By Jon Basile, Courtney Churchill, Josh Leigh, & Cody Small

The Ins and Outs of Sports Related Concussions in Middle/High School

Athletes

Test Your Concussion KnowledgeTrue or False:

1. A concussion generally isn’t considered severe unless the athlete loses consciousness or “blacks out.”

2. Properly fitting helmets and mouthguards prevent concussions in children.3. Adolescent boys are more likely than adolescent girls to sustain a concussion.4. A sideline assessment test, in which a coach or athletic trainer asks the injured

athlete a series of questions immediately following injury, can help determine the severity of a concussion.

5. If a child no longer has any symptoms 24 hours after sustaining a mild concussion, it’s safe for him or her to return to play.

6. The best way to diagnose a concussion is with a CT scan or MRI.

7. Most emergency room physicians are well trained in the management and treatment of sports concussions.

8. It’s possible for children to experience headaches and difficulty concentrating in class for weeks after a hard hit or a rough tackle.

9. The “three strikes and you're out” rule, suggests that children who have three concussions should no longer be allowed to participate in school-sponsored athletics.

10. There are cases where kids diagnosed with attention deficit hyperactivity disorder (ADHD) or other learning disabilities who could actually be suffering from undiagnosed post-concussion syndrome.

Moser, 2012

Why is this important?"If she had been given the information from a younger age all the way along, I know that she would have made a different choice," Stringer’s mother, Kathleen.

Rowan Stringer was just 17 when she died on May 12, 2013.

She had been tackled hard during a rugby game four days before, hitting her head and neck on the ground.

A friend of Rowan’s reported that she said she had a headache, was tired and had bags under eyes, yet never told her parents or an adult.

She texted her friend, “nothing would stop me unless I’m dead” she decided to play despite the undiagnosed concussion symptoms

Stringer died from Second Impact Syndrome, where a pre-existing injury followed by another head blow can cause death.

http://www.cbc.ca/news/canada/ottawa/rowan-stringer-ignored-concussion-symptoms-days-before-death-1.3077245

ObjectivesAfter this presentation the audience should understand the following:

● What a concussion is● What causes a concussion● Symptoms of a concussion● The risk of having multiple concussions● Lasting side effects of a concussion● Management to optimize healing● Return to play protocol

Concussions in Youth SportsYoung athletes brains are still developing and may be more susceptible to the effects of a concussion (Halstead & Walter, 2010).

● We must understand the Youth are not indestructible● A concussion is a form of Mild Traumatic Brain injury (mTBI)● Club sports are just as at risk as varsity leagues!

Reported concussions account for nearly 8.9% of all high school injuries

● Girls have a higher chance of concussion than boys○ Possibly due to weaker neck musculature and/or hormonal factors

● Highest risk exists in Girls Soccer, Basketball, Rugby, Lacrosse, and Ice Hockey● Boys have increased risk in Football, Basketball, Soccer, Lacrosse, and Hockey● It is important to remember a concussion can happen in any sport

http://www.cbc.ca/news/health/soccer-concussions-more-likely-from-contact-with-foe-than-ball-study-finds-1.3149686

Middle school prevalence is hard to assess due to lack of identification and reporting at young ages

What is/causes of a Concussion?Concussion can be caused by a direct (Coup) or indirect (Contre-coup) blow to the head, face, neck or torso.

Results in the rapid onset of short-lived impairment of neurologic function that can resolve spontaneously, however long term disturbance may persist.

A concussion can still be present even without a Loss of Consciousness (LOC)

● LOC only happens less than 10% of the time!

Concussion is not detectable on imaging such as MRI or CAT-scan.

3 Grades (Post-concussion symptoms may apply to all grades)

1. Confusion and Symptoms last less than 15 minutes2. Symptoms last more than 15 minutes still no LOC3. LOC for seconds or minutes, symptoms >15mins

https://kin450-neurophysiology.wikispaces.com/file/view/Cerebral_concussion.jpg/189385993/Cerebral_concussion.jpg

Common Signs and Symptom of Concussion1. Total Body Symptoms (Somatic)● Headache, Dizziness, ● Balance problems● Nausea/Vomiting ● Visual Disturbances● Sensitivity to sound

2. Mind/Brain Symptoms (Cognitive)

● Confusion● Forgetting what happened

before and after● Passing out● Not knowing where you are● Feeling “Foggy”, Glossy stare● Inability to focus● Delayed responses ● Slurred Speech● Trouble Falling Asleep● Sleeping more or less than

usual

http://www.bigteams.com/newssite/dt.common.streams.StreamServer1.jpg

3. Mood/Emotional Symptoms (Affective)

● Changing or excessive emotions● Irritability● Fatigue● Anxiety● Sadness

Concussion Symptom Checklist CDC, (2015)

Second Impact Syndrome ● Athlete suffers a head injury, returns to play too soon, and suffers another head

injury before the 1st has healed fully● Research shows this is prevalent in 40.5% of cases ● Results in rapid, catastrophic increase of pressure in the brain● How can this happen?

○ Student fails to report symptoms○ 1st head injury often overlooked or not thought to be serious ○ Student does receive medical attention after 1st injury

Post-Concussion Syndrome● Headaches● Seizures (Epilepsy)● Sleep disturbances (too much/too little)● Mood changes (irritability)● Light/Noise Sensitivity ● Cognitive Deficits● Physical Paralysis/Motor deficits ● Diminished concentration ● Attention Deficit Hyperactivity Disorder● Anxiety or Depression Disorders

What if my child hit his/her head and didn’t tell me?

Children do not always realize the importance to tell someone they hit their head or purposely don’t tell anyone to continue to play.

If your child tells you about an injury that happened earlier, watch for obvious and more subtle changes in your child’s thinking skills, physical functioning, and emotional or behavioral responses. For example, look for changes in the way he or she plays, or whether unsteady walking, etc.

Try Asking These Questions:1) Did you bump your head recently? If so, how hard? 2) Did something hit your head? 3) Have you had any balance problems or have you felt like you might fall when

you walk, run or stand?4) Have bright lights bothered you more than usual (sunlight, TV, or lights)? 5) Have loud noises bothered you more than usual?6) Have things looked blurry?7) Did anyone else see it happen? (Speak to them)8) Do you feel like “something is just not right”?

http://www.cstsonline.org/assets/media/documents/ParentsGuide_Concussion.pdf

Managing Your Child’s Concussion At Home ● Reduce and monitor exacerbations of your child’s symptoms● Ensure rest

○ Cognitive Rest■ Avoid electronic devices

○ Physical Rest■ Physical activity can prolong recovery ■ Sports and leisure related activities

● Promote independence ● Allow visits with friends with limits● Parenting strategies● Be aware of the signs and symptoms of you child’s concussion!

Managing Your Child’s Concussion at School ● Cognitive Rest is Key! ● School Accommodations:

○ Temporary leave of absence from school○ Shortening of the athletes school day○ Reduction of workloads in school○ Allowance of more time for homework assignments○ Avoid standardize tests as they are not true assessments of your child’s

knowledge○ Reintegration into school should occur with no production of symptoms ○ Don’t be afraid to communicate with your school’s teachers, nurses, and

administrators!○ Sometimes teachers can underestimate the symptoms of a concussion as

they are more mental rather than physical

Concussion Assessments

Baseline Assessment On the FieldSport Concussion Assessment Tool (SCAT)

● On field assessment given by a Trained Athletic Trainer (ATC), Coach, or Medical provider to detect possible concussion signs and symptoms.

● Used in both high school and professional sport to assess possible symptoms concussions.

● Includes:○ Glasgow Coma Scale○ Neuro Assessment○ Maddocks score○ Symptom Checklist○ Memory Tests○ Neck Examination○ Balance○ Coordination○ Delayed Recall

Return to Play: School StandardsIMPACT(Immediate Post-Concussion Assessment and Cognitive testing)

Baseline Assessment Individualized to each student● Computerized tests that allows for storage of results for future testing● Measurement taken at beginning of season, post test score taken after

injury is compared to the normative value● Test is designed to look at cognitive function:

○ Concentration○ Information processing○ Visual Memory○ Reaction time

How Does Physical Therapy Relate?● Referral occurs with symptoms lasting longer than 7-10 days● Performs a full body assessment to determine your child’s level of impairment● Prescribe exercises that focus on:

○ Increasing tolerance to activity and returning to play○ Balance○ Strength○ Vestibular Function

● Provide a safe environment for you child to exercise ● Are able to determine when your child is ready to return to play● Can advocate for your child’s health

Return to Play Protocol: Physical Therapy● Step-wise approach that determines when your child is ready to return to sports

related activities● Return to play guidelines include 6 different steps and can be completed either

by your school’s athletic trainers or a licensed physical therapists● Your child must present with no symptoms for one full day before they are

allowed to go onto the next step● IF your child does becomes symptomatic they return to the last asymptomatic

phase● When in doubt, sit them out!

Return to Play Protocol Continued…. Rehab Stage Functional Exercise Objectives

1. No Activity for 2 Days Symptom limited physical and cognitive rest

Recovery

2. Light Aerobic Exercise Walking, swimming,

stationary cycling, intensity

<70% max HR. No resistance

training

Increase

3. Sports Specific Exercise Skating drills in hockey,

running in soccer. No head

impact activities. (Borg 11-

14)

Add movement

Return to Play Protocol Continued….

Rehab Stage Functional Exercise Objectives

4. Non-contact training Drills Progression to more complex

training drills (passing drills

in football and hockey) May

begin progressive resistance

training

Exercise, coordination,

cognitive load

5. Full Contact practice Following medical clearance,

participate in normal training

activities

Restore confidence and

assess functional skills by

coaching staff

6. Return to Play Normal game play

Preventing Sports Related Concussions1. Don’t Rush

a. Recovery takes time. Ensure your child fully recovers before participating in activities that may lead to a second concussion.

2. Be a Good Role Modela. Communicate positive safety messages and model safety. Follow safety

rules. Don’t lie about symptoms. 3. Appropriate Sports Management

a. Proper fitting padding/uniforms/helmets/headgear, mouthguards, education, retirement from sports

Test Your Concussion Knowledge Post-test ReviewTrue or False:

1. A concussion generally isn’t considered severe unless the athlete loses consciousness or “blacks out.”

2. Properly fitting helmets and mouthguards prevent concussion in children.3. Adolescent boys are more likely that adolescent girls to sustain a concussion.4. A sideline assessment test, in which a coach or athletic trainer asks the injured

athlete a series of questions immediately following injury, can help determine the severity of a concussion.

5. If a child no longer has any symptoms 24 hours after sustaining a mild concussion, it’s safe for him or her to return to play.

6. The best way to diagnose a concussion is with a CT scan or MRI.

7. Most emergency room physicians are well trained in the management and treatment of sports concussions.

8. It’s possible for children to experience headaches and difficulty concentrating in class for weeks after a hard hit or a rough tackle.

9. The “three strikes and you're out” rule, suggests that children who have three concussions should no longer be allowed to participate in school-sponsored athletics.

10. There are cases where kids who are diagnosed with attention deficit hyperactivity disorder (ADHD) or other learning disabilities could actually be suffering from undiagnosed post-concussion syndrome.

Moser, 2012

References Concussion Symptom Checklist. Center of Disease Control, (2015). Retrieved from: http://www.cdc.gov/concussion/pdf/TBI_schools_checklist_508-a.

pdf.

Defense and Veterans Brain Injury Center. (2014). A parent’s guide to returning your child to school after a concussion. Retrieved from

http://www.cstsonline.org/assets/media/documents/ParentsGuide_Concussion.pdf

Dompier, T., Kerr, Z., Marshall, S., Hainline, B., Snook, E., … & Simon, J. (2015). Incidence of concussion during practice and games in youth, high

school, and collegiate American football players. JAMA Pediatrics, 169(7), 659-655. doi:10.1001/jamapediatrics.2015.0210

Giza, C., & Hovda, D. (2001). The neurometabolic cascade of concussion. Journal of Athletıc Traınıng, 36(3), 228-235.

Halstead, M., & Walter, K. (2010). Clinical Report- Sport related concussion in children and adolescents. American Academy of Pediatrics, 126(3),

596-615. doi:10.1542/peds/2010-2005

Iverson, G., Silverberg, N., Mannix, R., Maxwell, B., Atkins, J., … Berkener, P. (2015). Factors associated with concussion-like symptom reporting in

high school athletes. JAMA Pediatrics, 10, E1-E9. doi:10.1001/jamapediatrics.2015.2374

Lloyd, J. (2009, May 5). High school athletes face serious concussion risks. USA Today, p. 7.

Moser, R. S., & Pascrell, B. (2009). Ahead of the game: The parents’ guide to youth sports concussion. Dartmouth College Press.

Tyler, J., & Nelson, M. (2000, May). Second impact syndrome: Sports confront consequences of concussions. USA Today, pp. 72-74.