Concussions and Head Injuries

1. Kevin Avilla DPT, ATC, CSCS Concussions and Head Injuries

2. My Background • Clinical Doctorate Physical Therapy – Northeastern University • MS in Exercise Science UMASS-Amherst • BS in Athletic Training - Northeastern University • Adjunct Professor /Teaching Assistant • Lasell College – Athletic Training Education Program • Northeastern University - Athletic Training Education Program Physical Therapy Department • NATA Certified Athletic Trainer 12 years • Division I / II /III University and College Settings

3. Objectives • Inside the Numbers • Defining Concussion/MTBI • Symptomatic Profile • Anatomy and Mechanism of Injury • Management / Return to Play • Complications /Long term concerns • Role of Protective Equipment

4. MTBI in the News

5. The Scariest Moments in Sports

7. Terminology!! • MTBI (Mild Traumatic Brain Injury) / Concussion • WHY??? • Use this term when explaining to parents, and athletes • Sound harsh ………………but that is reality

8. Understanding Concussions • TERMINOLOGY!!!TERMINOLOGY!!!

9. Hockey and Concussions • Speed • Fast moving players • Fast moving objects • Surfaces • Ice • Boards • Contact • Mechanisms

10. A Quick Quiz!!!! What’s the Injury Yellow Card Syndrome

11. Inside the Numbers • 207,830 patients with Sports Related TBIs were treated in U.S. Emergency annually (CDC 2001-2005) • A previous national estimate of 300,000 SR-related TBIs included only those TBIs involving loss of consciousness • studies have reported that only 8%--19% of SR-related TBIs involve loss of consciousness. • Researchers have suggested that 1.6--3.8 million SR-related TBIs occur each year, including those not treated by a health-care provider.

12. Inside the Numbers • Ages 5--18 years account for an estimated 65% of ED visits for SR-related TBIs. • CDC Research • Ages15 to 24 years, sports are the second leading cause of traumatic brain injury behind only motor vehicle crashes • 2001 -2009 the number of ED visits increased 62% • Estimated incidence rates rose from • 190 per 100,000 up to 298 per 100,000 • 9.7 % of “Hockey Related” injuries were TBIs** • The Sports Concussion Institute estimates that 10% of athletes in contact sports suffer a concussion each season.

13. Inside the Numbers - High School Sports • A 2007 Study Journal of Athletic Training found (OSU Ohio State and Nationwide Children’s Hospital) • 8.9% of all injuries to high school athletes • 9 sports studied • boy’s football, soccer, basketball, wrestling and baseball and girl’s soccer, volleyball, basketball and softball • Increased 5.5% reported a decade earlier. • Concussion rates are increasing in high school sports • 2006 - 92,000 cases of concussions in American high school sports. • 1999 - 62,000 cases • Why??

14. Inside the Numbers – Gender Bias • In sports both sexes played in, high school girls had higher rates of concussion than boys. • also seen among college athletes. • Proposed Rationale: • Females may be more honest in reporting symptoms • Neck muscular strength • Smaller head mass

15. Inside the Numbers - Hockey Specific • Comprehensive Review* - (1985 -2000) American football, boxing, ice hockey, judo, karate, tae kwon do, rugby, and soccer • “ice hockey athletes demonstrated the highest incidence of concussion (3.6 per 1000 athlete-exposures) [AEs]” • “At the professional level, similar concussion incidence rates were found in both ice hockey and rugby.” • (6.5 per 1000 player-games, 95% CI 4.8–8.6) - Ice Hockey • (9.05 per 1000 player-games, 95% CI 4.1–17.1) - Rugby *Journal of Athletic Training 2006;41(4):470–472 Contact Sport Concussion Incidence

16. Inside the Numbers - Hockey Specific • Data collected from 8 teams in a Division I athletic conference for 1 season using a standardized form: • 113 injuries in 23,096 athlete exposures. • 65% of injuries occurred during games • Concussion (18.6%) was the most common injury, followed by knee MCL sprains, AC joint injuries, and ankle sprains. *Flik et al. The American Journal of Sports Medicine Vol. 33, No. 2, 2005 American Collegiate Men’s Ice Hockey Injuries

17. Inside the Numbers – Women’ s Hockey • Game injury rates 5 times higher than the injury rate in practices (12.6 versus 2.5 injuries per 1000 athlete-exposures, rate ratio = 5.0, 95% confidence interval = 4.2, 6.1, P < .01). • Concussions were the most common injury in both games (21.6%) and practices (13.2%). Agel et al. Journal of Athletic Training 2()07:42(2):249-254Descriptive Epidemiology of Collegiate Women's Ice Hockey Injuries: National Collegiate Athletic Association Injury Surveillance System,2000-2001 Through 2003-2004

18. Inside the Numbers - Hockey Specific • Studies indicate 1 in 20 collegiate level hockey players will experience a concussion during their college careers • Nonfatal catastrophic spinal cord and brain injury rates in HS athlets: • 2.6 per 100,000 hockey players • 0.7 per 100,000 football players • Each season 10%–12% of minor league hockey players 9–17 years report a head injury

19. Inside the Numbers- NHL • MTBI incidence rates 97/98 -07/08 seasons • HIGH 1.81/1000 athlete exposures in 1998-99 • LOW 1.04/1000 athlete exposures in 2005-06. • downward trend in the number of concussions reported • time lost from play per concussion increased over the same period (p<0.0005). • Forwards suffered a disproportionately high percentage of concussions (p<0.0001). The Canadian Journal Of Neurological Sciences 2008 Nov; Vol. 35 (5), pp. 647-51.

20. Inside the Numbers- NHL • CMAJ 2011Study -1997 – 2004 • Team physicians reported 559 concussions • 1.8 concussions per 1000 player-hours. • Varied post-concussion symptoms • Time loss (in days) increased 2.25 times for every subsequent concussion sustained during study

21. What is a concussion? • A clinical syndrome occurring as the result of trauma to the head and characterized by immediate and transient impairment of neural function. • A brain injury

22. Trauma and Dysfunction • Trauma to the brain (Concussion)=dysfunction of the brain • Resulting Symptoms: • Alteration in motor patterns • Changes in cognitive ability • Changes in memory (amnesia) • Visual Changes • Unusual behavior / mood changes • Disorientation • Vomiting • Splitting headache, intense pain, or pressure

24. Comparison to a soft tissue or joint injury Example- dislocation of the shoulder • Understand that • trauma = dysfunction • Trauma = shoulder is out of normal alignment • Resulting Dysfunction • ↓ Range of Motion • Swelling • Pain • ↓ Strength • ↓ Functional ability

25. Understanding Concussions • Force and impact ≠ Severity of Concussion • With each concussion the relative force required is diminished • Large and small forces alike can cause prolonged concussion symptoms • Large impacts may appear worse then they are, and vise versa

26. Concussion Symptoms • Symptoms may arise immediately after impact or take some time to develop • A delayed onset of symptoms may make it difficult to recognize early in the injury process, especially in “lower grade” concussions • Symptoms are unique to the athlete and all concussions present differently

27. Symptomatic Presentation • The concussive forces may cause confusion, amnesia, either immediately or shortly after impact. • Often times recognized by other athletes • Major Symptoms may be day(s) later • The alteration in function is secondary to trauma on the brain Symptoms scores via Impact Testing (Former UMASS Athlete)

28. Understanding the Anatomy • Brain is essentially free floating with the skull surrounded by a layer of protective fluid • Within the skull the brain has some ability to move • Similar to an egg yolk within an eggshell

29. Mechanism of Concussions • How concussion occur: • 2 main mechanism • Coup and Countrecoup • Coup Mechanism – Direct Trauma Occurs when a moving head hits a stationary objects: • The brain has direct contact with the skull at the site of impact • Head hitting the ice after a fall • Head hitting the boards

30. Mechanism of Concussions Impact • Countrecoup Mechanism • Injury to the brain occurs in the opposite direction of the initial force or impact • Generally seen when the head and neck accelerate and decelerate quickly • “whiplash effect” • Can have combo type concussions • Coup-countrecoup Injuries • Collision with “whip lashing” and the head hitting the ice afterwards Force Movement of the Brain

32. Concussion Grading • A number of grading scales exist with the implication that a higher grade = greater severity. I don’t care about grades

33. General Rules for Managing Athletes with Concussions • Treat athlete based on symptoms, grading scales can be deceiving. • Loss of consciousness does not necessarily indicate the seriousness • Continue to stress to athletes and parents that these are brain issues • Utilize Coaches Card • A tool for management • Some inherent problems if sole basis of decision

34. General Rules for Managing Athletes with Concussions • Avoid alcohol as symptoms may be masked • Appropriate adjustments to academic coursework • Avoid stimulating environments • video games • Theaters • Concerts

35. ''I was the captain of a team, the father of three, and all of a sudden I was having trouble taking a shower,'' LaFontaine said. ''There was depression, emotional issues. I could not watch a hockey game on television. It was too fast for me.''

36. Loss of Consciousness • If an athlete become unconscious after a head injury or fall – Cervical Spine Injury • Athlete should not be moved • What is your action plan? • Has it been practiced? • Things to consider • CPR /AED Certification – readily available?? • Ambulance – entrance, designate coach, manager • The injured athlete???

37. Returning to Play (RTP)Proper Management Monitor symptoms • Athlete’s condition can worsen ma be larger medical concern • Sub-dural hematoma • Epi-dural hematoma • pressure on the brain, resulting in bruising (hematoma) injuring brain tissue • a progressive decline in function and increase in the severity of symptoms • Occur acutely, but recent research has shows more likely when RTP to soon from a head injury and sustaining another

38. Returning to Play (RTP) Proper Management • Using Subjective and Objective Measures • Many organizations are utilizing computer based assessments to evaluate the athletes function • IMPACT Testing • Computer based assessment • Baseline measure – post concussion measures • Measures a number of variables • Visual memory • Verbal memory • Reaction time • Recall • A tool in the overall management of concussions • Often will show significant decrease in function even though reported symptoms appear to be improving

39. Neurophysiologic Testing

41. Returning to Play (RTP)Proper Management • A Stepwise progression • Can only move through progression 1 day at a time • Any manifestations of previous symptoms athlete move to previous level • 1-Asymptomatic Rest • 2-Light activity to stimulate an increase in HR (no jarring of the head) • 3-Sports-Specific Tasks- Skating • 4-Non-contact practice • 5-Full contact training with medical clearance • 6-Return to competition *Younger athletes will need more to time to heal

42. Return to Play • Never in the same game if concussion suspected • Who makes the decision? • -League Policies?? • Signed Documentation • State Mandates: • Zak Lysted Bill

43. Zak Lysted Bill

44. Sample Legislation - MA • 105 CMR 201.000 ~Head Injuries and Concussions in Extracurricular Athletic Activities. • All parties must participate in yearly training • Student removed form competition not allow to return same day • Must have documented clearance to RTP • Only the following professional can designate RTP: • A duly licensed physician; certified athletic trainer, nurse practitioner in consultation with a licensed physician; or neuropsychologist • From this policy and required documentaiton, statistical database will be generated

45. Second Impact Syndrome • A catastrophic event when a second concussion occurs while the athlete is still symptomatic from the first • The second concussion causes additional swelling and greater damage to the brain tissue • SIS is fatal • Widespread damage can result in many changes within brain’s functioning, resulting in permanent brain damage • In general athletes who have sustained a concussion are 3xmore likely to sustain a second concussion than those with no history of head injury • Athletes who are still symptomatic from a previous concussion should always be Dq’d with SIS in mind

46. Secondary Impact Syndrome (5:22)

47. Concussions-LongTerm Risk • Generally as the number of total concussions increase so does the likelihood of PCS (Post-Concussion Syndrome) • PCS-is a set of disorders that affect many brain functions including: emotions, behavior and cognitive ability • Just as repeated soft tissues become cumulative, so do injuries to the brain • Only problem the brain cannot be repaired surgically at the end of the season • Can last for weeks, months, and even years • Generally PCS is the reason you hear athletes retiring early

48. Post-Concussion Syndrome • ''I can't remember that day, I can't remember what happened,'' …..''I got knocked out. It took me about three weeks before I could start eating normally, before I could start remembering a lot of things.'‘ - Jeremy Stevenson

49. Chronic Traumatic Encephalopathy • “DimentiaPugilista” • Repeated concussions have been linked to Alzheimer's disease, clinical depression • Also implicated in Parkinson's • Example: Muhammad Ali • Patients with a history of brain injuries have been shown to exhibit Alzheimer’s related symptoms at an average of 8 years younger than patient with no associated history • A study of more than 2,500 retired NFL players found that those who had at least three concussions during their careers had triple the risk of clinical depression as those who had no concussions.

50. Chronic Traumatic Encephalopathy • Chronic Traumatic Encephalopaty • Receiving much attention in the mainstream media • BU Center for Traumatic Encephalopathy • Research is supporting the links between several conditions and repeated head trauma