1. Tackling Sports Concussions
Head On
H dO
Jeffrey Rosenberg MD
Sports Medicine
September 5 2012
5,

2. Traumatic Brain Injury
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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,
Change-Blood, Fluid, Local
Damaged Tissue

3. Myth #1: Only Football Players Get
Concussions
>170,000
>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
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9% of all sports related injuries
Male 10-19 yo: Football Bicycling
10 19 Football,
Female 10-19 yo: Soccer,
Basketball,
Basketball Bicycling

4. 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 d cu t to ignore in NJ as o
o e difficult g oe J of
2011 regulations

5. Myth #2:Can only get Concussion if
Hit in the Head
Direct blow most common
− Helmet to Helmet; Head to
other Body Part
− G
Ground d
Indirect Forces
Linear or rotational forces
Getting hit from the side in
the body
Brain cell injury and dysfunction
No anatomic damage

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. Myth #3: Can't be a concussion if
you aren't knocked out
aren t
Only 10% of concussions have LOC
“Got my Bell Rung”
− If any symptoms, this is a concussion as well
symptoms
Symptoms may not start immediately after
the
th hit
Seizure activity at injury very scarey but
not permanent

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

9. Confusion
Hallmark symptom of TBI is confusion
Eyes glassy, loss of focus
Incoherent speech
I h t h
Going to wrong team's huddle
Memory Loss
− Loss of memory prior to event-retrograde
amnesia
− Loss of future memory-anterograde amnesia

10. Myth #4: Of course he can play doc next
week,
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
Ding's matter

11. Second Impact Syndrome
Continued symptoms sign that
brain
b i metabolism not yet normal
t b li t t l
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
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sports, JH, HS sports

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

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

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

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

16. Myth #6: We need to go to the ER
Generally not needed
If significant LOC confusion or worsening
LOC, confusion,
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. Myth #7-'Captain looks fine' so he didn't
have a concussion
Unlike physical injury, its hard to 'see' the
injury
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− 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,
g
etc

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. Complications to Recovery
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Concussion
History
Headache History
Developmental
History
Hi t
Psychiatric History

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
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21. Post Concussion
Let the child sleep, Daytime Naps
p, y p
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 f repeated injury
t ti l for t di j

22. Post Concussion
Not much the parents can do to help other
than provide emotional support interact
support,
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. Myth #8: There are no treatment for
concussions
conc ssions
Insomnia-Melatonin
Emotional symptoms
− Role for amitriptyline/SSRI
py
Physical symptoms
− Balance can improve with vestibular therapy
Concentration
− ADHD medications
Amantidine
Nuvigil
N i il

24. Return to Play
All physical sx must be gone
IMPACT scores return to
baseline
Medical clearance
5
5-7 day return to p ay
etu play
protocol
− Start with minimal exertion
− Progress daily
− If symptoms reoccur must
return to previous step

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

26. Myth #9 (from the NFL/NHL)
No long t
N l term risk f
i k from concussions
i
With each concussion, repeated injuries
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occur with less force, symptoms last
longer, more difficult to return to sport
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Symptoms may be life long
Retire from sports

27. Chronic Traumatic Encephalopathy
Pathological changes in
brain from multiple,
b i f li l
usually mild, injuries
(even 'dings')
dings )
− Deposits of protein
similar to Alzheimer's
Alzheimer s
Collision sports
Substance abuse
Dementia, Depression,
Death
Violent Suicide

28. Chronic Traumatic Encephalopathy
Families of NFL
players donating
brain tissue after
suicide/death
18/19 had CTE
Huge lawsuits in
future