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Concussions 101

Concussions 101. Michael J. Sileo , MD Hayley Rintel-Queller , MD Orthopedic Associates of Long Island (OALI). Thanks!. Lisa M. Lally Hannah Kuemmel, ATC. Facts. 10% of all contact athletes sustain concussions annually

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Concussions 101

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  1. Concussions 101 Michael J. Sileo, MD Hayley Rintel-Queller, MD Orthopedic Associates of Long Island (OALI)

  2. Thanks! • Lisa M. Lally • Hannah Kuemmel, ATC

  3. Facts • 10% of all contact athletes sustain concussions annually • Approximately 300,000 sports related concussions occur each year (reported) • An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion

  4. Facts (con’t) • “Bell ringers”=concussion • account for 75% of all concussive injuries • Concussions are cumulative in athletes who return to play prior to complete recovery

  5. Dilemma • Concussions are more common and more serious than previously recognized • Seasoned doctors, coaches and parents recall treatments from the past and think that is still the standard of care • Seemingly mild initial symptoms may lead to long lasting symptoms • Youth athletes are more at risk for bad outcomes than their “professional counterparts” given their vulnerable/developing brains

  6. Definition • A concussion is a Mild Traumatic Brain Injury. • “Concussus” derived from the Latin “to shake violently” • Concussions may range from “bell ringers” to prolonged loss of consciousness.

  7. Definition • Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. • Concussion result in a functional disturbance rather than a structural injury. • No abnormality on standard structural neuroimaging studies is seen in concussion.

  8. Mechanism: Deceleration Injury

  9. Mechanism: Rotational Injury

  10. “Neurometabolic Imbalance”

  11. On-field signs and symptoms • Signs Observed • Appears dazed • Confused about play • Answers question slowly • Forgets plays, score, opponent • Personality/behavior change • Forgets events before and after hit • Loss of consciousness • Symptoms Reported • Headache • Nausea • Balance problems • Double/fuzzy vision • Sensitivity to noise/light • Feeling “foggy” • Change in sleep pattern • Concentration/memory issues

  12. What kids might say… • “I just don’t feel right…” • “My head feels heavy…” • “I feel like I am under water…” • “I got my bell rung…” • “I feel like I am not really here right now…”

  13. Uh, he was hit… now what? Concussion: The Return to Play Dilemma

  14. Initial Management • Appropriate sideline evaluation by appropriately trained medical professional • Rule out more serious intracranial pathology • If there is any focal neurologic deficit or progressively worsening symptoms, further imaging is warranted (ie, MRI, CT scan)

  15. Sideline Evaluation • ORIENTATION • What is your name? Your coach’s name? • What stadium/city is this? • Who is the opponent? What color are their jerseys? • What day/date/month/year/season is it? • What did you do in school today? • AMNESIA • Anterograde • Girl, dog, green • Retrograde • What happened prior to hit? What is score • Concentration • Days of week backwards, number backward

  16. Sideline Evaluation • Functional Testing • Romberg Sway • 20 seconds • Heel-to-toe stance • Oculomotor testing • Smooth vs. saccades • 20 yard jog • No increase in symptoms

  17. Appropriate Sideline Decisions • WHEN IN DOUBT, SIT THEM OUT! • Take helmet away • If a player loses consciousness • The player must be removed from play • If a player is removed from play for concussive symptoms • Frequent reevaluation • Deterioration of symptoms • Immediately to ER

  18. Treatment • Priority #1: ** Avoid re-injury ** • Evaluation by medical provider • Trained in concussion management • REST • Cognitive and physical • OALI Return to play protocol • 5 step protocol to return to play is much more conservative in youth than in older athletes.

  19. Cognitive Rest • May need to be out of school to start • Reduced course and work load • Extra time and a quiet location for tests • Minimal TV, computers, texting, video gaming, etc

  20. Graduated Return to Play • 1. Rest until asymptomatic (physical,mental) • 2. Light aerobic exercise w no weight training. • No significant head movement • 3. Moderate aerobic activities and weight lifting. Minimal changes in head position • 4. Increased weight training, aerobic activity • Add plyometrics,, proprioceptive challenge, head mvmt • 5. Sport specific, non-contact training • 6. Full contact training • 7. Return to contact competition

  21. Prognosis • Symptoms generally resolve in 7-10 days, but may be longer in adolescents and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of concussion) • If treated properly, the athlete will recover completely without any untoward effects. • If the athlete is not treated properly, they are at significantly increased risk of sustaining another concussion and having long term effects. • Post Concussive Syndrome • Second Impact Syndrome • Chronic Traumatic Encephalopathy [CTE] • Severe Emotional Problems • ADHD/ Learning disability??

  22. Second impact syndrome • A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event. • Can result in devastating/catastrophic increase in intracranial pressure • This catastrophic demise is very rapid and carries a 50% mortality rate along with almost a 100% morbidity rate • Most common in the high school population secondary to poor autoregulatory control of intracranial blood flow

  23. What happened to M. Ali? Chronic Traumatic Encephalopathy

  24. Recommendations for High School Athletes • EDUCATION, EDUCATION, EDUCATION • All coaching staff, referees, parents, athletes, and covering medical providers should be mandated to participate in an educational session on concussion recognition and initial management • Appropriate preventive measures • No tolerance on poor technique (ie, spear tackling) • Appropriate sideline decisions

  25. Orthopaedic Associates of Long Island (OALI) Concussion Management Program • Neurocognitive Testing/Evaluation • Evaluates attention/concentration, memory/recall, processing speed, and reaction time • Computerized models have simplified this • ImPACT (others available) • Testing done in 30 minutes or less • Currently utilized by NCAA, NFL, MLB, NHL, WWE • Ideal to have baseline

  26. Unique Contribution ofNeurocognitive Testing Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion Lovell, Collins et al., Am J Sports Med, 2006

  27. Continued…

  28. St Charles/OALI Comprehensive Concussion Management Program • Working with many local high school sports teams • Baseline Neurocognitive testing (ImPACT) • Appropriate sideline decision making • Appropriate ER follow up • Post injury testing combined with clinical evaluation • Treatment Decisions • Return to play progression

  29. Keys to Success • Education • Coaches, athletes and parents, medical staff • Proper recognition and proper treatment results in full recovery for these athletes • Baseline and post-injury testing helps provide an objective measure for safe return to play

  30. … Michael J. Sileo, MD Hayley Queller, MD Phil Schrank, MD Gregg Jarit, MD Orthopaedic Associates of Long Island (631) 689-6698 www.oali .net

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