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  • Pathophysiology : The functional changes associated with or resulting from disease or injury. Biomechanics: is the application of mechanical principles on living organisms.
  • 5 Emergency Departments (ED’s) in Edmonton, AlbertaPatient: all personsin a 1-year period reporting to the ED’s with a Head Injury (HI)HI defined as: IC9 – CM coded skull fracture, loss of consciousness, concussionAll children and adultsThese number include sports, recreational and other accidents. Emergency Department; Children’s Hospital; Calgary, ABPatients: 4 year period (2000-2003), ages 6-16Finland (2001) Head injuries accounted for 9% of all sports/recreation injuries for under 6 year-olds; 13% for children ages 6 to 16. France (2003): Head & neck injuries accounted for 17.25% of all sports/recreation injuries.
  • Retrospective survey of 289 players in the CFL in 1997 Athletes were asked: 1. whether they had experienced specific symptoms after a blow to the head; 2. whether they had sustained a concussionResults: 44.8% reported the experience of headaches, dizziness, memory difficulties, blurred/abnormal vison, nausea, after a hit.Only 18.8% recognized they’d experienced a concussionSymptoms lasted at least 1 day in > 25% of casesOther evidence of underreporting – Wiliamson (2006) under reporting in hockey in BCProblem with definition Self-reporting vs. interview; report fewer in an interviewGirls report more symptoms
  • US/Canada Sports & Recreation Injuries identified by athletic trainers
  • Number of concussion related ED visits 2005 from sport, top 5 causes by age and sex. Note: Based on registrants who live in the Capital Health region and are active on the Alberta Health Care Insurance.
  • HockeyProfessional (Europe): 14.3% of all injuries; 0.16/1000 hoursCollege (Canadian Intercollegiate): 7.5% of injuries; 1.5/1000 hoursHigh School (US): 18.7/1000 hoursMinor HockeyHigh School: (Canadian); 17.6/1000 hoursPeewee: 23.1/1000 hoursBantam: 10.7/1000 hoursTae kwon Do(tournaments) Concussions accounted for 50/1000 athlete exposuresOther reports 5.1 to 17.1/1000 athlete exposuresSkating (athletes presenting to hospitals; 1993 to 2003)Total Injuries: 1,235,467Hockey: 4.6%; Roller skating (0.6%); Inline skating (0.8%)Children < age 6 had 2X the head injuries as older childrenRugbyPremier League (Europe): 9.05/1000 player hoursHigh School: 10.26/1000 player hoursBoxingProfessionals: 0.8/10 roundsAmateur: 7.9/1000 man minutes
  • HockeyProfessional (Europe): 14.3% of all injuries; 0.16/1000 hoursCollege (Canadian Intercollegiate): 7.5% of injuries; 1.5/1000 hoursHigh School (US): 18.7/1000 hoursMinor HockeyHigh School: (Canadian); 17.6/1000 hoursPeewee: 23.1/1000 hoursBantam: 10.7/1000 hoursTae kwon Do(tournaments) Concussions accounted for 50/1000 athlete exposuresOther reports 5.1 to 17.1/1000 athlete exposuresSkating (athletes presenting to hospitals; 1993 to 2003)Total Injuries: 1,235,467Hockey: 4.6%; Roller skating (0.6%); Inline skating (0.8%)Children < age 6 had 2X the head injuries as older childrenRugbyPremier League (Europe): 9.05/1000 player hoursHigh School: 10.26/1000 player hoursBoxingProfessionals: 0.8/10 roundsAmateur: 7.9/1000 man minutes
  • American Academy of Neurology (1997)Guidelines to diagnosing severity in concussionsGenetic markers can expose athletes with higher likelihood of mild cognitive impairment & longer recovery from head injuries
  • Recent changes in the approach and management of concussions are a result of research.
  • Impairments are often identified in reaction time, memory, concentration, processing speed, and complex problem solving.
  • Studies have found that those with a history of concussion are 3 to 5 times more likely to sustain a concussion than those with no history (Guskiewicz et al. 2003; Zemper 2003).Guskiewicz et al (2005) investigated the association between head injury and the likelihood of developing Mild Cognitive Impairment and Alzheimer’s Disease later in life. However, this recommendation (permanent removal after 3 concussions) is based only on opinion and not on scientific fact.
  • Moser et al. (2005) Number of concussions and increased recovery timeField, et al (2003) identified a relationship between age and recovery from a sports-related head injuryFound that high school athletes with a concussion had prolonged memory dysfunction (at least 7 days), compared to college athletes with a concussion (approx 3 days) Conclusion: This preliminary data points to the need for more studies into the connection between age and recovery time, and suggeststhat younger athletes may need longer recovery times following a head injuryAsplund, et al (2004), on the other hand, found no relationship between concussion outcome and variables such as age, sex, or history of a Learning Disability
  • Since 1950 there have been 38 cases reported.
  • ImPact – can complete a baseline test for $25, post-concussion test for $10 but results must be read by certified medical doctor. Both HeadMinder and CogSport have options to buy their baseline/concussion assessment tests fro approximately $500.
  • Research regarding the use of mouth guards as preventative equipment is inconclusive (Barbick, 2005).Some studies showing no difference in athletes using mouth guards versus those who don’t (Mihalik, 2007). Use of mouth guards continues to be mandated by Athletic Associations to reduce maxillofacial and dental trauma.

Sport concussion 2010 Sport concussion 2010 Presentation Transcript

  • Sport Concussion
    A Publication of
    The Sport Medicine Council of Alberta 1
  • The Purpose of this Course
    To raise awareness on the seriousness of sport concussions.
    To decrease the number of sport related concussions.
    To provide insight into the newest information on concussion management and prevention.
    2
    Sport Concussion 3
  • Look on the bright side
    3
    For a few seconds you forgot you were a Calgary Flame
    Sport Concussion 3
  • Some Humor
    4
    Sport Concussion 6
  • The Myths of Concussions
    Its not a serious injury
    A second hit to the head will make the concussed person feel better
    Concussions get better within 7 days
    Its only a short-term injury
    You have to lose consciousness
    Others…
    5
    Sport Concussion 84
  • The Challenge of Concussions
    6
    Sport Concussion 84
  • What is a Concussion?
    Section 2
    7
    A Publication of
    The Sport Medicine Council of Alberta 5
  • Definition
    “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”.
    8
    Sport Concussion 6
  • Diagnostic Tests
    Concussions involve a disruption of brain function rather than structural damage.
    The majority of time CT scans or MRI tests show no obvious damage.
    9
    Sport Concussion 42
  • Neurometabolic Changes and Concussion
    Trauma/Concussion
    Diffuse axonal injury
    Massive release of K+ ions
    Glycolysis for K + pumps
    Sport Concussion 7
  • Neurometabolic Changes and Concussion
    Sport Concussion 7
  • fMRI
    12
    Sport Concussion 3
  • fMRI
    13
    Sport Concussion 3
  • Impact Mechanics
    A contrecoup injury is a result of axial rotation with acceleration, this causes an injury away from the actual impact site.
    14
    Sport Concussion 12
  • Concussion Rates
    15
    A Publication of
    The Sport Medicine Council of Alberta 5
  • How Often Do Concussions Occur?
    On average, 3-5% of all sport and recreational injuries are head injuries.
    The majority of sport related head injuries are mild.
    The most common cause of sport related head injuries are falls.
    16
    Sport Concussion 15
  • How Often Do Concussions Occur?
    Patients younger than 20 years old are more likely to suffer a sports related head injury.
    Males are more frequently injured. These statistics are changing as more females engage in contact sports.
    Very few head injuries are hospitalized.
    17
    Sport Concussion 16
  • Recognition of Concussions
    It is common for athletes to underreport the incidence of sport concussions.
    Often athletes do not associate their symptoms with those of a concussion.
    18
    Sport Concussion 17
  • Athletic Trainers Report
    Athletic Trainers from Canada and the United States identified head injuries as 5% of their total sports injuries.
    X Top sports?
    19
    Sport Concussion 18
  • Top Causes of Concussions
    Female
    Soccer
    Horseback Riding
    Cycling
    Ice Hockey
    Snowboarding
    Male
    Ice Hockey
    Cycling
    Football
    Soccer
    Snowboarding
    20
    Sport Concussion 19
  • Sport Specific Rates
    Hockey:
    High School: 17.6/1000 hours
    Peewee: 23.1/1000 hours
    Bantam: 10.7/1000 hours
    Peewee:
    Children under age 6 had twice
    the head injuries as older
    children.
    • Hockey
    • Professional (Europe): 14.3% of all injuries; 0.16/1000 hours
    • College (Canadian Intercollegiate): 7.5% of injuries; 1.5/1000 hours
    • High School (US): 18.7/1000 hours
    21
    Sport Concussion 21
  • Peewee Hockey
    N = 125 (86% response rate)
    Average age: 11.5 years-old with 5.6 years of playing experience
    No. of players with concussion: 11 (incidence rate = 9.87%) 16 total
    7 players with 1 concussion
    3 with 2 concussions
    1 with 3 concussions(1 non hockey related)
    Mechanism of Injury: player contact (n = 10)
    hits from behind (n = 4)
    fall (n = 1)
    collision into boards (n = 1)
    Avg # of practices missed: 3.25 (range 0 – 6)
    Avg #. of games missed: 2.00 (range 0 – 4)
    Avg duration of symptoms: 7.03 days (range 1 - 21 days)
    No. subjects with ED visit: n = 1
    No. with previous concussion: n = 2
    22
    Sport Concussion 21
  • Common Signs/Symptoms
    Section – 4
    23
    A Publication of
    The Sport Medicine Council of Alberta 22
  • Common Signs/Symptoms
    Nausea, vomiting
    Dizziness
    Confusion
    Fatigue
    Light headedness
    Headaches
    Irritability
    Disorientation
    Seeing bright lights
    Feeling of being stunned
    Depression
    Inappropriate behavior
    Decreased work/playing ability
    Inability to perform daily activities
    Cognitive and memory dysfunction
    Sleep disturbances
    Vacant stare
    Poor balance
    24
    Sport Concussion 24
  • Any 1 Symptom
    Signs/symptoms may vary for each athlete.
    A concussion should be suspected in the presence of any one symptom.
    25
    Sport Concussion 25
  • Nausea
    Be cautious if nausea is a significant symptom.
    Some athletes will suffer a mild cognitive impairment for longer periods of time when nausea is present.
    26
    Sport Concussion 27
  • How Do I Manage a Suspected Concussion?
    Section 5
    27
    A Publication of
    The Sport Medicine Council of Alberta 28
  • Recovery Model
    Concussion Recovery Model vs. Orthopedic Recovery Model
    Concussions need to be managed differently than orthopedic injuries.
    “No pain. No gain.” Does not apply.
    28
    Sport Concussion 8
  • Removing a Player from Play
    Remove the player from the current game or practice.
    Do not leave the player alone; monitor for signs and symptoms.
    Do not administer medication.
    Inform coach, parent or guardian about the injury.
    Sport Concussion 31
  • Return Within a Game?
    Be very cautious
    Hockey Canada: If player is asymptomatic after 15 minutes, can return…
    Not if LOC, Neck Injury, ANY symptom
    Must be evaluated by qualified professional
    Sport Concussion 31
  • When in Doubt, Sit Them Out!
    No athlete with a concussion should continue to play or return to a game after sustaining a concussion.
    Center for Disease Control
    International Concussion
    Guidelines (Zurich, 2009)
    31
    Sport Concussion 33
  • Deteriorating Neurological Function
    Athletes need to be carefully monitored for the first 24-48 hours. If any of the below symptoms occur refer them to the emergency department.
    Headaches that worsen
    Seizures
    Looks drowsy or can’t be awakened
    Repeated vomiting
    Slurred speech
    Can’t recognize people or places
    Increased confusion, unusual behavioral change, or irritability
    Weakness or numbness in arms or legs
    Neck pain
    32
    Sport Concussion 34
  • Screening/Diagnosis
    Section 6
    33
    A Publication of
    The Sport Medicine Council of Alberta 35
  • Simple or Complex
    Concussions can be classified as either simple or complex.
    34
    Sport Concussion 36
  • Simple Concussion
    A simple concussion usually resolves without complication in 7-10 days.
    This is the most common type of head injuries, accounting for 75% of all concussions.
    35
    Sport Concussion 37
  • Complex Concussion
    A complex concussion involves persistent symptoms and prolonged cognitive impairment.
    36
    Sport Concussion 38
  • Post Concussion Syndrome
    Following a concussion, an athlete can suffer from long term sleep disturbances, memory and concentration troubles, depression and even psychiatric problems.
    37
    Sport Concussion 39
  • Other Issues
    38
    A Publication of
    The Sport Medicine Council of Alberta 35
  • History of Concussion
    Athletes with a history of concussion are at an increased risk of:
    Future concussions (3 to 5 x more likely)
    Worse on-field presentations following their next concussion
    Experiencing acute changes in their memory performance and reaction times
    Slowed recovery
    39
    Sport Concussion 45
  • 3 Concussions
    After an athlete has sustained 3 concussions, serious consideration should be given to removal from contact sports.
    However, each athlete should be considered on an individual basis.
    Athletes with a history of 3 or more concussions have a slower recovery rate than athletes with one prior concussion.
    40
    Sport Concussion 46
  • How Many is too Many?
    There is no magic number of how many concussions are too many.
    This must be evaluated individually.
    Return to play decisions should be guided by neuropsychological test results and symptoms reported by the athlete regardless of the number of concussions.
    41
    Sport Concussion 48
  • Long Term Consequences
    Studies from retired NFL players suggested
    Increased incidence
    Depression (2 to 4x higher than normal population)
    Cognitive Difficulties
    Chronic Traumatic Encephalopathy
    42
    Sport Concussion 48
  • Does Age Affect Recovery Time?
    High school athletes may exhibit slower recovery after sports related concussions compared to collegiate athletes.
    43
    Sport Concussion 49
  • Younger Athletes
    Younger athletes are more prone to complex concussions than college athletes.
    Younger athletes show more signs of mood disturbance (irritability, lower frustration tolerance) than older athletes.
    44
    Sport Concussion 50
  • Second Impact Syndrome
    It is thought to occur when an athlete suffers a second blow to the head while recovering from an initial concussion.
    This can happen up to 14 days post injury.
    The result is a catastrophic increase in intracranial pressure which, in rare cases, can lead to death.
    It most often occurs in athletes under 21 years of age.
    This is very rare and there is still debate on when it occurs.
    45
    Sport Concussion 51
  • Return to Activity
    Section 8
    46
    A Publication of
    The Sport Medicine Council of Alberta 58
  • 47
    Sport Concussion 6
  • Medical Doctor Evaluation
    An athlete should be evaluated by a medical doctor after any blow to the head.
    Hockey Canada’s Guidelines
    48
    Sport Concussion 32
  • Medication
    Only take medications your medical doctor has prescribed only after medical assessment.
    Do not drink alcohol or
    take non-prescription drugs.
    49
    Sport Concussion 56
  • Medical Decision
    Return to play is a medical decision that should not be made by a parent, coach, trainer or athlete.
    Each case must be handled individually
    7 Day rule does not apply
    An athlete should complete a sport specific rehabilitation program and cleared by a medical doctor.
    50
    Sport Concussion 61
  • Pocket SCAT2
    Sport Concussion
  • Symptoms in Sports concussion
    Everyone “feels fine”
    Always ask:
    1.“On a scale of 0 to 100%, how do you feel?”
    2.“what makes you not 100%?”
    3. Checklist – SCAT2
    Sport Concussion
  • 6 Return to Activity Steps
    If it is decided that an athlete will return to play a stepwise process must be followed.
    (Available in the SCAT-2)
    53
    Sport Concussion 62
  • Graded Exertion Protocol
    • 24 hours per step
    • If there is recurrence of symptoms at any stage, return to previous step
  • Step 1
    • CORNERSTONE =rest until asymptomatic
    • Rest from activity
    • 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
    REST = ABSOLUTE REST!
    Sport Concussion
  • Step 2
    Light aerobic exercise. No resistance or weight lifting.
    56
    Sport Concussion 64
  • Step 3
    Sport specific activities and training.
    57
    Sport Concussion 65
  • Step 4
    Drills without body contact. May add light resistance training and progress to heavier weights.
    58
    Sport Concussion 66
  • Step 5
    Begin drills with body contact.
    59
    Sport Concussion 67
  • Step 6
    Game play.
    60
    Sport Concussion 68
  • Progress Symptom-Free
    With this stepwise process, an athlete should continue to progress through the levels unless any post-concussion symptoms occur.
    61
    Sport Concussion 69
  • 24 Hours Rest
    If post-concussion symptoms occur, the athlete should rest 24 hours before returning to that activity.
    62
    Sport Concussion 70
  • Neuropsychological Testing
    Section 9
    63
    A Publication of
    The Sport Medicine Council of Alberta 71
  • Baseline Assessment
    Complete a pre-season, baseline cognitive assessment and symptom score for each athlete.
    In the event of a concussion, compare an athlete’s post-concussion symptoms to their baseline scores.
    64
    Sport Concussion 72
  • Software Companies
    ImPACT : Immediate Post-concussion Assessment and Cognitive Testing.
    www.impacttest.ca
    $25 for baseline, $10 for post-testing
    Glen Sather Clinic (U of A)
    CogSport ®
    www.cogsport.com
    65
    Sport Concussion 53
  • ImPACTImmediate Post-Concussion Assessment and Cognitive TestingComputerized Neurocognitive Testing
    Mark Lovell, Ph.D.-UPMC Dept. of Orthopaedic Surgery
    Micky Collins, Ph.D.-UPMC Dept. of Orthopaedic Surgery
    Joseph Maroon, M.D.-UPMC Dept. of Neurological Surgery
  • ImPACTPost-Concussion Evaluation
    • Demographic/Concussion history questionnaire
    • Concussion Symptom Scale
    • 21 Item Likert scale (e.g. headache, dizziness, nausea, etc)
    • Eight neurocognitive measures
    • Measures domains of memory, working memory, attention, reaction time, mental speed
    • Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores
    • Detailed clinical report
    • Outlines demographic, symptom, neurocognitive data
    • Automatically computer scored
  • Clinical ProtocolNeurocognitive Testing
    Day 5-10
    24-72 Hours
    Concussion
    Baseline Testing
    Beyond if necessary
  • Implementation
    Account is set up under the name of the organization
    Organization appoints an administrator
    Administrator provides account name and passcode to athletes allowing them access to testing
    Baseline tests completed on-line (anywhere)
    When test is complete and baseline determined, a confirmation is sent to the team administrator and athlete
  • Follow-up
    Follow-up tests are completed on-line (anywhere)
    ONLY a designated health professional can access testing results
  • Composite Summary of Results
    In addition to the individual scores for each module described, ImPACT 2.0 also yields summary composite scores for Verbal Memory, Visual Memory, Reaction Time, Processing Speed and Impulse Control.
    Numeric Display of all Composites over Time
  • Verbal Memory Composite
    Is comprised of the average of the following scores:
    Total percent correct score from Module 1 (Word Discrimination)
    2) Total correct hidden symbols from Module 4 (Symbol Matching)
    3) Percent of total letters correct from Module 6 (3 Letters)
    Graphic Display of Verbal Memory Composite over time
  • Other Issues
    73
    A Publication of
    The Sport Medicine Council of Alberta 71
  • Mouth Guards
    Mouth Guards have not been proven to prevent concussions.
    Mouth Guards are required by many Athletic Associations because they reduce trauma of jaw, facial and dental injuries.
    74
    Sport Concussion 78
  • Helmets
    Helmets are known to reduce the risk of intracranial injury however, there is no helmet that can prevent all head injuries.
    An athlete should wear the correctly sized helmet and one specific to the activity (hockey, football, snowboard, bike).
    75
    Sport Concussion 79
  • The Good
    Sport Concussion 80
  • Prevention cont.
    New technologies and changes in equipment
    SWAT Hockey does not indorse any specific manufactures product.
  • The Bad
    Sport Concussion 80
  • Force to the Head in just 6 milliseconds
    A bare head A good helmet
    Sport Concussion 82
  • Upcoming technology
    A pair of football cleats….. 150 dollars
    Football pads……………… 250 dollars
    Registration in football……. 250 dollars
    Protecting your head…….. Priceless
    Sport Concussion 80
  • Thank-You for Coming!Dr. Martin Mrazik6-135 Education NorthUniversity of Alberta
    81
    Sport Concussion 85