This document provides an overview of sport concussions including: - The purpose is to raise awareness of concussions, decrease their number, and provide information on management and prevention. - It discusses common signs and symptoms, diagnostic tests, recovery models, return to play protocols, and neuropsychological testing. - Key points emphasized are that concussions are serious injuries, athletes should be immediately removed from play if a concussion is suspected, and return to play decisions should not be made until cleared by a medical professional.

1. Sport Concussion A Publication of The Sport Medicine Council of Alberta 1

2. 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

3. Look on the bright side 3 For a few seconds you forgot you were a Calgary Flame Sport Concussion 3

4. Some Humor 4 Sport Concussion 6

5. 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

6. The Challenge of Concussions 6 Sport Concussion 84

7. What is a Concussion? Section 2 7 A Publication of The Sport Medicine Council of Alberta 5

8. Definition “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”. 8 Sport Concussion 6

9. 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

10. Neurometabolic Changes and Concussion Trauma/Concussion Diffuse axonal injury Massive release of K+ ions Glycolysis for K + pumps Sport Concussion 7

11. Neurometabolic Changes and Concussion Sport Concussion 7

12. fMRI 12 Sport Concussion 3

13. fMRI 13 Sport Concussion 3

14. 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

15. Concussion Rates 15 A Publication of The Sport Medicine Council of Alberta 5

16. 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

17. 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

18. 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

19. 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

20. Top Causes of Concussions Female Soccer Horseback Riding Cycling Ice Hockey Snowboarding Male Ice Hockey Cycling Football Soccer Snowboarding 20 Sport Concussion 19

22. Professional (Europe): 14.3% of all injuries; 0.16/1000 hours

23. College (Canadian Intercollegiate): 7.5% of injuries; 1.5/1000 hours

24. High School (US): 18.7/1000 hours21 Sport Concussion 21

25. 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

26. Common Signs/Symptoms Section – 4 23 A Publication of The Sport Medicine Council of Alberta 22

27. 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

28. 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

29. 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

30. How Do I Manage a Suspected Concussion? Section 5 27 A Publication of The Sport Medicine Council of Alberta 28

31. 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

32. 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

33. 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

34. 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

35. 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

36. Screening/Diagnosis Section 6 33 A Publication of The Sport Medicine Council of Alberta 35

37. Simple or Complex Concussions can be classified as either simple or complex. 34 Sport Concussion 36

38. 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

39. Complex Concussion A complex concussion involves persistent symptoms and prolonged cognitive impairment. 36 Sport Concussion 38

40. 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

41. Other Issues 38 A Publication of The Sport Medicine Council of Alberta 35

42. 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

43. 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

44. 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

45. 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

46. Does Age Affect Recovery Time? High school athletes may exhibit slower recovery after sports related concussions compared to collegiate athletes. 43 Sport Concussion 49

47. 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

48. 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

49. Return to Activity Section 8 46 A Publication of The Sport Medicine Council of Alberta 58

50. 47 Sport Concussion 6

51. 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

52. 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

53. 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

54. Pocket SCAT2 Sport Concussion

55. 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

56. 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

59. Rest from activity

60. No training, playing, exercise, weights

61. Beware of exertion with activities of daily living

62. Cognitive rest

63. No television, extensive reading, video games?

64. Caution re: daytime sleepREST = ABSOLUTE REST! Sport Concussion

65. Step 2 Light aerobic exercise. No resistance or weight lifting. 56 Sport Concussion 64

66. Step 3 Sport specific activities and training. 57 Sport Concussion 65

67. Step 4 Drills without body contact. May add light resistance training and progress to heavier weights. 58 Sport Concussion 66

68. Step 5 Begin drills with body contact. 59 Sport Concussion 67

69. Step 6 Game play. 60 Sport Concussion 68

70. 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

71. 24 Hours Rest If post-concussion symptoms occur, the athlete should rest 24 hours before returning to that activity. 62 Sport Concussion 70

72. Neuropsychological Testing Section 9 63 A Publication of The Sport Medicine Council of Alberta 71

73. 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

74. 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

75. 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

77. Concussion Symptom Scale

78. 21 Item Likert scale (e.g. headache, dizziness, nausea, etc)

79. Eight neurocognitive measures

80. Measures domains of memory, working memory, attention, reaction time, mental speed

81. Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores

82. Detailed clinical report

83. Outlines demographic, symptom, neurocognitive data

85. 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

86. Follow-up Follow-up tests are completed on-line (anywhere) ONLY a designated health professional can access testing results

87. 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

88. 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

89. Other Issues 73 A Publication of The Sport Medicine Council of Alberta 71

90. 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

91. 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

92. The Good Sport Concussion 80

93. Prevention cont. New technologies and changes in equipment SWAT Hockey does not indorse any specific manufactures product.

94. The Bad Sport Concussion 80

95. Force to the Head in just 6 milliseconds A bare head A good helmet Sport Concussion 82

96. 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

97. Thank-You for Coming!Dr. Martin Mrazik6-135 Education NorthUniversity of Alberta 81 Sport Concussion 85