Tackling Sports Concussions Head On

Jeffrey Rosenberg MDSports Medicine

September 5, 2012

Traumatic Brain InjuryConcussions are one type of TBIDiffuse Injury, No Anatomic

Changes

Focal Brain Injury-More SevereSubdural Hematoma, Epidural Hematoma, Intra-cerebral Hematoma

Associated with Anatomical Change-Blood, Fluid, Local Damaged Tissue

Myth #1: Only Football Players Get Concussions

>170,000 Sports and Recreations TBI/year from birth to 19 yo

ER visits increased by 60%

Birth to 9 yo: Playground and Bicycle Related Injury

9% of all sports related injuries

Male 10-19 yo: Football, Bicycling

Female 10-19 yo: Soccer, Basketball, Bicycling

Silent EpidemicUp to 50% of concussions not

reportedAthletes hide symptoms, don't

report any problemsCoaches want the players to play

Athletic Trainer, not coach has the final say

Parents play down severity to let the athlete participate

More difficult to ignore in NJ as of 2011 regulations

Myth #2:Can only get Concussion if Hit in the Head

Direct blow most common Helmet to Helmet; Head to

other Body Part Ground

Indirect ForcesLinear or rotational forces

Getting hit from the side in the body

Brain cell injury and dysfunctionNo anatomic damage

Brain Injury

Trauma causes brain tissue to release chemicals: Calcium/Glutamate Increases need for blood flow for metabolism

to recover from injury Unfortunately, the arteries are constricted

Imbalance between metabolic needs and blood flow into the brain

Myth #3: Can't be a concussion if you aren't knocked out

Only 10% of concussions have LOC “Got my Bell Rung”

If any symptoms, this is a concussion as wellSymptoms may not start immediately

after the hitSeizure activity at injury very scarey but

not permanent

Loss of Consciousness

If LOC continues, need to start ABC protocol

Assume cervical spine injuryUsually LOC is seconds only

Confusion

Hallmark symptom of TBI is confusionEyes glassy, loss of focusIncoherent speechGoing to wrong team's huddleMemory Loss

Loss of memory prior to event-retrograde amnesia

Loss of future memory-anterograde amnesia

Myth #4: Of course he can play doc next week, he only has a concussion

Loss of consciousness, Amnesia, Confusion used to be used to 'grade concussions' These 'grades' would determine return to play

No data to support the grading systems 15 different systems No longer used

Treat each concussion individually Symptoms must completely resolve prior to

return to activitiesDing's matter

Second Impact Syndrome

Continued symptoms sign that brain metabolism not yet normal

With additional injury (even mild) the blood vessels open wide which increases the pressure in the brain Coma, Death 10-15 die a year <19 yo Younger the brain, more susceptible

This is why conservative in youth sports, JH, HS sports

Myth #5: 'Johnny' will be ready by next week

Each concussion is different, hard to predict

Longer recovery with repeated concussions

Younger patients typically need more time

None the less, most better with 5-7 daysSame day return to play no longer

recommended for youth sports If College athlete or Pro, maybe

Sideline Assessment

Assess symptoms: headache, confusion, nausea, vision

Neurological Exam Pupillary Response ROM/Strength Balance/Coordination

SCAT Orientation Memory Confusion

Sideline Assessment

Take HelmetDone for the dayATC or MD will re-evaluate every 15-20

mins to make sure things are worsening If so, off to the ER

In New Jersey, coaches, refs have duty to make athletes sit if any concern

Red Flag Symptoms Headaches that worsen Look very drowsy, can’t be awakened Can’t recognize people or places Unusual behavior change Seizures Repeated vomiting Increasing confusion Increasing irritability Neck pain Slurred speech Weakness or numbness in arms or legs Loss of consciousness

Myth #6: We need to go to the ER

Generally not neededIf significant LOC, confusion, or worsening

mental state CT and MRI are always normal by definition If neurological status worsens must be imaged to

r/o bleedNo longer recommend waking up athlete every

hour over night Observe for unusual breathing patterns or

atypical movements (jerking, tremor, convulsions)

Myth #7-'Captain looks fine' so he didn't have a concussion

Unlike physical injury, its hard to 'see' the injury No post game activities

Treatment of concussion Rest, Rest, Rest Brain Rest, Physical Rest Quite, Dark NSAIDs/Tylenol for headache No electronics, phones, texting, computers,

etc

Brain Rest

If minimal sx ok to go to school monday Most athletes will need to miss some school Schools finally understanding and are

required to complyTake to MD on monday or tuesday for

eval

Complications to Recovery

Concussion History

Headache HistoryDevelopmental

HistoryPsychiatric

History

Post Concussion

Every patient has different set of symptomsPhysical

Headaches, N/V, FATIGUE, Balance, SensitivityThinking

Mentally Foggy, Concentration, Memory, SlowEmotional

Irritability, Sadness, Nervous, More EmotionalSleep

Drowsiness, Sleep more or Less, Difficult sleeping

Post Concussion

Let the child sleep, Daytime Naps recommended at the beginning

Eat and stay hydratedLimit Activities requiring thinking or

concentrating Read, TV, Computer, etc

Watch the grass growDo not attend anything with flying objects

or potential for repeated injury

Post ConcussionNot much the parents can do to help

other than provide emotional support, interact with school nurse and administration

Frustration can kick inSchool provide tutoring > 5 daysReturning to school can be gradual

Part time No gym or sports Breaks in nurses station Lunch in quiet place

Myth #8: There are no treatment for concussions

Insomnia-MelatoninEmotional symptoms

Role for amitriptyline/SSRIPhysical symptoms

Balance can improve with vestibular therapyConcentration

ADHD medicationsAmantidineNuvigil

Return to Play

All physical sx must be goneIMPACT scores return to

baselineMedical clearance5-7 day return to play

protocol Start with minimal exertion Progress daily If symptoms reoccur must

return to previous step

ImPACT Testing

Focused neuropsychiatric, computer based test

Memory, Coordination, Concentration

Preseason Testing Optimal@2 days post injury can

provide prognosisWhen symptoms are gone to

confirm brain function normal

Myth #9 (from the NFL/NHL)

No long term risk from concussions

With each concussion, repeated injuries occur with less force, symptoms last longer, more difficult to return to sport

Symptoms may be life longRetire from sports

Chronic Traumatic Encephalopathy

Pathological changes in brain from multiple, usually mild, injuries (even 'dings') Deposits of protein similar

to Alzheimer's Collision sports Substance abuse Dementia, Depression,

Death Violent Suicide

Chronic Traumatic Encephalopathy

Families of NFL players donating brain tissue after suicide/death

18/19 had CTE

Huge lawsuits in future