Identifying and Managing Sports Related Head Injury Jason R. Freeman, Ph.D. Donna K. Broshek, Ph.D. Howard Goodkin,, M.D., Ph.D. Brain Injury and Sports Concussion Institute Depts. Of Psychiatry & Neurobehavioral Sciences and Neurology University of Virginia Health System
Sports TBI- Public Health Concern 300,000 to 500,000 a year Children & young adults most frequent (5 24 yrs) Can result in disability; interfere with reaching full educational & occupational potential Athletes are at risk for multiple head injuries Increases risk for poor outcome (5-
Concussions are Brain Injuries Direct Effects Indirect Contrecoup Effects
Concussion Diagnosis A concussion diagnosis does NOT require loss of consciousness, only altered consciousness Severe head injury produces obvious consequences, visible on neuroimaging Concussion rarely produces structural change, it causes neurochemical change Concussion disrupts the balance between energy supply and demand in the brain (leaving the brain vulnerable if a second injury occurs)
Second Impact Syndrome SIS results when the vulnerable brain experiences a second concussion event Can occur even if both are mild, but in close temporal proximity Catastrophic metabolic cascade ensues Youth have increased vulnerability Zachery Lystedt case
Sports Concussions Concussions previously minimized by the public and professionals as insignificant and inevitable A concussion is a mild traumatic brain injury High profile concussions have raised awareness Steve Young, Troy Aikman, Jay Cutler, Eric Lindros, Sid Crosby Also the suicides of high profile athletes Andre Waters 2006; Most recently Dave Duerson Recently, Zachery Lystedt
Virginia Senate Bill 652 Mandates concussion education in all local schools for coaches, student-athletes, & parents & policies and procedures Student-athletes & parents to receive annual education Any athlete with suspected concussion shall be removed from play/activity Shall not return the same day MUST be evaluated by health care professional Requires written clearance for return to activity Intentional flexibility (vagueness) to consider what resources are available to given locale
Concussion Management Medical care and return to play decisions tailored to each student-athlete No one-size size-fits-all return to play criteria Huge benefit of baseline cognitive testing No athlete returns to sports/activity until asymptomatic and cleared in writing by qualified health professional Zurich Guidelines - return to physical activity Academic Accommodations - return to cognitive activity
UVA Concussion Team Consultation with CCS How to implement Senate Bill 652 Baseline cognitive evaluations for all student athletes? Which test(s)? Who educated, when, and how On line training options/resources Live talks to coaches, nurses, teachers, parents, student athletes es Local definitions- qualified health providers Algorithm for how ATC uses other resources to assess, make decisions, and clear concussed athletes to return Apply concussion management to the classroom
Zurich Graduated Return to Play 1. No activity, complete physical and cognitive rest. Once asymptomatic, proceed to level 2 2. Light aerobic exercise such as walking or stationary cycling, no resistance training 3. Sport specific exercise - for example, skating in hockey, running in lacrosse; no head impact activities 4. Non-contact training drills may start progressive resistance training 5. Full contact training after medical clearance 6. Return to play normal game play * Generally each step takes 24 hours so a minimum of one week is required to be cleared to play.
Concussions & Academics Concussion related cognitive deficits: inattention, poor concentration, memory disruption, slowed processing, slowed task performance Other symptoms affect academics: headache, fatigue, dizziness, light/noise sensitivity, poor sleep, ringing in ears Temporary (usually) Accommodations: Ensure adequate physical and cognitive rest: No video games, minimize texting! Relax time demands Reduced work load Monitor stimulation of environment (noise, lighting)