The Head, Face, and Neck Injuries and Prevention

Prevention of Injuries to the Head, Head injuries are prevalent in sport, particularly in collision and contact sports Education and protective equipment are critical in preventing injuries to the head and face Head trauma results in more fatalities than other sports injury Morbidity and mortality associated w/ brain injury have been labeled the silent epidemic Morbidity—diseased state, disability, or poor health Mortality—death

Bones of the Skull

Layers Under the Skull

Prevention Protective equipment Mouthguards have benefit in prevention oral injury, but no evidence of concussion reduction Head gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence Helmets reduce head and facial injury in skiing and snowboarding and are recommended for alpine sports Helmets reduce other forms of head injury (e.g. fracture) in cycling, equestrian, motor sports

Head injuries

Injury Definition: Sports concussion “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…”

Cerebral Concussion (Mild Traumatic Brain Injury) Characterized by immediate and transient post-traumatic impairment of neural function with no focal lesions found on neuroimaging Cause of Injury Result of direct blow, acceleration/deceleration forces producing shaking of the brain Signs of Injury Altered level of consciousness post-traumatic amnesia are two factors that must be considered http://youtu.be/q3DkaM8BgAw

Cerebral Concussion (Mild Traumatic Brain Injury) Other signs & symptoms may include Brief periods of diminished consciousness or unconsciousness that lasts seconds or minutes Headache, tinnitus, nausea, irritability, confusion, disorientation, dizziness, anterograde amnesia, retrograde amnesia, concentration difficulty, blurred vision, photophobia, sleep disturbances Classification grading systems of concussions have undergone extensive debate in recent years No single system has been fully endorsed The logical approach seems to be to focus on the presence and duration of various signs and symptoms

Cerebral Concussion (Mild Traumatic Brain Injury) Care The decision to return an athlete to competition following a brain injury is a difficult one that takes a great deal of consideration If any loss of consciousness occurs ATC must remove the athlete from competition Cervical spine injury should be assumed Objective measures (BESS and SAC) should be used to determine readiness to play

Cerebral Concussion (Mild Traumatic Brain Injury) Care (continued) All post-concussive symptoms should be resolved prior to returning to play -- any return to play should be gradual Athlete must be cleared by the team physician Recurrent concussions can produce cumulative traumatic injury to the brain Following an initial concussion the chances of a second episode are 3-6 times greater

Postconcussion Syndrome Cause of Injury Condition which occurs following a concussion May be associated w/ those concussions that don’t involve a LOC or in cases of severe concussions Signs of Injury Athlete complains of a range of post-concussion problems Persistent headaches, impaired memory, lack of concentration, anxiety and irritability, giddiness, fatigue, depression, visual disturbances May begin immediately following injury and may last for weeks to months

Postconcussion Syndrome Care ATC should treat symptoms to greatest extent possible Return athlete to play when all signs and symptoms have fully resolved Once the signs and symptoms have resolved, the athlete should be continually monitored in order to ensure that they have not returned.

Second Impact Syndrome Cause of Injury Result of rapid swelling and herniation of brain after a second concussion before symptoms of the initial injury have resolved Second impact may be relatively minimal and not involve contact w/ the cranium Impact disrupts the brain’s blood autoregulatory system leading to swelling, increasing intracranial pressure 50% mortality rate, 50% morbidity rate

Second Impact Syndrome Signs of Injury Often athlete does not LOC and may looked stunned W/in 15 seconds to several minutes of injury athlete’s condition degrades rapidly Dilated pupils, loss of eye movement, LOC leading to coma, and respiratory failure Care Life-threatening injury that must be addressed w/in 5 minutes w/ life saving measures performed at an emergency facility Best management is prevention from the ATC’s perspective

Skull Fracture Cause of Injury Signs of Injury Care Most common cause is blunt trauma Signs of Injury Severe headache and nausea Palpation may reveal defect in skull May be blood in the middle ear, ear canal, nose, ecchymosis around the eyes (raccoon eyes) or behind the ear (Battle’s sign) Cerebrospinal fluid may also appear in ear and nose Care Immediate hospitalization and referral to neurosurgeon

Epidural Hematoma Cause of Injury Blow to head or skull fracture which tear meningeal arteries Blood pressure, blood accumulation and creation of hematoma occur rapidly (minutes to hours)

Subdural Hematoma Cause of Injury Result of acceleration/deceleration forces that tear vessels that bridge dura mater and brain Venous bleeding (simple hematoma may result in little to no damage to cerebellum while more complicated bleed can damage cortex)

Epidural or Subdural Hematoma Hematoma Type Epidural Subdural   Location Between the skull and the dura Between the dura and the arachnoid Involved vessel Bleeding Arteries Bridging veins Symptoms Lucid interval followed by unconsciousness Gradually increasing headache and confusion CT appearance Biconvex lens Crescent-shaped

Evaluation

Detailed clinical assessment outlined in SCAT3 and Child SCAT3 NOTE: Developed by SCAT3 Subcommittee (Meeuwisse, McCrory, Dvorak, Echemendia, Guskiewicz Iverson, Johnston, McCrea, Putukian, Raftery, Schneider)

Assessment of Head Injuries Observation (continued) Inability to focus attention and is the athlete easily distracted? Memory deficit? Does the athlete have normal cognitive function? Normal emotional response? How long was the athlete’s affect abnormal? Is there any swelling or bleeding from the scalp? Is there cerebrospinal fluid in the ear canal?

Assessment of Head Injuries Palpation Neck and skull for point tenderness and deformity Special Tests Neurologic exam Assess cerebral testing, cranial nerve testing, cerebellar testing, sensory and reflex testing Eye function Pupils equal round and reactive to light (PEARL) Dilated or irregular pupils Ability of pupils to accommodate to light variance Eye tracking - smooth or unstable (nystagmus, which may indicate cerebral involvement) Blurred vision

Assessment of Head Injuries Special Tests Balance Tests Romberg Test Assess static balance - determine individual’s ability to stand and remain motionless Tandem stance is ideal Coordination tests Finger to nose, heel-to-toe walking Inability to perform tests may indicate injury to the cerebellum

Assessment of Head Injuries Special Tests Cognitive Tests Used to establish impact of head trauma on cognitive function and to obtain objective measures to assess patient status and improvement On or off-field assessment Serial 7’s, months in reverse order, counting backwards Tests of recent memory (score of contest, breakfast game, 3 word recall) Neuropsychological Assessments Standardized Assessment of Concussion (SAC) provides immediate objective data concerning presence and severity of neurocognitive impairment

Assessment of Head Injuries Brain injuries occur as a result of: Direct blow, or sudden snapping of the head forward, backward, or rotating to the side May present as life-threatening injury or cervical injury (if unconscious) May or may not result in Loss of consciousness Disorientation or amnesia Motor coordination Balance deficits Cognitive deficits

Assessment of Head Injuries History Determine loss of consciousness and amnesia Additional questions (response will depend on level of consciousness) Do you know where you are and what happened? Can you remember who we played last week? (retrograde amnesia) Can you remember walking off the field (antegrade amnesia) Does your head hurt? Do you have pain in your neck? Can you move your hands and feet?

Assessment of Head Injuries Observation Is the athlete disoriented? Is there a blank or vacant stare? Can the athlete keep their eyes open? Is there slurred speech or incoherent speech? Are there delayed verbal and motor responses? Gross disturbances to coordination?

Management

Recovery Majority (80-90%) resolve in short (7-10 day) period May take longer in children and adolescents

Management CORNERSTONE = initial period of rest until acute symptoms resolve Physical Rest No training, playing, exercise, weights Beware of exertion with activities of daily living Cognitive Rest No television, extensive reading, video games? Caution re: daytime sleep

Management Expect gradual resolution within 7-10 days Gradual return to school and social activities that does not result in significant exacerbation of symptoms Proceed through step-wise return to sport / play (RTP) strategy

Graduated RTP Protocol Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage 1. No activity Symptom limited physical and cognitive rest. Recovery 2.Light aerobic exercise Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training. Increase HR 3.Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities. Add movement 4.Non-contact training drills Progression to more complex training drills e.g. passing drills in football and ice hockey. May start progressive resistance training Exercise, coordination, and cognitive load 5.Full contact practice Following medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff 6.Return to play Normal game play 24 hours per step (therefore about 1 week for full protocol) If recurrence of symptoms at any stage, return to previous asymptomatic level and resume after further 24 hr period of rest

Same day return to play? NO! Unanimously agreed that no RTP should occur on the day of concussive injury

Return to Play / Sport Must pass graded exertion first =remain asymptomatic Is the athlete confident to go back? New helmet/head gear? Other “protective” equipment / behaviors / factors? Consider implications of multiple/recent injury

“Difficult” or persistently symptomatic concussion patient Persistent symptoms (>10 days) in about 10-15% Important to consider other issues Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion In order to consider sub-symptom threshold exercise and other forms of therapy /rehabilitation

Psychological & Mental Health issues Psychological approaches may have application especially in selected situations (modifiers) Evaluate for affective symptoms (depression, anxiety) as common in all forms of traumatic brain injury Depression-may be consequence of concussion, underlying pathophysiological abnormality, may be multifactorial but should be considered in management

Management Pharmacotherapy Prolonged symptoms (sleep disturbance, anxiety) Modify underlying pathophysiology Upon return to play should not be on medication that could mask symptoms Antidepressants?