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OAA Concussion Seminar

OAA Concussion Seminar. Scot Brayford MS, OTR/L, PA-C Division of Sports Medicine Orthopaedic Associates of Allentown. OAA Concussion Seminar. October 6, 2011 Pennsylvania ’ s Lystedt Law passes 30 th state to adopt legislation Initial legislation introduction would have been 4 th state

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OAA Concussion Seminar

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  1. OAA Concussion Seminar Scot Brayford MS, OTR/L, PA-C Division of Sports Medicine Orthopaedic Associates of Allentown

  2. OAA Concussion Seminar October 6, 2011 Pennsylvania’s Lystedt Law passes • 30th state to adopt legislation • Initial legislation introduction would have been 4th state • 2006 Zach Lystedt suffered brain injury upon return to MS football game. Washington was first state legislature to pass law • Lystedt Law highlights • Educational materials for parents • Information meeting with parents in pre season • Mandates removal from play(coach/ATC/MD) on day of injury • Coaches will have concussion course once/year

  3. OAA Concussion Seminar Goals • Define concussion • Epidemiology • Pathoanatomy • Address the FAQ of concussion • Challenge the common stereotypes of concussion • Give brief foundation of current events • ImPACT overview

  4. OAA Concussion Seminar What is a concussion? • American Academy of Neurology • A trauma induced alteration in mental status that may or may not involve loss of consciousness • Centers for Disease Control • A disruption in brain function due to a blow or jolt to the head • Zurich 2008 Consensus statement • A complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces The definitions highlight the functional changes that occur, not the structural changes, nor the mechanism

  5. OAA Concussion Seminar What is a concussion? • May or may not be caused by a direct blow to the head • Rotational component is important • Rapid onset impairment in neurologic function • Symptoms may be short lived vs. long lasting • Neuroimaging studies grossly normal

  6. OAA Concussion Seminar What is the pathoanatomy of concussion? • Generally a coup vs. contrecoup from sudden acceleration-deceleration mechanism • Insult to head causes a flood of neurotransmitters (glutamate) causing neurons to fire • Calcium goes into neuron • Potassium goes out • Neurons continue to fire, requiring more energy, but calcium in the cell and potassium outside restricts cells ability to get energy • At it’s basic core, concussion is an energy crisis of the brain • Energy crisis causes symptoms • Activities which exacerbate energy crisis can cause symptoms

  7. OAA Concussion Seminar Why do our definitions of concussion keep changing? • Concussion is a complicated injury that has multiple presentations • Approximately 90% of the concussion research has been completed in the last 10 years • Our understanding of concussion is far from complete **At present there are approximately 19 different concussion guideline/classification measures, none have been proven to have inter-rater and intra-rater reliability, thus no consensus on rating system

  8. OAA Concussion Seminar Concussion Epidemiology • Most common head injury • 1.4 million per year in United States • Incidence of concussion in > 75y/o and older only demo higher than 15-24 y/o demographic • 300,000 sports related concussions/year • Approximately 60,000 in high school sports • 63% from football, 7% from ice hockey • 15-20% of football players annually • 34% of college football players have had at least one concussion • 90% of concussions are mild, with symptoms resolving in <10 days

  9. OAA Concussion Seminar Concussion Epidemiology (weird facts) • Concussion is the leading cause for missed games for Canadian youth ice hockey players • Approximately 6% of cheerleaders will experience a concussion during their cheer career • 82% at experienced at practice • From 1988 through 2004 the rate of incidence of concussions for field hockey and ice hockey was actually higher than football • 800,000 participants compared to 35 million

  10. LOC Amnesia Poor coordination Slowed responses Memory problems Repetitive questions Forget play/opponent Irritable/emotional Headache Foggy Dizziness Lightheadedness Photophobia Tired/sleepy OAA Concussion Seminar What are the signs/symptoms of concussion?

  11. OAA Concussion Seminar Who warrants an urgent referral to ER? • Loss of consciousness on the field/court lasting greater than 30 seconds • Deterioration of neurological function • Decreasing level of consciousness • Abnormally unequal, dilated, or unreactive pupils • Any signs or symptoms of associated head/neck injuries, spine or skull fractures, or bleeding • Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation • Weakness or numbness • Slurring of speech • Headaches that are worsening over time • Cranial nerve deficits • Released to care of parents with post concussion instructions

  12. OAA Concussion Seminar Common misconceptions/stereotypes The athlete says he/she feels “fine”. • 75% of athletes surveyed report not knowing the signs/symptoms of concussion (Kaut 2003) • 50% of high school football concussions go unreported (McCrea 2004) • “Symptoms not serious enough to report” • Did not want to let team/players down • Did not want to be removed from play • Anecdotal evidence from practice at OAA

  13. OAA Concussion Seminar I thought the helmet would prevent concussions • In 1960’s helmets initiated to decrease incidence of dental injuries, facial lacerations and severe head injuries (depressed fractures, hematoma, fatalities) • Fractures, hematomas and fatalities exceedingly rare • NOCSAE (National Operating Committee on Standards for Athletic Equipment) was established • Still have not established standard to decrease concussion • Virginia Tech Helmet Study (May 2011) • Established STAR rating system • Riddell Revolution Speed top performer • Riddell VSR4 second lowest performer; Adams 2000 lowest • Not available for sale since 2010; company recommends alternatives • Most popular football helmet in use for all levels • Revo decreased likelihood of concussion by 30% from VSR4 • Rothlisberger and Rodgers had concussions in 2010 in VSR4 • Even top performer only decreased incidence by 30% • HELMETS ARE NOT THE MAGIC BULLET

  14. OAA Concussion Seminar I thought the helmet would prevent concussions • 2010 University of North Carolina study demonstrates number of impacts/year in football players • QB’s = 5900; OL/DL = 89000! • 2010 Purdue study followed 21 players from a HS football team • Accelorometer study over course of season • 11 players identified due to severity or number of hits taken • 3 diagnosed with concussion • 4 showed no changes; 4 showed significant neuro-cognitive slowing WHILE DISPLAYING ASYMPTOMATIC BEHAVIOR • Four STAR rated: Shutt ION 4D, Schutt DNA Pro+, Xenith X1, Riddell Revolution, and Riddell Revolution IQ

  15. OAA Concussion Seminar The CT scan was negative, so he/she can be cleared from concussion • Likely the largest misconception in concussion management • CT scan negative in +90% of all concussions • Concussion a functional change, not a structural change • If intracranial injury can be excluded, CT likely not indicated • Medical-legal implications for NOT CT • Parental expectations • Easier to check a box than to do necessary education

  16. OAA Concussion Seminar • CT in recent years has expanded • Risk vs. benefit reward • Rule out epidural, subdural, hematoma, skull fracture – life threatening conditions • Natasha Richardson – subdural • If CT scan is positive, it is NOT concussion • One CT scan equals 200-250 x-rays • One out of 5000 10y/o; One out of 10000 adolescents will develop lethal malignancy from CT scan • If CT scan is negative, this is concussion • Does not eliminate possibility of prolonged recovery • MRI may have limited role in protracted symptoms • Functional MRI is likely future, potentially 10 years away from being clinically beneficial

  17. OAA Concussion Seminar The Emergency Room doctor said I could return to play in one week • Likely the second most common misconception • ER doctors have likely ruled out life threatening injuries • Unlikely to have taken the time or effort to do a full evaluation for concussion • Approximately 30-40% of concussions will be recovered enough to return to play in one week • Approximately 50-60% in two weeks • Approximately 80% in three weeks • Prolonged recovery has some hallmarks • Retrograde amnesia is 10x more likely • Anterograde amnesia is 4x more likely • Dizziness as a initial presenting symptom is 4x more likely • Fogginess as primary complaint in office evaluation is 6x more likely • Vestibular or balance issues that aren’t improving with brain rest alone • Note LOC not listed • College and pro athletes may recover quicker • Mature brains, better initial recognition?, quicker/daily access to rehab

  18. OAA Concussion Seminar His/her head didn’t even get hit, so it can’t be concussion OR it shouldn’t take long to recover • Coup vs. Contrecoup mechanism • Risk factor consideration • Age <14 y/o • Migraine history • Consideration of family history of migraine • Potential start of post-traumatic migraine • Female > male • Concussion history? • History of learning disability or ADHD? • Neck strength a factor? • Research theorizes a correlation with greater neck strength and the ability to absorb greater accelerations/forces • No definitive study at present. No clear training regime outlined.

  19. OAA Concussion Seminar He/she says she is asymptomatic. • Players want desperately to return to play • Culture of sport; role coaches play in creating an environment of self reporting and acceptance of return to play guides are important • Time to be a parent vs. be a fan • Be an informed advocate • When in doubt, keep in them out • Conservative steps for high school; even more conservative for Junior High

  20. OAA Concussion Seminar • Benefits of baseline testing • ImPACT – Immediate Post Concussion Assessment and Cognitive Testing • University of Pittsburgh – Lovell, Collins & Maroon • How the brain functions at baseline compared to functioning after concussion • Demographic questionnaire • 21 Item Likert symptom scale • 8 neurocogitive measures

  21. OAA Concussion Seminar Jim Thorpe’s Concussion Program • Player suspected of head injury remove from play and not be returned • Physical exam by ATC • Evaluation by ER? • 24-72 hour ImPACT • Academic accommodations • Communication with concussion provider • Office evaluation • Return to play on Zurich

  22. Thank you

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