Evidence-Based Approach Concussion in Sport Evidence-Based Approach

What is a concussion A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces; alteration in the mental status that may or may not involve loss of consciousness

Brain Function by Area Cerebrum Cerebellum Motor function Sensory information (touch, pain, pressure, temperature) Special senses (vision, hearing, smell, taste) Cognition Memory Cerebellum Balance and coordination Smooth, synergistic muscle control

Brain Function by Area Diencephalon Brain Stem Routing of afferent information to the appropriate cerebral areas Body temperature regulation Maintenance of the necessary water balance Emotional control (anger and fear) Brain Stem Heart rate regulation Respiratory rate regulation Control over the amount of peripheral blood flow

Mechanisms of injury Direct blow to head, face, neck or else where on the body with an ‘impulsive force’ transmitted to the head Typically results in rapid onset of short-lived impairment of neurologic function that resolved spontaneously Most commonly seen as a direct blow to the head The brain moves, what moves?

MOI Coup A coup injury results when a relatively stationary skull is hit by an object traveling at a high velocity (struck in the head with a baseball). This type of mechanism results in trauma on the side of the head that was struck

MOI Contrecoup A contrecoup injury occurs when the skull is moving at a relatively high velocity and is suddenly stopped, such as when falling and striking the head on the floor (football hit) The fluid within the skull fails to decrease the brain’s momentum proportional to the skull, causing the brain to strike the skull on the side opposite the impact. Forces are also transmitted to the spinal column

Symptoms Headache Pressure in the head Neck Pain Balance problem Dizziness Nausea or vomiting Visual Problems photophobic Hearing problems Ringing in the ears Feeling dazed or dinged Confusion Feeling slowed down Feeling like in a fog Drowsiness Fatigue or low energy Emotional Irritability Difficulty concentrating

Retrograde Amnesia The athlete has difficulty remembering or cannot remember evens occurring before the injury What happened? What play did you get hurt on? Where are you? Who am I? Who are we playing? Who did we play last week? What did you eat today?

Anterograde Amnesia Athlete has difficulty remembering or cannot remember immediate recall (memorization) Usually give a list of 3-5 unrelated items Why not related items? List such as Hubcap Film Dog Ivy The list is immediately recalled by the athlete and then about every 5 minutes after

Amnesia Why is amnesia important? Retrograde amnesia that lasts for days is usually significant for a severe concussion They can’t remember events from the previous day before the injury is usually more a red flag than that day of injury Anterograde amnesia can result in intracranial bleeding This is a medical emergency Do we see this often?

On the field assessment Watch the field- if you see the hit you’ll better understand how to treat it Athlete’s position Decerebrate position- extension of extremities and retraction of head (lesion of brain stem) Decorticate posture- flexion of elbows and wrists, clenched fists and extension of lower extremity (lesion above brain stem) Check level of consciousness How do we do this? How to proceed if they are conscious? How to proceed if they are unconscious?

Conscious Athlete An offensive lineman is practicing and takes a hit to the left temple, he is stumbling around and you hold him to ask him questions. You suspect he could be concussed… how do you proceed? History What happened, do you remember how it happened? Did you black out? What else…. Inspection Position of head, bony structures Eyes- look for nystagmus, pupil size while taking the history Palpation As warranted

Conscious Athlete Usually perform a SCAT card on them Sport Concussion Assessment Tool Signs, Memory(Modified maddocks questions), Cognitive assessment (recall), neurological screening We do all this Athlete then fills out the back of the card Symptom score Determine practice status (almost always they are held) Watched on the sidelines (hide helmet and pads, etc) Have someone near them asking them questions Re-evaluation inside

Tests These tests can be performed on the field or in the clinic Romberg Test BESS Test Cranial nerve assessment Neurocognitive testing ImPact Every athlete takes a baseline freshmen and junior year (or when they transfer in) Retake test usually when symptom free

Home Directions If they are bad enough to go to the ER how to transport? Drive or ambulance NATA statement They have a sheet for directions at home Fill it out, give it to them Wake up during the night or no? I’ve had multiple physicians wake them up and multiple not

Grading Scales American Academy of Neurology ACSM guidelines Cantu Concussion Rating Guidelines Colorado Medical Society Concussion Guidelines Prague Group

American Academy of Neurology Grade 1 No LOC, transient confusion, sx resolve in less than 15 min Grade 2 No LOC, transient confusion, symptoms or mental status abnormalities resolve in more than 15 minutes (could take days upon days) Grade 3 Any LOC either brief (seconds) or prolonged (minutes)

Prague Group Severity not determined until after symptoms resolve Simple Injury resolves over 7-10 days Complex Persistent symptoms, specific, prolonged cognitive impairment Finding its not specific enough

Gradual RTP Refer to Document No activity Light aerobic exercise Sport-specific exercise Non-contact training drills Full-contact practice Return to play If at any point the athlete experiences symptoms, they must wait 24 hrs then start back at level 2.

Return to Play Final RTP is up to the physician But also up to the athletic trainer YOU are with the athlete all the time, if you don’t feel comfortable letting them play, don’t!

Postconcussion syndrome Cognitive impairments for sometime after the injury Actually very common Usually last at least 3 months post injury Can last years Pro football players have had to retired due to this Second impact syndrome Rare but possible Increased risk for concussion when they have already sustained a concussion during the game Many athletes dying from this now