1. Evidence-Based Approach
Concussion in Sport
Evidence-Based Approach

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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

9. 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

10. 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?

11. 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

12. 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?

13. 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?

14. 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

15. 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

16. 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

17. 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

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

19. 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)

20. 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

21. 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.

22. 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!

23. 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