Brain Injuries in Athletics

1. Brain Injuries in Athletics

2. Objectives • Define and explain these terms: • Concussion • MTBI • Second-Impact Syndrome • Post-Concussion Syndrome • Intracranial hemorrhage • Mortality • Morbidity Continued….

3. Objectives • Define and explain these terms: • GSC • SAC • BESS • IMPACT • ISS • HITS • Be familiar with the incidence of head injury in sport • Explain the various mechanisms of head injury • Understand assessment procedures for head injuries • Be familiar with current management practices for head injury

4. Cardinal Principles • Treat every unconscious athlete as if she/he has a cervical spine injury until proven otherwise! • No athlete should return to participation while symptomatic!

5. An injury of transient physiologic dysfunction resulting from biomechanical forces acting on the brain. It does not necessarily involve loss of consciousness (LOC) Concussion/MTBI (Mild traumatic brain injury)

6. Incidence of concussion • Has been vastly underreported in the past, due to outdated definition. • Fewer than 9% of collegiate concussions occurred with LOC (loss of consciousness). • 47% of high school football concussions go unreported (McCrea, Hammeka, Olsen, Leo, Guskiewicz, 2004). BIG PROBLEM!!! • Current estimate is 1.6-3.8 million per year (Langlois, Rutlan-Brown, Wald, 2006) • Accounts for 9% of all high school athletic injuries (Langlois, Rutlan-Brown, Wald) • Long-term effects are just starting to become known

7. Why is the brain so susceptible to injury??

9. Mechanisms of MTBI • Coup • Contrecoup

10. MTBI Signs and Symptoms* *+ HEADACHE Possiblenausea, tinnitis, photophobia

11. Amnesia • Retrograde • Anterograde

12. Signs vs. Symptoms?

13. Assessment of Concussion • Immediate, on-field • Follow-up • Long-term All include both physical and neurocognitive testing

14. Immediate Assessment • Note time of injury/initial assessment

15. MTBI Signs and Symptoms* *+ HEADACHE Possiblenausea, tinnitis, photophobia

16. Graded Symptom Checklist (GSC) Assessment of Concussion

18. Standardized Assessment of Concussion (SAC) Assessment of Concussion

20. Balance Error Scoring System (BESS) Assessment of Concussion

23. Head Impact Telemetry System Assessment of Concussion1130 NATA 2005 Case Studies 2[1].pdf

24. 3 Important Things for the Clinician • Recognizing the injury and its severity • Determining if the athlete requires additional attention and/or assessment • Deciding when it is safe for the athlete to return to sports activity

25. Management of the Concussed Athlete

26. Play or no-play?? • No LOC, no amnesia, other symptoms clear quickly (<15 minutes) – may return • New NFL policy – any athlete demonstrating signs of concussion is out at least for the remainder of that day • Out of collision activities at least 6 symptom-free days – WHY??

27. Second-Impact Syndrome (SIS) • Estimates of 3-6x greater liklihood of sustaining a second concussion if returns too early (i.e. non-resolution of symptoms = NOT symptom-free) • Brain is much more sensitive, and not as great an impact is required to cause substantial trauma • 50% mortality rate/100% morbidity rate

28. Post-Concussion Syndrome • Persistence of concussion symptoms • May persist forever • Must have continual follow-up to document signs and symptoms

29. Repeated MTBI • Cumulative effect of multiple concussions over time • Just beginning to see the effects of this

30. The Dangers of Concussion • Second-Impact Syndrome • Don’t yet know the effects of cumulative MTBI • And…

31. Intracranial Hemorrhage • Intracerebral hemorrhage (right) • Cerebral hematoma • Epidural hematoma • Subdural hematoma

32. Intracranial Hemorrhage Signs and Symptoms* *+ HEADACHE Possiblenausea, tinnitis, photophobia

33. Indicators that things are heading South • Slowing pulse • Slow increase in blood pressure • Mental status changes (for the worse) • Initiate Emergency Action Plan

36. Epidural Hematoma • Occurs as a result of acceleration-deceleration mechanism • Rapidly developing • Deteriorating status begins 10 minutes to 2 hours post-ictal • “Lucid Interval” Phenomenon • Always check for associated skull fracture (common) • Immediate surgery required

39. Subdural Hematoma • Blow to the head • Much more insidious onset • Why?

40. 3 Important Things for the Clinician • Recognizing the injury and its severity • Sideline evaluation • Serial follow-up evaluations • Patient and family education • Determining if the athlete requires additional attention and/or assessment • Progression of symptoms • Deciding when it is safe for the athlete to return to sports activity • Symptom-free! • Neurocognitive testing within baseline limits

41. References • Corvassin, T, Elbin, R., Stiller-Ostrowski, J. and Kontos, A. (2009). Immediate post-concussion assessment and cognitive testing (ImPACT) practices of sports medicine professionals. Journal of Athletic Training, 44(6), 639-44. • Broglio, SP and Guskiewicz, KM (2009). Concussion in sports: the sideline assessment. Sports Health, 1(5), 361-369. • Kutcher, J. (2010). Management of the complicated sports concussion patient. Sports Health, 2(3), 197-202. • www.nata.org/health

42. Questions?