Recognition and Care of Concussion

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1 Recognition and Care of Concussion Seattle Sport Concussion Program: Philip D. Heywood MS, ATC, AT/L Enter department name here

2 Objectives: Definition and Pathophysiology Concussion facts Recognizing Concussions Caring for the concussed athlete (RTP) Washington State Law

3 What is a Concussion? A complex pathophysiological process affecting the brain, induced by biomechanical forces. -Zurich Concussion Statement 2012 Complex no easy concussions Pathophysiological function and microscopic structure problems Biomechanical forces a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head

4 What is a Concussion? Common features of a concussion: Rapid onset of usually short-lived neurological impairment which typically resolves spontaneously A range of clinical symptoms that may or may not involve loss of consciousness (LOC). Less than 10% of sports concussions involve loss of consciousness

5 Pathophysiology of Concussions A concussion is a disturbance in brain function. Results in a variety of nonspecific symptoms Certain chemical levels are altered at the cellular level. Blood supply to the brain decreases. The brain s demand for glucose increases. The result is a metabolic imbalance referred to as an energy crisis. This Energy crisis leaves neuronal tissue vulnerably The brain needs time to recover and heal

6 Concussion Basics If the brain was like a computer a concussion would be a software issue, not a major hardware problem Imaging (CT and MRI) shows structure, not function Routine Imaging will be normal in most cases Normal imaging does not equal normal function!

7 Concussion: Epidemiology 3.8 million recreation or sports related concussions among children and adults Langois et al, J Head Trauma Rehab, ,000 Emergency Department visits for concussion in children 0-19 years of age annually Meehan & Manix, J Peds 2010 and 2011

8 Concussion: Epidemiology High School Reporting Information Online & NCAA Injury Surveillance System ( ) 8.9 % all high school athletic injuries 5.8 % all collegiate athletic injuries 16.8% had previous concussion (that season or prior season) Sports Concussion Rates Football Girls soccer Boys soccer Girls basketball Gessel et al, J Athl Trning 2007

9 Concussion: Epidemiology in High School Athletes Concussion rate per 1000 athlete-exposures Football: 0.47 Girl s soccer: 0.36 Boy s soccer: % higher Girl s basketball: 0.21 Boy s basketball: % higher Gessel LM et al. Concussions Among United States High School and Collegiate Athletes Journal of Athletic Training 2007; 42:

10 Gender Comparable Sports Girls had a higher rate of concussions than boys Concussions represented a greater proportion of all injuries in girls sports Girls had a greater proportion of concussions due to player-playing surface contact and player-equipment contact Marar,M et al. AJSM online 01/27/12

11 Concussion: Epidemiology Risk for future sports concussion: 1 previous concussion: 1.5x risk 2 previous concussions: 2.8x risk 3+ previous concussions: 3.5x risk Guskiewicz, JAMA 2003

12 Concussion: Epidemiology 59% of athletes had a previous history of concussion(s) 71% of those injuries occurred in the same season as the catastrophic injury 39% of athletes at time of catastrophic injury were playing with residual symptoms from a previous concussion Boden, AJSM 2007

13 Concussion Symptom Resolution 25% had symptom resolution within one day 40% had symptom resolution within three days (except girl s track and field and swimming Marar,M et al. AJSM online 01/27/12

14 Concussion Basics: Knowing your Athletes A concussion should be suspected in the presence of ANY ONE OR MORE of the following: Symptoms (Headache, nausea, ringing in ears) Physical signs (unsteadiness, LOC, Appears dazed) Impaired brain function (e.g. confusion, difficulty remembering) Abnormal behavior (e.g. severe anger, sadness)

15 Treatment: Immediate Response Any athlete with a suspected concussion should IMMEDIATELY BE REMOVED FROM PLAY Should Not BE LEFT ALONE and should not drive a motor vehicle Seek Medical Attention right away if: You notice any change in behavior/worsening of symptoms Loss of consciousness more then 1 minute, Vomiting more then once, double vision, excessive drowsiness or inability to recognize familiar people. Seek Health Care Professional afterwards No Alcohol Do NOT use aspirin or anti-inflammatory medication

16 Concussion Basics: Knowing your Athlete If you suspect a concussion remove athlete from play and have them evaluated by a Licensed Health Care Provider trained in the evaluation and management of concussion: Medical Doctors (MD) Doctor of Osteopathy (DO) Advanced Registered Nurse Practitioner (ARNP) Physicians Assistant (PA) Licensed Certified Athletic Trainers (AT/L) As a coach what should I expect from my player s healthcare providers?

17 What My Team s Health Care Provider Should Know SCAT3 SCAT3 Child Zurich Consensus Statement

18 Recognizing when a concussion occurs SYMPTOMS Symptoms may include one or more of the following: Cognitive Somatic Affective Sleep Confusion Post-traumatic amnesia (PTA) Retrograde amnesia (RGA) Loss of consciousness (LOC) Disorientation Feeling in a fog Vacant stare Inability to focus Delayed verbal and motor responses Slurred/incoherent speech Excessive drowsiness Headache Fatigue Disequilibrium, dizziness Nausea/vomiting Visual disturbances (photophobia, blurry/double vision) Phonophobia Emotional lability Irritability Drowsiness Sleeping less Sleeping more Trouble falling asleep

19 Recognizing when a concussion occurs: Decreased Brain Function 1 point for each correct answer Orientation What month is it? 0 1 What is the date today? 0 1 What is the day of the week? 0 1 What year is it? 0 1 What time is it right now? 0 1 Orientation score of of 5 Memory Function Failure to have immediate/ delayed recall of words may suggest a concussion List 5 separate words and have athlete repeat them immediately and after 5min Example: Candle, Paper, Sugar, Iron, Sunset -Months in Reverse Order Concentration Ask the patient to state the months backwards starting from the current month. Circle omissions. Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan OR -Days of the Week Backwards Ask the patient to state the days of the week backwards starting from the current day. Circle omissions. Fri-Thur-Wed-Tue-Mon-Sun-Sat

20 Recognizing when a concussion occurs: Balance Function Balance examination -Balance testing is to be performed for 20 seconds each. Instruct the athlete to place the hands on the hips and close the eyes. -Dominant foot is defined as the foot you kick with (a) Double leg stance: The feet should be placed shoulder-width apart. (b) Single leg stance: The athlete should lift the dominant foot. The hip should be at 30 degrees of flexion and the knee at 45 degrees of flexion. (c) Tandem stance: The dominant foot should be in the front. Balance testing: types of errors (max. 10 per trial) 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 seconds Which foot was tested? Left Right (i.e. which is the non-dominant foot) Total errors Double leg stance of 10 Single leg stance (non-dominant foot) of 10 Tandem stance of 10 Balance examination score of 30

21 Treatment: until signs/symptoms clear DO NOT allow athlete to run/jump, raise heart rate or put themselves in a situation where they can get hit again. This involves playing pickup ball, weight lifting, PE, or running down the street chasing their friends. Athlete may have a hard time with concentration. If athlete complains of a severe headache or dizziness limit time at school, no TV and Video Games! Allow athlete to rest and stay inactive until all signs and symptoms have cleared Do NOT engage in any physical activity until cleared by a Licenced ed Health Care Provider!

22 Treatment: Return to Play Guidelines Athlete will not be returned to play the same day of injury. When returning athletes to play, they will then follow a stepwise symptom-limited program, with stages of progression. 1. Rest until asymptomatic 2. Light aerobic exercise (running, biking) 3. Sport-specific exercise 4. Non-contact training drills 5. Full contact training drills after medical clearance 6. Return to competition (game play) Approximately 24 hours (or longer) for each stage. If symptoms return at any stage athlete should return to stage 1. MEDICAL CLEARANCE MUST BE GIVEN BEFORE RETURN TO PLAY!

23 RTP In-depth

24 Second Impact Syndrome Rare Limited to teenagers No cases in NFL/ NHL/ MLB

25 Concussions in the News

26 Zachery Lystedt Law: Engrossed House Bill 1824 Washington State Legislature Develop guidelines and informative hand outs for all athletes/families/coaches. Signed document stating they know and understand the importance of this issue prior to participating in practice or competition. Updated Yearly

27 Zachery Lystedt Law: Engrossed House Bill 1824 An athlete who is suspected of sustaining a concussion in the State of Washington MUST BE HELD OUT. Once removed, no return until evaluated by a licensed health care provider trained in the evaluation and management of concussion. Licensed Health Care Providers Medical Doctors (MD) Doctor of Osteopathy (DO) Advanced Registered Nurse Practitioner (ARNP) Physicians Assistant (PA) Licensed Certified Athletic Trainers (AT/L) Research is currently being done to determine which other licensed health care providers may have sufficient training to qualify to authorize return to play. The WIAA will update schools and this website as this information becomes available. Must have written clearance to return to play!!!

28 Zachery Lystedt videos/09000d5d81c7a785/part-three-the-zackery-lystedt- Youth-Sports-Concussion-Law-Meet-Zackery-Lystedt

29 Concussion Legislation 49 states and District of Columbia currently have concussion legislation for young athletes

30 In Conclusion You know your athletes best RTP is key when keeping kids safe Promote honesty with your athletes, and set clear expectations for your team Where applicable work with your ATC to educate administrators, parents, and Student athletes

31 In Conclusion Do not let a injured athlete back into practice or games until they have been evaluated and cleared in writing by a licensed healthcare provider trained in the evaluation and management of concussions. This is not only the Law (in Washington State); It Is The Right Thing To Do!

32 Helpful Resources Consensus Statement on Concussion in Sport; 4 th International Conference on Concussion in Sport, Zurich 2012 SCAT 3 Graduated Return to Play Zackery Lystedt Law CDC Heads Up Tool Kit WIAA website- Coaches video

33 Seattle Sports Concussion Clinic Appt: Appt:

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