% 22 * Includes only time loss concussions

23. Football Concussions 2010 23 Concussions resulting from player-to-player contact Type of contact: head to head (66%), head to other body site (26%), head to playing surface (8%) Position of head during contact: head-up (38%), head- down (25%), no flexion (4%), unknown (33%) Direction of impact: front (45%), side (22%), top (8%), back (5%), unknown (20%) Did athlete see impact coming: yes (37%), no (27%), unknown (37%)

24. Girls’ Soccer Concussions 2010 24 Concussions resulting from player-to-player contact Type of contact: head to head (48%), head to other body site (45%), head to playing surface (7%) Position of head during contact: head-up (21%), head- down (26%), no flexion (7%), unknown (46%) Direction of impact: front (24%), side (43%), top (3%), back (14%), unknown (16%) Did athlete see impact coming: yes (55%), no (25%), unknown (20%)

25. Summary Concussion is a temporary disruption of ANY function of the brain caused by trauma All coaches and parents should become familiar with common signs and symptoms of concussion and be alert for them No return to play if concussion is suspected Grading scales are no longer used ANY athlete in ANY sport at ANY age is at risk for concussion