1. Overview of Concussion Tim Kelliher M.D.

2. The Youth Concussion “Epidemic”
Between the number of ED visits for year olds for concussion tripled
40% of all concussions diagnosed in the ED occur in children/adolescents between ages 5-19.
Approximately 9% of all high school sports injuries are concussions (Bakhos2010) (Meehan 2010)

3. How Common is Concussion in Sports
The reporting of sports related concussions are on the rise
It is estmated that between 1.6 and 3.8 million sports-related concussions occur in the US each year.
300,000 of these are sustained by high school athletes
Girls sustain almost 2x as many concussions as boys participating in similar sports
The sports with the highest incidence rates (per 100,000 exposures) include:
Football - 60
Girl’s Soccer - 35
Boy’s Lacrosse - 30
Girl’s Lacrosse – 20
Boy’s Soccer -17
Wrestling – 17 Girl’s Basketball – 16 Softball – 11 Boy’s Basketball – 10 Field Hockey - 10
All Athletes Are At Risk

4. It’s the Law
In 2010 Massachussetts passed a law for safety regulations for scholastic athletes
Required annual training and education for coaches, AT, RN, athletic directors and parents
Mandatory reporting/record keeping of each concussion
Athletes suspected of concussion cannot return to play without written authorization from MD or neuropyschologist.
September 2013 law was expanded to require return to play decisions be made by a medical provider who has specific training in post-traumatic head injury assessment and management.

5. Concussion Defined
“A concussion is a type of traumatic brain injury or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth. This disturbance of brain function is typically associated with normal structural neuroimaging”
The Centers for Disease Control

6. Symptoms of a Concussion
Fall into four categories and may be subtle making it difficult to assess
Physical
Cognitive
Emotional
Sleep
Headache
Feeling “foggy”
Irritability
Drowsiness
Nausea
Difficulty concentrating
Sadness
Sleeping more than usual
Vomiting
Difficulty remembering
More emotional
Sleeping less than usual
Balance problems
Confused about recent events
Nervousness
Trouble falling asleep
Dizziness
Answers questions slowly
Visual problems
Appears dazed
Fatigue
Unable to multi-task
Light/noise sensitivity
When in doubt, sit them out

7. Recovery from Sports Related Concussion – how long does it take?
May be longer in younger athletes than what is widely reported
It’s the 20 percent who’s recovery is longer than 21 days that become difficult to treat
(Collins 2006, Neurosurgery)
80%
75%
50%

8. Physical and Cognitive Rest
Avoid activities that create symptoms until at least 24 hours of being symptom free
Physical Rest
No weight training
No cardiovascular conditioning
No sports/recreational activities
Get more rest than usual
Cognitive Rest
Avoid stimulating environments
Limit texting, screen time and Listening to music or reading
Limit playing video games
Academic accomodations may be needed

9. Concussion: Need For Imaging ?
Most Concussions DO NOT need to be imaged 1. Loss of consciousness >60 seconds 2. Evidence of skull fracture 3. Focal neurological deficit on exam 4. Seizure 5. Vomiting 6. Prolonged short term memory deficits

10. Concussion: Negative Outcomes
Post Concussion Syndrome (PCS)
Second Impact Syndrome (SIS)
Chronic Traumatic Encephalopathy (CTE)

11. Post Concussion Syndrome
“Miserable minority”
Up to percent of patients
No clear cut definition
When recovery from concussive deficits persists beyond the normal window of recovery and become chronic
Complex array of symptoms

12. Symptoms of Post Concussion Syndrome
Impaired attention, memory, and/or executive functions
Depression
Poor sleep
Dizziness
Chronic pain (headache)
Feeling frustrated or impatient, panic attack
Irritability, easily angered
Sensitivity to noise and light
Decreased alcohol tolerance
Blurred vision
(Alexander 1995;Savola 2003)
225,000 new persons each year show long term deficits as result of mTBI
(Meaney 2011)

13. Second Impact Syndrome
Seen rarely and only in young persons (≤ 23 yo)
Occurs when a second concussion (often minor) sustained when still symptomatic from an earlier concussion
Rare but catastrophic; between 1980 – high school athletes fatalities due to second-impact syndrome
The athlete may look dazed or stunned and then collapse due to the rapid onset of cerebral swelling
Brainstem failure can occur in as little as 2 to 5 minutes
This is a life threatening emergency. Call and follow the ABC’s of CPR
(Byard 2009, Cantu 1998, Cantu 2010, Thomas 2011, Weinstein 2013)

14. Chronic Traumatic Encephalopathy (CTE)
A progressive degenerative disease of the brain found in individuals with a history of repetive brain trauma
Recognized in boxers during the 1920’s – “dementia pugilstica” or punch drunk
Has been diagnosed post mortum in boxers, football, ice hockey and soccer players
Clinical deficits similar to Alzheimer’s and Parkinson’s Disease
Dementia Memory loss
Aggression Confusion
Depression Tremors
Suicidality Gait/balance deficits

15. Baseline Testing &
Education
On field Assessment
Medical Management
Physical Therapy
Return to Play
It’s a Team Approach
Collaboration with school system: Athletic department, ATC, RN
Baseline neurocognitive testing
Standardized “best practice” assessment tools
PCP and Neurologists trained in concussion management
Physical Therapists trained in concussion management
Agreed upon return to play guidelines

16. Baseline Testing - ImPACT Testing
ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) developed in early 1990’s at University of Pittsburgh
Leader in computerized neurocognitive assessment tools – used by professional, collegiate and high school sports teams in addition to the military and many clinical concussion programs.
Evaluates
Verbal memory
Visual memory
Processing speed
Reaction time

17. What it is…. What it isn’t…
ImPACT Testing
What it is….
What it isn’t…
One important piece of the concussion evaluation/management process
A tool that can help health care professionals track cognitive recovery
A tool to help communicate post- concussion status to athletes, coaches and parents
A tool to help health care professionals and educators make decisions about academic needs
A “panacea” or cure-all for concussion
A tool to diagnose concussion
A substitue for medical evaluation and treatment

18. Return to Play
Sypmtom free at rest and with cognitive exertion for at least 24 hours Post -injury ImPact test witin normal range of baseline Normal balance/vestibular examination Progressed through graded activity (Zurich Return to Play (RTP) protocol - stages 2-4) Evaluated by Concussion Specialist MD to make RTP decision - if failed RTP criteria - return to medical management Minimum of 5 days to return to play

19. Return to Play Protocol
Phase
Activities
Goals
Recovery
Symptom limited physical and cognitive rest
Light aerobic exercise
Walking, swimming, stationary bike at < 70% max HR
No weight training
Increase HR
Sport Specific exercise
Skating, running drills, 80% max HR
No head impact
Add movement
Non contact Sports drills
More complex drills such as passing. 90% max HR
May start weight training
Exercise, coordination and cognitive load
Full contact practice
Needs medical clearance by MD trained in concussion management
Restore confidence and assess functional abiliity
Return to competition
International Conference on Concussion in Sports Zurich 2012
Athletes need to be symptom free for 24 hours following activity to progress to next stage
A minimum of 5 days is needed to complete the RTP protocol