1. Concussion in Sports Sports Injury Management Session 4

2. “ He got his bell rung.” He got “ dinged”.

3. What is the big deal about concussions? A concussion is a functional injury to the brain. Silent epidemic Multiple injuries have cumulative effects Over 50% of concussions go unreported – – 1.6 – 3.8 TBIs reported account for 10% of sports injuries Athletes can / WILL hide symptoms YOU are the first line of defense!

4. How do I evaluate a concussion? 1- Primary Survey ABC’s to determine if life-threatening or limb-threatening 2- Secondary Survey Normal injury evaluations concentrating on neurological deficits RESULTS FROM ONE TEST SHOULD NOT SUPERSEDE ANOTHER! REMEMBER: No direct blow is necessary for a concussion. (whiplash, shaken baby syndrome)

5. A HELMET WILL NOT PREVENT A CONCUSSION! The following information is on a sticker on every helmet worn by high school football players in North Carolina. WARNING Do not strike an opponent with any part of this helmet or facemask. This is a violation of football rules and may cause you to suffer severe brain damage or neck injury including paralysis or death. Severe brain injury may occur accidentally while playing football. NO HELMET CAN PROTECT SUCH INJURIES. YOU USE THIS HELMET AT YOUR OWN RISK.

6. ASSESSMENT PROTOCOL History Observation Palpation AROM / PROM Strength Tests Stress Tests Functional Tests

7. HISTORY What happened? What were you doing when it occurred? What position were you playing when it occurred? SYMPTOMS: headache, blurred vision, tinnitus, numbness/weakness, nausea, photophobia, dizziness SYMPTOMOLOGY: asymptomatic or symptomatic – no longer “graded” LEVEL OF CONSCIOUSNESS: alert, lethargic, stuporous, semicomatose, comatose IF SEMICOMATOSE OR COMATOSE, CALL 911!

8. OBSERVATION Watch the athlete closely during the observation. - Aphasia: difficulty finding / saying the right words - Obvious deformities / abnormalities - Coordination - Pupillary signs: PEARRL, size, response to light, eye movement, tracking - Respirations - Overall demeanor

9. PALPATION PULSE: could / should be somewhat elevated, a decrease may indicate a brain bleed BLOOD PRESSURE: sideline check, need to know what is normal for that athlete PALPATE: for signs of trauma; painful areas, deformities, swelling, crepitus (especially in the C-spine area → C-spine fx?)

10. ROM and Strength AROM / PROM: neck and any other suspect area Strength: neck and any other suspect area Dermatomes / Myotomes: to check for nerve damage

11. Stress Tests 3 C’s - Cognition - Coordination - Cranial Nerves

12. Stress Tests: Cognition 3 word recall Serial 7s Recite months of year in reverse order Recite days of week in reverse order Mental status testing (more later) Neuropsychological testing (more later)

13. Cognition: Mental Status Testing Standard Assessment of Concussion (SAC) - Orientation - Immediate memory - Exertional maneuvers - Neurological screening - Concentration - Delayed recall - Total score is computed (Handout included at the end of this section.)

14. Cognition: Neuropsychological Testing Assess cognitive factors such as memory, concentration, impulse control, and reaction time Paper and Pencil Tests - GOOD: a lot of normative data exists - BAD: time consuming, inability to access reaction time Computerized NP tests - GOOD: trained administrators may not be needed, test multiple subjects at once, reaction time can be assessed - BAD: expensive (start-up costs, copyrighted program)

15. COORDINATION Heel to opposite knee Finger to nose Postural control Used to use Romberg test, no longer used, replaced with BESS

16. COORDINATION: Postural Control BALANCE ERROR SCORING SYSTEM (BESS) Dr. Kevin Guskiewicz - Clinical Test Battery 6 20 sec. trials Uses 3 different stances Uses 2 different surfaces All performed with eyes closed - Recorded errors * hands lifted off iliac crests * opening eyes * step, stumble, fall * moving into > 30° of hip flexion or abduction * remaining of test position for > 5 sec. Handout included at the end of this section.

17. CRANIAL NERVES II – Optic Nerve, III – Oculomotor, IV – Trochlear, VII – Facial II - Optic Nerve: visual acuity III - Oculomotor: pupil reaction IV - Trochlear: eye movement VII - Facial: smile, grimace

18. CRANIAL NERVES Upper Extremity Clearing Exam C1 & C2 – Neck Flexion C3 – Neck Side Flexion C4 – Shoulder Elevation C5 – Shoulder Abduction C6 – Elbow Flexion / Wrist Extension C7 – Elbow Extension / Wrist Flexion C8 – Thumb extension / Ulnar Deviation CUE: “Don’t let me move you.”

19. CRANIAL NERVES Lower Extremity Clearing Exam L2 – Hip flexion L3 – Knee Extension L4 – Ankle Dorsiflexion L5 – Toe Extension S1 – Ankle Plantar Flexion S1 – Ankle Eversion CUE: “Don’t let me move you.”

20. FUNCTIONAL TESTING Exertional tests performed to seek evidence of early post-concussion symptoms or an increase in symptomatic severity - Valsalva Maneuver: situps - Biking, jogging, or short sprints - Progress to sport specific activities

21. CONSIDERATION FOR RETURN TO PLAY New ruling by the North Carolina High School Athletic Association (NCHSAA) - High school and youth activities: NO RETURN TO PLAY SAME DAY NCHSAA Sports Medicine Advisory Committee A RTP (Return to Play) form is being designed – Must be signed by a PHYSICIAN licensed to practice medicine in NC before an athlete with a suspected concussion may return to practice or play

22. NCHSAA Concussion Return to Play Form

23. SERIAL EVALUATIONS TOI (time of injury): clinical evaluation and symptoms checklist 1-3 hrs. after injury: symptoms checklist 24 hrs. after injury: follow-up clinical evaluation and symptoms checklist RED FLAGS!!!!!!!! – s/sx that last > 7 – 10 days – Extensive LOC (loss of consciousness) – Deterioration over time – Personality changes (A subdural hematoma has a 7 – 10 day incubation period.)

24. SERIAL EVALUATION – con’t. Once the athlete is ASYMPTOMATIC – Where is athlete relative to baseline scores (provided you were able to do baseline scores) – When athlete returns to baseline on ALL SCORES Another 48 hrs. rest, then reassess If after 48 hrs. rest, performs to baseline or better, conduct exertional tests – If ASYMPTOMATIC for 24 hrs. after exertional tests, can RTP – If becomes SYMPTOMATIC within 24 hrs. after exertional tests, NO RTP until athlete returns to baseline, then reassess again

25. What is Second Impact Syndrome? Occurs when an athlete sustains a 2 nd head injury before the symptoms of the 1 st injury have resolved. (Cantu & Voy, 1995) It is thought to be a problem with auto- regulation of blood flow in the brain.

26. Is brief LOC an isolated marker of severity? LOC is not associated with total number of symptoms at follow-up or overall duration of symptoms. LOC is not predictive of NP deficits at follow-up. LOC is not associated with neuroimaging or electrophysiological abnormalities. (McCrory et al., 2000; Collins et al., 2003; Erlanger et al,. 2003; Guskiewicz et. al., 2007; Lovell et al., 1999; Guskiewicz et al., 2001; Johnston et al., 2001, Dupuis et al., 2003.)

27. Can amnesia be an isolated marker? Duration of PTA (post traumatic amnesia) was found to be correlated with the severity and outcome of severe TBI (traumatic brain injury). Earlier studies suggest that amnesia is NOT a prognostic marker following mild TBI. More recent studies suggest amnesia is predictive of symptoms and NP deficits following concussion in athletes. (Levin et al., 1979, 1982; Sciarra et al., 1984; Fisher et al., 1966; Gronwall et al., 1980; Yarnell et al., 1973; Maddocks et al., 1995; Guskiewicz et al., 2001; Lovell et al., 1999; Erlanger et al., 2003; Collins et al., 2003)

28. Do cumulative effects last? Depression (Guskiewicz 2007) Memory and concentration problems Delayed recovery following subsequent concussion Increased likelihood of sustaining additional concussions (Guskiewicz 2003) Hx of 1 concussion: 1.5 x more likely to sustain repeat concussion Hx of 2 concussions: 2.8 x more likely to sustain repeat concussion Hx of 3 concussions: 3.5 x more likely to sustain repeat concussion In North Carolina, 3 reported concussions = end of athletic career in contact sports.

29. Are there cumulative risks for children? Increased time for exposure. Developing brain Under-reporting

30. Managing Functional Academic Deficits NEUROLOGICAL DEFICITFUNCTIONAL SCHOOL PROBLEM MANAGEMENT STRATEGY Attention / ConcentrationShort focus on lecture, classwork, homework Shorter assignments, break down tasks, lighter work load “Working” MemoryHolding instructions in mind, reading comprehension, math calculations, writing Repetition, written instructions, use of calculator, short reading passages Memory Consolidation / Retrieval Retaining new information, accessing learned information when needed Smaller chunks to learning, recognition cues Processing SpeedKeep pace with work demand, process verbal information effectively Extended time, slow down verbal information, comprehension techniques FatigueDecreased arousal / activation to engage basic attention, working memory Rest breaks

31. COMPUTERIZED PROGRAMS AVAILABLE ANAM - Automated Neuropsychological Assessment Metrics Used with military subjects GOOD: very inexpensive, possibly no cost to schools BAD: no comparative data for < 18 y/o ImPACT – Immediate Post-concussion Assessment and Cognitive Testing GOOD: comparative data for males and females < 18 y/o BAD: may be cost prohibitive

32. REFERENCES NFHS Sports Medicine Handbook, 3 rd Ed. Kevin Guskiewicz, PhD., ATC; University of North Carolina; Evaluation of Concussion in Sport; NCATA 32 nd Annual Clinical Symposium & Business Meeting; March 6-8, 2009, Concord, NC. Spencer Elliott, MA, LAT, ATC; Carolinas Medical Center, Concord, NC; Tools of the Trade: Concussion Assessment; NCATA 32 nd Annual Clinical Symposium & Business Meeting; March 6-8, 2009; Concord, NC.