CONCUSSIONS 101MARK BROWN,MD,FAAP

CONCUSSION CENTER NORTH ATLANTA

Or…. why are we making such a big deal about

it????©MARK BROWN , MD,FAAP-CONCUSSION CENTER NORTH ATLANTA

2012www.concussioncenternorthatlanta.com

WHY ARE WE MAKING SUCH A BIG DEAL ABOUT CONCUSSIONS?

1.8-3.5 MILLION CONCUSSIONS PER YEAR IN CONTACT SPORTS YOUTH TEENS

20 concussions per 1 knee surgery

NFL FACTS-LONG TERM ISSUES1/1000 CHANCE 30-49 YEAR OLD MAN RECEIVES

DIAGNOSIS OF ALZHEIMER’S, DEMENTIA OR OTHER ORGANIC BRAIN SYNDROME

1/53 CHANCE EX-NFL PLAYERS DIAGNOSED WITH SAME PROBLEMS!!

WHAT IS A CONCUSSION

DECELLERATION/ROTATION INJURY-HEAD STOPS OR CHANGES DIRECTION BUT BRAIN KEEPS MOVING AND BOUNCES OFF INSIDE OF SKULL

IT IS A METBOLIC EVENT NOT STRUCTURAL

WHAT HAPPENS IN A CONCUSSIONCELLS IN BRAIN STRETCHED BUT NOT

TORN LEAK POTASSIUM OUT OF CELLSTRIGGERS BRAIN TO TRY TO PUMP

POTASSIUM BACK IN/BRAIN GOES INTO HYPERDRIVE WANTS MORE SUGAR AND BLOOD FLOW TO HEAL

CALCIUM LEAKS INTO CELLS AND CAUSES CONSTRICTION OF BLOOD FLOW

SO………………………………..

CONCUSSIONINTRACELLULAR EVENTS

COMPLICATED OR UNCOMPLICATED CONCUSSON?

IF YOUR PLAYER OR CHILD IN INJURED ON THE FIELD HOPEFULLY TRAINER OR MEDICAL PERSONEL THEIR, BUT IF NOT………

EMS TO HOSPITAL OR HOME UNDER PARENT’S CARE?

CT OR NO CT

CONSUSSION SYMPTOMS THAT INDICATE NEED FOR CT

UNCONSCIOUS > 30 SECONDSSEIZURE BLOOD FROM EARSVOMITING 3 OR MORE TIMESSEVERE NECK PAIN/NUMBNESS WEAKNESS ARMS

OR LEGSPERSISTANT/WORSENING CONFUSION OR

DISORIENTATION/SLURRED SPEECH HEADACHE SUDDENLY MUCH WORSE-ALMOST

ALWAYS WITH RECURRENT VOMITINGFOCAL NEUROLOGICAL ABNORMALITY ON

PHYSICIANS EXAM

CONCUSSION SYMPTOMS THAT INDICATE NO NEED FOR CT

NO LOC(96.8%) OR JUST FEW SECONDSAMNESIA AROUND THE EVENTHEADACHE-OFTEN PRESSURE TYPEONE OR TWO EPISODES OF VOMITING/NAUSEADROWSY BUT EASILY AROUSEDBLURRED VISION* /SENSITIVE TO LIGHT AND NOISEREPETATIVE QUESTIONS/CONFUSION *SLOW RESPONSE TO CONVERSATION/BLANK STAREBALANCE ABNORMALITIES

(*SYMPTOMS IMPROVE SHORTLY AFTER CONCUSSION)

WHAT HAPPENS IN CONCUSSIONJUST WHEN BRAIN NEEDS MORE BLOOD AND

NUTRIENTS IT GETS LESS…

“THE TIRED BRAIN”

THIS METABOLIC CRISIS BETWEEN ENERGY NEEDS AND SUPPLY THAT CAN LAST …FEW HOURSFEW DAYS FEW WEEKS

AS LONG AS MISMATCH SYMPTOMS OF CONCUSSSION WILL CONTINUE AND MORE

IMPORTANTLY PATIENT WILL BE AT RISK FOR 2 COMPLICATIONS WHICH ARE…

WHAT HAPPENS IN CONCUSSION

SECOND IMPACT SYNDROMECATASTROPHIC FATAL OR PERMANTLY

DAMAGING SWELLING OR BLEEDING OF BRAIN THAT OCCURS ONLY IN A PATIENT WHO HAS HEAD TRAUMA AND: IN A PATIENT WHO IS NOT FULLY RECOVERED

FROM PREVIOUS CONCUSSION IN PLAYERS UNDER 23 YEARS OF AGE/USUALLY

UNDER 21 VERY RARE ONLY 1-2 CASES IN USA PER YEAR

BUT EFFECTS ARE PERMANENT OR FATAL

WHAT HAPPENS IN CONCUSSION

POST-CONCUSSIVE SYNDROMECONCUSSIVE SYMPTOMS OVER 3 WEEKS

SYMPTOMS OF CONCUSSION RECUR WITH MINOR STRESS AND OR TRAUMA OVER SEVERAL MONTHS

NOT AS SERIOUS AS SECOND IMPACT BUT CAN BE SEVERELY DEBILITATING

AS IN SECOND IMPACT ONLY HAPPENS IN A PATIENT WHO HAS NOT FULLY RECOVERED FROM PREVIOUS CONCUSSION(S)

WHAT HAPPENS IN CONCUSSIONHOW LONG DOES IT TAKE TO RECOVER?

60-70% BY 10 DAYS70-80% BY 2 WEEKS90% BY 3 WEEKS95% BY 4 WEEKS

THE REMAINING 5% CAN TAKE WEEKS OR MONTHS BUT MOST OF THESE HAD PREVIOUS CONCUSSIONS THEY NEVER FULLY RECOVERED FROM SO MOST OF THESE ARE ACTUALLY PATIENTS WITH CHRONIC CONCUSSIVE SYNDROME

WHAT HAPPENS IN A CONCUSSION

HOW DO WE PREVENT COMPLICATIONS??IMMEDIATE REMOVAL FROM GAME PLAY AND NO

RETURN UNTIL CLEARED BY MEDICAL PROFESSIONAL.

DOCUMENT NO FOCAL FINDINGS ON COMPLETE NEUROLOGICAL AND PHYSICAL EXAMINATION

NO EXERTION AT ALL UNTIL SYMPTOM FREE AT REST

THEN BEGIN SUPERVISED ORGANIZED PROGRAM OF INCREASING ACTIVITIES UNTIL SYMPTOM FREE AT FULL EXERCISE(ALL SPORTS DRILLS OTHER THAN CONTACT)

DOCUMENT NORMAL NEUROPSCHYCOLOGICAL TESTING(ImPACTtm)

SYMPTOM FREE AT FULL CONTACT SPORT ACTIVITY

WHAT IS SYMPTOM FREE? ALL OF THESE SYMPTOMS SHOULD BE TOTALLY GONE

SYMPTOMS“FOGGY”HEADACHENAUSEA/VOMITLIGHT SENSITIVENOISE SENSITIVETROUBLE

CONCENTRATINGDIZZYBALANCE PROBLEMSNUMBNESS

SYMPTOMSTROUBLE FALLING

ASLEEPSLEEP MORESLEEP LESSDROWSYFATIQUEMORE EMOTIONAL IRRITABLESADNERVOUS

WHAT IS PROGRESSIVE EXERCISEWHEN SYMPTOM FREE AT REST FOR 1 DAY

START LIGHT EXERCISE WALKING/LIGHT JOG/LIGHT WEIGHT LIFTING NO SQUATS OR

BENCH PRESSES LOWER WEIGHTS THEN ….START MODERATE EXERCISE

MODERATE JOGGING, BRIEF RUNNING, MODERATE WEIGHT LIFTING ALL EXERCISES LOWER REPS AND WTS. THEN …

START HEAVY EXERCISE SPRINTING/RUNNING/REGULAR FULL WEIGHT LIFTING/FULL NON

CONTACT SPORT WORKOUTS.

PROGRESS TO NEXT LEVEL WHEN SYMPTOM FREE AT PREVIOUS LEVEL FOR A DAY. IF HAVE SYMPTOMS REST FOR A DAY AND GO

BACK TO PREVIOUS LEVEL THAT YOU TOLERATED.

STATE AND INTERNATIONAL GUIDELINES FOR RETURN TO PLAY

GEORGIA HIGH SCHOOL ASSOCIATIONNO RETURN TO PLAY DAY OF INJURYNEED TO BE CLEARED BY HEALTH

PROFESSIONAL DEFINED BY THE STATE(MD,DO,CMT)

CLEARANCE SHOULD INCLUDE GRADUAL INCREASED EXERTION TOLERANCE

2009 ZURICH CONSENSUS ON CONCUSSIONSSAME AS GEORGIA BUT ADDED

NEUROPSYCOLOGICAL TESTING

WHY NEUROPSYCHOLOGICAL TESTING?TRUE HEALING OF BRAIN IS VERY HARD TO

TESTSTANDARD CT AND MRI NOT HELPFULFUNCTIONAL MRI HAS BRIDGED THE GAP

PATIENT DOES TASK(FUNCTION) WHILE IN MRI

UNFORTUNATELY EXTREMELY EXPENSIVE/TIME CONSUMING/REQUIRING MULTIPLE PERSONEL

BREAKTHROUGH STUDY 2006-7 CORRELATED IMPACTTM WITH fMRI

FUNCTIONAL MRI VS ImPACTTM SCORES VS PATIENT SELF REPORTING

FUNCTIONAL MRI-PATIENT DOES TASKS WHILE IN MRI

AREA OF BRAIN THAT HAS TO WORK HARDER THAN NORMAL TO DO TASK IN RED

STUDY HAS SHOWN ATHLETES REPORT FEELING “NORMAL” AT TIME STILL ABNORMAL FMRI.

SEVERAL STUDIES HAVE CORRELATED FULL RECOVERY OF NORMAL fMRI TO NORMAL ImPACT POST INJURY SCORES.

SO…..IF WE HAVE …..CLEARED BY PHYSICIAN NO FOCAL PROBLEMS

SYMPTOM FREE AT REST AND THEN FULL EXERTION

NORMAL ImPACT TEST

WE HAVE

FULL RECOVERY!!

CONCUSSION PREVENTIONHELMET FIT MOST CRITICAL

ESPECIALLY IN YOUNGER GROUPSTEACH PROPER TECHNIQUES

HEADS UP AT ALL TIMESNO SPEARING

SEVERE PENALTIES

CONDITIONING/HYDRATIONNECK STRENGTHLIMIT “HITS”

POP WARNER RECOMMENDATIONS CONTACT PRACTICES 1/3 TOTAL DRILLS HEAD TO HEAD 3 FEET APART

HOW TO FIT FOOTBALL HELMET*First, make sure the helmet has a sticker with the

acronym NOCSAE, which stands for the National Operating Committee on Standards for Athletic Equipment. The national organization certified and then evaluates and recertifies helmets to make sure they meet safety standards.

Next, inspect the helmet for damage on the outside and inside.

When evaluating the helmet for proper sizing, make sure the ear holes line up with the ears, the front of the helmets sits about an inch or two-

finger width from the eyebrow, the cheekpads touch the cheeks and the back shell

covers the skull but doesn’t cut into the neck.The helmet shouldn’t twist when the face mask is pulled

from side to side *AKRON BEACON JOURNAL 2011

FURTHER INFORMATION AND ImPACT© TESTING

FOR SUMMARY OF TALK TONIGHT FOR CODE TO TAKE BASELINE ImPACT©

TEST

E-mail brownosu77@aol.com

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REFERENCESMcCrory, P., et.al., Consensus statement on concussion in

sport, held in Zurich, November 2008, Journal of Clinical Neuroscience, 16(2009), 755-763

Lovell, MR, et al, Functional brain abnormalities are related to clinical recovery and time to return-to-play decisions in athletes. Neurosurgery. Aug 2007;61(2):352-60

Collins MW et al, Cumulative effects of concussion in high school athletes. Neurosurgery, 51:1175-1181,2002

Guskiewicz K, et al, Cumulative effects associated with recurrent concussion in collegiate football players, The NCAA Concussion Study, JAMA 2003;290(19):2549-55

Collins, MW et al, Return to play following sports-related concussions, Clinics in Sports Medicine , 2004 July23(3), 421-441

Cantu, RC. Second -impact syndrome with a small subdural hematoma. J Neurotrauma. 2010 Se:27(9):1557-64