Epidemiology Pathophysiology Comprehensive Concussion Management Treatment Complications Concussion Law

Epidemiology Pathophysiology Comprehensive Concussion Management Treatment Complications Concussion Law

1.5-2 million concussions occur each year Marked increase in reported injury over the last 10 years secondary to increased awareness 10-20% of these injuries are sports related 47-63% of all sports related concussions occur in football Up to 20% of football players will sustain a concussion per season 25% of all high school students will sustain a concussion prior to graduating from high school If not appropriately treated, a patient who sustains concussion is 4-6 times more likely to sustain a second Cumulative effects Bell ringers =concussion account for 75% of all concussive injuries

7-21 47 Per 100,000 player games in HS athletes (JAT 2007) 22-36 7 18

Concussion= Mild Traumatic Brain Injury (mtbi) Caused by a blow to part of the body with an impulsive force transmitted to the head Results in the rapid onset of short-lived impairment of neurologic function that typical resolve spontaneously in a sequential fashion functional disturbance rather than a structural injury May or may not be associated with LOC 90% of mtbi has no associated LOC

% of normal K+ glucose Cerebral blood flow glutamate 2 6 12 20 30 6 24 3 6 10 Minutes hours Days

The invisible injury Concussions common and more serious than previously recognized Old treatment guidelines Mild initial symptoms may lead to long lasting symptoms Fewer than 50% of student athletes with symptoms of concussion reported their symptoms (McCrea 2004) Media exposure High exposure athletes have played through concussions and return to play quickly after concussions Youth athletes are more at risk for bad outcomes than their professional counterparts

Not all concussions are associated with LOC. Not all concussions present with headache. Concussion symptoms are secondary to a SUPPLY/DEMAND issue Energy/Metabolic Crisis secondary to decreased blood flow and increased demand for glucose Symptoms from concussion develop over hours to days Cannot assess severity of injury based on initial evaluation

*Education Program* (Baseline Neurocognitive Testing) Appropriate recognition Appropriate ER evaluations Appropriate Treatment with Follow-up visits Graduated Return to Activity

MOST IMPORTANT PART OF CONCUSSION PROGRAM That is why we are here!! Coaching staff, referees, parents, athletes, medical providers should be able to recognize a concussion Appropriate preventive measures in sports No tolerance on poor technique (ie, spear tackling) Injured players MUST have a return to play assessment with documentation by a medical practitioner well versed in concussion

Evaluates attention/concentration, memory/recall, processing speed, and reaction time Ideal to have baseline vs. post-concussive information ImPACT, CogState, HeadMinder Testing done in 30 minutes or less Able to test large numbers of athletes to obtain baselines Results available as soon as testing is over Pre and Post-injury tests easily compared

Individuals vary widely in cognitive skills Compare the student athlete to themselves pre and post-injury Not every A student performs to A potential on neurocognitive testing Determine influence of prior head injuries/concussions Caution regarding baseline assessment The purpose of the baseline assessment is to measure the normal cognitive abilities of an individual Getting a valid baseline can be a challenge Distraction Low motivation Throwing the test Bad day

Signs Observed Appears dazed Confused about play Answers question slowly Forgets plays, score, opponent Personality change Retrograde amnesia* Anterograde amnesia* Loss of consciousness Symptoms Reported Headache Nausea Balance problems Double/fuzzy vision Sensitivity to noise/light Feeling sluggish Feeling foggy Change in sleep pattern Concentration/memory issues

Cognitive Symptoms Attention problems Memory dysfunction fogginess Fatigue Cognitive slowing Neuropsychiatric More Emotional Sadness Nervousness Irritability Sleep Disturbance Difficulty falling asleep Change in sleep pattern Physical Symptoms Headaches Visual Problems Dizziness Noise/Light sensitivity Nausea

WHEN IN DOUBT, SIT THEM OUT! If a player is removed from play for concussive symptoms with or without LOC No same day return to play Take away the athlete s helmet, cleat, etc Continue to monitor for worsening symptoms An adult must be responsible for following the athlete Decision whether to go to ER Make sure the athlete has appropriate medical follow up

Patients with head injury should be seen in the ER if there is loss of consciousness or if there are any focal neurologic symptoms Rule out more serious intracranial pathology CT scan MRI No one should get a clearance note from the ER.

Athlete s with concerning symptoms should be taken out of play IMMEDIATELY. There should be no same day return to play in the adolescent population ** Avoid re-injury ** Patient should be seen by a medical provider trained in concussion management. REST Cognitive and physical Return to play protocol 5 step protocol to return to play is much more conservative in youth than in older athletes.

Increased sleep Good sleep hygiene Low threshold to start melatonin Take naps when able No sports, gym, cardiovascular conditioning, strength training ** Avoid re-injury **

May need to be out of school/work to allow for appropriate rest Reduced course/work load Accomodations Minimal TV, computers, texting, video gaming, etc Avoid loud noise, bright lights, vibration, etc No concerts, no gigs

No school, limited time in school, specific classes No testing or testing accommodations Limited time for homework Auditory learning Notes/scribe provided to student Extended time to make up assignments Home bound tutoring IEP/504 plans

Symptoms generally resolve completely in 7-10 days, but may be longer in youth and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of untreated concussion) Any single concussion generally has limited long term consequences (Brain Inj 2008) Athletes with 2+ concussions may exhibit significantly lower grade point averages than matched students with no concussion history (Neurosurgery 2005) Nearly 14% of children age 6-18yo with mild TBI remain symptomatic at 3 months post injury (Pediatrics 2010) 2.3% of children 0-18yo are symptomatic at 1 year (Pediatrics 2010)

Rest until asymptomatic (physical,mental) Light aerobic activities with no weight training Moderate aerobic activities and weight lifting; minimal proprioceptive challenge Increased weight training and aerobic activities. Add plymetrics and balance/proprioceptive challenge Sports-specific, aggressive non-contact training Full contact training Return to contact competition (game play) Each stage is at least 24 hrs and return to previous stage if symptoms reoccur

If not treated properly, the patient is at increased risk of long term effects Post Concussive Syndrome Second Impact Syndrome Chronic Traumatic Encephalopathy [CTE] Emotional Problems ADHD/LD?? Risk of retirement from sport

It s the law in 40 states as of 7/12; 8 states pending NY was the 33 rd state to pass such a law as of 7/12 The ultimate goal would be to prevent injury Realistic goal: prevent long term effects from concussions

parents of student-athletes must sign a permission slip before their kids can participate in practice or games any student-athlete suspected of a concussion must immediately be removed from play any student-athlete with a concussion must obtain medical clearance before returning to play * The New York law actually goes one step further, requiring coaches, physical education teachers, school nurses, and athletic trainers to undergo biennial concussion training (only adopted in 50% of the state legislations)

*Education *Baseline Testing * Post-Injury Testing * Clinical Eval Asymptomatic at rest Concussion 0 1-3 * Sideline Eval Days * ER Eval 3+ Days * F/u Clinical RTP progression

Halstead, M, et al. (2010). Sport-Related Concussion in Children and Adolescents. Pediatrics. 126 (3), 597-615. McCrory, P, et al. (2009). Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br. J. Sports Med. 43 (Supp I), i76-90. Toledo, E, et al. (2012). The young brain and concussion: Imaging as a biomarker for diagnosis and prognosis. Neurosci and Biobehav Rev. 36 (1), 1510 1531. http://www.cdc.gov/concussion/index.html http://www.impacttest.com/