Concussions in athletes with update on Zurich Concussion recommendations and return to play guidelines for athletes that sustain a concussion.

1. Concussion 101
The Sports Medicine Podcast
SportsMedicinePodcast.com

2. Concussion Rules and Laws
50 states have concussion laws

3. Concussion Rules and Laws
33 states have seat-belt use laws

4. Concussion Rules and Laws
California AB 25 - 2012
• Mandates removal of suspected concussion from play
• Concussion and head injury info sheet signed yearly
California AB 1451 - 2013
• Training for coaches every 2 years
California AB 588 - 2014
• Extends requirements to private and charter schools

5. Concussion Rules and Laws
CIF Rule 313 from 2010
• A student-athlete who is suspected of sustaining a
concussion or head injury in a practice or game shall be
removed from competition at that time for the remainder
of the day. The student-athlete who has been removed
from play may not return to play until the athlete is
evaluated by a licensed health care provider trained in the
education and management of concussion and receives
written clearance to play from that health care provider.

6. Concussion Rules and Laws
CIF Rule 313 from 2010
• A student-athlete who is suspected of sustaining a
concussion or head injury in a practice or game shall be
removed from competition at that time for the remainder
of the day. The student-athlete who has been removed
from play may not return to play until the athlete is
evaluated by a licensed health care provider trained in the
education and management of concussion and receives
written clearance to play from that health care provider.

7. What is a concussion?
Zurich 2012
•“Concussion is a brain injury and is defined as a
complex pathophysiological process affecting the
brain, induced by biomechanical forces. Several
common features that incorporate clinical, pathologic
and biomechanical injury constructs that may be
utilized in defining the nature of a concussive head
injury include…”

8. 1. Concussion may be caused either by a direct blow to the head, face,
neck or elsewhere on the body with an ‘‘impulsive’’ force
transmitted to the head.
2. Concussion typically results in the rapid onset of short- lived
impairment of neurologic function that resolves spontaneously.
However in some cases symptoms and signs may evolve over a
number of minutes to hours.
3. Concussion may result in neuropathological changes but the acute
clinical symptoms largely reflect a functional disturbance rather
than a structural injury and as such, no abnormality is seen on
standard structural neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms that may or
may not involve loss of consciousness. Resolution of the clinical and
cognitive symptoms typically follows a sequential course. However
it is important to note that in some cases, post-concussive
symptoms may be prolonged.
What is a concussion?
Zurich 2012

9. How Concussions Happen

10. What is a concussion?
• Direct blow to head or
• Blow to other part of body with force
transmitted to head

11. What is a concussion?
• Disturbance in brain function
• Brain “shaken” back and forth
• Loss of consciousness NOT required

12. What is NOT a concussion?
• Bleeding in or around the brain
• Stroke
• Skull fracture
• Seizure

14. Symptoms of Concussion
• Initial symptoms
• Headache
• Fatigue
• Dizziness
• Difficulty thinking
• Loss of consciousness

15. Symptoms of Concussion
• Delayed symptoms
• Sleep disturbances
• Frustration/agitation
• Forgetfulness
• Fatigue
Symptoms of Concussion

16. Sports at Risk of
Concussions
Sport Boys Girls
Football 11.2 NA
Lacrosse 6.9 5.2
Soccer 4.2 6.7
Wrestling 6.2 NA
Basketball 2.8 5.6
Field Hockey NA 4.2
Softball NA 1.6
Baseball 1.2 NA
Source: National Academy of Sciences, Datalys Center (2010-12)
PER 10,000 ATHLETIC EXPOSURES

17. Management of concussions
Sideline management
• Exam by medical staff
• SCAT3 form

18. Sport Concussion Assessment Tool
SCAT3

19. Management of concussions
Neuroimaging - CT or MRI
• Limited use in concussions
• Used for ruling out other
conditions with specific findings
on exam

20. Recovery from concussions
• CORNERSTONE = initial period of rest
until acute symptoms resolve
Physical Rest
No training, playing, exercise, weights
Beware of exertion with activities of daily
living
Cognitive Rest
No television, extensive reading, video games?
Caution re: daytime sleep

21. Recovery from concussions
• About 40% resolve in 1-3 days
• Most 85% to 90% resolve in 7 -10 days
• Children and teens may take longer….

22. Return to Play - Step #1
Physical and cognitive rest
• Physical
• No training or practice
• Cognitive
• Limited reading, studying
• Limit computers, phones
• Limit music, video games

23. Return to Play - Step #2
Light Aerobic Exercise
• Walking, stationary bike
• No weight lifting
Objective
• Increase heart rate

24. Return to Play - Step #3
Sport Specific Exercise
• Add running drills
• No heading -soccer
• Non contact
Objective
• Add Movement

25. Return to Play - Step #4
Non-contact Drills
• More complex drills
• Passing drills in football
and soccer
• No heading if soccer
Objective
• Exercise,
coordination,
cognitive load

26. Return to Play - Step #5
Full Practice
• Medical Clearance
• Full contact practice
• Should not be on any
medications for the
concussion

27. Return to Play - Step #6
Return To Game Play
• Should have 24 hours
between each step
• If symptoms occur then
return back to next
lower level

28. Neuropsych testing for
concussions
•Should NOT be sole basis
of management decisions,
but an aid to clinical
decision making
•Important component in
overall assessment and RTP

29. Chronic Traumatic Encephalopathy
CTE
• Neurodegenerative disease
• First reported in 1928
• Protein deposts in brain
• Repetitive trauma to brain (maybe)
• Not related to number of
concussions (lower impacts?)

30. Prevention of concussions
Mouthguards
• May decrease biomechanical
force but no studies show
decrease in concussions
Helmets
• Probably no decrease in
concussions
• May prevent head trauma

31. Summary
Many different causes
Remove from practice or game if suspected
Medical Evaluation for full return to play
Most resolve in 7 to 10 days
Gradual return to play and return to school
Difficult to prevent

32. Questions?