Jeffrey Rosenberg MD, Physician of Sports Medicine spoke on October 18, 2018 about concussions in sports.

1. Concussion in Sports
Jeffrey Rosenberg MD
Physician of Sports Medicine
October 18, 2018

2. Traumatic Brain Injury

Concussions are one type of
TBI

Diffuse Injury, No Anatomic
Changes

Focal Brain Injury-More
Severe

3. High Shool Football Player Dies After Helmet-to-
Helmet Collision
Damon Janes, a 16-year-old junior running back for the Brocton (N.Y.) High School varsity
football team, died on Monday, Sept. 16 as a result of injuries suffered from a helmet-to-
helmet hit

4. ● Pike County High School linebacker Dylan
Thomas died on Sunday.

5. Family of Montclair High
School football player
Ryne Dougherty who died
in 2008 settles lawsuit for
$2.8 million
Montclair High School football
player Ryne Dougherty died on Oct.
15, 2008, two days after collapsing
in a junior varsity game against Don
Bosco Prep.

6. Myth: Only Football Players Get
Concussions
 >300,000 Sports and Recreations
TBI/year from birth to 19 yo
 ER visits increased by 60%
 Birth to 9 yo: Playground and
Bicycle Related Injury
 Girls 2x> Boys for same sports
 Male 10-19 yo: Football, Bicycling
 Female 10-19 yo: Soccer,
Basketball, Bicycling
 4X higher rate in 08 vs 97

7. Silent Epidemic
 Up to 50% of concussions not
reported
 Athletes hide symptoms, don't
report any problems
 Coaches want the players to play
 Athletic Trainer, not coach has the
final say
 Parents play down severity to let the
athlete participate
 More difficult to ignore in NJ as of
2011 regulations

8. Prevention
● Special Helmets
● Mouthgards
● Headbands

9. Myth :Can only get Concussion if
Hit in the Head
 Direct blow most common
 Helmet to Helmet; Head to
other Body Part
 Ground
 Indirect Forces
 Linear or rotational forces
from Quick Changes in
Direction
 Getting hit from the side in
the body, twisting, pivoting

10. Brain Injury
 Trauma causes brain tissue to release
chemicals: Calcium/Glutamate
 Increases need for blood flow for metabolism
to recover from injury
 Unfortunately, the arteries are constricted
 Imbalance between metabolic needs and
blood flow into the brain

11. Myth : Can't be a concussion if you
aren't knocked out
 Only 10% of concussions have LOC
 “Got my Bell Rung”
 If any symptoms, this is a concussion as
well
 Symptoms may not start immediately
after the hit (up to 48 hours)
 Seizure activity at injury very scary
but not permanent

12. Loss of Consciousness
 If LOC continues, need to start ABC
protocol
 Assume cervical spine injury
 Usually LOC is seconds only

13. Symptoms
 Dizziness, Headaches, Confusion
 Eyes glassy, loss of focus
 Incoherent speech
 Going to wrong team's huddle
 Memory Loss
 Loss of memory prior to event-retrograde
amnesia
 Loss of future memory-anterograde amnesia

14. Sideline Assessment
 Assess symptoms: headache, confusion,
nausea, vision
 Neurological Exam
 Pupillary Response
 ROM/Strength
 Balance/Coordination
 SCAT
 Orientation
 Memory
 Confusion

15. Sideline Assessment
 Take Helmet
 Done for the day
 ATC or MD will re-evaluate every 15-20
mins to make sure things are worsening
 If so, off to the ER
 In New Jersey, coaches, refs have duty to
make athletes sit if any concern

16. Red Flag Symptoms
 Headaches that worsen
 Look very drowsy, can’t be awakened
 Can’t recognize people or places
 Unusual behavior change
 Seizures
 Repeated vomiting
 Increasing confusion
 Increasing irritability
 Neck pain
 Slurred speech
 Weakness or numbness in arms or legs
 Loss of consciousness

17. Myth : We need to go to the ER!
 Generally not needed
 If significant LOC, confusion, or worsening
mental state
 CT and MRI are always normal by definition
 If neurological status worsens must be imaged to
r/o bleed
 No longer recommend waking up athlete every
hour over night
 Observe for unusual breathing patterns or
atypical movements (jerking, tremor,
convulsions)

18. Myth -'Captain looks fine' so he didn't have a
concussion
 Unlike physical injury, its hard to 'see' the
injury
 No post game activities
 Treatment of concussion
 Rest, Rest, Rest
 Brain Rest, Physical Rest
 Quiet, Dark
 NSAIDs/Tylenol for headache
 No electronics, phones, texting, computers,
etc

19. Myth 'Johnny' will be ready by next
week
 Each concussion is different, hard to predict
 Longer recovery with repeated concussions
 Younger patients typically need more time
 None the less, most better with 5-7 days
 Same day return to play no longer
recommended for youth sports
 If College athlete or Pro, maybe

20. Post Concussion
 Every patient has different set of symptoms
 Physical
 Headaches, N/V, FATIGUE, Balance, Dizziness,
Sensitivity to sound and light, Vision Problems
 Thinking
 Mentally Foggy, Concentration, Memory, Slow
 Emotional
 Irritability, Sadness, Nervous, More Emotional
 Sleep
 Drowsiness, Sleep more or Less, Difficult
sleeping

21. Myth : Of course he can play next week,
he only had a Grade I concussion
 Loss of consciousness, Amnesia, Confusion
used to be used to 'grade concussions'
 These 'grades' would determine return to play
 No data to support the grading systems
 15 different systems
 No longer used
 Treat each concussion individually
 Symptoms must completely resolve prior to
return to activities
 Ding's matter

22. Brain Rest
 If minimal sx ok to go to school Monday
 Many athletes need to miss 1-3 days of
school
 Schools finally understanding and are
required to comply
 Take to MD on Monday or Tuesday for
eval

23. Post Concussion
 Let the child sleep, Daytime Naps
recommended at the beginning
 Eat and stay hydrated
 Limit Activities requiring thinking or
concentrating
 Read, TV, Computer, etc
 Watch the grass grow
 Do not attend anything with flying objects
or potential for repeated injury

24. Complications to Recovery
 Concussion
History
 Headache History
 Developmental
History
 Psychiatric History

25. Post Concussion
 Not much the parents can do to help other
than provide emotional support, interact
with school nurse and administration
 Frustration can kick in
 School provide tutoring > 5 days
 Returning to school can be gradual
 Part time
 No gym or sports
 Breaks in nurses station
 Lunch in quiet place

26. Myth : There are no treatment for
concussions
 Insomnia-Melatonin
 Emotional symptoms
 Role for amitriptyline/SSRI
 Physical symptoms
 Balance can improve with vestibular therapy
 Concentration
 ADHD medications
• Vision Therapy

27. Second Impact Syndrome
 Continued symptoms-- brain
metabolism not yet normal
 With additional injury (even mild)
the blood vessels open wide which
increases the pressure in the brain
 Coma, Death
 10-15 die a year <19 yo
 Younger the brain, more susceptible
 This is why conservative in youth
sports, JH, HS sports

28. Return to Play
 All physical sx must be gone
 IMPACT scores and Balance
return to baseline
 Medical clearance
 5-7 day return to play
protocol
 Start with minimal exertion
 Progress daily
 If symptoms reoccur must
return to previous step

29. ImPACT Testing
 Focused neuropsychiatric,
computer based test
 Memory, Coordination,
Concentration
 Preseason Testing Optimal
 @2 days post injury can
provide prognosis
 When symptoms are gone to
confirm brain function normal

30. Myth (from the NFL/NHL)
No long term risk from concussions
 With each concussion, repeated injuries
occur with less force, symptoms last
longer, more difficult to return to sport
 Symptoms may be life long
 Retire from sports

31. Chronic Traumatic Encephalopathy
 Pathological changes in
brain from multiple,
usually mild, injuries
(even 'dings')
 Deposits of protein
similar to Alzheimer's
 Collision sports
 Substance abuse
 Dementia, Depression,
Death
 Violent Suicide

32. Chronic Traumatic Encephalopathy
 Families of NFL
players donating
brain tissue after
suicide/death
 18/19 had CTE
 $675 Million
Settlement