1. Closed Head Injuries in High School Athletics Kent Jason Lowry, MD Northland Orthopedic Associates

2. Concussion or Mild Traumatic Brain Injury A process affecting the Brain induced by direct or indirect biomechanical forces Features include: Rapid onset of short lived neurological impairment- -usually resolves spontaneously Symptoms reflect a functional disturbance rather than a structural injury Imaging studies usually normal

3. Epidemiology Occur commonly in both helmeted and non- helmeted sports. Published injury rates include: 0.14-3.66 injuries/1100 player seasons at the H.S. level. (3-5% of injuries in all sports) 0.5-3.0 injuries/1,000 athlete exposures at the collegiate level. Self-reporting data suggests a significantly higher incidence of concussion. The true incidence is unknown.

4. Pathophysiology Head injuries result in a relative decrease in cerebral blood flow in a setting of increase requirements for nutrition (glucose). This mismatch in metabolic supply and demand leads to cell dysfunction and increased vulnerability to a second injury (Second Impact Syndrome).

5. Signs & Symptoms Confusion Posttraumatic amnesia (PTA) Retrograde Amnesia (RGA) Loss of Consciousness (LOC) Disorientation Feeling “in a fog,” “zoned out” Vacant stare Inability to focus Delayed verbal & motor responses Slurred speech Excessive Drowsiness

6. Signs & Symptoms Headache Fatigue Dizziness Nausea/vomiting Visual disturbances (Photophobia, double vision) Phonophobia Emotional lability Irritability

7. “On the field”/sideline evaluation If a player shows ANY signs or symptoms, the player should not return to play/practice The player should not be left unattended and regular monitoring is essential during the first few hours Medical evaluation should occur following the injury Return to play must follow a medically supervised process “When in doubt, sit them out!”

8. Sideline Concussion Assessment Tool Represents a standardized tool for evaluation and player education. Developed by combining over eight existing concussion tools. Provides a logical stepwise evaluation process. Applicable across all sports

9. Post injury considerations Medical evaluation is necessary Reevaluate the player every few hours during the first 24-48 hrs of the injury Worsening symptoms should prompt an Emergency room visit. Limit activities both physically and cognitively Consider discussing injury with teachers (concentration and attention by exacerbate the symptoms and delay recovery)

10. Return to play Should be medically directed Decision making is individualized, not based on a rigid timeline Progressive aerobic and resistance exercise challenge tests must be utilized. Neuropsychological testing may be considered as an additional tool. Neuropsychological testing should NOT be the sole basis for return to play and provides no additional information when players have symptoms.

11. Return to play guidelines Return of symptoms at any step, necessitates stopping and restarting at the previous level 24 hrs later. 1.No activity, Complete rest. Once asymptomatic, proceed to level 2 2.Light aerobic exercise (walking or stationary cycling), no resistance training. 3.Sport Specific exercise with progressive addition of resistance training 4.Non-contact drills 5.Full contact training after medical clearance 6.Return to game play

12. Second Impact Syndrome Controversial, rare (6-10 / year in the US) Only seen in athletes < 20yo Results from a second head injury prior to recovery from a previous injury Results in massive brain swelling and hemorrhage leading to permanent disability or death.

13. Prevention From: “Concussion and the Team Physician: a Consensus Statement”. Concussions cannot be completely prevented Helmet use decreases the incidence of skull fracture and major head trauma, but does not prevent, and may actually increase, the incidence of concussion. Improper use of the head and improper fit of the helmet may increase the risk of concussion.

14. Conclusions Head injuries are common If you think a head injury has occurred: Don’t play the athlete until evaluation has occurred Prevention of a catastrophic second impact syndrome is our goal.

15. Questions?