Michael J. Sileo, MD. Orthopedic Associates of Long Island (OALI)

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1 Michael J. Sileo, MD Orthopedic Associates of Long Island (OALI)

2 ! Jeremy Thode, AD! Center Moriches BOE

3 ! Safety of our student-athletes is our Number 1 concern! NYS is now forcing our hand " Referees can remove athletes from play " Chief medical officers required to return athletes to play " Required concussion management program! The Media " Mark Sanchez, Joe Mauer, Sidney Crosby

4 ! 5 STEP PROGRAM " EDUCATION, EDUCATION, EDUCATION " Baseline neurocognitive testing " Proper sideline decisions " Proper ER evaluation, when necessary " Follow up, return to play

5 " The right helmet / mouthpiece will prevent all concussions " You can t diagnose a concussion without an MRI " Only neurologists should treat concussions " He/she was fine after the game. There is no way they have a concussion

6 ! 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

7 ! Bell ringers =concussion " account for 75% of all concussive injuries! Concussions are cumulative in athletes who return to play prior to complete recovery

8 ! Concussions are more common and more serious than previously recognized " Difficult to diagnose " Symptoms typically worsen hours later " 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

9 ! A concussion is a Mild Traumatic Brain Injury. " Concussus derived from the Latin to shake violently " Symptoms may manifest in other ways than just a headache

10 ! Concussion result in a functional disturbance rather than a structural injury. " No abnormality on standard structural neuroimaging studies is seen with a concussion.

11

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14 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

15 ! Not all concussions are associated with LOC!!! I just don t feel right! My head feels heavy! I feel like I am under water! I got my bell rung

16 Concussion: The Return to Play Dilemma

17 ! 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)

18 ! ORIENTATION " 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

19 ! Cognition " Serial sevens, months in reverse! Neurologic evaluation " Cervical spine! Functional Testing " Romberg Sway! 20 seconds " Heel-to-toe stance " Oculomotor testing " 20 yard jog

20 ! 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

21 ! Concussion test! Evaluation of attention, concentration, memory/recall, processing speed, reaction time! Ideal to have baseline vs. post concussive information " Can result in safer and FASTER return to play! Computerized models have made this testing more accessible " Testing typically done in 30 minutes or less

22 ! Administered before season starts! St. Charles! Only PART of the concussion program

23 ! ImPACT " Currently utilized by NCAA, NFL, MLB, NHL, WWE

24 Testing reveals cognitive deficits in asymptomatic athletes within 4 days postconcussion Lovell, Collins et al., Am J Sports Med, 2006

25

26 ! 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.

27 ! 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

28 ! 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

29 ! 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??

30 ! Chronic headaches! Fatigue! Sleep difficulty! Personality changes! Light sensitivity! Deficits in short term memory, problem solving, academics

31 ! 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

32 Chronic Traumatic Encephalopathy

33 ! Generally takes 3-10 days " Longer in certain circumstances! Careful supervision! Requires re-evaluation after to protocol for final clearance! Can be performed by trained ATC, physical therapists

34 ! Final RTP decision should only be done by school-certified, concussion certified physician! Close the loop! Only way to ensure that baseline data is properly utilized! Any clinician can become ImPact certified by taking online course

35 ! 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

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