Concussion In Sport

Considered a traumatic brain injury with transient manifestations

Mild Moderate Severe Concussion falls under classification of mTBI Diagnosed by assessment of clinical S/S -no imaging

Caused by impulsive force transmitted to the head -could be direct blow or transmitted from force (i.e. body) Results in rapid onset of short-lived impairment of neurologic function that resolves spontaneously Acute clinical S/S reflect functional disturbance rather than structural injury -No abnormality seen on standard structural neuroimaging studies -Chemical disturbance vs. anatomical disturbance Graded set of clinical S/S that may or may not involve LOC -Resolution of symptoms typically follows sequential course; however in some cases, S/S may be prolonged -only ~10% of SRC involve LOC

Sports-related concussions -"True" incidence is unknown -1.6-3.8 million/year in the US -~50% are estimated to go unreported -For every 1 concussion in the NFL, there are 50,000+ at the youth level -often don't have the support personnel to recognize at rec level

0.24 concussions/1000 athlete exposures Football—1.55/1000 Girl's soccer—0.36/1000

0.40-0.60 concussions/1000 athlete exposures Football—3.02/1000 Women's soccer—2.1/1000 Ice hockey—1.96/1000 Men's soccer—1.3/1000

History of prior concussion—risk factor for recurrent concussion -Also associated with more severe/longer duration of symptoms and cognitive deficits Age—insufficient evidence although the majority of concussions are in pediatric/adolescent age group -Younger athletes may have a more prolonged recovery Type of sport—certain sports, positions, and individual playing styles have greater risk of concussion -20% of HS football players will sustain a concussion per season Sex—conflicting evidence for sex as a risk factor -Males > females -Females have higher rate of concussion (1.7:1) when compared in similar participation -May be related to weaker neck muscles -Females at greater risk in soccer and basketball -Females more prone to post-concussion symptoms Substantial risk of increased morbidity and/or mortality in any athlete who returns to play prior to recovery

80-90% of concussions resolve in 1-3 weeks Some reports indicate within 7-10 days

Release of large quantities of glutamate Results in massive neuron firing Ionic fluxes (K+ efflux, Ca++ influx) -Mismatch of ions Increased ATP needed to move K+ back inside the cell -but concussion decreases ATP production Mitochondrial dysfunction due to excess Ca++ and decreased cerebral blood flow Decreased ATP production Lactate accumulation Increased cerebral glucose demand Axonal injury in some cells

A major excitatory neurotransmitter; involved in memory

Demand for glucose/energy production is down second impact before recovery can lead to more severe injury/death

Neuron During Injury releases its K+ (Potassium) which rushes out of the cell body and toxic Ca2+ (Calcium) ions rush into the cell leading to metabolic dysfunction -energy crisis (ATP) -massive release of neurotransmitters (glutamate?) -increased vulnerability leading to cell death

Concussed brain is less responsive to physiological neural activation Excessive cognitive or physical activity before complete recovery may prolong dysfunction Balance cog/phys rest to help recovery and yet not inhibit recovery

LOC Clear confusion or disorientation Balance/motor incoordination Needs help getting off field/court Stumbling, slow movts Loss of memory Blank or vacant look

Symptoms are delayed Symptoms are subtle Symptoms are inaccurately reported by athlete Afraid of losing playing time Doesn't realize the significance

Rapid screening for suspected SRC -not to dx concussion, other injuries If clear on-field signs of SRC, player should be immediately removed from participation -LOC -tonic posturing -dilated pupil Otherwise, proceed with sideline evaluation using appropriate assessment tools

Recognition of injury Assessment of symptoms Assessment of cognitive function Assessment of cranial nerve function Assessment of balance

Need for a standardized, evidence-based, multifaceted assessment tool SCAT—2004 SCAT2—2008 SCAT3/ChildSCAT3—2012 SCAT5/ChildSCAT5—2016 -<13 yo

Maddocks questions Glasgow Coma Scale C-spine assessment Symptom checklist Standardized Assessment of Concussion (SAC) Neurologic screen mBESS Delayed recall

Currently represents the most well-established tool for sideline evaluation Useful immediately after injury Utility decreases significantly 3-5 days after injury -except symptoms checklist Symptom checklist has clinical utility for tracking recovery

Serial monitoring for deterioration is essential Every 5 minutes until athlete's condition improves Initial few hours after injury Athlete should not be left alone for initial 24 hours

Athlete is given the form, asked to read it aloud, and then to complete it Assesses both symptom presence and severity Clinical utility for tracking recovery

Physical Cognitive Emotional/Affective Sleep disturbance

Headache -most common (80-90%) Dizziness -2nd most common (up to 80%) Fatigue Nausea/vomiting Photo/phonophobia Trouble with balance Visual disturbance Tinnitus

Retrograde amnesia Post-traumatic amnesia Disorientation Confusion Feeling mentally foggy Decreased reaction time Difficulty concentrating

Emotional lability Irritability Sadness/depression Anxiety/nervousness -helps to know the athlete

Drowsiness Difficulty falling asleep Sleeping more/less than usual Fragmented sleep

Relatively quick and easy Quick assessment of 4 neurocognitive domains: 1. Orientation to time 2. Immediate memory with word recall 3. Concentration 4. Delayed recall Key is comparison to athlete's own pre-participation baseline

Ask athlete a series of 5 questions regarding time, day, date, etc. What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? Aimed at establishing athlete's awareness and orientation to time

Recite list of 5 or 10 words and ask athlete to repeat "I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order." 3 trials Rate of 1 word/second Do NOT inform athlete of delayed recall of same list later during the administration of the test

Recite increasingly long series of numbers and ask athlete to recite list in reverse order "I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7." Ask athlete to recite months of the year in reverse order

Ask athlete to recite word list from immediate memory portion of SAC "Do you remember the list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order." Performed after the neurological screen Performed after 5 minutes have elapsed since end of Immediate Recall section

Compare athlete's test score to his/her baseline Differences of 2-3 pts considered significant Little to no practice effect Decrease from baseline of ?1 point found to be 94% sensitive 76% specific

finger to nose tandem gait CN exam Balance -modified BESS (on firm surface -drunk test

Where the SAC assesses cognitive function, mBESS assesses balance and equilibrium Relatively quick and easy Total of 3 stances with eyes closed and hands on iliac crests Firm surface DL SL (non-dominant LE) Tandem (non-dominant LE at the back) Stance held for 20 seconds and errors counted Errors consist of any of the following: Lifting hand(s) from iliac crest(s) Opening eyes Step, stumble, or fall Lifting forefoot or heel Moving hip into >30 deg abduction Remaining out of test position for more than 5 sec

Maximum number of errors per position is 10 Errors for each position added together for final mBESS score out of 30 Increase of 3 errors or more over baseline score considered significant Considerations for implementation include distraction, taping/bracing, pads, fatigue, and inter-rater reliability

Practice effect Score may be affected by fatigue Score may be affected by environment (distraction, taping/bracing, pads, etc.) Concerns of inter- and intra-rater reliability

Baselines should be completed BEFORE season/contact begins Maintain list of baselines and keep them handy Keep a small laminated version of SAC on sideline

SCAT5 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete's readiness to return to competition after concussion Not intended to replace a comprehensive neurological evaluation

Clinical reaction time Gait/balance assessment Oculomotor screening Neuropsychological assessment -gold standard -clinical neuropsychologist trained in concussion

Suspected diagnosis can include 1 or more of the following clinical domains: Symptoms Physical signs (e.g. loss of consciousness or amnesia) Balance impairment Behavioral changes (e.g. irritability) Cognitive impairment Sleep disturbance If any 1 or more of these components is present, a concussion should be suspected and the appropriate management strategy implemented -Important to note that these S/S are not specific to concussion

Suspicion of concussion requires removal of the athlete from competition (practice) Serial monitoring is essential over the initial few hours (i.e. do not leave athlete alone) Player with diagnosed concussion should not be allowed to return to play on the day of injury Symptom checks on daily basis -main method of determining RTS -best to compare to baseline Possible academic restrictions No activity until symptom free

LOC ?1 minute -some say 30 secs Repeated vomiting -more than once is indicative of inc ICP Progressively worsening headache Seizure activity Focal neurological deficit Unilateral dilated pupil Ataxia Apraxia Dermatomal/myotomal changes -esp if bilat Basilar skull fracture signs -bruising around ear (battle's sign) -discharge from ear -raccoon eyes GCS <13

Stabilize and access EMS for athlete with LOC ?1 minute Indication of C-spine trauma/fracture GCS score <13

?8 indicates coma or severe TBI 9-12 indicates moderate brain injury 13-14 indicates mild brain injury

LOC ?1 minute Seizure Poor A x 4 Repeated vomiting Severe or worsening headache

CT or MRI CT is initial test of choice (0-48 hrs post-injury) Sensitivity to fractures and intracranial bleeding Faster and more cost-effective MRI may be more appropriate if imaging needed later

Testing that evaluates a healthy person's decision making ability, reaction time, attention, verbal and design memory. Testing can either be pen and paper or be completed with the use of online computer software (ie ImPACT) In the event of an injury, a re-test would be completed. ImPACT Axon Sports (formerly Cogsport) Headminder

Controversial 3 commonly used grading systems Cantu Colorado Medical Society American Academy of Neurology

Symptoms resolve <30 min No LOC

Transient confusion without amnesia No LOC PCSS resolve <15 min

LOC <1 min OR PTA Other PCSS >30 min but <7 days

Transient confusion with amnesia No LOC PCSS resolve >15 min

LOC for >1 min or PTA for >24 hrs PCSS >7 days

Any LOC

PTA <10 min = very mild injury PTA <1 hr = mild injury PTA 1 to 24 hrs = moderate injury PTA 1 to 7 days = severe injury PTA >7 days = very severe injury **Inherent problem: Subjective report from an impaired patient

No classification system Majority (80-90%) will resolve in 7-10 days with gradual return to play post-recovery May be longer in children and adolescents EVERYONE deserves individualized management Paradigm Shift From a guideline/grading scale approach for managing concussion To a more data driven and individual approach

Cognitive rest Physical rest Medication use (??) -Limited evidence to support pharmocotherapy Cognitive rehabilitation Vestibular rehabilitation

Prognostic factors (e.g. history, comorbidities, etc.) Advice YOU give the athlete Athlete's willingness/ability to follow advice

concussion symptoms lasting >3 wks Memory/concentration deficits Personality change Mood swings Headache Fatigue Dizziness Impaired sleep Visual disturbances Berlin expert consensus—persistent symptoms >10-14 days in adults; >4 wks in children

Rare but catastrophic 2nd concussion occurs while still symptomatic from previous injury More likely to cause brain swelling and widespread damage High incidence of mortality

Neurological degenerative disease Dementia pugilistica Diagnosed post-mortem Result of multiple head injuries from contact sports Characteristic atrophy of brain tissue and deposition of tau protein

Goal was to get every individual involved in athletics to become more proactive in identifying and treating athletes with signs and symptoms of concussion

Designed to reduce youth sports concussions and increase awareness of TBI Requires youth athletes to be cleared by a licensed healthcare provider before returning to play/practice HCP=MD, DO, CN with concussion training, or PA with concussion training

"Any player who exhibits signs, symptoms, or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion, or balance problems) shall be immediately removed from the game and shall not return to play until cleared by an appropriate health-care professional" **Designated HCP—ATC, NP, PA, MD, or DO

The only means for athlete to return to practice/play is for he/she to be evaluated and cleared by MD, DO, or CN with concussion training

No athlete should return to play or practice on the same day as concussion Any athlete with a concussion should be cleared by an MD, DO, CN (with concussion training), or PA (with concussion training) After medical clearance, returning to play should follow a step-wise protocol

that school and community organizations sponsoring youth athletic activities establish guidelines to inform and educate coaches, youth athletes, and other adults involved in youth athletics about the nature, risk, and symptoms of concussion and head injury Individuals (coaches, parents, and student-athletes) are required to sign a form indicating that they have read and acknowledge the educational information CDC-checklist Persons who remove athletes from competition for S/S of concussion are required to use the CDC Concussion S/S Checklist when evaluating the athlete Annual online education for coaches Coaches must either the NFHS online course or the CDC online course

Supporting Athletes, Families, and Educators to Protect the Lives of Athletic Youth Legislation introduced to Congress in February 2015 to promote safety in youth sports Recognizes PT's as health care professionals qualified to make return-to-play decisions for youth sports concussions Has not been enacted

Multidisciplinary Healthcare professionals for treatment of concussion may include: physicians with expertise in concussion, neuropsychologists, and physical therapists After a concussion, limit ANY kind of exertion - physical and cognitive No two concussions are the same Physical therapy following concussion Evaluation and treatment of vestibular impairments Dizziness/BPPV Oculomotor impairment Impaired balance Evaluation and treatment of cervical spine impairments Hypomobility Flexibility Weakness Cervicogenic headaches Cervicogenic dizziness Graded return-to-play exertion rehab

Physical and cognitive rest until asymptomatic Asymptomatic 24 hr period of self-report symptoms at "0" Restoration of neuropsych function to "Normal" (athlete's pre-morbid level of function) Graduated return to play protocol

Taken into account by physician guiding RTP decision Number of previous concussions, severity and duration of symptoms LOC, amnesia Age (pediatric, college, professional) Frequency of concussions (time between) Comorbidities (depression, ADHD, learning disorders, sleep disorders) Sport, position, style of play