Alabama Association of School Nurses Concussion (and a quick mention of Neck Injuries) Update and Review June 1, 2011

1. Alabama Association of School NursesConcussion(and a quick mention of Neck Injuries)Update and ReviewJune 1, 2011

2. Robert S. Gilbert, DO AKA “Dr. Bob” Premier Urgent and Family Care premierurgent@yahoo.com 4643 Camp Coleman Road, Suite 117 Office: (205) 655-4924 Trussville, AL 35173 Fax: (205) 655-5059 Position Family Practice Physician Professional Experience 04/2010 to Present Premier Urgent and Family Care, Managing Partner 10/1997 to 04/2010 Emergency Department with over 25,000 clinical hours in level two and three facilities. 12/1997 to 07/2001 University of Alabama at Birmingham, Assistant Professor of Family Medicine Education 10/1997 to Present Board Certified in Family Medicine 7/1994 to 6/1997 The University of Alabama at Birmingham, Family Medicine Resident 9/1990 to 5/1994 New York College of Osteopathic Medicine Certifications Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Advanced Trauma Life Support, Advanced Airway Management, Alabama Ems Online Director, Moderate Complexity Laboratory Director

3. Concussion Defined The American Academy of Neurology Concussion is a trauma-induced alteration in mental status that may or may not be associated with loss of consciousness. The Third International Conference on Concussion in Sport Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

4. Zurich z

5. Consensus Statement on Concussion In Sport – The 3rd International Conference on Concussion in Sport, held in Zurich, November 2008 Who showed up? Centre for Health, Exercise and Sports Medicine, University of Melbourne, Australia Sport Medicine Centre, Faculty of Kinesiology and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich, Switzerland Ottawa Sport Medicine Centre, Ottawa, Canada Huguenot House, Dublin, Ireland Emerson Hospital, Concord, Massachusets, USA

6. Consensus Statement on Concussion in Sport – The 3rd International Conference on Concussion in Sport, held in Zurich, November 2008 What was the plan? Develop conceptual understanding of concussion in sport using a formal consensus-based approach. Develop guidelines for use by physicians, therapists, athletic trainers, health professionals, coaches and other individuals involved in the care of injured athletes, whether at the recreational, elite or professional level. Just for kicks… The Zurich consensus makes a distinction between Concussion and Mild Traumatic Brain Injury (mTBI) and does not recommend they be used interchangeably. (Problem is… they didn’t define mTBI!)

7. Consensus Statement on Concussion in Sport – The 3rd International Conference on Concussion in Sport, held in Zurich, November 2008 What did they come up with? Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with impulsive force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury. Concussion may result in a graded set of clinical syndromes that may or may not involve LOC. Resolution of the clinical and cognitive symptoms typically follows a sequential course. Post-concussive symptoms may be prolonged in a small percentage of cases. Concussion shows no abnormality on standard structural neuroimaging studies.

8. Classification What is it called? The Old System – NO LONGER USED! Grade 1: Transient confusion, no loss of consciousness (LOC) and all symptoms resolve within 15 min. Grade 2: Transient confusion, no LOC, but symptoms or mental status abnormalities persist longer than 15 min. Grade 3: Any LOC, either brief (seconds) or prolonged (minutes). Concussion grading based on the presence or absence and duration of loss of consciousness, confusion, and posttraumatic amnesia have not been shown to be clinically useful in the management of concussion. Grading a concussion with the intent of then determining severity and to return to play has been abandoned. The severity of concussion in an individual athlete can only be ascertained retrospectively after full clinical recovery has occurred.

9. Epidemiology – How often does it happen? Epidemiology How often does it happen? Annually there are approximately 2-4 million concussions in all age groups. Approximately 300,000 head injuries occur yearly in high-school sports. Concussions comprise 90% of head injuries. Concussions comprise 8.9% of all high-school athletic injuries. Concussion occurs at a rate of 6 to 25% of high school players per season. Males account for 70%. 30% of high-school and collegiate athletes return to play the same day, and 70% after 4 days. 80 – 90% of concussions resolve within 7 to 10 days.

10. Males account for 70%.

11. Epidemiology Problem is… Athletes may not report symptoms or head injury for fear of being excluded from participation. It is generally accepted the reported incidence of concussion is a gross underestimate. In a study of high-school football players with concussion: 47.3% reported their injury. 52.7% did not report their injury because: 66% did think their injuries were serious enough to report. 36% did not realize their symptoms were consistent with concussion. 41% did not want to be held out of play. The highest number of concussions occur football, followed by ice hockey, soccer, wrestling, basketball, field hockey, baseball and softball. Athletes who have ever had a concussion are at increased risk for another concussion. Injuries are most often reported to Athletic Trainers.

12. Anatomy

13. Etiology Why Did It Happen? Concussion occurs as a result of sudden acceleration, deceleration, or rotational forces imparted to the brain with or without direct impact. Mechanism of injury may be subtle and not obvious. Magnitude of impact does not correlate with clinical injury. Concussion can also occur in noncontact sports.

14. Pathophysiology What Happened? Concussion is related to dysfunction of brain metabolism rather than structural injury or damage. Concussion on a cellular level is characterized by disruption, increased permeability, and depolarization of neuronal cell membranes resulting in neuronal suppression. The increased cellular metabolic activity increases the need for energy and glucose. A complex cascade causes decreased blood flow to the brain creating a mismatch between metabolic demands and supply. This results in neuronal dysfunction that can last from 1 to 10 days or more following the concussion, during which time the brain is more vulnerable to further injury.

15. Second Impact Syndrome A second concussion seen in an athlete who still has persistent symptoms or has not clinically fully recovered from the previous concussion. It is unclear whether Second Impact Syndrome represents a new brain injury or is a complication of the initial injury. Characterized by: Rapidly progressive brain edema. Brain stem herniation. High mortality within minutes.

16. Signs and Symptoms Mental Status Changes Amnesia– Retrograde / Anterograde Confusion Concentration Difficulties Disorientation Easily Distracted Excessive Drowsiness Feeing Dinged, Stunned, or Foggy Impaired Level of Consciousness Inappropriate Play Behaviors Loss of Consciousness Poor Concentration and Attention Seeing Stars or Flashing Lights Slow to Answer Questions or Follow Directions Loss of consciousness only occurs in 10% of concussions.

17. Signs and Symptoms Physical or Somatic Ataxia or Loss of Balance Blurry vision / Double vision Decreased performance or Playing Ability Dizziness / Vertigo / Lightheadedness Fatigue / Weakness Headache Insomnia / Hypersomnia Nausea / Vomiting Poor Coordination Ringing in the Ears Seizures Slurred or Incoherent Speech Vacant stare / Glassy Eyed Vasovagal Syncope

18. Signs and Symptoms A Word on Seizures… A variety of immediate motor phenomena (e.g. tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury. … Yeah, Whatever….

19. Signs and Symptoms Behavioral or Psychosomatic Anxiety / Nervousness Depression (May be Long Term) Emotional Lability Irritability Low Frustration Tolerance Personality Changes

20. Signs and Symptoms Warning Signs: Amnesia Headache That Gets Worse and/or Persistent Loss of Consciousness > 1 Minute Repeated Vomiting or Nausea Slurred Speech Weakness / Numbness / Decreased Coordination

21. Criteria Prove It! There are no tests to “prove” an individual has sustained a concussion.  Concussion implies a more severe injury, such as a brain contusion or bleed, is not present. Concussion is a diagnosis of exclusion.

22. Criteria Common Concussion checklists include: Concussion Resolution Index Concussion Symptom Inventory Head Injury Scale McGill ACE Post-concussion Symptoms Scale Pittsburgh Steelers Post-concussion Scale Post Concussion Symptom Scale Post-concussion Scale Revised Standardized Assessment of Concussion (SAC) Sports Concussion Assessment Tool 2 (SCAT2) Concussed athletes scored 29% better on the SAC at the time of their injury compared with their baseline evaluation.

23. English 101 Webster’s Dictionary  SCAT Noun or Verb; perhaps from Greek skat-, skōr excrement Definition: An animal fecal dropping Jazz singing with nonsense syllables To go away quickly To move fast

24. Assessment What to look for? Findings on neurologic examination should be normal with concussion, other than the mental status or cognitive functions. Abnormal or focal findings on neurologic examination prompt consideration of intracranial pathology and emergent evaluation and management. Children are particularly prone to drowsiness, vomiting, and irritability, which are sometimes delayed for several hours after apparently minor injuries.

25. Assessment Neurologic Examination Eyes: Extraocular Movements, Ocular Fundi, Pupil Reaction, Visual Acuity, Visual Fields Deep-tendon Reflexes Finger-nose Test Pronator Drift Muscle Strength Romberg Test Tandem Gait Speech Postural stability has been shown to be a sensitive indicator of sensory-motor dysfunction in concussion. A variety of balance testing options are available including: The Sensory Organization Test on the NeuroCom Smart Balance Master System Balance Error Scoring System (BESS) The Modified BESS

26. On-Field Evaluation  “when in doubt, sit them out!” Have an emergency action plan and concussion protocol in place. A B C D E AAOX3 is not reliable. Glasgow Coma Scale Sport Concussion Assessment Tool 2 (Scat2) Remember: Sideline assessment tools are not designed to take the place of more comprehensive evaluation or testing. Some symptoms may appear right away, while others may not be noticed for days or months.

27. On-Field Evaluation Glasgow Coma Scale  I. Motor Response6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response II. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No sounds III. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening The final score is determined by adding the values of I+II+III. Approximately 10% of patients with a GCS of 15 will have an acute lesion on non contrast head CT.

28. On-Field Evaluation

29. On-Field Evaluation

30. On-Field Evaluation Differential Diagnosis  Many symptoms of concussion are not specific to concussion. This creates a difficult dilemma in making the diagnosis. Differential Diagnosis in athletes include: Heat-related Illness Dehydration Hypoglycemia Acute Exertional Migraine

31. Referral When to send? Amnesia Asymmetric Pupils Drowsy or Cannot be Awakened Headache That Gets Worse and/or Persistent Increasing Confusion, Restless or Agitation Loss of Consciousness > 1 Minute Repeated Vomiting or Nausea Secondary Injury Seizures Slurred Speech Unusual Behavior Weakness / Numbness / Decreased Coordination

32. Neurophysiologic Testing Tests typically performed at least 24 to 48 hours after injury, when the athlete is symptom free, and when compared with preseason baseline tests. Neurophysiologic testing should be interpreted by a Neuropsychologist. Computerized Testing The advantage is the ability to test athletes without neuropsychologists having to administer the tests. The validity of computer-based neurophysiologic testing in sport-related concussions remains unsettled. The performance of computerized neurophysiologic tests seems to be variable, but better than pencil-and-paper tests. The same neurophysiologic test suite needs to be used for baseline and post injury evaluation.

33. Neurophysiologic Testing NeuANAM (Automated Neuropsychological Assessment Metrics) www.armymedicine.army.mil/prr/anam.html Developed by the United States Department of Defense. Assess how normal physical and cognitive performance might be affected by chemical warfare agents. ANAM has been used for evaluation of other types of injuries, including concussion in athletes. ANAM scores do not measure or indicate return to baseline after a concussion. CogSport www.cogstate.com Measures psychomotor function, processing speed, visual attention, vigilance, visual learning, verbal learning, and memory. The suite is sensitive to cognitive changes seen in sport-related concussions compared with baseline performance, which is necessary for the evaluation of an athlete after concussion. CRI (Concussion Resolution Index) www.headminder.com Web-based test that includes measures of cognitive functions related to postconcussion syndrome. Includes memory, reaction time, and speed of decision making and of information processing. CRI was developed specifically to allow for comparison of an athlete’s baseline and postconcussion performance. ImPACT (Immediate Postconcussion Assessment and Cognitive Testing or Immediate Measurement of Performance and Cognitive Testing) www.impacttest.com Designed specifically to evaluate NP function in athletes at baseline and after concussive injury. One of the most widely used test suites for evaluation of concussion in athletes, including professional players. SAC, eSAC (Standardized Assessment of Concussion) www.csmisolutions.com A brief examination intended for use at the sideline. Based on the American Academy of Neurology’s 1997 Practice Parameter for management of sports-related concussion. An electronic version operating on handheld personal digital assistants is available. rophysiologic Testing

34. Management What Now? Following a concussion, complete physical and cognitive rest is recommended. Educational accommodations for athletes recovering from concussion: Reduce the number of work assignments Allow more time to complete class work Allow more time for tests Outline and break complex tasks into simple steps Provide written instructions Provide distraction-free areas for work Provide a note taker Incorporate less stressful course work Cognitive rest also implies limiting such activities as playing video games, texting, and watching television during the recovery period.

35. Management

36. Return To Play When? There are NO accepted guidelines for return to play.  DO NOT follow the conventional return-to-play guidelines. A more conservative RTP approach is now recommended because of the different physiological response, longer recovery time, and specific risks (e.g. diffuse cerebral swelling) during childhood and adolescence. An individualized, stepwise plan for return to play is now the preferred practice. Each athlete follows a variable time course to recovery from acute cerebral concussion. Any abnormality on CT or MRI scans should result in termination of the season, and return to play at any future time should be discouraged.

37. Return To Play

38. Return To Play The National Collegiate Athletic Association (NCAA) and The National Federation of State High School Associations (NHFS) mandate: Removal from play once any signs or symptoms of concussion are present. Cannot return to play the same day. Immediate evaluation by a health care provider trained in concussion management. Evaluation by a physician or their designee before return to play.

39. Return To Play Zurich Most practitioners consider at least 7 to 10 days of rest before beginning the Zurich recommendations. This will protect vulnerable cells and axons by minimizing cerebral glucose demands and avoiding additional strains on cerebral blood flow. Before the athlete is allowed to start the return to play guidelines, they must be: Asymptomatic at rest. Asymptomatic on exertion. Examination must be normal.

40. Return To Play The Zurich Conference Consensus Statement stepwise approach. 1. No activity; complete physical and cognitive rest (e.g. scholastic work, video games, text messaging). 2. Light aerobic exercise Walking, Swimming, Stationary Cycling. Keep intensity <70% maximal predicted heart rate. NO resistance training. 3. Sport-specific exercise. Running NO head impact activities. 4. Noncontact training drills with progression to more complex training drills. Start resistance training. 5. Full-contact practice following medical clearance. 6. Return to unrestricted sport participation. The athlete should continue to proceed to the next level if asymptomatic. If symptoms recur, go back to the previous asymptomatic step and try to progress after 24 hours of rest.

41. Multiple Concussions The adverse effects of repeated concussions on the brain are cumulative and greater as the interval between successive concussions gets shorter. Multiple concussions have been associated with cumulative effects on cerebral function and cognition, including early onset of memory disturbances and even dementia. There is no agreement as to how many concussions in a given period of time should disqualify the athlete from further participation in high-risk sports. Some have suggested as few as three.

42. Concussion Management Program Emergency Concussion Action Plan These programs should include: Concussion education programs for athletes, parents, and coaches focusing on recognition, the recovery process, and return-to-play guidelines. Guidelines for faculty, administrators, parents, and students to ensure cognitive rest. Concussion-prevention strategies including proper fit and maintenance of protective equipment, teaching correct sport technique, and proper maintenance of fields and facilities. Baseline and post-concussion neurocognitive testing for student athletes. Strict accident reporting protocol for coaching staff.

43. Resources

44. Cervical Spine Injuries The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level. 0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the college level are diagnosed with cervical cord neuropraxia. It has been reported to occur in 50-65% of players over a 4-year collegiate career. The mechanism of catastrophic cervical injury is most often a forced hyperflexion injury.

45. Cervical Spine Injuries Stinger The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Characterized by temporary pain, paraesthesias and/or motor weakness in one or more extremity. These 'stinger' or 'burner' injuries are characterized by unilateral burning pain radiating from the neck, down the arm to the hand. There is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury.

46. On-Field Evaluation 911 ABCDE approach should be utilized. Airway is first assessed while maintaining cervical spine stability Breathing and ventilation Circulation Disability (neurological status) Exposed for the secondary survey The athlete's helmet and shoulder pads should remain in place with immobilization of the cervical spine. The helmet and shoulder pads serve to provide support and alignment to the injured cervical spine.

47. On-Field Management Immobilization Collars The hard collar does immobilizes the neck to a substantially greater degree than a soft collar, but it is very poor at controlling rotational movement. The range of flexion decreases from 35° in unrestrained volunteers to 24° in a hard collar. Backboards Tape

48. Return to Play No set of guidelines for return to play is agreed upon. Relative contraindications to return to play include: Recurrent episodes Symptoms lasting >24 hours Absolute contraindication to return to play Spinal instability, Ligamentous injury, Persistent neck pain or loss of motion Edema in the spinal cord the athlete sustaining a stinger may return to play when the paraesthesias resolve and full strength and painless full range of neck motion are appreciated. The patient must be able to demonstrate a full, painless cervical range of motion and have no evidence of neurological deficit prior to returning to play.

49. Conclusion Q&A