Concussion

1. Concussion Chris Coulson, D.O. TLC Family Care, Union IVHS Team Physician

2. Concussion Facts • Each year in ED 173,265 sports and recreation TBI diagnosed from birth-19 yo. • Over 1 million visits annually in ED for TBI • Increase by 60% last decade • Bicycling, football, playground activities, basketball, soccer

7. Concussion • Do you need to be knocked out to have a concussion?

8. Concussion • If recognized and treated properly most children recover fully from a concussion • Multiple concussions tend to take longer to recover each time • Prolonged post-concussion symptoms • Increased cognitive impairment

9. Definition of concussion • Disturbance in brain function caused by direct or indirect force to head. • Mild traumatic brain injury • No universal definition • Functional rather than structural injury • Results from shear stress to brain tissue • Caused by rotational or angular forces • Direct impact to head not required • HA most common symptom

10. Pathophysiology • Shear forces disrupt neuronal membranes • Allows K+ efflux into extracellular space • Resultant increase calcium and excitatory AA • Causes more K+ efflux • Leads to suppresion of neuron activity • Na+/K+ pumps try to restore balance • Increased energy requirment • But paradoxical decrease in cerebral blood flow • Disruptions of autonomic regulation can persist for weeks • Vulnerable to additional injury

14. Second Impact Syndrome • Child sustains a second trauma to head • Not recovered from a previous concussion • Can lead to deadly cascade of events that causes rapid brain swelling

16. Second impact syndrome • A second blow to the head, even a minor one, can result in a loss of autoregulation of the brain's blood supply; this leads to a vascular engorgement and subsequent herniation of the brain that is usually fatal.3

17. Left without injury Right with head injury Red indicates electrical activity in response to task

19. Concussion Classification • No consensus regarding classification of concussion • Cantu, Colorado Medical Society, American Academy of Neurology • Based on concussion grade 1-3 • Focused on LOC and amnesia • Research has shown these markers do not accurately reflect concussion severity or recovery • Ideally determine severity time of injury, provide prognostic info, guide RTP. • Does not exist • So, individual approach • Monitor symptoms to resolution • Graded RTP strategy

21. OHSAA • Who can return a player to practice? • Only an MD, DO, or LAT • Not a chiropractor • Authorization in writing to administration of the school

22. OHSAA-6 step protocol RTP • No exertional activity until asymptomatic • When athlete appears clear, begin low impact activity such as walking, stationary bike, etc • Aerobic activity to specific sport, strength training • Non-contact skill drills, dribbling etc • Full contact in practice setting • Game play competition

23. OHSAA • Athlete must remain asymptomatic to progress to the next level • Any symptoms, athlete returns to previous level and need reevaluated by health care professional. • Medical check should occur before contact • Final written clearance from the medical professional shall be obtained before the athlete engages in any unrestricted or full contact activity.

24. Neuropsychological testing • Most beneficial when baseline measurements available for comparison. • Computer based • ImPACT • CogSport • Others • Written • Labor intensive • Several different ones • Cornerstone of evaluation, but no evidence it affects outcomes

27. Sideline assessment tools • SAC • Standardized Assessment of Concussion • Single, simple tool • Assesses a variety of domains in the initial concussion assessment • Immediately after injury: memory, orientation, concentration, delayed recall • SCAT 2 • Sport Concussion Assessment Tool 2 • Multiple assessment tools • BESS (balance error testing, SAC, Glasgow Coma Scale, Maddock’s questions

30. Does protective gear prevent concussion? • No evidence that protective gear prevents concussion • Helmets and mouth guards reduce risk of skull and dental fractures • Not the incidence of concussion • Rule changes to eliminate dangerous behaviors • More of a protective effect

32. ZackeryLystedt Law • 2009 enacted by Washington State • Requires concussion education for coaches, athletes, parents • Mandates removal if any sign of concussion • Need cleared by licensed health care professional

33. Educator’s guide • I am an educator. Why should concussions matter to me? • If you received a note from a physician stating a student in your class had a concussion and needed academic accommodations, would you know how to change student’s coursework? • Not only to continue participating in class • But to help him/her recover

34. Educator’s guide • Would you be able to explain to a parent what changes you have made and why?

35. Educator’s guide • Concussion is a serious brain injury • Significantly affect ability of brain to function at normal capacity • Key to recovery=physical and mental rest • Gradual progression back to activity • Athletics • Classroom

36. Educator’s guide • Most concussions resolve days-weeks • Think of it no different than a student who missed a few days due to a minor illness. • However, some symptoms linger • Potential for long-term academic and social difficulties

37. Educator’s guide • Proper management of a concussed student in the classroom by his/her educators is vital. • It allows student to continue to make academic progress through accommodations • It also prevents damage to the student’s academic record.

38. Common concussion symptoms • Physical • Cognitive • Emotional • Sleep

39. Physical symptoms • Headache • Dizziness • Balance Problems • Nausea/Vomiting • Fatigue • Sensitivity to light • Sensitivity to noise

40. Cognitive • Feeling mentally foggy • Feeling slowed down • Difficulty concentrating • Difficulty focusing

41. Emotional • Irritability • Sadness • Nervousness • More emotional than usual

42. Sleep • Trouble falling asleep • Sleeping more than usual • Sleeping less than usual

44. Concussion symptoms • These symptoms have a significant impact on classroom learning and schoolwork • Physical symptoms interfere with ability to focus and concentrate • Cognitive symptoms impact ability to learn, memorize and process information • Trouble keeping track assignments and tests

45. Concussion symptoms • Struggles with school work • Worsen frustration, irritability, nervousness • originally caused by changes in brain chemistry

46. Concussion symptoms • Disturbance in sleep patterns • Result in fatigue • Drowsiness during day • Compounds all the other problems

47. Concussion Management • No two concussion are the same • Developing brains are highly variable • Each student has unique symptoms and recovery time • Notes from physicians will be variable • Some will have detailed instructions for accomad. • Some will just state the student has a concussion • Educators need to help determine needs for academic assistance and what form.

48. Concussion management • Physician may recommend absence from school or half-day work • Academic work demands focus, memory, concentration • Decreasing amount of activity in brain through absence of school and school work will help decrease symptoms • Healing process will begin

49. Concussion management • AVOID: • Extensive computer use • Texting • Video games • Television • Loud music • Music through headphones • Why? • These activities make the brain work harder to process information • Exacerbate symptoms, slow recovery process

50. Concussion management • No participation in any physical activity until cleared by a physician • No gym • No weigtlifting • No sports • Why? • Physical activity after concussion magnifies existing symptoms • SIS risk