Concussion 101Presented by:

Jason Viel MS LAT ATCjason.viel@rockvalleypt.com

Kacey Morrison, BS, MAT, ATC(L), CSCSkacey.morrison@rockvalleypt.com

Objectives

• Recognize common features and symptoms of concussion

• Exposure to current concussion testing systems

• Understand the principles of concussion management

• Understand the return to learn and return to play principles

• Understand the role you may play in the concussion management process

It’s Just a Concussion…

Definition

con·cus·sion

noun \kən-ˈkə-shən\ : an injury to the brain that is caused by something hitting the head very hard ( US ) ( Brit )

Identifying a Concussion

What we think should look like this….

Identifying a Concussion

…often times is more like this.

Concussion Facts or Myths?!• Statement #1: Everyone with a concussion needs a CT scan or MRI right away.

• Statement #2: You should not treat the headache from concussion with any

medications because you might mask some symptoms.

• Statement #3: Someone with a concussion should be woken up every 2-3

hours.

• Statement #4: Children recover at the same rate as adults.

• Statement #5: A concussion requires loss of consciousness.

• Statement #6: There are no long term effects of concussion.

• Statement #7: An athlete needs to be hit on the head to sustain a concussion.

• Statement #8: Injury to the brain only occurs at the initial impact of the

concussion.

• Statement #9: Helmets and equipment will prevent concussion if the newest

model is used.

2013 Consensus Statement on Concussion in Sport: 4th

International Conference on Concussions, Zurich

Identified common features

1. Direct blow to the head OR impulsive force transmitted through the head

2. Rapid onset ‘short-lived’ neurological impairments

3. More of a functional disturbance rather than a structural one

4. Core set of common features/clinical signs which may or may not involve a loss of consciousness

Clinical Features of a Concussion

SOMATICLOC/AmnesiaCoordinationBalance/dizzy

HeadacheBEHAVIOR

MoodIrritability

LabileCOGNITIVEReaction time

MemoryAttention

“Fogginess”

SLEEP DISTURBANCE

ExcessiveUnable to initiate Unable to sustain

Fragmented

Most Commonly reported Symptoms (Lovell, Collins et al 2004)

High School & College Athletes - within 3 days of injury N = 515

• # 1 Headache 71 %

• # 2 Feeling slowed down 58 %

• # 3 Difficulty concentrating 57 %

• # 4 Dizziness 55 %

• # 5 Fogginess 53 %

• # 6 Fatigue 50 %

• # 7 Visual Blurring/double vision 49 %

• # 8 Light sensitivity 47 %

• # 9 Memory dysfunction 43 %

• #10 Balance dysfunction 43%

What happens to the brain Blunt trauma

Coup-Counter Coup

Diffuse Axonal Injury

2 categories

Primary - from the initial blow or insult, shearing of axons

Secondary – occurs hours to days later, most likely due to injury and altered homeostasis due to initial impact and cellular damage

More of a process than a single event

Metabolic Cascade following Concussion

1. Release of neurotransmitters- Glutamate

2. Massive neuron firing. Creates large cellular demand.

3. Ca+ influx blocking oxygen preventing cellular respiration

4. K+ efflux cause vasoconstriction

5. This prevents fuel, glucose, from getting to the cells.

6. This leads to cellular death and dysfunction

= an ENERGY CRISIS that can last for 7 to 10 days

(Giza CC, Hovda DA. 2001)

Metabolic Cascade following Concussion

Incidence and Prevalence

• 12 yr study showed Football accounted for more than 50% of all concussions Lincoln et al 2011

• Girls Soccer accounted for the most concussions in girls sports. Lincoln et al

2011

• From 1997-2008 concussion rate increased 4.2 fold Lincoln et al 2011

• In sports with boys and girls teams (i.e. soccer, basketball, baseball/softball) girls had a higher rate of concussion than the boys. Lincoln

et al 2011

• Concussion Rates for helmeted boys sports rose at nearly twice that of non-helmeted sports. Lincoln et al 2011

Epidemiology of Concussion

• Marar et al in 2012 studied one school district and 20 sports during the 2009-2010 school year

• 66% of all concussions occurred in competition and 34% in practice

• Football accounted for the most concussions, girls soccer was second followed by wrestling and girls basketball.

• Most common symptoms reported were– Headache (94.2%)

– Dizziness (75.6%)

– Concentration difficulty (54.8%)

– Confusion (45%)

– Light sensitivity (36%)

– Nausea (31.4%)

• Girls had a higher rate of concussion than boys in gender-comparable sports

• Most student-athletes missed more than 1 week of sports activity

• Football accounted for the most concussions, girls soccer was second followed by wrestling and girls basketball.

• Girls had a higher rate of concussion than boys in gender-comparable sports

Girls vs. Boys and Concussions

• In sports where boys and girls can boy play, girls have a higher rate of concussion incidence

• Concussions also represent a greater proportion of all injuries in girls compared to boys

• Biomechanical differences in the head and neck

• Girls may also be more honest about reporting injuries

• Girls had a higher proportion of player-playing surface contact and player-equipment contact

• Girls also had a higher proportion of recurrent concussions

Girls vs. Boys and Concussions

State Legislation

• Currently 49 of the 50 states have some form of legislation regarding concussions and sport

• Iowa and Illinois both passed in 2011

• Washington State was the first in 2009

• Arkansas is only state without

State Legislation

• In Iowa and Illinois any athlete suspected of concussion is to be removed from competition until cleared by an allied health care professional

– Also all athletes 7th-12th grade and their parents/guardians must be given and sign off on information regarding concussions prior to practicing

– All coaches of 7th-12th graders must complete an online concussion informational course prior to their season starting

• In Iowa that health care professional can be MD, DO, Athletic Trainer, Physical Therapist, Chiropractor, Nurse Practitioner, Physician Assistant

• In Illinois that health care profession can be MD, DO or Athletic Trainer

Illinois Public Act 099-0245

• Reiterates that only Health Care Professionals able to diagnose or clear a concussion is MD, DO, ATC(L)

• Mandates that any IHSA participating school have a Concussion Oversight Team

• Prioritizes and formally addresses the Return to Learn

• Updates evidence based emphasis on Return to Play

Management of Concussions

• When available some sort of baseline test should be used• Most common are ImPACT, Concussion Vital Signs, CogSport, Axon, Sideline

Assessment of Concussion (SAC), SCAT3

• When using these tests must keep in mind that they are only a tool to help with recognition and management of concussions not a clearance.

• Newer concussion management tool being used by Rock Valley Physical Therapy• C3 Logix (Cleveland Clinic Concussion Management)

C3 Logix

• Uses Graded Symptoms Checklist

• SAC

• BESS Test (Balance)

• Visual Acuity (both Static and Dynamic)

• Choice and Simple Reaction Time

• Processing Speed

• Trails A and B

C3 Logix Sample Polygon

C3 Logix Sample Polygon

Return to Learn

• 5 Phase Framework

• Identifying what the student can do without increasing symptoms

• Avoiding “triggers” that worsen symptoms

• Entry point into the framework is variable and dependent upon symptom severity

• Symptom specific accommodations in place to assist the student return to school as timely as possible

Return to LearnPhase 1: NO SCHOOL

• Symptom Severity: High symptom load that prevent him or her from being able to benefit from being in school. Physical symptoms typically interfere with even basic tasks.

• Treatment: physical and mental rest as much as possible

• Interventions: – No activities that exacerbate symptoms such as TV, video games,

computer use, phone or music – Other triggers that worsen symptoms – noted and avoided to help

promote healing– No physical activity

Return to LearnPhase 2: HALF DAY ATTENDANCE WITH ACCOMMODATIONS

• Symptom Severity: Manageable symptoms – basic tasks achieved but symptoms may be exacerbated by complex mental activities

• Treatment: Balance rest with gradual reintroduction to school, avoid worsening symptoms and triggers

• Interventions: – Part day attendance with focus on core subjects prioritize what classes to

attend and how often– Symptoms reported by student addressed with specific accommodations– Eliminate busy work– Homework eliminated or reduced, out of school emphasis is on rest– No physical activity

Return to LearnPhase 3: FULL DAY ATTENDANCE WITH ACCOMMODATIONS

• Symptom Severity: Symptoms in this stage diminished in both number and severity, short time spans with known triggers do not have drastic effects on symptom levels

• Treatment: As student improves, gradually increase demands by increasing amount of work, length of time spent on work, difficulty of work. Gradually reintroduce known symptom triggers for short periods of time.

• Interventions:– Full day attendance, continue to prioritize assignments, tests and projects, limit to

one test per day.– Prioritize in class learning, gradually increase amount of homework– Reported symptoms addressed by specific accommodations with gradual

reduction as symptoms wane and resolve– No physical activity

Return to Learn

Phase 4: FULL DAY ATTENDANCE WITHOUT ACCOMMODATIONS

• Symptom Severity: Student should not have symptoms

• Treatment: Accommodations are removed when student can fully function without them

• Interventions– Construct a plan to finish completing missed academic work and

keep stress levels low– No physical activity until released by an MD or ATC

Return to Learn

ACCOMMODATIONS:

• must be reasonable

• must be requested by student or guardian

• must be reported to Concussion Oversight Team

Return to Learn

Phase 5: FULL SCHOOL AND EXTRACURRICULARS

• Symptom Severity: No symptoms are present

• Treatment: No accommodations are needed

• Interventions– Before returning to sports participation student should

complete the graduated return to play protocol

Return to Play

• No athlete should return to play if concussion is suspected

• Return to play should take around 1 week and be a graduated process

• Each step must be 24 hours in between and athlete must be asymptomatic

• If symptoms return athlete must go back to previous step once symptoms resolve.

Return to Play

• Sample RTP

– Day 1: Asymptomatic and return to school for full day, light aerobic exercise (stationary bike or jogging)

– Day 2: More strenuous aerobic activity including sport specific drills (running, cutting) no contact of any kind Sport drills without body contact. Such as pass catching, running with ball in football. Dribbling and spot shooting in basketball. Dribbling or passing/shooting on side in soccer, no contact

– Day 3: Begin full contact drills but no full practice

– Day 4: Full Practice no limitations

– Day 5: Release for game play

Recovery

• 80-90% of sports related concussions resolve within 2 weeks of the inciting event (Makdissi et

al., 2010; McClincy et al., 2006; McCrea et al., 2009, 2013; McCrory et al., 2013)

• 10-20% experience a protracted recovery greater than 2 weeks

• A smaller percentage “the miserable minority” can develop symptoms that may persist for months to even years

On field predictors for prolonged recovery

• Headache (Guskiewicz 2008)

• Dizziness (Guskiewicz 2008, Lau et al 2011)

• On Field Amnesia (Collins 2003, McCrea et al 2013)

• Loss of consciousness (McCrea et all 2013)

Risk Factors for Poor Recovery

• Prior History of Injury

– (More is not better)• (Collins et al., 2002; Eisenberg et al., 2013; Guskiewicz et al., 2003;

Kerr et al., 2012; Schatz et al., 2011; Zemper, 2003).

• Younger Age?

– (Be more conservative with children)

• Gender?

– (Women may be at increased risk)

Post Concussive Syndrome

• Term used to describe the constellation of symptoms after concussion

• Originally used when symptoms lasted longer than 3 months

• Controversial

What are the causes of persistent symptoms?

Does such a ‘syndrome’ exist? Overlap of symptoms with other conditions

Neurological vs. psychological?

Post Concussive Syndrome

“Ongoing symptoms are either a prolonged version of the concussion pathophysiology or a manifestation of other processes, such as cervical injury, migraine headaches, depression, chronic pain, vestibular dysfunction, visual dysfunction, or some combination of conditions. The pathophysiology of ongoing symptoms from the original concussion injury may reflect multiple causes: anatomic, neurometabolic, and physiologic.” (Leddy JJ, et al. 2012)

Public Misconceptions about mTBI

• 60% agree . . . How quickly a person recovers

from head injury depends mainly on how hard

they work at recovering.

• 40% agree . . . Sometimes a second blow to the head can help a person remember things that were forgotten. (Gillumet and Paglia, 2004)

Post Concussive Syndrome Risk Factors for a prolonged recovery

• Re-injury before complete recovery

• Over-exertion, especially early after injury

• Significant stress

• Prior illness or injury

Second Impact Syndrome

• Extremely Rare

• Almost always fatal (McCrory and Berkovic 1998)

• Preston Plevretes E:60 Second Impact -YouTube

Education

• Currently no test done at the hospital will diagnose a concussion.

• CT Scans/MRI’s are to rule out brain bleeds etc

• If medication is given we recommend that it does not have an NSAID in it.

Handouts

• An Educator’s Guide to Concussions in the Classroom

• RVPT’s Classroom Concussion Assessment Form

• Concussion Fact Sheet for School Professionals

Questions or Concerns…

References

• Lovell, Collins et al, Grade 1 or “ding” concussions in high school athletes. Am J Sports Med January 2004 vol. 32 no. 1 47-54

• Lovell, M. R., M. W. Collins, G. L. Iverson, M. Field, J. C. Maroon, R. Cantu, K. Podell, J. W. Powell, M. Belza, and F. H. Fu. 2003. Recovery from mild concussion in high school athletes. Journal of Neurosurgery 98(2):296-301.

• Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001 ;36(3):228-235

References

• Makdissi, M., D. Darby, P. Maruff, A. Ugoni, P. Brukner, and P. R. McCrory. 2010. Natural history of concussion in sport: Markers of severity and implications for management. American Journal of Sports Medicine 38(3):464-471.

• McCrea, M., K. M. Guskiewicz, S. W. Marshall, W. Barr, C. Randolph, R. C. Cantu, J. A. Onate, J. Yang, and J. P. Kelly. 2003. Acute effects and recovery time following concussion in collegiate football players: The NCAA Concussion Study. JAMA 290(19):2556-2563.

References

• McCrory, P., W. H. Meeuwisse, M. Aubry, B. Cantu, J. Dvořák, R. J. Echemendia, L. Engebretsen, K. Johnston, J. S. Kutcher, M. Raftery, A. Sills, B. W. Benson, G. A. Davis, R. G. Ellenbogen, K. Guskiewicz, S. A. Herring, G. L. Iverson, B. D. Jordan, J. Kissick, M. McCrea, A. S. McIntosh, D. Maddocks, M. Makdissi, L. Purcell, M. Putukian, K. Schneider, C. H. Tator, and M. Turner. 2013c. SCAT3. British Journal of Sports Medicine 47(5):259-262.

• Register-Mihalik JK, Mihalik JP, Guskiewicz KM. Balance deficits after sports-related concussion in individuals reporting post-traumatic headache. Neurosurgery, 2008;63(1), 76-82.

References

• Collins, M. W., G. L. Iverson, M. R. Lovell, D. B. McKeag, J. Norwig, and J. Maroon. 2003. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sport Medicine 13(4):222-229.

• Chrisman, SP, Rivara, FP, Schiff, MA, Zhou, C and Comstock, RD. 2013. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Inj 27(1):1-9.

• Leddy JJ et al. Rehabilitation of Concussion and Post-concussion Syndrome. Sports Health. 2012; 4(2): 147-154

References

• Guilmette TJ, Paglia MF. The public's misconception about traumatic brain injury: a follow up survey. Arch Clin Neuropsychol 2004; 19(2):183-189

• Alsalaheen, B.A., Mucha, A., Morris, L., Whitney, S., Furman, J., Camiolo-Reddy, C., & Sparto, P. (2010). Vestibular rehabilitation for dizziness and balance disorder after concussion. Journal of Neurologic Physical Therapy, 34(2), 87-93.

• Eisenberg, M. A., J. Andrea, W. Meehan, and R. Mannix. 2013. Time interval between concussions and symptom duration. Pediatrics 132(1):8-17.

References

• Kerr, Z. Y., S. W. Marshall, H. P. Harding, Jr., and K. M. Guskiewicz. 2012. Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. American Journal of Sports Medicine 40(10):2206-2212.

• McCrory PR, Berkovic SF (1998). Second impact syndrome. Neurology 50 (3): 677–83

References

• 1) Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. American Journal of Sports Medicine. 2012; 1-9

• 2) Lovell M. The Management of Sports–Related Concussion: Current Status and Future Trends. Clin Sports Med. 2009(28) 95–111.

• 3) Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in Concussion Incidence in High School Sports. American Journal of Sports Medicine. 2011; 1-6.