Anatomy Of An Adolescent Concussion: It’s Not Child’s Play A presentation at George Mason High School, Falls Church, VA by Vicki Galliher, ATC, VATL, ACSM on 2/22/2012

1. Anatomy Of
An Adolescent
Concussion:
It’s Not
Child’s Play
Vicki Galliher, ATC,
VATL, ACSM

2. 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

3. 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

4. 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.

5. A concussion is the
most complicated
injury to the most
complicated organ
of
the body

6. Brain Function Mapping

7. 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

8. What happens to your brain?
Power Up Electrical Surge Lost Equilibrium
1 2 3 4
Altered Brain Function Fall Out
•Cognitive
•Visual
•Emotional

9. 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

11. 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.

12. Milliseconds after concussion …

13. Fire in the brain

14. 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.

15. 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

16. 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

17. 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.

18. Second Impact Syndrome - Video
• Dr. Jeffrey Barth, PhD, ABPP-CN
• Director, Brain Injury & Sports
Concussion Institute
• University of Virginia School of
Medicine
http://bcove.me/50uubwlm

19. Second Impact Syndrome
• Preston Plevretes – Life after tragedy
• ESPN: E-60 Second Impact
http://espn.go.com/video/clip?id=5163151

20. The Road
To Recovery …
You only get one
opportunity to manage
the concussion recovery
process the right way

21. Comprehensive medical
Immediate Intervention
assessment
1 2
Team
Approach
•Health care
professionals
•Family support
•School support
4 3
Cognitive Physical
safeguards safeguards

22. Immediate Intervention …
• Remove from play
• Initial assessment &
observation
• Refer for medical evaluation

23. Comprehensive
medical assessment
• Medical evaluation
• Diagnostic imaging
• Neuropsychological testing &
follow-up

24. 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

25. Cognitive safeguards …
Cognitive rest is the most
often neglected aspect of
concussion management

26. 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

27. 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

28. Symptom resolution
Cognitive progression D
Physical progression
Slow and steady
C
B
A It’s Your BRAIN !
•Be patient
•Be honest
•Don’t rush back

29. Current Research & Trends
•Cumulative Effects
•Diagnostic Imaging
•Baseline Testing
•Technology
4
3
1 2

30. Cumulative
Effects

31. 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

32. Diagnostic
Imaging

33. Diagnostic Imaging
• X-rays
• CT Scan
• MRI (Functional / Resting State)
• EEG (Electroencephalograph)
• PET Scan (Positive Emission Tomography)
• DTI Scan (Diffusion Tensor Imaging)

34. Diffusion Tensor Imaging (DTI)

35. DTI Image of Concussed Brain

36. Baseline
Testing

37. IMPACT Testing
• Immediate Post-Concussion Assessment
& Cognitive Testing (IMPACT)
• Pre-season testing is essential in
establishing baseline cognitive & visual
processing values for the student-athlete
• Re-establish baseline values following
concussion recovery

38. Technology

39. Technology
• Helmet design – force &
acceleration sensors
• Mouthguard design
• Playing equipment

40. Thoughts from those living the
reality of an adolescent
concussion

41. It’s not easy …
• Can I do this? … No! Well, can I
do that? … No! What about? … No!
• But I’m BORED !!!
• It’s like being under HOUSE
ARREST !!!

42. Final thoughts &
questions …

43. Thank you …
• Vicki Galliher, ATC, VATL, ACSM
• Athletic Training Coordinator, GMHS
• galliherv@fccps.org
• 571-722-6331 (Office Cell)
• 703-248-5500 Ext 5583 (Office
Phone)