2. Definition:
• Concussion is a temporary injury to the brain caused by a
bump, blow or jolt to the head. – NHS
• A concussion is an injury to the brain that results in
temporary loss of normal brain function. – AANS
• Is a disturbace in brain function caused by direct or
indirect force to the head. Resulting in a variety of non-
specific signs and/or symptoms and most often does not
involve loss of consciousness – SCAT3
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3. What is concussion?
• Traumatic brain injury = disturbance of the brain’s function
• There are many symptoms of concussion
• Loss of consciousness is NOT a requirement when
diagnosing concussion – occurs in less than 10%
• A brain scan will usually be normal
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4. Concussion facts
• Brain injury
• ALL concussions are serious
• Concussion can often occur WITHOUT loss of
consciousness
• Players/ patients with ANY S&S of concussion must be
IMMEDIATELY removed from playing or training
• Players MUST NOT return to play on the same day of any
suspected concussion
• Most concussions will recover with physical and mental
rest
• Children and adolescents may take longer to recover
• Can occur without an obvious blow to the head
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5. Who is at risk?
• CONCUSSION CAN HAPPEN AT ANY AGE & TO
ANYONE.
• HOWEVER, CHILD & ADOLESCENTS:
- Are more susceptible to concussion
- Take longer to recover
- Have more significant memory & mental processing issues
- Are more susceptible to rare & dangerous neurological complications, which in
some circumstances could be fatal due to brain swelling (AKA second impact
syndrome)
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6. Signs of concussion:
• Dazed, blank or vacant look
• Lying motionless on the ground/ slow to get up
• Unsteady on feet/ balance problems or falling over/ loss of
coordination
• Loss of consciousness or unresponsive
• Confused/ not aware of plays or events
• Grabbing/ clutching of head
• Seizure (fits)
• Nausea or vomiting
• More emotional / irritable than normal for that person
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7. Symptoms of concussion:
• Headache or a feeling of pressure in the head
• Confusion/ mental clouding or fleeing slowed down
• Visual problems
• Drowsiness/ feeling ‘foggy’ / difficulty concentrating
• Amnesia surrounding the traumatic event
• Dizziness or ‘seeing stars’
• Ringing in the ears
• Nausea
• Vomiting
• Slurred speech
• Delayed response to questions
• Appearing dazed
• fatigue
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8. Delayed Concussive Symptoms
• Can be delayed for hours/ days after injury
- Concentration & memory complaints
- Irritability & other personality changes
- Sensitivity to light & noise
- Sleep disturbances
- Psychological adjustment problems & depression
- Disorders of taste & smell
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9. What causes concussion?
• Concussion can be caused by a direct blow to the head,
but can also occur when blows to other parts of the body
result in rapid movement of the head (e.g. whiplash type
injuries)
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10. What happens during concussion?
• https://www.theguardian.com/sport/video/2013/dec/14/con
cussion-sport-head-games-video
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11. Continued…1
Primary Injury
• The brain is cushioned by fluid & protective membranes called
meninges
• During impact, the brain is pushed against the inside of the
skull & can get bruises
• Different parts of the brain move at different speeds equaling
shearing forces which can stretch & tear nerve tissue
• This rupturing alters the balance of ions & chemicals in the
brain impairing nerve cell function & releasing toxins = death of
other neurons
• Released toxins contribute to loss of consciousness seen in
concussion
• Some nerve fibres can recover
• Severely injured nerve fibres can permanently lose their ability
to send signals & communicate with other brain cells
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12. Continued…2
Secondary injury
• Post concussion syndrome (PCS)
• These emerge several hours after trauma
• Can last months or years
• Playing through concussion can increase risk of PCS
• Sub concussive impacts (‘lots of small impacts to the head’), when
repeated over time can lead to severe degenerate brain diseases
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13. Why has concussion become ‘vogue’?
• Boxing Chronic Traumatic Encephalopathy (CTE) has
been known since 1987 – has been nicknamed ‘Boxer’s
head’
• Hollyword film – Concussion 2015
Dr. Bennet Omalu forensic pathologist found a common trend in
professional NFL players autopsy's.
Dr Omalu’s research on CTE has changed the management of
sports & concussion
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14. What did Dr Omalu find?
• Large accumulation Tau protein in NFL players brain
• These clumps of tau protein are similar to beta-amyloid
protein which contributes to Alzheimer’s disease
• Autopsy concluded: tau protein concentrations more
consistent with "a 90-year-old brain with advanced
Alzheimer’s”
• This what put down to Long’s NFL career
• These findings were found in many NFL players brains: -
Terry Long’s (45yo)
Mike webster (50yo)
Justin Strzelczyk (36yo)
Andre Wlaters (44yo)
Tom McHale (45yo)
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16. Sub concussive impacts and Diffusion
tensor imaging
• Study on football players who header the ball
• Seeing how milder blows alter the structure of axon
bundles within the brain
• Found heading was associated with lower fractional
anisotropy at three locations in temporo-occipital white
matter
• Lower levels of FA associated with poorer memory scores
• Multiple sub concussive blows over time = Chronic
Traumatic Encephalopathy
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17. Further studies
• Results from several studies have suggested increased risks of various
neurological disorders in professional sports people with head traumas,
including
1. amyotrophic lateral sclerosis
2. subclinical effects such as impaired cognitive function,
3. Parkinson's disease
4. other neurological symptoms, such as headache and sleep disturbances.
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18. Chronic Traumatic Encephalopathy
• Changes in mood & behaviour appear during 30s & 40s
• Followed by difficulties in thinking & memory and
sometimes followed by dementia
• Symptoms:
- Memory loss
- Confusion
- Impaired judgment
- Impulse control problems
- Aggression
- Depression
- Anxiety
- Suicidal thoughts
- Parkinson’s
- Progressive dementia
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19. CTE continued…1
How is it diagnosed?
• No known way to diagnose while living
• Diagnosed by postmortem neuropathological analysis
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20. Why screen for concussion?
• 50-80% NFL player concussions go unreported &
untreated
• This is one sport, and at professional level – What about other
sports and at different levels?
• Potential complications of concussion:
Post-traumatic headaches
Post-traumatic vertigo
Post-concussion syndrome
Cumulative effects of multiple injuries
Second impact syndrome
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21. Screening Process – SCAT5
• What is SCAT?
• most recent revision of a sport concussion evaluation tool
for use by healthcare professionals in the acute
evaluation of suspected concussion.
• The revision of the SCAT3 (first published in 2013)
culminated in the SCAT5.
• The revision was based on a systematic review and
synthesis of current research, public input and expert
panel review
• The SCAT5 for 13yrs+
• Child SCAT5 5–12Yrs
Consisting of: a side-line assessment (either Glasgow Coma Scale
or Maddocks score) and a six-part in-depth screening
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22. SCAT5 – Immediate/on-field Assessment
• Step 1:Red flags
Any of the following the athlete should be removed form
participation & evaluated
Red flags:
1. Neck pain & tenderness
2. Double vision
3. Weakness or tingling/ burning in arms or legs
4. Severe or increasing headache
5. Seizure or convulsion
6. Loss of consciousness
7. Deteriorating conscious state
8. Vomiting
9. Increasingly restless, agitated or combative
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34. • Immediate memory:
• Either use traditional 5 word per trial list or 10 word list to
minimise ceiling effect
• All 3 trials must be administered
• Carry out at the rate of 1word per second
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36. • Step 3 continued: Concentration - Digital Backwards;
• Choose one of the lists
• Explain to patient you are going to read a string of
numbers and you want them to repeat back to you, but in
REVERSE order e.g 1-2-3 = 3-2-1
• Begin with 3 digit string, if correct move to next string
• One point for each string length
• Stop after incorrect on both trials
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37. • Step 3 continued: Concentration - Months in reverse;
• Same as the numbers but with months
• 1 point for entire sequence
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39. • Step 4: Neurological Screen – Balance exam
• Modified Balance Error Scoring System (mBESS)
Lasts 20 seconds each stage
One error point for every error in that 20seconds
Maximum number of errors = 10
Types of errors:
1. Hands lifted off iliac crest
2. Opening eyes
3. Step, stumble or fall
4. Moving hip into >30 degrees ABD
5. Lifting forefoot or heel
6. Remaining out of test position >5sec
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41. • Step 5: Delayed Recall
Perform after 5minutes from immediate recall section
Score 1 point for each correct response
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42. • Step 6 : Decision
• Total all sections
• Remember: Scoring on the SCAT5 should not be used as
a stand alone method to diagnosis; measure recovery or
make decisions about patients readiness to return.
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43. Concussion Injury Advice
• REST THE BODY & REST THE BRAIN
Majority resolve in 7-10days
Can be longer in children & adolescents – need more conservative approach
• REST is the cornerstone of concussion treatment. This involves resting
the body, ‘physical rest’ and resting the brain ‘cognitive rest’ lasting
24HRS. This means the avoidance of
PHYSICAL ACTIVITY
COGNITIVE ACTIVITIES
• Do not undertake strenuous exercise for a minimum of TWO WEEKS –
comprised of relative rest
• Avoid alcohol
• Avoid prescription or non-prescription drugs – specifically avoid:
sleeping tablets
DO NOT use aspirin, anti-inflammatory medication or stronger pain medications
• Do not drive until cleared
• Return to play/ sport requires clearance by a healthcare professional
• After the minimum rest period – seek medical practitioner
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44. Graduated Return to Play Programme
(GRTP)
• 1st 2 weeks relative rest period
• Once completed and patient is symptom free the GRTP
should commence
• If a player is still showing S&S of concussion he/she
should NOT start the GRTP & receive further assessment
from medical practitioner
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47. What can we do?
• Sportsmen & older adults in clinic take a SCAT on initial
consultation
• Educate: players, parents, partners, coaches, carers
• Relevance to everyday practice
Amateur sport not as medically controlled
Falls / bumps of elderly
• Treatment?
NMT & SCS: C.E.S, trapezius, rhomboids, lev scap, supra- &
infraspinatus, T.E.S
Gentle mobilisation Csp, CTJ, TSP
Inhibition/ BLT suboccipitals
Lymphatics?
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49. References
• NHS. (2015). Concussion. Retrieved from http://www.nhs.uk/conditions/Blood-
groups/pages/introduction.aspx
• Concussion. (n.d.). Retrieved from http://www.aans.org/Patients/Neurosurgical-
Conditions-and-Treatments/Concussion
• LASKAS, J. M. (2009). Bennet Omalu, Concussions, and the NFL: How One
Doctor Changed Football Forever. Retrieved from https://www.gq.com/story/nfl-
players-brain-dementia-study-memory-concussions
• Lipton, M. L., Kim, N., Zimmerman, M. E., Kim, M., Stewart, W. F., Branch, C. A.,
& Lipton, R. B. (2013). soccer heading is associated with White Matter
Microstructural and cognitive abnormalities. Radiology, 268(3), 850–857.
Retrieved from http://pubs.rsna.org/doi/pdf/10.1148/radiol.13130545
• Lipton, M. L., Kim, N., Zimmerman, M. E., Kim, M., Stewart, W. F., Branch, C. A.,
& Lipton, R. B. (2013). Soccer Heading Is Associated with White Matter
Microstructural and Cognitive Abnormalities. Radiology, 268(3), 850–857.
https://doi.org/10.1148/radiol.13130545
• Sabharwal RK, Sanchetee PC, Sethi PK, Dhamija RM. Chronic traumatic
encephalopathy in boxers. J Assoc Physicians India. 1987 Aug;35(8):571-3.
• Echemendia, R. J., Meeuwisse, W., McCrory, P., Davis, G. A., Putukian, M.,
Leddy, J., ... & Schneider, K. (2017). The Sport Concussion Assessment Tool 5th
Edition (SCAT5). Br J Sports Med, bjsports-2017.
- http://www.wru.co.uk/downloads/WRU_Concussion_Guidance_English.pdf
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Editor's Notes
Give the sheet to the patient & get them to fill it out
Total the number of symptoms
Total the symptom severity score