Concussion: Concepts, Controversy and Confusion New York State Association of Independent Schools

1. Concussion: Concepts, Controversy and ConfusionNew York State Association of Independent Schools John Cottone, EdD, ATC SUNY Cortland May 4, 2010

2. Acknowledgement Thanks to Brian P Rieger, PhD Chief Psychologist & Clinical Assistant Professor Department of Physical Medicine & Rehabilitation SUNY Upstate Medical University Director, CNY Sports Concussion Center NYSPHSAA Concussion Team & Safety Committee NYS TBI Coordinating Council  Public Education Committee For his assistance and generosity in providing materials this presentation

3. Concussion Discussion • What is a concussion ? • How do I recognize a concussion when it occurs ? • What is the recommended treatment for concussion ? • What are the risks associated with an unrecognized concussion or with multiple concussions ? • What are the current guidelines for return to sports, school, and other activities after concussion ? • How can educators help a student who is recovering from a concussion ?

4. 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

5. Definition of Concussion • Centers for Disease Control • American Academy of Neurology • American Congress of Rehabilitation Medicine

6. Outdated AAN Criteria forSports-related Concussion Grade 1 Transient Confusion Symptoms resolve in <15 minutes No LOC Grade 2 Transient Confusion Symptoms last >15 minutes No LOC Grade 3 LOC: a) brief b) prolonged

7. Outdated Prague 2004 Guidelines • Simple concussion • LOC < 1 minute • resolves in 7-10 days • first concussion • Complex concussion • LOC > 1 minute • symptoms last longer than 7 – 10 days • history of multiple concussions • increasing “concussability”

8. Zurich 2008 Guidelines • No grading of injury • Treat every concussion seriously • Recovery may take longer in children and adolescents

9. Sports Concussion • Football, hockey, and soccer are the riskiest male team sports • Soccer and lacrosse are the riskiest female team sports • In high school sports played by both sexes, girls have a higher rate of concussion • Collegiate athletes have a higher rate of concussion than HS athletes • Concussion represents a higher proportion of all injuries in HS athletes vs. collegiate

10. Concussion Management Advisory Team • Athletic Trainer • School MD • School Nurse • Athletic Director • Coaches • Teachers • Parents (school community) • Athletes

11. Concussion Management Advisory Team • Policies and Procedures • Development • CMAT • Implementation • Athletic Directors provide oversight • Coordinate with other school officials

12. Guidelines for Coaches • Prevention and Preparation • Educate the school community • Teach athletes about not playing hurt • Prevent re-injury • Prepare year round • Preseason • In Season • Postseason

13. Guidelines for Coaches • Advocate and teach safety first • Know when to remove athlete • Ensure appropriate care • Communicate • Athlete • Parent • Administrator • RTP only after medical clearance • k

14. Guidelines for Parents • What is a concussion? • Signs and symptoms • Know to seek medical attention • Know when to “sit out” • Communicate to coach, medical staff

15. Guidelines for Athletes • What is a concussion • Prevention • Know signs and symptoms • Report to ATC, coach, parent • Never play with S/S • Tell the truth

16. Preseason Baseline Testing • Guidelines intended for implementation by athletic trainer, athletic director, coaches • Concussion History • SAC or BESS testing • Neuropsychological testing

17. Neuropsychological Testing In Sports Concussion • Computerized tests that measure attention, memory, and reaction time • Sensitive to effects of concussion • Tests can be repeated multiple times to monitor recovery • Ideally, pre-injury baseline testing done for all athletes • ImPACT, CogSport, HeadMinder • ImPACT Test

18. Creation of an Action Plan • Recognition (knowing when to remove athlete from participation) • Evaluation (appropriate medical attention) • Communication Loop • Return to Play (medical decision) • Establish protocol

19. First Aid • Detect and Care • Determine the need for and then activate the emergency action plan • Perform emergency procedures they are qualified to perform (e.g.: CPR) • Addition to Education Law

20. Sideline Evaluation • Head trauma (blow or jolt) • LOC or amnesia for the trauma • Focal neurologic finding • Signs & Symptoms (SCAT card) • confused, wobbly, emotional. . . • Assess cognition • 3 word recall • Months backwards • Standardized testing • SAC • BESS • NO RETURN TO PLAY THAT DAY • PubMed Central, Table 2: J Athl Train. 2001 Jul–Sep; 36(3): 274–279.

21. Common Physical Problems • Headache • Dizziness and lightheadedness • Clumsiness and poor balance • Fatigue and lack of energy • Sleep disturbance • Blurred vision and light sensitivity • Ringing in the ears

22. Common Cognitive Problems • Feeling ‘dazed’ or ‘foggy’ or ‘fuzzy’ • Easily distracted and easily losing track of things • Trouble doing more than one thing at a time • Poor learning and memory • Poor reading comprehension

23. When to Seek Medical Attention • Any athlete who has had a concussion needs medical clearance before he or she is allowed to return to play • NFHS | Concussion Rule Revised, Strengthened in High School Football • Anyone with a loss of consciousness should be seen that day

24. When to Transport by EMS • Anyone with an altered level of consciousness or focal exam should be transported with full spinal immobilization • Anyone who has had a seizure • Anyone with more than a brief LOC ( > 1 min)

25. Principles of Concussion Treatment • No cure for concussion, but treatment can help the person feel better and function better while symptomatic • Early diagnosis and education is critical • Rest early (7-10 days?) and then gradually increase activity

26. Recovery from Concussion • Usually takes 1-2 weeks • High school age youth take longer to recover • Recovery may be complicated by non-injury variables

27. Recovery From Sports ConcussionHow Long Does it Take on ImPACT? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 N=134 High School athletes Collins et al., 2006, Neurosurgery

28. Post-Concussion Syndrome (PCS) • Term used to describe complicated recovery from concussion • Symptoms generally thought to have a neurological basis at first • When symptoms persist, non-injury factors appear to play an increasingly significant role over time • Controversial topic

29. Recovery from concussion • Classic post-concussion presentation is fatigue and poor tolerance for exertion • Symptoms are worsened by . . . • mental effort • environmental stimulation • emotional stress • physical activity

30. Multiple Concussions • Second Impact Syndrome • A second concussion within a week of first • Rare but almost always fatal • Increasing concussability • Longer recovery • Accumulating damage ? • Problems can be subtle and hard to detect • Possible lifelong symptoms and problems

31. Concussion Controversies • Prague guidelines (or any guidelines) • Soccer headgear • Concussion mouth guards • Concussion football helmets • Computerized cognitive testing • Baseline pre-season testing • Causes of post-concussion syndrome • Treatment of post-concussion syndrome

32. Concussion in the Classroom • Fatigue - tires easily in class and over the course of the day • Headache and other symptoms worsen with reading or concentration • Trouble doing more than one thing at a time (e.g., listening to the teacher and taking notes) • Frequent visits to the nurse’s office

33. Concussion in the Classroom • Late or incomplete homework • Easily overloaded and ‘shuts down’ • Takes longer to read and learn • Bothered by bright light in the classroom or noise in the cafeteria • Emotional outbursts • Lack of motivation

34. Zurich Return to Play Guidelines • Zurich 2008 guidelines for high school and younger athletes 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

35. 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 Neurocognitive test results

36. 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

37. Managing Complex Concussion • Consider referral to specialized provider or program if . . . • History of multiple concussions or other risk factors • Prolonged recovery (> 2 weeks) • Worsening symptoms

38. 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

39. 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 class and crowded hallways or stairwells • Provide academic accommodations • Communicate and Educate

40. 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

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

42. Summary • CDC now recognizes concussion as a significant public health issue • Proper recognition and management of concussion can prevent serious problems • Avoid risky activities and sports until symptom free, at rest and with exertion • Provide reassurance, support, and academic accommodations as needed • Concussion is more than just a bump on the head !