What’s New In Concussions: Prevention and Management

1. What’s New In Concussions: Prevention and Management ACHA Annual Meeting, San Francisco May 2009

2. Presenters Dr. James MacDonald, MD, FAAFP University of California – Santa Cruz Santa Cruz, CA Dr. Lori Dewald, EdD, ATC, CHES, F-AAHE Salisbury University Salisbury, MD

3. Background….UCSC • Our clinic • Our student population • Mostly Young • Mostly Healthy • Very Active!

4. UCSC Division III Sports men’s tennis women’s tennismen’s basketballwomen’s basketball men’s soccer women’s soccermen’s volleyballwomen’s volleyballmen’s water polowomen’s water polowomen’s cross-countrywomen’s golfmen’s and women’s swimming and diving

5. …..And More • Club Sports • Rugby, Ultimate, Baseball, Lacrosse, Cheerleading, Dance and more • Activities and Classes • Jiu Jitsu, Capoeira, Biking, Lifting, Swimming, Skating, Snowboarding, Surfing………. • Our Campus!

6. Background….Salisbury University • 8000 students. • One of the most successful Division III athletic departments in the country. • Multiple national championships in multiple sports annually.

7. Salisbury University*NCAA Division III Our sports Women’s Field Hockey Men’s Football Women’s Soccer Men’s Soccer Women’s Cross Country Men’s Cross Country Women’s Basketball Men’s Basketball Women’s Lacrosse Men’s Lacrosse Women’s Softball Men’s Baseball Women’s Track/Field Men’s Track/Field Women’s Tennis Men’s Tennis Women’s Swimming Men’s Swimming Women’s Volleyball

8. Athletics does not deal with… • Club sports • Other activities (i.e. dancers, theatre, etc.) • These are dealt with by the student health center!

9. What’s New In Concussion • A move away from consensus “grading” to a binary diagnosis scheme: simple vs. complex • A move away from arbitrary days, and a move toward symptom-based protocol for return to play • A move toward more objective assessment of recovery (quantifying symptoms, neuropsychological performance, balance) • Increasing research!

10. Ever Increasing Research and Awareness

11. Brain Anatomy

12. Concussion—A Definition Diffuse, reversible brain injury associated with trauma.Functional not structural!! Caused by inertial forces from trauma that lead to shear strain. Concussion is a metabolic injury: injury results in increased energy demands as repair begins. Hallmark: Mental Status changes, including confusion, amnesia, even loss of consciousness.

13. Epidemiology • CDC estimate: more than 1.6 million/year/USA. • 300,000+ are sports related. • This means that 1.3 million occur in other ways….such as alcohol-related stunts, etc. • 92% of repeat concussions occur within 10 days of the first! Kevin Guskierwicz 2000

14. YouTube Video • This is the way your students might get this in a “non athletic” way

15. Concussion—a metabolic injury • Increased demand for glucose coupled with decreased cerebral blood flow. • Can be seen on PET, fMRI imaging (not clinically useful). • Vasoconstrictive effects are due to local accumulations of calcium in endothelium of cerebral vasculature. • http://www.nytimes.com/library/sports/other/concussion.swf

17. How lay people understand it • A “Ding”. • Getting Your Bell Rung. • “Just shake it off and get back in the game”. • The difference between injury and pain.

18. The reality…. • Concussus—Latin:”to shake violently”. • Traumatic functional brain injury. • With rapid onset of short lived neurological deficits!!!!!! • No two concussions have the same signs or symptoms. • Student health centers see more concussions than athletic trainers, because you have the entire student body as your patients. • Intramural sports, accidents, general student body, physical education classes, and weekend warriors experience more concussions annually.

19. What it’s not! • Epidural hematoma • Subdural hematoma • Brain contusion • Cervical Spine injury • Transient quadriplegia • Facial fracture

20. Concussion--Signs • Appears “dazed and confused”. • Forgets Plays. • Unsure of game, score, opponent. • Moves clumsily. • Answers questions slowly. • Loss of consciousness. • Personality changes. • Amnesia—both retrograde and antegrade. • No “localizing signs” on neurological exam. • Imbalance. • Seizure. • Inappropriate emotions.

21. Concussion--Symptoms • Headache, nausea. , vomiting • Dizziness. • Blurry Vision. • Light, sound sensitivity. • Feels sluggish or slow. • Feels groggy or foggy. • Concentration problems. • Difficulty balancing • Tinnitus • Sadness or finding everything funny • Hallucinations

22. SCAT 2

23. Testing Monitoring of the following critical domains • Neuropsychological (Standardized Assessment of Concussion, SAC) • Balance (Balance Error Scoring System, BESS) • Symptoms (Graded Symptom Checklist) • These can all be found in the newly released SCAT2 widely distributed now on the internet

24. Concussion—Associated Sports • All sports have the potential for concussions! • Football • Soccer • Rugby • Wrestling • Boxing • Martial Arts • Skiing • Snowboarding • Lacrosse “I like to believe that my best hits border on felonious assault.”  ~Jack Tatum “Float like a butterfly, sting like a bee.” ~Muhammad Ali

25. Concussion--diagnosis • Best done on the field or shortly thereafter. • Neurological examination, including mental status testing. • Grade I (Mild): <30 min. amnesia, no LOC. • Grade II (Moderate): 30 min to 24 hours of amnesia, and/or < 5 min. of LOC. • Grade III (Severe): >24hr amnesia and/or >5 min LOC. “LOC” means “loss of consciousness” NO!!!!!

26. On field mental status • Orientation and evaluation of retrograde amnesia. • Who are we playing? • Which goal is ours? • Who is winning? • Who scored last? • Who did we play last week? • Did we win last week? • Are your parents at this game?

27. Mental Status--continued • Concentration. • Months backwards. • Digits or Name backwards. • Evaluate antegrade amnesia: three to five word recall.

28. Additional considerations • Brains appear “normal” on CAT scans, x-rays, and MRI’s. • PET, SPECT, and “functional” MRI’s are the preferred imaging. Especially to be used immediately after the injury and then as a comparative tool for determining concussion recovery. Difficult to find though. • The effects of concussions are cumulative! • The adolescents and teens are more vulnerable to concussions than adults…but researchers still do not know exactly why this is. Girls possibly, too.

29. Recent research • Study by Collins et al. revealed that the presence of amnesia and not LOC was most predictive of post injury difficulties at three days post injury. • Studies by Erlanger et al. found that LOC was not predictive of deficits following sports related concussion. • Women appear at higher risk for concussions: why?

30. Cantu’s Guidelines for return to play NO!!!!!

31. Step Wise Return to Play Protocol • No activity; complete rest. Once asymptomatic, proceed to level (2), and so on… • Light aerobic exercise such as walking/cycling. • Sports specific training—e.g. running in rugby or skating in hockey. • Non-contact training drills. • Full contact training. • Game play. With this stepwise progression, athlete should continue to next level if asymptomatic at current level. If symptoms develop, drop back to previous asymptomatic level and try to progress again after 24 hours.

32. Disqualifying considerations • Disqualifying for a game or practice. • Disqualifying for the season. • Disqualifying for a career.

33. Second Impact Syndrome • This dreaded complication occurs when athlete is still symptomatic from initial head injury and sustains a second head injury. • Second injury shear force causes enough damage to result in cerebral edema leading to brain stem herniation. • Signs: fixed, dilated pupils; slowing and then stopping of respiration; a rigid, abnormal posture. • Rare, but becoming more common!

34. Post-concussion Syndrome • By definition what is seen in a complex concussion • Prolonged • Inattention • Affective symptoms • Difficulty Concentrating • Headaches

35. Long term complications • Long term deficits have been observed from a single concussive event. • More events = higher risk of long term deficits; but how much is too many? • Dementia pugilistica—is this secondary to concussion or multiple lower level traumatic events to the brain?

36. Chris Nowinski

37. Encephalopathy • Increasingly researched. • Anecdotal information mounting.

38. Athletes to donate brains for concussion study

39. Long Term Complications, Cont. Center for the Study of Retired Athletes, Univ. of North Carolina

40. Retirement? • No evidence based recommendations guide practitioner. • Anecdotal cases of athletes with poor outcomes dictate many decisions. • Some evidence that certain preconditions (ApoE gene; associated learning disabilities) are associated with higher risk. • Having a frank discussion with the athlete about risks/benefits seems appropriate course at this current juncture.

41. Concussion—How to avoid it • Customized mouthguard is a must…..for teeth protection! • Head protection. • Avoiding sports at risk. • Pre-season neck strengthening? • Wearing appropriate/advanced, sport specific head gear. • Not wearing head gear???? • “Minding your manners” if you’ve had a concussion. • Correct tackling, etc. • Turf?

42. What’s New? Grading of concussions is simplified: there are simple and complex concussions. Return to play/work decisions are simplified: functional assessment as opposed to old criteria. Increasing recognition of impact in the school room and not just the playing field. Increasing recognition of longer term consequences. Increasing Awareness!

43. What’s new continued • Neuropsychometric testing preseason, after trauma, and postseason. • Genetic testing for apolipoprotein E (ApoE) gene. • Sport specific differences. • Gender specific differences. • Females more susceptible than males. • Age specific differences. • Handheld device that is taped to the forehead and reads the brain’s electrical activity immediately after the possible concussion and compares it immediately to normal brain function.

44. Increasing Awareness CDC “Heads Up” Program

45. National Athletic Trainers’ Association Position Statement on Sport-Related Concussions

46. Another Video! This time from the CDC

47. Suggestions • QI • In service • Readings • Track Diagnosis code • Chart Review • Feedback

48. Summary • A functional, not a structural injury. • Be comfortable with return to play/work progression. • Consider additional injuries and rule out/treat as indicated. • Consider referral for complex concussions. • Students will present just as likely as athletes Practice Pearl!!!

49. Resources • NATA Position Statement on Concussions (available at http://www.nata.org/statements/position/concussion.pdf) • Pediatrics Vol. 123 No. 1 January 2009, pp. 114-123 Review Article on Concussions • British Journal of Sports Medicine (the entire May 2009 issue). • www.chrisnowinski.com • CDC’s “Head’s Up” program, at http://www.cdc.gov/ConcussionInYouthSports/ • The 3rd International Conference on Concussion in Sport, Zurich, 2008 (being widely distributed)

50. Thanks, From UCSC and Salisbury!