CONCUSSION MANAGEMENT DAN MUSE, MD

CONCUSSION MANAGEMENT THE OBJECT OF CONCUSSION MANAGEMENT IS TO RETURN THE ATHLETE TO HIS/HER NORMAL COGNITIVE LEVEL.

WHAT IS A CONCUSSION? “Sports concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”. British Sports Med 2005;39:196—204. doi: /bjsm VIENNA CONFERENCE OR

WHAT IS A CONCUSSION? A Mild Traumatic Brain Injury A change in brain function that occurs when there is a direct blow to the head or impact to the body that causes the brain to shake violently This impact results in chemical changes in the brain Radiographic imaging is normal

WHAT ARE THE SYMPTOMS?

Concussions result in cognitive, physical, emotional and sleep complaints. What is addressed depends on the symptoms. Symptoms have the potential of exacerbating each other i.e. fragmented sleep may result in worsening headaches and decreased ability to concentrate.

WHAT ARE THE SYMPTOMS?

WHAT SYMPTOMS ARE OBSERVED?

TBI SIGNS AND SYMPTOMS Signs observed by the parent coach or trainer Signs reported by athlete Appears to be dazed or stunned Is confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness (even temporarily) Shows behavior or personality change Forgets events prior to hit (retrograde amnesia) Forgets events after hit (anterograde amnesia) Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling "foggy" Change in sleep pattern Concentration or memory

DANGER SIGNS OF A TBI Headache that gets worse and does not go away. Weakness, numbness or decreased coordination. Repeated vomiting or nausea. Slurred speech. You should be taken to an emergency department right away if you: Look very drowsy or cannot be awakened. Have one pupil (the black part in the middle of the eye) larger than the other. Have convulsions or seizures. Cannot recognize people or places. Are getting more and more confused, restless, or agitated. Have unusual behavior. Lose consciousness (a brief loss of consciousness should be taken seriously and the person should be carefully monitored).

COACHES/TRAINER/EMT ROLE WHEN AN ATHLETE HAS A CONCUSSION

IF YOU SUSPECT A HEAD INJURY AT A PRACTICE OR GAME..... Remove the athlete from play. Look for signs and symptoms of a concussion if your athlete has experienced a significant bump or blow to the head or body. When in doubt, keep the athlete out.

IF YOU SUSPECT A HEAD INJURY AT A PRACTICE OR GAME..... Inform the athlete’s parents or guardians about the possible concussion. Explain to the parents what occurred and what you observed. Suggest to the parents that the athlete is evaluated by a health care professional.

COACHES ROLE WHEN AN ATHLETE HAS A CONCUSSION Relaying to the parents, emt’s or doctor directly the following information can help in the assessment of the patient: 1. How did the contact occur and how much force was involved. 2. Was it a direct blow to the head or body or both. 3. Any loss of consciousness (passed out/knocked out) and if so, for how long 4. Any memory loss immediately following the injury 5. Any seizures immediately following the injury

18 MY PLAYER HAS A CONCUSSION. WHAT DO I DO WITH HIM NOW? 18

19 There is not much you can do.... Concussions get better by resting the brain and preventing further injuries. Until the concussion is healed, sports are out of the question. Continuing to play games and practicing can result in a delay in healing, a second concussion or even other injuries. 19

A repeat concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death. (Second Impact Syndrome)

21 HOW DO YOU “REST” A BRAIN? Everything we do causes activity on the brain. We want to minimize the activity to the essentials such as school work Structured days with normal sleep/wake patterns assist in the healing. Avoid high concentration activities like video games. Use common sense.....if something precipitates or exacerbates the symptoms, stop doing them and rest. 21

22 KEEP THE PLAYER INVOLVED IF POSSIBLE If the player is interested Let him/her be a team manager. Have the player on the bench during the games. “Consult” the player on what he/she thinks about certain drills, line combinations etc. 22

23 DON’T LET THE PLAYER ON THE ICE UNTIL MEDICALLY CLEARED. YOU DON’T WANT TO RISK A SECOND INJURY. 23

CONCUSSION BIAS

FACES OF HOCKEY PLAYERS

FACES OF CONCUSSED HOCKEY PLAYERS

CONCUSSION BIAS Concussions are hidden injuries that we can’t see. They lack validation such as stitches or a cast. There is no imaging such as an xray that shows the concussion.

CONCUSSION BIAS Culturally our generation has grown up believing that a concussion is just getting “your bell rung” It was a badge of honor to puke on the sidelines and then get back in there and play. If you didn’t, you were a and you let the team down.

CONCUSSION BIAS Because concussions are hidden injuries there is pressure to down play the significance by: The player The family The coach Friends…….

CONCUSSION BIAS We can’t trust a concussed athlete to diagnose their own injury Athletes are notorious for hiding symptoms Studies suggest that up to 50% of athletes experience concussion symptoms per year but only 10 percent report Most SIS (SECOND IMPACT SYNDROME) cases are known to have played with symptoms

31 RETURNING TO PLAY AFTER A CONCUSSION 31

32 RETURN TO PLAY Don’t rush the player back. Gradually increase the activities the player does in practice. If a player strained his/her hamstring, you would not have them sprinting the first day back. 32

33 RETURN TO PLAY BE AWARE THAT THE PLAYER MAY NOT HAVE FULLY RECOVERED FROM THE CONCUSSION. PHYSICAL ACTIVITY CAN EXACERBATE CONCUSSIVE SYMPTOMS. 33

RETURN TO PLAY ALWAYS KEEP IN MIND THAT PLAYERS (AND SOMETIMES PARENTS) ARE NOT FORTHRIGHT WITH INFORMATION AND MAY NOT RELAY THAT INFORMATION TO THE DOCTOR THE HEALING CAN CONTINUE AFTER THE SYMPTOMS RESOLVE. UNFORTUNATELY, THE DOCTOR MAY NOT BE UP TO DATE ON CONCUSSION MANAGEMENT.

IT’S YOUR TEAM. AS COACH YOU HAVE THE FINAL SAY AS TO WHO PLAYS... Believe your eyes. If the athlete appear to still have a concussion or if the athlete begins to complain of symptoms consistent with a concussion after returning, remove the player from the game or practice and do not allow the player to participate until reevaluated by a healthcare professional.

NEUROCOGNITIVE TESTING

TESTS THAT EVALUATE DIFFERENT PARTS OF THE BRAIN SUCH AS MEMORY VISUAL SPEED REACTION TIME RETENTION OF INFORMATION

ImPACT ImPACT: Immediate Post-Concussion Assessment and Cognitive Testing ImPACT was developed to provide a scientific way of evaluating readiness to return to play following concussion

ImPACT: Design and Structure Designed to evaluate multiple aspects of cognitive functioning in brief time period Subtests measures multiple cognitive processes Verbal and Visual Memory Cognitive Speed Interaction of Memory and Speed (Cognitive Efficiency)© Self-report of symptoms

What ImPACT Is and Isn’t: IS a useful and reliable/valid concussion management program. IS a tool to help determine recovery from injury. IS a tool to help manage concussion-(e.g. return to exertion, return to academics, return to play). IS a tool to help communicate post-concussion status to coaches, parents, clinicians. IS NOT a substitute for medical evaluation/treatment

ImPACT TEST It is our “CAT Scan” It is another tool to assure the symptoms not only have resolved, but that the brain has healed. It is a lie detector test for those who may not be honest about the extent of the symptoms.

CONCUSSION MANAGEMENT COMPONENTS EDUCATION TRAINING IN CONCUSSION CONCUSSION POLICY MEDICAL EVALUATION

CONCUSSION MANAGEMENT EDUCATION WHO SHOULD BE EDUCATED ON CONCUSSIONS? PLAYERS COACHES TRAINERS FAMILY MEMBERS SUPPORT STAFF INVOLVED WITH THE PLAYERS INCLUDING REFEREES AND GAME EMT’S

CONCUSSION MANAGEMENT EDUCATION WHAT SHOULD BE COVERED? CONCUSSION AWARENESS AND PREVENTION SIGNS AND SYMPTOMS OF A CONCUSSION WHAT TO EXPECT IF A PLAYER GETS A CONCUSSION HEALTH RISKS OF RETURNING TO SOON LONGTERM COMPLICATION OF MULTIPLE CONCUSSIONS

CONCUSSION RESOURCES ON LINE COURSES FOR COACHES 1. National Federation of High School Coaches on line course: ?courseID= ?courseID= CDC on line course for coaches:

CONCUSSION RESOURCES WEBSITES ON CONCUSSION ml ml

SPORTSMART DAN MUSE, MD KEN LAWSON, MD CONCUSSION MANAGEMENT CERTIFIED IMPACT CONSULTANTS (508)

GAME HEALTH PROFESSIONALS BASELINE ImPACT TESTING FOR TEAM AND PROGRAMS AT THE PROGRAM SITE. CONCUSSION MANAGEMENT CPR AND AED FIRST AID TRAINING SPORTS INJURY MANAGEMENT

GAME HEALTH PROFESSIONALS DAN MUSE, MD (781)