The why and how of concussion screening

1. CONCUSSION
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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)
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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)
Rory Tyrrell

10. What happens during concussion?
• https://www.theguardian.com/sport/video/2013/dec/14/con
cussion-sport-head-games-video
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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)
Rory Tyrrell

15. Rory Tyrrell

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
Rory Tyrrell

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.
Rory Tyrrell

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
Rory Tyrrell

19. CTE continued…1
How is it diagnosed?
• No known way to diagnose while living
• Diagnosed by postmortem neuropathological analysis
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

23. • Step 2: Observable signs
Rory Tyrrell

24. • Step 3: Memory Assessment – Maddocks questions
Rory Tyrrell

25. • Step 4: Examination Glasgow Coma Scale (GCS)
Rory Tyrrell

26. • Continued
Rory Tyrrell

27. • Cervical Spine Assessment
Rory Tyrrell

28. Off-field Assessment
• Step 1: Athlete background
Rory Tyrrell

29. Rory Tyrrell

30. • Step 2: symptom evaluation
Rory Tyrrell

31. Rory Tyrrell

32. Rory Tyrrell

33. • Step3: Cognitive Screening
Rory Tyrrell

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
Rory Tyrrell

35. Example:
Rory Tyrrell

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
Rory Tyrrell

37. • Step 3 continued: Concentration - Months in reverse;
• Same as the numbers but with months
• 1 point for entire sequence
Rory Tyrrell

38. • Step 4: Neurological Screen
Rory Tyrrell

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
Rory Tyrrell

40. •
Rory Tyrrell

41. • Step 5: Delayed Recall
Perform after 5minutes from immediate recall section
Score 1 point for each correct response
Rory Tyrrell

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.
Rory Tyrrell

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
Rory Tyrrell

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
Rory Tyrrell

45. •
Rory Tyrrell

46. What could be added?
• Neck examination
Cervical instability
Ortho tests: compression, distraction, spurlings
WAD questioning
• Neurological examination
 Cranial Nerve testing
Rhombergs
Reflexes, myotomes & dermatomes
Rory Tyrrell

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?
Rory Tyrrell

48. Links
- http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjs
ports-2017-097506SCAT5.full.pdf
- http://www.wru.co.uk/downloads/WRU_Concussion_Guid
ance_English.pdf
- https://www.theguardian.com/sport/video/2013/dec/14/con
cussion-sport-head-games-video
- https://www.bbc.co.uk/iplayer/episode/b09g0gzk/alan-
shearer-dementia-football-and-me
Rory Tyrrell

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
Rory Tyrrell