Concussions and Head Injuries

Kevin Avilla DPT, ATC, CSCS

My Background

Clinical Doctorate Physical Therapy – Northeastern University

MS in Exercise Science UMASS-Amherst

BS in Athletic Training - Northeastern University

Adjunct Professor /Teaching Assistant Lasell College – Athletic Training Education Program Northeastern University - Athletic Training Education Program

Physical Therapy Department NATA Certified Athletic Trainer 12 years

Division I / II /III University and College Settings

Objectives

Inside the Numbers

Defining Concussion/MTBI

Symptomatic Profile

Anatomy and Mechanism of Injury

Management / Return to Play

Complications /Long term concerns

Role of Protective Equipment

MTBI in the News

The Scariest M

oments in Sports

Terminology!!

MTBI (Mild Traumatic Brain Injury) / Concussion▪ WHY???

Use this term when explaining to parents, and athletes

Sound harsh ………………but that is reality

Understanding Concussions

TERMINOLOGY!!!TERMINOLOGY!!!

Hockey and Concussions

Speed Fast moving players Fast moving objects

Surfaces Ice Boards

Contact Mechanisms

Yellow Card

Syndrome

A Quick Quiz!!!!

What’s the Injury

Inside the Numbers

207,830 patients with Sports Related TBIs were treated in U.S. Emergency annually (CDC 2001-

2005)

A previous national estimate of 300,000 SR-related TBIs included only those TBIs involving loss of consciousness studies have reported that only 8%--19% of SR-related

TBIs involve loss of consciousness. Researchers have suggested that 1.6--3.8 million SR-

related TBIs occur each year, including those not treated by a health-care provider.

Inside the Numbers

Ages 5--18 years account for an estimated 65% of ED visits for SR-related TBIs.

CDC Research Ages15 to 24 years, sports are the second leading cause of traumatic

brain injury behind only motor vehicle crashes

2001 -2009 the number of ED visits increased 62% Estimated incidence rates rose from

▪ 190 per 100,000 up to 298 per 100,000▪ 9.7 % of “Hockey Related” injuries were TBIs**

The Sports Concussion Institute estimates that 10% of athletes in contact sports suffer a concussion each season.

Inside the Numbers - High School Sports

A 2007 Study Journal of Athletic Training found (OSU Ohio State and Nationwide Children’s Hospital) 8.9% of all injuries to high school athletes

▪ 9 sports studied ▪ boy’s football, soccer, basketball, wrestling and baseball and girl’s soccer,

volleyball, basketball and softball

Increased 5.5% reported a decade earlier.

Concussion rates are increasing in high school sports 2006 - 92,000 cases of concussions in American high school sports. 1999 - 62,000 cases

▪ Why??

Inside the Numbers – Gender Bias

In sports both sexes played in, high school girls had higher rates of concussion than boys. also seen among college athletes.

Proposed Rationale: Females may be more honest in reporting

symptoms Neck muscular strength Smaller head mass

Inside the Numbers - Hockey Specific

Comprehensive Review* - (1985 -2000) American football, boxing, ice hockey, judo, karate, tae kwon do, rugby, and soccer

“ice hockey athletes demonstrated the highest incidence of concussion (3.6 per 1000 athlete-exposures) [AEs]”

“At the professional level, similar concussion incidence rates were found in both ice hockey and rugby.”▪ (6.5 per 1000 player-games, 95% CI 4.8–8.6) - Ice Hockey▪ (9.05 per 1000 player-games, 95% CI 4.1–17.1) - Rugby

*Journal of Athletic Training 2006;41(4):470–472 Contact Sport Concussion Incidence

Inside the Numbers - Hockey Specific

Data collected from 8 teams in a Division I athletic conference for 1 season using a standardized form: 113 injuries in 23,096 athlete exposures. 65% of injuries occurred during games Concussion (18.6%) was the most common injury, followed

by knee MCL sprains, AC joint injuries, and ankle sprains.

*Flik et al. The American Journal of Sports Medicine Vol. 33, No. 2, 2005 American Collegiate Men’s Ice Hockey Injuries

Inside the Numbers – Women’ s Hockey

Game injury rates 5 times higher than the injury rate in practices (12.6 versus 2.5 injuries per 1000 athlete-exposures, rate ratio = 5.0, 95% confidence interval = 4.2, 6.1, P < .01).

Concussions were the most common injury in both games (21.6%) and practices (13.2%).

Agel et al. Journal of Athletic Training 2()07:42(2):249-254Descriptive Epidemiology of Collegiate Women's Ice Hockey Injuries: National Collegiate Athletic Association Injury Surveillance System,2000-2001 Through 2003-2004

Inside the Numbers - Hockey Specific

Studies indicate 1 in 20 collegiate level hockey players will experience a concussion during their college careers

Nonfatal catastrophic spinal cord and brain injury rates in HS athlets: 2.6 per 100,000 hockey players 0.7 per 100,000 football players

Each season 10%–12% of minor league hockey players 9–17 years report a head injury

Inside the Numbers- NHL

MTBI incidence rates 97/98 -07/08 seasons

HIGH 1.81/1000 athlete exposures in 1998-99 LOW 1.04/1000 athlete exposures in 2005-06. downward trend in the number of concussions reported time lost from play per concussion increased over the same

period (p<0.0005). Forwards suffered a disproportionately high percentage of

concussions (p<0.0001).

The Canadian Journal Of Neurological Sciences 2008 Nov; Vol. 35 (5), pp. 647-51.

Inside the Numbers- NHL

CMAJ 2011Study -1997 – 2004

Team physicians reported 559 concussions

1.8 concussions per 1000 player-hours.

Varied post-concussion symptoms

Time loss (in days) increased 2.25 times for every subsequent concussion sustained during study

What is a concussion?

A clinical syndrome occurring as the result of trauma to the head and characterized by immediate and transient impairment of neural function.

A brain injury

Trauma and Dysfunction Trauma to the brain (Concussion)=dysfunction of

the brain

Resulting Symptoms:

• Alteration in motor patterns

• Changes in cognitive ability

• Changes in memory (amnesia)

• Visual Changes

• Unusual behavior / mood changes

• Disorientation

• Vomiting

• Splitting headache, intense pain, or pressure

Comparison to a soft tissue or joint injury

Example- dislocation of the shoulder

Understand that trauma = dysfunction

Trauma = shoulder is out of normal alignment

Resulting Dysfunction ↓ Range of Motion Swelling Pain ↓ Strength ↓ Functional ability

Understanding Concussions

Force and impact ≠ Severity of Concussion With each concussion the relative

force required is diminished

Large and small forces alike can cause prolonged concussion symptoms

Large impacts may appear worse then they are, and vise versa

Concussion Symptoms

Symptoms may arise immediately after impact or take some time to develop

A delayed onset of symptoms may make it difficult to recognize early in the injury process, especially in “lower grade” concussions

Symptoms are unique to the athlete and all concussions present differently

Symptomatic Presentation

The concussive forces may cause confusion, amnesia, either immediately or shortly after impact.

▪ Often times recognized by other athletes ▪ Major Symptoms may be day(s) later

The alteration in function is secondary to trauma on the brain Symptoms scores via

Impact Testing(Former UMASS Athlete)

0

10

20

30

40

50

Day 1 Day 8 Day 11

Understanding the Anatomy

Brain is essentially free floating with the skull surrounded by a layer of protective fluid

Within the skull the brain has some ability to move

Similar to an egg yolk within an eggshell

Mechanism of Concussions

How concussion occur: 2 main mechanism

▪ Coup and Countrecoup

▪ Coup Mechanism – Direct Trauma Occurs when a moving head hits a stationary objects:

▪ The brain has direct contact with the skull at the site of impact

Head hitting the ice after a fall Head hitting the boards

Mechanism of Concussions Countrecoup Mechanism

Injury to the brain occurs in the opposite direction of the initial force or impact

Generally seen when the head and neck accelerate and decelerate quickly

“whiplash effect”

Can have combo type concussions Coup-countrecoup Injuries Collision with “whip lashing”

and the head hitting the ice afterwards

Movement of the

Brain

Impact

Force

Concussion Grading

A number of grading scales exist with the implication that a higher grade = greater severity.

Symptoms Gra

de I

Grade II Grade III

L. O . C None No L.O.CLOC up to 5 minutes*

L.O.C secs – mins> 5 minutes*

Altered Mental State Limited, <15minutes

> 15 minutes

RTP Criteria Upon resolution of Symptoms

Medical Authority1 week asymptomatic

Medical Authority

Notes: Often not reported

-LOC treat as cervical spine injury

-LOC treat as cervical spine injury -Transport via medical advanced medical services

I don’t care about grades

General Rules for Managing Athletes with Concussions

Treat athlete based on symptoms, grading scales can be deceiving.

Loss of consciousness does not necessarily indicate the seriousness

Continue to stress to athletes and parents that these are brain issues

Utilize Coaches Card A tool for management Some inherent problems if sole basis of decision

General Rules for Managing Athletes with Concussions

Avoid alcohol as symptoms may be masked

Appropriate adjustments to academic coursework

Avoid stimulating environments video games Theaters Concerts

''I was the captain of a team, the father of three, and all of a sudden I was having trouble taking a

shower,'' LaFontaine said. ''There was depression, emotional issues. I could not watch a hockey game on television. It was too fast for me.''

Loss of Consciousness

If an athlete become unconscious after a head injury or fall – Cervical Spine Injury Athlete should not be moved

What is your action plan? Has it been practiced?

Things to consider▪ CPR /AED Certification – readily available??▪ Ambulance – entrance, designate coach, manager▪ The injured athlete???

Returning to Play (RTP)Proper Management

Monitor symptoms Athlete’s condition can worsen ma be

larger medical concern

▪ Sub-dural hematoma

▪ Epi-dural hematoma

▪ pressure on the brain, resulting in bruising (hematoma) injuring brain tissue

▪ a progressive decline in function and increase in the severity of symptoms

Occur acutely, but recent research has shows more likely when RTP to soon from a head injury and sustaining another

Returning to Play (RTP) Proper Management

Using Subjective and Objective Measures Many organizations are utilizing computer based assessments to

evaluate the athletes function

IMPACT Testing▪ Computer based assessment▪ Baseline measure – post concussion measures

▪ Measures a number of variables Visual memory Verbal memory Reaction time Recall

▪ A tool in the overall management of concussions▪ Often will show significant decrease in function even though reported symptoms

appear to be improving

Neurophysiologic Testing

Returning to Play (RTP)Proper Management

A Stepwise progression Can only move through progression 1 day at a time Any manifestations of previous symptoms athlete move to previous level

▪ 1-Asymptomatic Rest▪ 2-Light activity to stimulate an increase in HR

(no jarring of the head)▪ 3-Sports-Specific Tasks- Skating▪ 4-Non-contact practice▪ 5-Full contact training with medical clearance▪ 6-Return to competition

*Younger athletes will need more to time to heal

Return to Play

Never in the same game if concussion suspected Who makes the decision?

-League Policies?? Signed Documentation State Mandates:

Zak Lysted Bill

Zak Lysted Bill

Sample Legislation - MA

105 CMR 201.000 ~Head Injuries and Concussions in Extracurricular Athletic Activities. All parties must participate in yearly training Student removed form competition not allow to return

same day Must have documented clearance to RTP

▪ Only the following professional can designate RTP:▪ A duly licensed physician; certified athletic trainer,

nurse practitioner in consultation with a licensed physician; or neuropsychologist

From this policy and required documentaiton, statistical database will be generated

Second Impact Syndrome

A catastrophic event when a second concussion occurs while the athlete is still symptomatic from the first

The second concussion causes additional swelling and greater damage to the brain tissue

SIS is fatal

Widespread damage can result in many changes within brain’s functioning, resulting in permanent brain damage

In general athletes who have sustained a concussion are 3xmore likely to sustain a second concussion than those with no history of head injury

Athletes who are still symptomatic from a previous concussion should always be Dq’d with SIS in mind

Secondary Impact Syndrome (5:22)

Concussions-Long Term Risk

Generally as the number of total concussions increase so does the likelihood of PCS (Post-Concussion Syndrome)

PCS-is a set of disorders that affect many brain functions including: emotions, behavior and cognitive ability

Just as repeated soft tissues become cumulative, so do injuries to the brain Only problem the brain cannot be repaired surgically at the end of the

season

Can last for weeks, months, and even years

Generally PCS is the reason you hear athletes retiring early

Post-Concussion Syndrome

''I can't remember that day, I can't remember what happened,'' …..''I got knocked out. It took me about three weeks before I could start eating normally, before I could start remembering a lot of things.'‘

- Jeremy Stevenson

Chronic Traumatic Encephalopathy

“Dimentia Pugilista”

Repeated concussions have been linked to Alzheimer's disease, clinical depression

Also implicated in Parkinson's Example: Muhammad Ali

Patients with a history of brain injuries have been shown to exhibit Alzheimer’s related symptoms at an average of 8 years younger than patient with no associated history

A study of more than 2,500 retired NFL players found that those who had at least three concussions during their careers had triple the risk of clinical depression as those who had no concussions.

Chronic Traumatic Encephalopathy

Chronic Traumatic Encephalopaty Receiving much attention in

the mainstream media

BU Center for Traumatic Encephalopathy

Research is supporting the links between several conditions and repeated head trauma

Concussion Prevention

Concussions in contact sports will always occur

However numbers can be limited with proper fitting equipment Proper Helmet fitting

▪ Use of HECC certified helmet▪ Constant review of “snugness" of the helmet

What’s the best type of Helmet?

Enforcement of current rules structure

Role of Protective Equipment – Helmet Types

Facial protection showed a statistically significant (p<0.05) reduction in the number and type of facial injuries

(FFP) versus half facial protection (HFP), FFP offered a significantly higher level of protection against facial injuries and lacerations than HFP (relative risk (RR) 2.31, CI 1.53 to 3.48)

There was no significant difference in the rate of concussion or neck injury (CI 0.43 to 3.16) between full and partial protection.

In those who sustained concussion players with FFP returned to practice or games sooner than players with partial facial protection (PFP)

Facial protection and head injuries in ice hockey: a systematic review. Authors: Asplund C; Bettcher S; Borchers J Affiliation: The Ohio State University Sports Medicine Center, 2050 Kenny Road, Suite 3100, Columbus, OH 43221, USA. chad.asplund@osumc.edu. Source: British Journal of Sports Medicine (BR J SPORTS MED), 2009 Dec; 43(13): 993-9

Role of Protective Equipment Mouth Guards

2005 Study – University male football (394) and university males (129)

and female (123) rugby athletes reporting to 2003 fall training camps.

Primary Measure Concussion Symptoms based on American Academy of Neurology Concussion

Secondary endpoints included the incidence of dental trauma events and observed concussion symptoms.

Experimental Groups Specific Type II Mouth Guard Control Group – allowed to used mouth guard of choice.

Barbic et. al. Comparison of Mouth Guard Designs and Concussion Prevention in Contact Sports: A Multicenter Randomized Controlled Trial Clinical J Sport

Med Volume 15, Number 5, September 2005

Role of Protective Equipment Mouth Guards

“This trial found no benefit in concussion prevention when using the WIPSS Brain-Pad mouth guard when compared with other mouth guards in standard use by athletes participating in football and rugby at 5 Canadian universities”

Knapik et al.

“There is currently insufficient evidence to determine whether mouth guards offer protection against concussion injury, and more work of good methodological quality is needed. Mouth guard use should be promoted in sports activities where there is a significant risk of orofacial injury”

Mouth guards in Sport Activities History, Physical Properties and Injury Prevention Effectiveness. Sports Med 2007; 37 (2): 117-144

NATA Position Statement on Concussions

“no advantage in wearing a custom-made mouth guard over a boil-and-bite mouth guard to reduce the rise of cerebral concussion in athletes. However, ATCs and coaches should mandate the regular use of mouth guards because a properly fitted mouth guard, with no alterations such as cutting off the back part, is of great value in protecting the teeth and preventing fractures and avulsions that could require many years of expensive dental care.”

Additional Resources

CDC (Center for Disease Control and Prevention) Heads Up CampaignCoaches Tool Kit

http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm

http://www.biausa.org/

IMPACT Testing Home Pagehttp://www.impacttest.com

Thank You

Discussion Questions Comments

Kevin Avilla▪ kevinavilla@gmail.com