1. Definitions A concussion is defined as a “traumatically induced alteration in mental status.” Amnesia - loss of memory - times vary.

2. The Head The head is not as forgiving as an arm, leg etc. The brain does not like changes in blood flow or pH levels. The brain has a different blood flow than the rest of the body.

3. Concussions This is the most common “brain” injury in sport. Ranges from a minor “ding” with short periods of symptoms, to a prolonged loss of consciousness with persistent cognitive effects.

4. Concussions Memory Loss Can be associated with amnesia which may occur immediately or develop several minutes later. There are two kinds of amnesia:

5. Concussions 1. Retrograde Amnesia - loss of memory for events that occurred before injury (breakfast, score, team playing, etc).

6. Concussions 2. Anterograde Amnesia - is defined as a loss of memory for events that occurred after the injury.

7. Concussions - Problem??? With this possibility of “delayed development of symptoms”… This greatly increases the need for careful evaluation and observation before the athlete is allowed to play.

8. Concussions Causes of Concussions: Direct blow to the head Landing on your butt!! Whiplash mechanism.

9. Concussions Contracoup Injury This is a type of movement of the brain inside the skull… When you get hit in the front of the head, the brain shifts (backwards) and pain will be felt at the back of the head (opposite side of injury).

10. Concussions Observed Features of Concussions: Headache Vacant stare Confusion Tinitis (ringing in ears) Nausea/vomitting Blurred vision Dizziness

11. Concussions Other more serious symptoms: Altered Consciousness Memory deficits Lack of coordination/balance Disorientation Emotions Pupil size***Eyes are poor indicator of concussion on sport field

12. Classification of Concussions: GRADE 1 Transient confusion (inattention inability to maintain a coherent stream of thought and carry out goal directed movements. No loss of consciousness Concussion symptoms or mental status abnormalities resolve in less than 15 min. GRADE 2 Transient confusion Amnesia possible No loss of consciousness Concussion symptoms or mental status abnormalities (including amnesia) upon examination last more than 15 min. GRADE 3 Any loss of consciousness, it can be brief (seconds) or prolonged (minutes).

13. Concussions Grade 1 Concussion: Remove from contest Player should be re- evaluated every 5 minutes for at least 15 minutes for signs of amnesia and other mental status changes. Management Recommendations:

14. Concussions Grade 2 Concussion With grade 2 injury, the athlete should be removed from play for the remainder of event (day). Continue to assess any inter-crainial* pathology. *inter-crainial - inside the head (brain). Management Recommendations:

15. Concussions Grade 2 cont.d A trained person should evaluate the person next day. A physician should perform a neurologic examination to clear the athlete after 1 full asymptomatic week.

16. Concussion Grade 3 Concussion As with any loss of consciousness, the athlete should be transferred to an Emergency Department (hospital) for further observation by a doctor. Management Recommendations:

17. Concussions Grade 3 cont.d A thorough neurologic assessment is indicated. (CT scan, MRI) Keep casualty in the hospital if any pathology is indicated

18. Return to play Grade of ConcussionReturn to play only after asymptomatic time. Grade 1 15 minutes or less Multiple grade 11 week Grade 2 1 week Multiple grade 2 2 weeks Grade 3, brief LOC1 week Grade 3 prolonged LOC 2 weeks Multiple grade 3 1 month or longer, based on decision of evaluating physician, usually season terminator

19. Concussions Sideline Evaluation These are some of the tests that you can do with an athlete on the sidelines (grade 1) or later on (grade 2,3): Mental Status Testing Orientation – to time, place, injury Concentration – digits backward, numbers etc. Memory – details of contest, names of teams, recall 3 of 3 words, objects at 5 min. intervals

20. Concussion Exertional Tests 40 m sprint 5 push ups 5 sit ups 5 burpies Neurologic tests Strength Coordination Sensations Balance Check associated symptoms – headaches, dizziness, blurred vision, nausea, concentration, photophobia (sunlight) Sideline Evaluation cont.d

21. Concussions Second Impact Syndrome This condition occurs when the athlete returns to play to fast. Another concussion is suffered before the symptoms of the first are resolved. Loss of conciousness is not required.

22. Concussions SIS The hit does not need to be as hard or traumatic as the first. After suffering a second hit, the player may seem fine, but within seconds or minutes SIS may occur.

23. Concussions SIS Previously observed features, but after SIS we may be looking at an extremely debilitating or life a threatening head injury.

24. Concussions Apart from SIS, this is another syndrome we need to be aware of. As each person is different, the brain will react different to a concussion differently Post Concussion Syndrome

25. Concussions PCS The following may occasionally persist after concussions: Gait and Balance abnormality Exertional headache: When they do any physical activity they get a headache

26. Concussions PCS Emotional Lability Altered emotions, crying/agitation Sleep disturbances Neurotransmitters in the brain are not functioning correctly Cognitive impairment Reflexes, coordiation

27. Concussions PCS Athletes with these symptoms are not ready to return to sport. See next slide for return to play for these athletes:

28. Concussions Return to Play – Post Concussion Step 1 – no activity, complete rest, once asymptomatic proceed to step 2 Step 2 – Light aerobic exercise (walking, stationary biking) if asymptomatic proceed to step three, if not go back to 1 Step 3 – Sport specific training. Once asymptomatic proceed to step four, if not go back to 2

29. Concussions Return to play – Post concussion Step 4 – Non-contact drills, once asymptomatic proceed to step five, if not go back to 3 Step 5 – Full contact after medical clearance. Once asymptomatic proceed to step six, if not go back to 4 Step 6 – GAME PLAY!!!

30. Concussions Some Sports attempting to decrease Concussions. 2. Football: Equipment: Mandatory mouthguards Helmets safety checked each season Padding on all goal posts.

31. Concussions Football Cont. Rule Changes No spearing (tackling with head) No face masking No late hits Free catch Rules to protect quarterback and kicker

32. Concussions 2. Hockey Equipment Mandatory helmets Mouthgaurds – highly recommended Breakaway goal posts Padding around benches, glass Absorbing boards

33. Concussions Hockey cont.d No hitting from behind Rules to deter fighting No high sticking Goalie protection Longer suspensions

34. Concussions 3. Rugby Equipment: not too much here!!! Mandatory mouth guards Scrum caps are recommended Padding around goal posts No hard equipment

35. Concussions Rugby cont.d Rules: No high tackles No late hits No stomping Mark catches No blocking Wrap person when tackling