1. CONCUSSION AWARENESS AND MANAGEMENT Dr Kate Martin General and Trauma Surgeon Alfred Hospital, Melbourne. Monday 4 th August 2014.

2. Overview Definition: “What is concussion?” Incidence: “How common is concussion in AFL?” Effects of concussion: “Why is it important to identify concussion?” Diagnosis: “How do I recognise the signs and symptoms?” Red Flags: “When is urgent medical assessment required?” Management: AFL Guidelines 2013 Medical clearance Resources

3. What is Concussion? Traumatic Brain Injury – Mechanism Direct blow to the head or face Indirect force through acceleration/deceleration and shearing

4. What is Concussion? Traumatic Brain Injury - Classification Structural: skull fracture, bleeding around or within the brain May be mild through to severe May result in permanent dysfunction Concussion: disturbance in brain function without (identifiable) structural damage Nerve cells (neurones) are ‘stunned’ by forces applied through injury Effects are temporary

5. Incidence Concussion is common in Australian Football! 5-6 concussions per 1000 player hours = 6-7 injuries per team per season

6. Effects of Concussion Dysfunction of brain cells Effects depend on the area of the brain most affected, however tend to be very gener al.

7. Effects of Concussion – Headache – Blurred vision – Dizziness – Nausea – Poor balance – Fatigue – ‘Not feeling right’ – Confusion – Memory loss – Poor concentration – Loss of consciousness Most players with concussion have not lost consciousness

8. Identification is Important There are potential complications following concussion: Increased risk of subsequent injury including repeated concussion on return to play

9. Recognition and Diagnosis

10. The role of the trainer is to recognise that the player may be or is showing signs of concussion, and to initiate management. 3 important steps: 1.Recognising the injury 2.Removing the player from the game 3.Referral for assessment

11. Recognition and Diagnosis 1.Visible clues 2.Signs and symptoms 3.Memory function

12. Visible Clues Visible clues at time of injury: Loss of consciousness or responsiveness Motionless or slow to get up Unsteady on feet, falling over, poor coordination Dazed, blank or vacant look Confused, unsure of day, what is happening, which way team is kicking etc.

13. Visible Clues Visible clues at time of injury: Loss of consciousness or responsiveness Motionless or slow to get up Unsteady on feet, falling over, poor coordination Dazed, blank or vacant look Confused, unsure of day, what is happening, which way team is kicking etc.

14. Recognition and Diagnosis Early assessment is important: Get out to the player early- don’t wait for them to bring themselves off Obvious clues and symptoms may be early and transient

15. Recognition and Diagnosis Any player with suspected concussion must be removed from play First aid rules apply: A, B, C Apply a hard cervical collar and maintain spine precautions in players who have had a period of unconsciousness

16. Recognition and Diagnosis Any player with suspected concussion must be removed from play First aid rules apply: A, B, C Allow trainer time and space to complete assessment 1.Visible clues 2.Signs and symptoms 3.Memory function

17. Recognition and Diagnosis Any player with suspected concussion must be removed from play First aid rules apply: A, B, C Allow trainer time and space to complete assessment 1.Visible clues 2.Signs and symptoms 3.Memory function

18. Signs and Symptoms ‘Hard signs’ Confusion Drowsiness Loss of consciousness Seizure Dizziness Nausea or vomiting Balance problems Neck pain Blurred vision Amnesia

19. Signs and Symptoms ‘Subjective signs’ Headache ‘Pressure’ in head Irritability Nervous or anxious Sadness More emotional Feeling ‘slowed down’ Feeling ‘like in a fog’ Don’t feel right Difficulty remembering Difficulty concentrating Sensitivity to noise Sensitivity to light Fatigue or low energy

20. Memory Deficits Players usually expected to answer the following: “What day is it today?” “What is the month and year?” “Where are you?” Questions more relevant to the game: “What venue are we at today?” “Which half is it now?” “Who scored last in this game?” “What team did you play last week/game?” “Did your team win the last game?”

21. Memory Deficits Questions more relevant to junior players: “Where are we now?” “Which way are you kicking?” “What is your coaches' name?” “Is it before or after lunch?” “What school do you go to?”

22. Recognition and Diagnosis Sideline evaluation tool – Pocket Concussion Recognition Tool: Designed to help recognise concussion in all age groups Does not replace formal medical assessment and diagnosis

23. Recognition and Diagnosis Remember: The role of the trainer is to recognise or suspect concussion Formal diagnosis is made by a trained medical professional Any player with suspected concussion must not return to play in the same game “When in doubt, sit them out!”

24. Red Flags of Head Injury The following signs and symptoms require urgent medical assessment: Neck pain Weakness and/or tingling/burning in arms or legs Severe or increasing headache Increasing confusion or irritability Deteriorating conscious state Seizure or convulsion Repeated vomiting Unusual behavior change Double vision

25. Management: AFL Guidelines 2013 Game Day: Recognition of injury Removing the player from the game Referring for medical assessment Once concussion is suspected, the player should be assessed by medical doctor – Confirm concussion and exclude more serious structural injury – This should be the same day: venue, GP or hospital

26. Referral for Assessment Player must not drive Player should be accompanied Things you can do to help medical assessment: Provide as much information as possible – Document what symptoms and signs were or may have been present and how long they lasted – Provide your details for the doctor to contact you – Accompany player to assessment – Provide the player with a copy of SCAT-3 to take to their doctor

27. Medical Assessment Medical assessment includes: Taking of a history: – What happened and how? (mechanism) – What were the symptoms at the time? – How have the symptoms changed? Physical examination: – A, B, C and D (Disability) – Neurological assessment (sensory and motor function) – Cognitive assessment

28. Medical Assessment Medical assessment may also include: Specific investigations. Eg- imaging of the brain Involvement of other health specialists – Occupational therapists – Neuropsychologists – Neurologists – Paediatricians

29. Management of Return to Play General principles: Rest (mental and physical) until symptoms resolve Medical clearance prior to return to school or work, contact training and play. Return to activities in a graduated fashion Concussion rehabilitation should follow a step- wise symptom limited progression Children should not return to training or play until they have successfully returned to school

30. Concussion Rehabilitation Rest until symptoms recover Light aerobic activity- 24-48 hours after resolution of symptoms Light, no-contact training drills More complex non-contact training drills Full contact training- after medical clearance Return to competition 24 hours for each stage Drop back a stage if symptoms develop >10 days symptoms- medical review

31. Concussion Rehabilitation in Children Return to school program: Rest until symptom free Shorter school days Graduated return to full work load (assignments, tests, computers) Extra time to complete tasks Avoidance of noisy areas and activities Frequent breaks during class time, tests and homework Repetition and memory cues Use of peer helper or tutor

32. Concussion Rehabilitation in Children Return to play for children follows the same program as in adults Children should not return to training until they have successfully returned to school without a worsening of symptoms Medical clearance should be given prior to return to play

33. Summary Concussion is common in Australian Rules Football Important to recognise concussion in order to facilitate medical assessment Players must not return to play on same day Players must be medically cleared prior to recommencing contact training and play

34. Resources www.aflcommunityclub.com.au

35. References 2013. Davis, G et al. The Management of Concussion in Australian Football- with Specific Provision for Children 5-17 years. AFL Research Board; AFL Medical Officers’ Association. 2013. McCrory P et al. Consensus statement on concussion in sport: the 4 th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 47:250-258 2013. McCrory P et al. What is the evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and clinical outcomes? Br J Sports Med. 47:327-330 2014. Nordström A et al. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sports Med 0:1-4

36. Thank-you! ka.martin@alfred.org.au