Fixed tackling sports concussions head on

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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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  • Each year, an estimated 1.7 million people sustain a TBI annually. 1 TBI is a contributing factor to a third (30.5%) of all injury-related deaths in the United States. 1 About 75% of TBIs that occur each year are concussions or other forms of mild TBI. 2
  • Each year, U.S. emergency departments (EDs) treat an estimated 173,285 sports- and recreation-related TBIs , including concussions, among children and adolescents, from birth to 19 years. 1 During the last decade, ED visits for sports- and recreation-related TBIs, including concussions, among children and adolescents increased by 60%. 1 Overall, the activities associated with the greatest number of TBI-related ED visits included bicycling, football, playground activities, basketball, and soccer. 1 TBI represents almost 9% of all injuries reported in the 9 sports Numbers and rates are highest in football (55,007; 0.47 per 1000 athlete exposures) and girl’s soccer (29,167; 0.36 per 1000 athlete exposures 71.0% of all sports- and recreation-related TBI emergency department visits were among males. 70.5% of sports- and recreation-related TBI emergency department visits were among persons aged 10-19 years. For males aged 10-19 years, sports- and recreation-related TBIs occurred most often while playing football or bicycling. Females aged 10-19 years sustained sports- and recreation-related TBIs most often while playing soccer or basketball or while bicycling.
  • Players hide or deny sx so they can play-its all they want to do.
  • ,Assume c spine injury so must be placed on board for transport with head/shoulder pads stabilized
  • Dings matter because multiple dings implicated in CTE. Players at the college and pro level whom never had LOC/major concussion have patholigcal changes of CTE
  • If another brain injury occurs (seemingly minor), the blood vessels open wide which increases the pressure in the brain
  • Factors which can delay improvement: Prior mental health issues, ADD, number of prior concussions, LD Same day return to play no longer recommended for youth sports If College athlete or Pro, maybe if medical examined and cleared depending on multiple factor which include complete recovery of sympotms, normal side line assesement (including cognitive and neuro, balance testing, and after stressed physically)
  • Prior concussions/lenth of prior symptoms H.o Migranes seems to be associated with delayed improvement, don't know why LD, ADD complicate brains recovery H/o of depression, anxiety, school phobia, may worsen what were mild symptoms prior to the injury-prediagnosis state
  • Eric Lindross Jacob Bell Sidney Crosby
  • Fixed tackling sports concussions head on

    1. 1. Tackling Sports Concussions Head On Jeffrey Rosenberg MD Sports Medicine September 5, 2012
    2. 2. Traumatic Brain InjuryConcussions are one type of TBI Diffuse Injury, No Anatomic ChangesFocal Brain Injury-More Severe  Subdural Hematoma, Epidural Hematoma, Intra- cerebral Hematoma  Associated with Anatomical Change-Blood, Fluid, Local Damaged Tissue
    3. 3. Myth #1: 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
    4. 4. Silent EpidemicUp to 50% of concussions not reportedAthletes hide symptoms, dont 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
    5. 5. Myth #2: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Brain cell injury and dysfunctionNo anatomic damage
    6. 6. 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
    7. 7. Myth #3: Cant be a concussion if you arent 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 scarey but not permanent
    8. 8. Loss of ConsciousnessIf LOC continues, need to start ABC protocolAssume cervical spine injuryUsually LOC is seconds only
    9. 9. ConfusionHallmark symptom of TBI is confusionEyes glassy, loss of focusIncoherent speechGoing to wrong teams huddleMemory Loss − Loss of memory prior to event-retrograde amnesia − Loss of future memory-anterograde amnesia
    10. 10. Myth #4: 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Dings matter
    11. 11. Second Impact SyndromeContinued symptoms sign that 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
    12. 12. Myth #5: 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
    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 #6: 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 #7-Captain looks fine so he didnt 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. Brain RestIf minimal sx ok to go to school monday − Most athletes will need to miss some school − Schools finally understanding and are required to complyTake to MD on monday or tuesday for eval
    19. 19. Complications to Recovery Concussion History Headache History Developmental History Psychiatric History
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. Myth #8: 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
    24. 24. Return to PlayAll physical sx must be goneIMPACT scores 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
    25. 25. 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
    26. 26. Myth #9 (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
    27. 27. Chronic Traumatic Encephalopathy  Pathological changes in brain from multiple, usually mild, injuries (even dings) − Deposits of protein similar to Alzheimers  Collision sports  Substance abuse  Dementia, Depression, Death  Violent Suicide
    28. 28. 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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