Concussion in Sports

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Athletes (and non athletes as well) are increasingly reporting concussions to parents, coaches, and school nurses. How can you recognize a concussion? We will review the diagnosis and treatments for concussions, review dangers of multiple concussions and discuss the use of computerized neuropsychological testing prior to “return to play”.

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Concussion in Sports

  1. 1. Concussion in Sports Jeffrey Rosenberg MD Sports Medicine October 6, 2013
  2. 2. Traumatic Brain Injury  Concussions are one type of TBI  Diffuse Injury, No Anatomic Changes  Focal Brain Injury-More Severe
  3. 3. High School 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. 4. 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.
  5. 5. Myth: Only Football Players Get Concussions  >170,000 Sports and Recreations TBI/year from birth to 19 yo  ER visits increased by 60%  Birth to 9 yo: Playground and Bicycle Related Injury  9% of all sports related injuries  Male 10-19 yo: Football, Bicycling  Female 10-19 yo: Soccer, Basketball, Bicycling
  6. 6. 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
  7. 7. 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  Getting hit from the side in the body
  8. 8. 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
  9. 9. 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  Seizure activity at injury very scary but not permanent
  10. 10. Loss of Consciousness  If LOC continues, need to start ABC protocol  Assume cervical spine injury  Usually LOC is seconds only
  11. 11. Confusion  Hallmark symptom of TBI is 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
  12. 12. 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
  13. 13. Sideline Assessment  Assess symptoms: headache, confusion, nausea, vision  Neurological Exam Pupillary Response ROM/Strength Balance/Coordination  SCAT Orientation Memory Confusion
  14. 14. 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
  15. 15. 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
  16. 16. 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)
  17. 17. 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 Quite, Dark NSAIDs/Tylenol for headache No electronics, phones, texting, computers, etc
  18. 18. 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
  19. 19. Post Concussion  Every patient has different set of symptoms  Physical Headaches, N/V, FATIGUE, Balance, Sensitivity  Thinking Mentally Foggy, Concentration, Memory, Slow  Emotional Irritability, Sadness, Nervous, More Emotional  Sleep Drowsiness, Sleep more or Less, Difficult sleeping
  20. 20. Myth : Of course he can play doc next week, he only has a 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
  21. 21. Brain Rest  If minimal sx ok to go to school monday Many athletes need to miss some school Schools finally understanding and are required to comply  Take to MD on monday or tuesday for eval
  22. 22. 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
  23. 23. Complications to Recovery  Concussion History  Headache History  Developmental History  Psychiatric History
  24. 24. 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
  25. 25. 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  Amantidine  Nuvigil
  26. 26. 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
  27. 27. ImPACT Testing  Focused neuropsychiatric, computer based test  Memory, Coordination, Conce ntration  Preseason Testing Optimal  @2 days post injury can provide prognosis  When symptoms are gone to confirm brain function normal
  28. 28. 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
  29. 29. 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
  30. 30. Chronic Traumatic Encephalopathy  Families of NFL players donating brain tissue after suicide/death  18/19 had CTE  Huge lawsuits in future

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