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Participants will be able to: Define concussion injury and common features

Identify the mechanism of injury of concussion

Identify concussion signs and symptoms

Identify factors affecting special populations including pediatric, gender differences, and elite athletes

Identify current concussion evidence related to short term outcomes and long term prognosis

Researchers in Boston: Concussions Tied to Depression in former N.F.L. Players– New York Times 5/31/07

Concussion Policy to Include ‘Whistle-Blower’ Provision– ESPN 6/19/07

Head Games– Time Magazine 11/29/07

High School Sports and Concussions– NBC Nightly News 9/19/07

Real Sports Episode 188– HBO 11/20/2012

Outside the Lines – Five part series ‘The Concussion Crisis’– ESPN 5/7/2012

NATA Range of Motion List Serve– Weekly List ~5 newspaper articles per week on concussions

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Improvised Explosive Devices (IED)

Rocket Propelled Grenades (RPG)

Paratroopers

Department of Defense– Has become the largest

single employer in the US of certified athletic trainers

Concussions or other forms of MTBI account for an estimated 75%-90% of the 1.4 million traumatic brain injury (TBI) related deaths, hospitalizations, and ER visits that occur each year 5

Approximately 1.6 – 3.8 million sports and recreation-related TBIs occur in the United States each year17

On average, athletic trainers will care for 7 concussions per year

2000 BC – Papyrus date to the teachings of Imhotep

460 BC - The Corpus Hippocraticumwritten by Hipocrates

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1986 – Cantu publishes guidelines

1990 – Colorado Medical Society

1997 – American Academy of Neurology

2000 – No long term effects?

2004 – Pellman et al, “safe to return”

2007 – Depression and dementia linked

2009 – Chronic Traumatic Encephalopathy

Immediate and transient impairment of neural function including:– alteration of

consciousness

– disturbance of vision

– disequilibrium

Guskiewicz K, et al. National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion. Journal of Athletic Training. 2004 Jul-Sep; 39(3): 280–297

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces22

Current understanding of the pathophysiology of MTBI involves a paradigm shift away from a focus on anatomic damage to an emphasis on neuronal dysfunction involving a complex cascade of ionic, metabolic and physiologic events

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Mild Traumatic Brain Injury (MTBI)

“trauma-induced change in mental status, with confusion and amnesia, and with or without a brief loss of consciousness”

Oxidative Stress

ROS

Inflammation

NMDA Receptor

Ca2+

Ca2+Ca2+

Ca2+

K+K+

K+

K+

K+Glutamate Release

ExcitotoxicityAxonal damage

Cell Death

Pro-Inflammatory Cytokines

Macrophage recruitmentMicroglia activation

Oxidative Stress

ROS

Brain DysfunctionHeadacheDepressionCognitive Impairment

Protein, DNA,RNA Oxidation

Lipid Peroxidation

Hypermetabolism

Erin Barrett, PhD, DSM Nutritional Products

Neurometabolic Cascade Following Cerebral Concussion/MTBI

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Leading Causes of MTBI:1) Falls

2) Motor Vehicle Trauma

3) Accidents

4) Assaults

5) Sports

Cycling

Football

Hockey

Rugby

Soccer

Skiing

Snowboarding

Skateboarding

Bazarian J, et al. Mild traumatic brain injury in the United States, 1998-2000. Brain Injury 2005;19(2):85-91.

1 in 8 bicycle injuries is a concussion

Helmets reduce the risk:– Head Injury 85%

– MTBI 88%

– Severe Brain Injury 75%

Brain acceleration moves forward in the skull

Frontal lobes strike inside of skull (coup)– shear, tensile, &

compression strains axonal tissue within brain

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Coup-Contrecoup– Acceleration-deceleration

– Linear

Brain moves forward in the skull, frontal lobes strike inside of skull (coup)

Brain rebounds backward striking posterior skull causing injury to occipital lobe (contrecoup)

Both injuries produce injury to axonal tissue within brain

Another look at the contrecoup injury

Rotational – May be responsible for

majority of concussions Brain rotates on axis

causing stretching and tearing of axons

Stretching and tearing of blood vessels results in hematoma

Brain strikes skull causing contusion

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IED blast waves, four components to injuries Primary blast trauma: The shock wave causes

injury to fluid and gas-filled organs

Secondary blast trauma: These are injuries sustained by high speed shrapnel

Tertiary blast injuries: Blast winds trailing the primary shock wave can amputate limbs

Quaternary blast injuries: Result from exposure to heat and chemicals associated with the fire that follows the detonation

Numerous Scales… problematic!

Too many grading scales– At least 16 scales

– Too much variability Grade I/Mild Grade II/Moderate Grade III/Severe

Cantu No LOC or PTA <1 hourPTA 1–24 hours

LOC <5 minutesPTA >24 hours

LOC >5 minutes

Torg (Grade I–II)No LOC or amnesia (except PTA)

(Grade III–IV)LOC <few minutesPTA or retro. amnesia

(Grade V–VI) LOC/coma,confusion,amnesia

CMS No LOC Confusion w/no amnesia

No LOC Confusion w/amnesia

LOC

AAN No LOCSxs <15 minutes

No LOCSxs >15 minutes

Any LOC

CMS = Colorado Medical Society; AAN = American Academy of Neurology; LOC = loss of consciousness; PTA = posttraumatic amnesia; Sxs = symptoms (i.e., confusion, amnesia, etc.).

Grade of concussion Time until return to play*

Multiple Grade 1 concussion 1 week

Grade 2 concussion 1 week

Multiple Grade 2 concussion 2 weeks

Grade 3–brief loss of consciousness (seconds) 1 week

Grade 3–prolonged loss of consciousness (minutes) 2 weeks

Multiple Grade 3 concussions 1 month or longer, based on clinical decision of evaluating physician

*Only after being asymptomatic with normal neurologic assessment at rest and with exercise.

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• Assign importance to LOC– No scientific evidence– Rare and not correlated to injury resolution

Safety vs. Practicality– Mandatory Rest? What is the consequence?– Assumes standard use for all age groups– Poor job distinguishing “mild” concussion

Does not work - Must individualize each injury

Headache Imbalance Drowsiness Nervousness Difficulty concentrating

or remembering Nausea Fatigue Sensitivity to light/noise

Numbness/tingling Vomiting Trouble sleeping Feeling slowed down Dizziness Sleeping too much Sadness Feel “in a fog”

Graded Symptom Checklist (GCS)

Post Concussion Symptoms Scale (PCSS)

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Headache 71% Feeling slowed down 58% Difficulty concentrating 57% Dizziness 55% Fogginess 53% Fatigue 50% Visual Blurring 49% Light sensitivity 47% Memory dysfunction 43% Balance problems 43%

Symptoms Time 1 Time 2 Time 3Headache 88.5 61.5 32.7Difficulty concentrating 82.7 51.9 23.1Feeling slowed down 78.8 40.4 19.2Dizziness 78.8 30.8 17.3Nausea 77.3 21.2 15.4Fatigue 76.9 50.0 21.2Feeling mentally “foggy” 75.0 46.2 19.2Drowsiness 73.1 48.1 17.3Difficulty remembering 69.2 50.0 23.1Sensitivity to light 57.7 40.4 17.3Balance problems 55.8 26.9 11.5Sensitivity to noise 50.0 40.4 15.4Trouble falling asleep 45.0 25.0 15.4Irritability 38.5 36.5 11.5Sleeping more than usual 34.6 28.8 9.6Visual problems 32.7 19.2 7.7Sleeping less than usual 30.8 15.4 7.7Nervousness 30.8 15.4 7.7Feeling more emotional 19.2 11.5 7.7Sadness 19.2 7.7 5.8Numbness or tingling 15.4 7.7 1.9Vomiting 11.5 7.7 1.9Lovell et, al., (2006): Measurement of Symptoms Following Sports-Related Concussion: Reliability and Normative Data for the Post-Concussion Scale, Applied Neuropsychology, 13:3, 166-174

Signs– Dazed– Confused– Answers questions slowly– Personality changes– Retrograde amnesia

(forgets play prior to hit)– Anterograde amnesia

(forgets play after hit)– Loses consciousness– Postural Instability– Moves clumsily

Symptoms– Headache– Nausea– Dizziness– Double vision– Photosensitivity– Feeling sluggish– Feeling foggy– Change in sleep– Cognitive changes

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Frontal Lobe– Executive Functions

– Amnesia

– Multitasking

– Emotions/Mood

– Fogginess

– May have longer recovery

Temporal Lobe– Visual memory

– Verbal memory

– Processing sensory input

– Language and speech comprehension

– New memories

Parietal Lobe– Visual

– Somatosensory

– Auditory

– Vestibular System

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Occipital Lobe– Visual processing

– Balance

– Dizziness

– Attention

– Arousal (fatigue)

NATA October 2001 Special Issue

NATA Position Statement 2004– 1st attempt to outline best practices for ATC’s

Neurosurgery 2004– Pellman et al, NFL committee

Prague 2004

Zurich 2008

Zurich 2012

Published in September 2004 JATA

MD’s, AT’s, and PhD’s

Designed to “Bridge the gap between research and clinical practice”– Defining and Recognizing Concussions

– Evaluation and Making Return to Play Decisions

– Concussion Assessment Tools

– When to Refer an athlete to a Physician after Concussion

– When to disqualify an athlete

– Special considerations for the Young Athlete

– Home Care

– Equipment Issues

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1st Vienna (2001) 2nd Prague (2004) 3rd Zurich (2008) 4th Zurich (2012)

Sought to answer the questions in the following areas:– Agree on a definition– Acute Simple Concussion– Return to Play (RTP) Issues– Complex Concussion vs. Long Term Issues– Pediatric Concussion– Future Directions

Female athletes6

– Women outperform men on verbal memory

– Reported more cognitive, emotional, and sleep symptoms on baseline

– Typically have more severe post-concussion symptoms than males

– Take longer to recover

Younger athletes6

– The developing brain is more susceptible to injury

– Typically present with more symptoms

– Recovery time from concussions may be longer for children and adolescents

– Neurochemical processes appear to differ in developing brains

Researchers are considering whether neck musculature may serve to attenuate forces

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Migraine

Learning Disabilities– ADD/ADHD

Depression

Anxiety

Individuals with a history of concussion are at an increased risk of sustaining a subsequent concussion22

The greatest predictor of a concussion in sport is a previous injury

History and mental status testing– Orientation – Concentration – Memory – Symptoms

Maddock’s Questions– Where are we? – What quarter is it right now?– Who scored last in the practice / game?– Who did we play last game?– Did we win the last game?

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Coordination and balance – Finger-to-nose test– Gait– Romberg test– SLS stork stand– Balance Error Scoring System (BESS)

Exertional provocative test– 40-yard sprint– 5 sit-ups– 5 push-ups– 5 knee bends

Re-check vital signs every 5-7 min.

Neurologic examination– Cranial nerve assessment– Pupil abnormalities pupil size response to light eye movement nystagmus blurred or double vision

– Babinski’s reflex– Strength– Neuropsychological assessments

SAC - Standardized Assessment of Concussion– 5 Minute Administration– McCrea

GSC – Graded Symptom Checklist

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BESS - Balance Error Scoring System

ImPACT - Immediate Post concussion Assessment and Cognitive Testing

Riemann BL, et al. Relationship between clinical and forceplatemeasures of postural stability. Journal of Sports Rehabilitation. 1999;8:71-82.

Graded Symptom Checklist (GSC)

McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects andrecovery time following concussion in collegiate football players: theNCAA Concussion Study. JAMA. 2003;290(19):2556–2563.

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Standardized Assessment of Concussion (SAC)

McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects andrecovery time following concussion in collegiate football players: theNCAA Concussion Study. JAMA. 2003;290(19):2556–2563.

Balance Error Scoring System (BESS)

McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects andrecovery time following concussion in collegiate football players: theNCAA Concussion Study. JAMA. 2003;290(19):2556–2563.

Do symptoms predict recovery?

Brian C. Lau, et al. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med November 2011 39 2311-2318

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Absolute Rest– Physical

– Cognitive

Medication– Acetominophen

– NSAID’s probably shouldn’t be given

– DHA promising

No Activity Complete Physical & Cognitive Rest

Light Aerobic ActivityWalking, swimming, stationary cycling at 70% max HR; no resistance exercise

Sport Specific ActivitySpecific sport-related drills but not head impact

Non-Contact DrillsMore complex drills, may start light resistance training

Full-Contact PracticeAfter medical clearance, participate in normal training

Return to play

Graduate to following step after > 24 hours without symptoms

Return to previous step if symptoms recur

http://www.slideshare.net/ZoharShamash/concussions-a-hardhitting-problem

Head Impact Telemetry System (HITS)– Developed by helmet maker Riddell in use at

North Carolina, Virginia Tech, and Oklahoma

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• HITS measures the frequency and severity of collisions through use of accelerometers inside players’ helmets

• Sensors send data to computers which chart hits

• Reports can help guide both helmet design and on-the-field behavior

Data from 37,128 head impacts collected at Virginia Tech during games from 2006 to 2010 were analyzed12

One goal was to reveal threshold for injury

Multiple sub-concussive forces can cause “cumulative” MTBI– Some players receive 30-40 helmet hits/game

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“The accumulation of many hits may be more significant than a few big ones. We have seen a number of hits over 100 g that we expected would lead to concussion and didn’t. And there are lesser hits, in the 50 to 60g range, that led to players being taken out of the game. We believe that in many of these cases the players probably had a minor concussion from an earlier hit and played through it, creating the perfect storm where a lesser hit has a much greater effect.”

Dr. Kevin Guskiewicz, Research Director of the University of North Carolina at Chapel Hill

Center for the Study of Retired Athletes

Linemen sustained the highest number of impacts Skill positions sustained a higher number of severe

head impacts Data predicted a higher incidence of concussions in

skill positions compared to linemen at rates that were in strong agreement with the epidemiological literature (Pearson's r = 0.72 - 0.87)

The predicted rates of repeat concussions (21 - 39% over one season and 33 - 50% over five seasons) were somewhat higher than the ranges reported in the epidemiological literature

Offensive Line21%

Defensive Back16%

Linebacker16%

Defensive Line14%

Running Back9%

Receiver8%

Quarterback6%

Tight End5%

Special Teams5%

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Performed fMRI on an entire team– Pre-season → mid

season → post season

Changes to fMRI during the season– Injured– Non-injured

Number of impacts related to change– fMRI

Breedlove et al. Biomechanical correlates of symptomatic and asymptomatic neurophysiological impairment in high school football. Journal of Biomechanics Volume 45, Issue 7, 30 April 2012, Pages 1265–1272

Number of impacts sustained might be more relevant than magnitude of a hit

The number + magnitude of head impacts as well as their interaction were prominent in the regression results– Analogous to soft tissue injuries: an injury can be

caused by a small number of severe loads or frequent small loads or some combination of the two

Evan Breedlove , Jeff Gilger, Meghan Robinson, Katie Breedlove, Victoria Poole, Larry Leverenz, Tom Talavage,,Eric Nauman. The Subconcussive Effect of Number, Location, and Magnitude of Head Impacts in High School Football. Poster BSSMAT Big Sky, MT 2013

Post Traumatic Headaches

Second Impact Syndrome

Post Concussion Syndrome

Cumulative Neuropsychological Impairment

Post Traumatic Epilepsy

Post Traumatic Vertigo

Chronic Traumatic Encephalopathy

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Result of vasospasm; does not usually occur with impact, but develops shortly afterward

Signs & Symptoms– localized area of blindness that may follow the

appearance of brilliantly colored shimmering lights

– posttraumatic migraines

Management– immediate referral to a physician

2nd head injury occurs before the symptoms associated with previous injury have resolved

Does not necessarily require a blow to the head

Signs & Symptoms– May not lose consciousness…stunned

look…may leave field under own power– Rapid deterioration of condition LOC; dilated pupils; loss of eye movement;

respiratory failure

Brainstem failure in 2–5 min. Management

– Activate EMS

Prevent it from happening

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Can occur after a mild or serious concussion– Signs & Symptoms

decreased attention span persistent headaches blurred vision vertigo memory loss irritability inability to concentrate on even simplest task exercise may lead to headache, dizziness, and premature

fatigue

– Management no definitive treatment other than to treat headache symptoms

CTE has been known to affect boxers since the 1920’s

By the 1970’s– Pathology in boxers with dementia pugilistica

became distinguishable from other neurodegenerative disease

Recently CTE identified in retired professional football players and other athletes who have a history of repetitive brain trauma

A progressive degenerative disease of the brain – found in athletes (and others) with a history of repetitive

brain trauma, including symptomatic concussions as well as asymptomatic sub-concussive hits to the head

Trauma triggers progressive degeneration of the brain tissue– build-up of an abnormal protein called tau– These changes in the brain can begin months, years, or even

decades after the last brain trauma or end of active athletic involvement

Brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia9

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Defining and Recognizing Concussions

Evaluating and Making Return to Play Decisions

Properly using and interpreting Concussion Assessment tools

Understanding when to refer an athlete

Understanding when to disqualify an athlete

Providing proper post-injury/home care

Understanding current equipment issues/trends

All under the direction of a physician

Additional legislation – nationwide, conference, by governing bodies Changes in care guidelines

– Disqualify athletes after X number of concussions

– Holding athletes out for longer periods– Blood test being developed by the Army

Advances in equipment– Legislation regarding equipment– Sen. Udall’s (D-NM) request to CPSC and FTC

NCAA Concussion Policy (April 2010)

NFL Concussion Policy– Requires independent neurologic consultant

– Eye in the sky (2011)

– New CBA limits contact drills

Ivy Leauge – Limited Contact Practices

PAC 12 – Limited Contact Practices (2013)

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TSSAA Concussion Policy and Return to Play Form became effective July 2010“Any player who exhibits signs, symptoms, or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion or balance problems) shall be immediately removed from the game and shall not return to play until cleared by an appropriate health-care professional.”

Adapted from the Acute Concussion Evaluation (ACE) by the Center for Disease Control (CDC)

TSSAA Concussion Return to Play Form – Must be used for games and practice

– Must be completed by MD or DO

Congress considering nation wide policy for all school districts (Sep 2010)– Protecting Student Athletes From Concussions

Act H.R. 6172

State Laws– 49 of 50 states have formal guidelines

Develop a team approach and guidelines ahead of time

Have baselines completed and available

Education is always the key – of clinicians, athletes, coaches, parents, media, administrators, etc.

Be accurate (evaluations, documentation)

Be consistent (care, decisions)

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Consultation with Team Physician

Refer to appropriate guidelines– NATA Position Statement (2004) Best available reference on how to construct a policy

– Zurich (2012)

– Governing body guidelines

– Other published papers

“If you have seen one, you have seen one. They are all different.”

Richard Ellenbogen, MDProfessor and Department Chair Neurosurgical Surgery

University of Washington