Concussion: Concepts, Controversy and Confusion

New York State Association of Independent Schools

John Cottone, EdD, ATCSUNY Cortland

May 4, 2010

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AcknowledgementThanks to Brian P Rieger, PhD

Chief Psychologist & Clinical Assistant ProfessorDepartment of Physical Medicine & Rehabilitation

SUNY Upstate Medical University

Director, CNY Sports Concussion CenterNYSPHSAA Concussion Team & Safety CommitteeNYS TBI Coordinating Council Public Education

Committee

For his assistance and generosity in providing materials this presentation

Concussion Discussion

• What is a concussion ?• How do I recognize a concussion when it occurs ?• What is the recommended treatment for concussion ?• What are the risks associated with an unrecognized

concussion or with multiple concussions ?• What are the current guidelines for return to sports,

school, and other activities after concussion ?• How can educators help a student who is recovering

from a concussion ?

What is a concussion?

• Mild traumatic brain injury

• A disruption in normal brain function due to a blow or jolt to the head

• CT or MRI is almost always normal

• Invisible injury

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Definition of Concussion

• Centers for Disease Control

• American Academy of Neurology

• American Congress of Rehabilitation Medicine

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Outdated AAN Criteria forSports-related Concussion

Grade 1 Transient ConfusionSymptoms resolve in <15

minutesNo LOC

Grade 2 Transient ConfusionSymptoms last >15 minutesNo LOC

Grade 3 LOC: a) briefb) prolonged

Outdated Prague 2004 Guidelines

Simple concussion LOC < 1 minute

resolves in 7-10 days first concussion

Complex concussion LOC > 1 minute symptoms last longer than 7 – 10 days history of multiple concussions increasing “concussability”

Zurich 2008 Guidelines

No grading of injury Treat every concussion seriously Recovery may take longer in children and adolescents

Sports Concussion

• Football, hockey, and soccer are the riskiest male team sports

• Soccer and lacrosse are the riskiest female team sports

• In high school sports played by both sexes, girls have a higher rate of concussion

• Collegiate athletes have a higher rate of concussion than HS athletes

• Concussion represents a higher proportion of all injuries in HS athletes vs. collegiate

Concussion Management Advisory Team

• Athletic Trainer • School MD• School Nurse

• Athletic Director• Coaches• Teachers• Parents (school

community)• Athletes

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Concussion Management Advisory Team

• Policies and Procedures• Development – CMAT

• Implementation– Athletic Directors provide oversight– Coordinate with other school officials

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Guidelines for Coaches

• Prevention and Preparation• Educate the school community• Teach athletes about not playing hurt• Prevent re-injury• Prepare year round– Preseason– In Season– Postseason

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Guidelines for Coaches

• Advocate and teach safety first• Know when to remove athlete • Ensure appropriate care• Communicate

– Athlete– Parent– Administrator

• RTP only after medical clearance

• k

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Guidelines for Parents

• What is a concussion?• Signs and symptoms• Know to seek medical attention• Know when to “sit out”• Communicate to coach, medical staff

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Guidelines for Athletes

• What is a concussion• Prevention• Know signs and symptoms• Report to ATC, coach, parent• Never play with S/S• Tell the truth

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Preseason Baseline Testing

• Guidelines intended for implementation by athletic trainer, athletic director, coaches

• Concussion History• SAC or BESS testing• Neuropsychological testing

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Neuropsychological TestingIn Sports Concussion

Computerized tests that measure attention, memory, and reaction time

Sensitive to effects of concussion Tests can be repeated multiple times to

monitor recovery Ideally, pre-injury baseline testing done

for all athletes ImPACT, CogSport, HeadMinder ImPACT Test

Creation of an Action Plan

• Recognition (knowing when to remove athlete from participation)

• Evaluation (appropriate medical attention)• Communication Loop• Return to Play (medical decision)– Establish protocol

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First Aid

• Detect and Care

• Determine the need for and then activate the emergency action plan

• Perform emergency procedures they are qualified to perform (e.g.: CPR)

• Addition to Education Law19

Sideline Evaluation• Head trauma (blow or jolt)• LOC or amnesia for the trauma• Focal neurologic finding• Signs & Symptoms (SCAT card)

– confused, wobbly, emotional. . .• Assess cognition

– 3 word recall– Months backwards

• Standardized testing– SAC– BESS

• NO RETURN TO PLAY THAT DAY• PubMed Central, Table 2: J Athl Train. 200

1 Jul–Sep; 36(3): 274–279.

Common Physical Problems

Headache Dizziness and lightheadedness Clumsiness and poor balance Fatigue and lack of energy Sleep disturbance Blurred vision and light sensitivity Ringing in the ears

Common Cognitive Problems

Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ Easily distracted and easily losing track of

things Trouble doing more than one thing at a time Poor learning and memory Poor reading comprehension

When to Seek Medical Attention

• Any athlete who has had a concussion needs medical clearance before he or she is allowed to return to play

• NFHS | Concussion Rule Revised, Strengthened in High School Football

• Anyone with a loss of consciousness should be seen that day

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When to Transport by EMS

• Anyone with an altered level of consciousness or focal exam should be transported with full spinal immobilization

• Anyone who has had a seizure• Anyone with more than a brief LOC ( > 1

min)

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Principles ofConcussion Treatment

No cure for concussion, but treatment can help the person feel better and function better while symptomatic

Early diagnosis and education is critical Rest early (7-10 days?) and then gradually

increase activity

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Usually takes 1-2 weeks High school age youth take longer

to recover Recovery may be complicated by

non-injury variables

Recovery from Concussion

Recovery From Sports ConcussionHow Long Does it Take on ImPACT?

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10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School athletes

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Post-Concussion Syndrome (PCS)

Term used to describe complicated recovery from concussion

Symptoms generally thought to have a neurological basis at first

When symptoms persist, non-injury factors appear to play an increasingly significant role over time

Controversial topic

Recovery from concussion

Classic post-concussion presentation is fatigue and poor tolerance for exertion

• Symptoms are worsened by . . .– mental effort– environmental stimulation– emotional stress– physical activity

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Multiple Concussions

Second Impact Syndrome A second concussion within a week of first Rare but almost always fatal

Increasing concussability Longer recovery Accumulating damage ? Problems can be subtle and hard to detect Possible lifelong symptoms and problems

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Concussion Controversies

Prague guidelines (or any guidelines) Soccer headgear Concussion mouth guards Concussion football helmets Computerized cognitive testing Baseline pre-season testing Causes of post-concussion syndrome Treatment of post-concussion syndrome

Concussion in the Classroom

Fatigue - tires easily in class and over the course of the day

Headache and other symptoms worsen with reading or concentration

Trouble doing more than one thing at a time (e.g., listening to the teacher and taking notes)

Frequent visits to the nurse’s office

Concussion in the Classroom

Late or incomplete homework Easily overloaded and ‘shuts down’ Takes longer to read and learn Bothered by bright light in the classroom or

noise in the cafeteria Emotional outbursts Lack of motivation

Zurich Return to Play Guidelines

Zurich 2008 guidelines for high school and younger athletes who show ANY symptoms or signs of a concussion:

athlete should not return-to-play in the current game or practice

Athlete should be monitored for deterioration for 24 hours

return-to-play must follow a medically supervised stepwise process

athlete must be symptom-free at rest and after exertion

Zurich Return to Play Progression

1. No activity, complete rest

2. Light aerobic exercise but no resistance training

3. Sport specific exercise and progressive addition of resistance training

4. Non-contact training drills

5. Full contact training and scrimmage after medical clearance

6. Game playAlso should be symptom-free after mental exertion and have normal Neurocognitive test results

Medical Protocol Any athlete who suffers a concussion

should undergo medical evaluation within 24 hours

Anyone with LOC should be evaluated that day

If confused or not fully conscious, transport by EMS with immobilization

Follow athlete until asymptomatic First medical clearance is to begin RTP

progression If no return of symptoms with exertion,

then final clearance for game play

Managing Complex Concussion

Consider referral to specialized provider or program if . . .

History of multiple concussions or other risk factors

Prolonged recovery (> 2 weeks) Worsening symptoms

NYSPHSAAConcussion Checklist

First completed by coach or trainer on the sideline

Follows athlete until cleared to RTP Reviewed by trainer and school medical

director after doctor clearance Improves communication Enforces proper protocol

Guidelines for Return to Schoolafter Concussion

Out of school at first if necessary, and then gradual re-entry as tolerated

Avoid re-injury in sports, gym class and crowded hallways or stairwells

Provide academic accommodations

Communicate and Educate

Academic Accommodations

Rest breaks during school in a quiet location (not always the nurse’s office)

Reduced course and work load Decrease homework

Avoid over-stimulation, (e.g., cafeteria or noisy hallways)

Extra time and a quiet location for tests

P.E. Accommodations Avoid re-injury

Balance, vision, and reaction time may all be affected by concussion

Avoid physical and mental over-exertion Increased HR or BP may increase symptoms Lights and noise in gym or at a sporting event

will aggravate symptoms

Minimize exertion in first 1-2 weeks Increase activity gradually, as tolerated Don’t substitute mental activity for

physical activity !

Summary CDC now recognizes concussion as a

significant public health issue Proper recognition and management of

concussion can prevent serious problems Avoid risky activities and sports until

symptom free, at rest and with exertion Provide reassurance, support, and

academic accommodations as needed Concussion is more than just a bump on

the head !