Concussions in Football Jeffrey Kachmann, MD James Keszei
Topics Covered What is a Concussion; Symptoms/Signs of a Concussion; Research on Long Term Effects of Concussions; Second Impact Syndrome (video); How to Deal with Concussions, When in Doubt, Sit it Out (video); Athlete Responsibilities. Return To Play Guidelines Discussion/Questions/Comments (VIDEO)
What is a Concussion? A concussion is caused when there is a jarring or shaking that causes a a rapid onset of brief disruption of brain function. Research has indicated that concussions of youth brains can occur at much higher rate as compared to fully developed adult brains. It is VERY important to realize that it DOES NOT require a blow to the head to cause a concussion! Any acceleration/deceleration or twisting/rotational injury to the body can transmit to the brain. It is a GLOBAL brain injury. Concussions cause real injury to brain tissue. Youth brains react differently, more unpredictably when concussed, which is one of the main reasons why it is so important to recognize signs of concussions and have the athlete sit out until symptom free, while at rest and during exertion. Rotational forces result in more brain injury than blunt trauma.
Initial Evaluation The suspected head injured athlete exam should always begin with basic life support-ONFIELD-particularly with a loss of consciousness-LOC, neurologic symptoms, or spinal pain Airway-check the airway and note obstructions Breathing- breathing rate and pattern, skin/nailbedcolor Circulation-pulse rate and rhythm, nailbedcolor Spine-palpate the entire spine for tenderness or irregularities LOC/Concussion evaluation
Symptoms of a Concussion The Center for Disease Control (CDC) has provided the following signs and symptoms of a concussion: OBSERVATIONS OF COACHES, PARENTS, ATHLETIC TRAINERS Appears dazed and stunned; Is confused about assignment or position; Forgets instructions; Is unsure of game, score or opponent; Moves clumsily; Answers questions slowly; Loses consciousness (even briefly); Shows behavior or personality changes; Can’t recall events prior to hit or fall; Can’t recall events after a hit or fall. “WHEN IN DOUBT, SIT ‘EM OUT”
SYMPTOMS REPORTED BY ATHLETE Headache or “pressure” in head Nausea and/or vomiting Balance problems or dizziness Double or blurred vision Sensitivity to light Sensitivity to noise or ringing in ears Feeling sluggish, hazy, foggy or groggy Concentration or memory problems Confusion Does not “feel right” Neck Pain More irritable or emotional “WHEN IN DOUBT, SIT ‘EM OUT!”
WHAT SHOULD I DO??Any athlete suspected of having a concussion must be removed from play and evaluated by a trained professional knowledgeable about concussions:Trainer/TherapistNurse/NP/PADocHave someone reliable frequently observe and assess the child for at least 24-72 hours or until all signs and symptoms resolveMake sure you have a SCAT card available
THE SCAT CARD Name: ___________________________ Date __________ Sport/Team: _______________________ Mouth guard? YN 1) SIGNS Was there loss of consciousness or unresponsiveness? Y N Was there seizure or convulsive activity? Y N Was there a balance problem / unsteadiness? Y N 2) MEMORY Modified Maddocks questions (check correct) At what venue are we? __; Which half is it? __; Who scored last?__ What team did we play last? __; Did we win last game? __? 3) SYMPTOM SCORE Total number of positive symptoms (from reverse side of the card) = ______
SCAT CARD, COT’D 4) COGNITIVE ASSESSMENT 5 word recall Immediate Delayed (Examples) (after concentration tasks) Word 1 _____________ cat ___ ___ Word 2_____________ pen ___ ___ Word 3 _____________ shoe ___ ___ Word 4 _____________ book ___ ___ Word 5 _____________ car ___ ___ Months in reverse order: Jun-May-Apr-Mar-Feb-Jan-Dec-Nov-Oct-Sep-Aug-Jul (circle incorrect) or Digits backwards (check correct) 5-2-8 3-9-1 ______ 6-2-9-4 4-3-7-1 ______ 8-3-2-7-9 1-4-9-3-6 ______ 7-3-9-1-4-2 5-1-8-4-6-8 ______ Ask delayed 5-word recall now
SCAT CARD, COT’D 5) NEUROLOGIC SCREENING Pass Fail Speech ___ ___ Eye Motion and Pupils ___ ___ Pronator Drift ___ ___ Gait Assessment ___ ___ Any neurologic screening abnormality necessitates formal neurological evaluation by a trained professional
Concussion Treatment First recognize the concussion by onfield, sideline, or ER eval Close observation 24-72 hours minimum—check pupil size , consciousness, movements, ability to think and function Follow RTP-Return To Play- guidelines strictly Rest--Non stimulating environment for a week or until all symptoms cease-NO TV, IPOD, Video Games, Reading, Computers, Loud Noise, Bright Lights Tylenol as needed No alcohol or illicit drugs Frequent evaluations by trainer, medical professional One percent require emergent surgeries Take to the hospital if ever in doubt!
Send your player to the Hospital if: Headaches worsen Too drowsy to wake up Can’t Recognize people or places or very confused Repetitive vomiting—more than once! Seizures Extremity or facial numbness, tingling, pain or weakness Slurred speech Unsteady walk Dilated Pupils or unequal gaze Irregular, slow, or very fast pulse or breathing Any obvious injuries LOC (loss of consciousness) more than 5 minutes
Head Injuries can cause structural injury in and around the brain NEVER forget that a seemingly simple hit resulting in a concussion can cause a: skull fracture epi or subdural hematoma (blood clot on the outside or inside of the lining around the brain) post traumatic subarachnoid hemorrhage (salt n pepper bleeding on the brain surface) intracerebral hemorrhage (bleeding inside the brain-petecchial or larger clot) brain contusion (bruise) axonal shearing injury (nerve fiber or coating injury) Brainstem injury Malignant out of control brain swelling resulting in death or disability Spinal injury (VIDEO)
SECOND IMPACT SYNDROME One of the worst scenarios involving concussions occurs when a youth athlete is concussed during an event, returns to play, and receives a second concussion on top of the existing concussion. In this scenario, and athlete can suffer a traumatic brain injury that can debilitate the youth athlete for the rest of their life, or even result in their death. Particularly in children, a concussion can result in loss of autoregulation of brain blood flow with a rush of blood into the brain blood vessels causing very rapid brain swelling and herniation through the skull and instant death or severe debilty. I have personally witnessed this and it is very scary! WHEN IN DOUBT, SIT ‘EM OUT!
Brain Vulnerability After a Concussion The brain is VERY vulnerable to further injury after a concussion for minutes to days Large numbers of neurons (nerve cells) can die as a result of even small changes in intracranial (inside the head) pressure, blood flow, and anoxia (lack of oxygen—always remember the ABC’s of resuscitation!!!) after a concussion REMEMBER, CONCUSSIONS ARE VERY GROSSLY UNDERDIAGNOSED—UP TO 88% ARE UNRECOGNIZED!!!
REPEATS Athletes involved in a concussion are far more vulnerable to further concussions (VIDEO)
Research on Long Term Effects of Concussions New research regarding the long term effects of repeated concussions can cause some athletes to suffer the progressive neurodegenerative brain disease Chronic Traumatic Encephalopathy (CTE), which eventually leads to dementia. An estimated 10% to 20% of all athletes participating in contact sports suffer a concussion each season. Most athletes recover completely and can return to play following an appropriate period of recovery. Realize that cumulative concussions injure the brain permanently and cause long term effects now and later in life.
Long Term effects from Concussions Memory loss Cognitive disorders (problems thinking through things) Dementia Depression Anxiety PTSD-Post Traumatic Stress Disorder Substance abuse Poor Physical Performance Lack of energy or enthusiasm Irritabilty Headaches Dizziness Insomnia Tremors/Parkinsonism—Muhammad Ali
How to Deal With a Suspected Concussion The most important thing to remember when dealing with an athlete with a suspected concussion is to air on the side of caution. It is not worth the potential long term health problems, or traumatic brain injury, to rush an athlete back into a game or practice situation, prior to being symptom free at rest and during exertion. *****WHEN IN DOUBT, SIT THEM OUT***** Review your league’s concussion policy to ensure the safety of the players is the number one priority. Return to play policy. Many leagues, to include Youth, Middle School, and High School programs do NOT have a return to play policy, which could result in catastrophic injury coupled with legal action.
Athlete Responsibilities As Coaches you must let athletes know they will not be looked down upon or treated unfairly if they report a concussion. Athletes must feel confident they can report symptoms of a concussion without Coaches punishing them for not “Toughing it Out”. Most Athletes are very competitive, however, they are responsible for reporting symptoms and need to understand the potential long term negative effects of not reporting concussions.
www.sportslegacy.org Minimum Recommended Guidelines As a natural evolution of the 10 Point Plan, in September 2010, SLI announced the release of 7 Steps for Brain Safety: Minimum Recommended Guidelines for Youth Sports, a list of practical, simple, and free solutions to minimize brain trauma. On the following pages, you will find a link to recommended programs, as well as links to supplemental programs. Programs should adopt at least the recommended program. If you received a paper version of the 7 Steps, visit www.sportslegacy.org to locate the links. SLI’s 7 Steps for Brain Safety 1. Preseason Education for Coaches 2. Preseason Education for Athletes 3. Preseason Education for Parents 4. Coaches Use CDC’s Heads Up Clipboard Sticker 5. Adopt CDC’s Concussion Action Plan for Removal and Return-to-Play 6. Prevention through Neck Strengthening 7. Prevention through Overall Brain Trauma Reduction
Concussion Return To Play Guidelines SYMPTOMS GRADE 1ST 2ND3RD ***RTP time begins after completely asymptomatic <15 MIN/NO PTA* 1 RTP OK 20 min RTP in 2 wk End season/OK next yr PTA<30MIN/NO LOC**1 RTP 1 week RTP 3-4wks End season/OK next yr PTA>30MIN<24HR/LOC<5MIN 2 RTP 1 week RTP 1 mo or End season/OK next yr end season *PTA=post trauma amnesia **LOC=loss of consciousness ***RTP=return to play
Concussion RTP Guidelines, Cont’d SYMPTOMS GRADE 1ST 2ND3Rd PTA>24HR/LOC>5MIN3 RTP 4-6MO END SEASON OR END SEASON **STRONGLY CONSIDER TRANSPORT TO HOSPITAL ER FOR EVAL W GRADE 3 CONCUSSIONS**
Graduated Return to Play **Athlete MUST be asymptomatic at REST and after EXERTION No activity for ONE WEEK after injury and asymptomatic Cleared to return by trainer/medical professional Component scores of ImPact test normal Gradual daily increase in activity as follows unless symptoms recur—if they recur wait 24 hrs and start progressions from day one again: Light aerobic exercise—walk/slow jog/stationary bike, etc—no resistance training Sport specific activity—throwing/kicking a ball, etc Non contact training drills with resistance training Full contact training drills Return to sport without restriction
REMEMBER Always use certified headgear in practice and game play Make extra sure it fits and is secure Check air bladders and padding each and every time of use Use properly fitting mouthpieces at all times Use IMPACT or equivalent testing Use a SPECT card or equivalent sideline test WHEN IN DOUBT SIT ‘EM OUT!