Concussion: Concepts, Controversy and Confusion New York State Association of Independent Schools John Cottone, EdD, ATC SUNY Cortland May 4,

2 Acknowledgement Thanks to Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation SUNY Upstate Medical University Director, CNY Sports Concussion Center NYSPHSAA Concussion Team & Safety Committee NYS TBI Coordinating Council Public Education Committee For his assistance and generosity in providing materials this presentation

Concussion Discussion What is a concussion ? How do I recognize a concussion when it occurs ? What is the recommended treatment for concussion ? What are the risks associated with an unrecognized concussion or with multiple concussions ? What are the current guidelines for return to sports, school, and other activities after concussion ? How can educators help a student who is recovering from a concussion ?

What is a concussion? Mild traumatic brain injury A disruption in normal brain function due to a blow or jolt to the head CT or MRI is almost always normal Invisible injury 4

Definition of Concussion Centers for Disease Control American Academy of Neurology American Congress of Rehabilitation Medicine

6 Outdated AAN Criteria for Sports-related Concussion Grade 1Transient Confusion Symptoms resolve in <15 minutes No LOC Grade 2Transient Confusion Symptoms last >15 minutes No LOC Grade 3 LOC:a) brief b) prolonged

Outdated Prague 2004 Guidelines Simple concussion LOC < 1 minute resolves in 7-10 days first concussion Complex concussion LOC > 1 minute symptoms last longer than 7 – 10 days history of multiple concussions increasing concussability

Zurich 2008 Guidelines No grading of injury Treat every concussion seriously Recovery may take longer in children and adolescents

Sports Concussion Football, hockey, and soccer are the riskiest male team sports Soccer and lacrosse are the riskiest female team sports In high school sports played by both sexes, girls have a higher rate of concussion Collegiate athletes have a higher rate of concussion than HS athletes Concussion represents a higher proportion of all injuries in HS athletes vs. collegiate

Concussion Management Advisory Team Athletic Trainer School MD School Nurse Athletic Director Coaches Teachers Parents (school community) Athletes 10

Concussion Management Advisory Team Policies and Procedures Development – CMAT Implementation – Athletic Directors provide oversight – Coordinate with other school officials 11

Guidelines for Coaches Prevention and Preparation Educate the school community Teach athletes about not playing hurt Prevent re-injury Prepare year round – Preseason – In Season – Postseason 12

Guidelines for Coaches Advocate and teach safety first Know when to remove athlete Ensure appropriate care Communicate – Athlete – Parent – Administrator RTP only after medical clearance k 13

Guidelines for Parents What is a concussion? Signs and symptoms Know to seek medical attention Know when to sit out Communicate to coach, medical staff 14

Guidelines for Athletes What is a concussion Prevention Know signs and symptoms Report to ATC, coach, parent Never play with S/S Tell the truth 15

Preseason Baseline Testing Guidelines intended for implementation by athletic trainer, athletic director, coaches Concussion History SAC or BESS testing Neuropsychological testing 16

Neuropsychological Testing In Sports Concussion Computerized tests that measure attention, memory, and reaction time Sensitive to effects of concussion Tests can be repeated multiple times to monitor recovery Ideally, pre-injury baseline testing done for all athletes ImPACT, CogSport, HeadMinder ImPACT Test

Creation of an Action Plan Recognition (knowing when to remove athlete from participation) Evaluation (appropriate medical attention) Communication Loop Return to Play (medical decision) – Establish protocol 18

First Aid Detect and Care Determine the need for and then activate the emergency action plan Perform emergency procedures they are qualified to perform (e.g.: CPR) Addition to Education Law 19

Sideline Evaluation Head trauma (blow or jolt) LOC or amnesia for the trauma Focal neurologic finding Signs & Symptoms (SCAT card) – confused, wobbly, emotional... Assess cognition – 3 word recall – Months backwards Standardized testing – SAC – BESS NO RETURN TO PLAY THAT DAY PubMed Central, Table 2: J Athl Train Jul–Sep; 36(3): 274–279. PubMed Central, Table 2: J Athl Train Jul–Sep; 36(3): 274–279.

Common Physical Problems Headache Dizziness and lightheadedness Clumsiness and poor balance Fatigue and lack of energy Sleep disturbance Blurred vision and light sensitivity Ringing in the ears

Common Cognitive Problems Feeling dazed or foggy or fuzzy Easily distracted and easily losing track of things Trouble doing more than one thing at a time Poor learning and memory Poor reading comprehension

When to Seek Medical Attention Any athlete who has had a concussion needs medical clearance before he or she is allowed to return to play NFHS | Concussion Rule Revised, Strengthened in High School Football NFHS | Concussion Rule Revised, Strengthened in High School Football Anyone with a loss of consciousness should be seen that day 23

When to Transport by EMS Anyone with an altered level of consciousness or focal exam should be transported with full spinal immobilization Anyone who has had a seizure Anyone with more than a brief LOC ( > 1 min) 24

Principles of Concussion Treatment No cure for concussion, but treatment can help the person feel better and function better while symptomatic Early diagnosis and education is critical Rest early (7-10 days?) and then gradually increase activity

26 Usually takes 1-2 weeks High school age youth take longer to recover Recovery may be complicated by non- injury variables Recovery from Concussion

Recovery From Sports Concussion How Long Does it Take on ImPACT? N=134 High School athletes WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 Collins et al., 2006, Neurosurgery

Post-Concussion Syndrome (PCS) Term used to describe complicated recovery from concussion Symptoms generally thought to have a neurological basis at first When symptoms persist, non-injury factors appear to play an increasingly significant role over time Controversial topic

Recovery from concussion Classic post-concussion presentation is fatigue and poor tolerance for exertion Symptoms are worsened by... – mental effort – environmental stimulation – emotional stress – physical activity 29

30 Multiple Concussions Second Impact Syndrome A second concussion within a week of first Rare but almost always fatal Increasing concussability Longer recovery Accumulating damage ? Problems can be subtle and hard to detect Possible lifelong symptoms and problems

31 Concussion Controversies Prague guidelines (or any guidelines) Soccer headgear Concussion mouth guards Concussion football helmets Computerized cognitive testing Baseline pre-season testing Causes of post-concussion syndrome Treatment of post-concussion syndrome

Concussion in the Classroom Fatigue - tires easily in class and over the course of the day Headache and other symptoms worsen with reading or concentration Trouble doing more than one thing at a time (e.g., listening to the teacher and taking notes) Frequent visits to the nurses office

Concussion in the Classroom Late or incomplete homework Easily overloaded and shuts down Takes longer to read and learn Bothered by bright light in the classroom or noise in the cafeteria Emotional outbursts Lack of motivation

Zurich Return to Play Guidelines Zurich 2008 guidelines for high school and younger athletes who show ANY symptoms or signs of a concussion: athlete should not return-to-play in the current game or practice Athlete should be monitored for deterioration for 24 hours return-to-play must follow a medically supervised stepwise process athlete must be symptom-free at rest and after exertion

Zurich Return to Play Progression 1.No activity, complete rest 2.Light aerobic exercise but no resistance training 3.Sport specific exercise and progressive addition of resistance training 4.Non-contact training drills 5.Full contact training and scrimmage after medical clearance 6.Game play Also should be symptom-free after mental exertion and have normal Neurocognitive test results

Medical Protocol Any athlete who suffers a concussion should undergo medical evaluation within 24 hours Anyone with LOC should be evaluated that day If confused or not fully conscious, transport by EMS with immobilization Follow athlete until asymptomatic First medical clearance is to begin RTP progression If no return of symptoms with exertion, then final clearance for game play

Managing Complex Concussion Consider referral to specialized provider or program if... History of multiple concussions or other risk factors Prolonged recovery (> 2 weeks) Worsening symptoms

NYSPHSAA Concussion Checklist First completed by coach or trainer on the sideline Follows athlete until cleared to RTP Reviewed by trainer and school medical director after doctor clearance Improves communication Enforces proper protocol

Guidelines for Return to School after Concussion Out of school at first if necessary, and then gradual re-entry as tolerated Avoid re-injury in sports, gym class and crowded hallways or stairwells Provide academic accommodations Communicate and Educate

Academic Accommodations Rest breaks during school in a quiet location (not always the nurses office) Reduced course and work load Decrease homework Avoid over-stimulation, (e.g., cafeteria or noisy hallways) Extra time and a quiet location for tests

P.E. Accommodations Avoid re-injury Balance, vision, and reaction time may all be affected by concussion Avoid physical and mental over-exertion Increased HR or BP may increase symptoms Lights and noise in gym or at a sporting event will aggravate symptoms Minimize exertion in first 1-2 weeks Increase activity gradually, as tolerated Dont substitute mental activity for physical activity !

Summary CDC now recognizes concussion as a significant public health issue Proper recognition and management of concussion can prevent serious problems Avoid risky activities and sports until symptom free, at rest and with exertion Provide reassurance, support, and academic accommodations as needed Concussion is more than just a bump on the head !