Evaluation & Management of Sports Concussions (2015)

1. Current Concepts in the Evaluation and Managementof Sports Concussion March 2015 Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation SUNY Upstate Medical University Director, Upstate Concussion Center NYSPHSAA Concussion Team & Safety Committee

2. Sports ConcussionWhere are we now? More research on concussion in last 10 years than all previous years combined Guidelines for managing a concussion have not substantially changed since 2001 Increased concern about repeated subconcussive head trauma Growing recognition of the need to manage cognitive and academic exertion after injury—not just physical exertion

3. Sports ConcussionWhere are we now? Still little research on the treatment of complicated concussion, but a graded exercise program may promote recovery Increased recognition of the role of vestibular, visual, cervical, and psychological contributions to the persistence of symptoms after injury No clear guidelines for when to recommend retirement from contact sports All 50 states have passed sports concussion laws

4. Concussion—What are the risks? Athletes who return to play while still symptomatic from a concussion may be at increased risk of . . . Another concussion Death or severe disability Aggravation of symptoms Prolonged recovery, with associated medical, psychological, and academic difficulties

5. Concussion—What are the risks? Athletes who suffer multiple concussions may be at increased risk of . . . Another concussion (increasing concussability) More severe symptoms or prolonged recovery Permanent problems Headache Dementia Depression

6. Concussion Legislation Concussion Management Awareness Act Covers injuries suffered during school-sponsored activity in public schools Immediate removal of athlete from game or practice if suspected concussion Athlete must be symptom-free for 24 hours Must be cleared by licensed physician Mandates concussion education Authorizes Concussion Teams

7. What is a concussion? Mild traumatic brain injury A disruption in normal brain function due to a blow or jolt to the head CT or MRI is almost always normal Invisible injury

8. Blow or jolt to the head AND Loss of consciousness (≤ 30 min) OR Post-traumatic amnesia (≤ 24 hrs) OR Neurological finding OR Slurred speech, diplopia, etc. Alteration in mental state Dazed or disoriented or confused Definition of ConcussionAmerican Congress of Rehabilitation Medicine

9. Epidemiologyof Concussion • Falls, motor-vehicle accidents, and assaults are the most common causes • 1.6 to 3.8 million sports concussions each year in the United States • Only 10% of sports concussions involve loss of consciousness

10. Concussion in High School Sports Guerriero et al. 2012 Current Opinion in Pediatrics

11. Mechanisms of Injury • Complex physiological process • sudden chemical changes • traumatic axonal injury

12. Neurometabolic Cascade(Giza and Hovda 2001) • Abrupt neuronal depolarization • Release of excitatory neurotransmitters • Changes in glucose metabolism • Altered cerebral blood flow • The brain goes into an ENERGY CRISIS that usually last up to 7 – 10 days symptoms often get worse before they get better

13. Traumatic Axonal Injury • Brain is shaken and rotated inside the skull • Stretching and tearing of axons

14. Common Physical Symptoms • Headache • Nausea and vomiting • Fatigue and lack of energy • Clumsiness and poor balance • Dizziness and lightheadedness • Sleep problems

15. Vision Problems • Blurred or double vision • Bothered by bright or flourescent light • Eyes tire more easily • Trouble reading (e.g., words move on the page, skipping words or lines) Standard eye exam usually shows normal ocular health and acuity

16. Common Emotional Symptoms • Irritability • Anxiety or depression • Extreme moods • Easily overwhelmed • Personality change • Lack of motivation • Emotional outbursts

17. Common Cognitive Symptoms • Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ • Easily confused • Slowed processing • Easily distracted • Memory problems • Trouble reading • Poor mental stamina

18. Exertion effects • Symptoms are worsened by . . . • mental effort • environmental stimulation • emotional stress • physical activity

19. Mike • 15 year-old boy • Head hit the bottom of the pool after he dove in • 1st concussion with no LOC • Now 3-1/2 months post-injury

21. Invisible Injury • Student looks normal and sometimes feels normal • Standard medical and neurocognitive testing may not show significant impairment • Expectation from self and others to ‘get over it’ and ‘get back in the game’

22. Recovery from Concussion • Full recovery in 7-10 days. . .in most cases • Symptoms can last weeks or months • Symptoms can significantly disrupt academic functioning • Risk of depression and anxiety a ‘miserable minority’ experience persistent symptoms

23. Post-concussion syndrome Risk factors for complicated recovery • Re-injury before complete recovery • Over-exertion, especially early after injury • Significant stress • Unable to participate in sports or exercise • Medical uncertainty • Academic difficulties • Prior condition • TBI or migraine • Anxiety • ADHD

24. Principles of Concussion Management Avoid re-injury until recovered Avoid over-exertion during recovery Early education and reassurance improves outcome Return to school gradually with accommodations as needed Return to play must follow a medically supervised process

25. Managing Complicated Cases In cases of prolonged recovery (more than 2-3 weeks) or when there is a history of multiple concussions, consider referral to a specialized Concussion Management Program

26. Rehabilitation of Complicated Cases • Little research to guide treatment • Education and reassurance are often the most helpful • Sub-symptom threshold exercise may promote recovery • Medication can help sleep, headache, mood, nausea, and other symptoms • Vision problems often respond well to treatment

27. Zurich 2012 Guidelines • No grading of injury • Treat every concussion seriously • Elite athletes are not treated differently 4th International Conference on Concussion in Sport FIFA IOC IIHF

28. Zurich Return to Play Guidelines • Any athlete who show ANY symptoms or signs of a concussion: • athlete should not return-to-play in the current game or practice • Athlete should be monitored for deterioration for 24 hours • return-to-play must follow a medically supervised stepwise process • athlete must be symptom-free at rest and after exertion When in doubt – sit ‘em out

29. Medical Protocol • Any athlete who suffers a concussion should undergo medical evaluation within 24 hours • Anyone with LOC should be evaluated that day • If confused or not fully conscious, transport by EMS with immobilization • Follow athlete until asymptomatic • First medical clearance is to begin RTP progression • If no return of symptoms with exertion, then final clearance for game play

30. Sideline Evaluation • Standardized tools available • SCAT 3 • SAC • Signs & symptoms • Evaluation of cognition is an essential component • Standard orientation questions are unreliable • Postural stability testing is a valid addition to assessment • Serial testing recommended

31. Zurich Return to Play Progression • No activity, complete rest • Light aerobic exercise but no resistance training • Sport specific exercise and progressive addition of resistance training • Non-contact training drills • Full contact training and scrimmage after medical clearance • Game play Also should be symptom-free after mental exertion and have normal neruocognitive test results

32. NYSPHSAA Concussion Checklist • First completed by coach or trainer on the sideline • Follows athlete until cleared to RTP • Reviewed by trainer and school medical director after doctor clearance • Improves communication • Enforces proper protocol

33. Neuropsychological Testing In Sports Concussion • Computerized tests that measure attention, memory, and processing speed • Sensitive to effects of concussion • Tests can be repeated multiple times to monitor recovery • Helpful tool in making RTP decisions, and can also guide academic interventions • Pre-injury baseline testing can be done • ImPACT, CogSport, HeadMinder

34. Recommendations for coaches • Educate players, parents and staff • Zero tolerance for hiding symptoms • If you’re suspicious of concussion, pull the player off the field for evaluation • Have a plan (e.g., who will evaluate the player, and how ?) • A headache does not always mean concussion, but warrants further evaluation When in doubt – sit ‘em out

35. Guidelines for Return to School after Concussion • Out of school at first if necessary, and then gradual re-entry as tolerated • Avoid re-injury in sports, gym classs and crowded hallways or stairwells • Provide academic accommodations • Communicate and Educate

36. Academic Accommodations • Rest breaks during school in a quiet location (not always the nurse’s office) • Reduced course and work load • Decrease homework • Avoid over-stimulation, (e.g., cafeteria or noisy hallways) • Extra time and a quiet location for tests Provide reassurance and support

37. P.E. Accommodations • Avoid re-injury • Balance, vision, and reaction time may all be affected by concussion • Avoid physical and mental over-exertion • Exercise may increase symptoms • Lights and noise in gym or at a sporting event may aggravate symptoms • Minimize exertion in first 1-2 weeks • Increase activity gradually, as tolerated • Don’t substitute mental activity for physical activity !

38. Growing consensus . . . • Rest helps! • Out of school at least 1-3 days after concussion • Mandatory rest breaks when first return to school • Return to Learn must be complete before starting Return to Play progression • Family, school, and medical teams need to collaborate and communicate

39. Concussion—What are theschool’s responsibilities? Protect students’ health and safety Implement a policy that incorporates current guidelines for proper concussion management Educate school staff, coaches, parents, and athletes Accommodate students’ academic and physical needs as they recover

40. Prevention Teach and enforce good technique Don’t tolerate risky behavior Helmets need to be properly fitted and worn Helmet design might matter: Revolution better than VSR4 in college players, but manufacturer didn’t matter in a study of high school athletes No evidence that mouthguards or headbands prevent concussion

41. Resources • CDC: http://www.cdc.gov/concussion/sports/ • NFHS-CDC web-based training video for coaches • Upstate Concussion program • Upstate.edu/concussion • Concussion in the Classroom brochure & video • NYSPHSAA • http://www.nysphsaa.org/safety/ • Sample policy and Concussion Checklist riegerb@upstate.edu

42. Thanks ! upstate.edu/concussion riegerb@upstate.edu