Anatomy OfAn Adolescent Concussion: It’s Not Child’s Play Vicki Galliher, ATC, VATL, ACSM
By The Numbers• Concussions account for 1 in every 10 sports injuries according to the Centers For Disease Control & Prevention• Concussions send 1.7 million individuals to the emergency room (ER) each year• Nearly half of those ER visits are for children 14 years of age and younger
Thinking … then and now• Severity of concussion is only indirectly related to the physical force of the impact• Brain has no pain receptors – impact can only be perceived indirectly, as a headache or loss of consciousness• No clear threshold for concussive injury
Thinking … then and now• Less than 5% of all concussions are accompanied by loss of consciousness.• Football ranks only slightly higher than girls’ soccer for incidence of youth concussions. Youth ice hockey and wrestling are trending close behind.• There is no helmet that can prevent an athlete from sustaining a concussion.
A concussion is the most complicated injury to the mostcomplicated organ of the body
Not In Question• A concussion IS a traumatic brain injury (TBI). About 75% of TBIs that occur each year are concussions.• TBIs can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions• TBIs can cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age
What happens to your brain?Power Up Electrical Surge Lost Equilibrium 1 2 3 4 Altered Brain Function Fall Out •Cognitive •Visual •Emotional
Power up …• The brain consists of billions of nerve cells which communicate with distant nerve cells via long nerve fibers called axons• Severe sudden twisting or torquing of the brain - as occurs in sudden acceleration/deceleration motion - stretch, twist, and shear the delicate axon fibers
Electrical Surge … “Fire in the brain” • The nerve cells fire simultaneously, causing a mini-seizure. As they fire, K+ rushes out of the cells as Ca+ rushes in, clogging the neurons’ mitochondria. • To fuel the absorption of new K+, the neurons consume glucose (sugar). • Metabolization (breaking down) of glucose creates lactic acid. Lactic acid damages cell walls.
Lost equilibrium …• The calcium-clogged mitochondria do not get essential oxygen. This causes a neuronal energy crisis.• Blood flow diminishes and brain cells begin to die.• Brain cells in the adolescent brain are still developing. Cell death is devastating to the present & future functioning and growth of the adolescent brain.
Fall Out … “Post-Concussion Syndrome”• Physical symptoms can arise almost immediately to within 4 weeks from the initial concussive injury• The predominant physical symptoms include: headache, dizziness, moderate-to-extreme fatigue, insomnia, and irritability• Predominant cognitive symptoms include: memory loss (retrograde amnesia, anterograde amnesia), difficulty concentrating, impairment of higher level cognitive/executive functioning
In the aftermath …• The brain remains extremely fragile – healing must be uninterrupted by subsequent injury• Neurons are still starved for energy• Even a minor “secondary impact” can unleash a devastating molecular cascade
In the aftermath …• If healing is interrupted, brain cells that seemed to be regaining their balance begin committing suicide - end result is massive loss of neurons.• No one knows why this loss occurs, but the loss is permanent.• Youth are particularly susceptible – brain is still developing. Even slight cell loss can alter the trajectory of brain growth.
Second Impact Syndrome - Video • Dr. Jeffrey Barth, PhD, ABPP-CN • Director, Brain Injury & Sports Concussion Institute • University of Virginia School of Medicinehttp://bcove.me/50uubwlm
Second Impact Syndrome • Preston Plevretes – Life after tragedy • ESPN: E-60 Second Impacthttp://espn.go.com/video/clip?id=5163151
The Road To Recovery … You only get one opportunity to manage the concussion recovery process the right way
Comprehensive medicalImmediate Intervention assessment 1 2 Team Approach •Health care professionals •Family support •School support 4 3 Cognitive Physical safeguards safeguards
Immediate Intervention …• Remove from play• Initial assessment & observation• Refer for medical evaluation
Comprehensive medical assessment• Medical evaluation• Diagnostic imaging• Neuropsychological testing & follow-up
Physical safeguards …• No physical activity at school or home• No sports participation – must be extra vigilant with younger players who are more likely to be injured• Careful observation & monitoring of symptoms
Cognitive safeguards …Cognitive rest is the most often neglected aspect of concussion management
Cognitive safeguards …• Symptom exacerbation, or re- emergence of symptoms in the wake of cognitive or physical exertion, is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits• Neurometabolic activity can interfere with concussion recovery• Current research has demonstrated that a significant degree of symptom exacerbation follows cognitive exertion
Cognitive safeguards …•Cognitive rest !!!!!!!!!!!!• Minimize brain stimulation – cognitive & visual• Turn it off !! Computer Video Games Texting Reading Puzzles Music Lighting Audio Books Board & Card Games
Symptom resolutionCognitive progression DPhysical progression Slow and steady C BA It’s Your BRAIN ! •Be patient •Be honest •Don’t rush back
Current Research & Trends •Cumulative Effects •Diagnostic Imaging •Baseline Testing •Technology 4 3 1 2
Cumulative Effects of Multiple Concussions (Athletes with 3 or more prior concussions)• More likely to experience loss of consciousness, prolonged post-injury mental status changes and greater severity of post-injury symptoms• Exhibit impaired memory – short & long term• Longer recovery time with each subsequent concussion• Score significantly lower on auditory processing tasks• Exhibit slower cognitive & visual processing speed