Concussion: Definition, Demographics, Signs & Symptoms

Concussion: Definition, Demographics, Signs & Symptoms Andrew Gregory, MD, FAAP, FACSM Associate Professor Orthopedics & Pediatrics Team Physician, Vanderbilt & Belmont Universities

Objectives • Definition of concussion • Discuss common signs & symptoms • Review demographics • Who, what, when and how

Is this a concussion? • 11 yo was swinging on a tree limb, fell 5-6’ and hit the back of his head on the ground • Loses consciousness for one min according to other kids • Then has headaches and blurry vision • Vomits twice

Is this a concussion? • Seen at the Emergency Room - “normal exam”, CT Scan negative • Goes back to school with headaches needing Ibuprofen • Headaches get worse with physical activity (including practicing with his travel baseball team)

Self Reported Symptoms • Headache – 3/6 • Trouble Sleeping – 3/6 • Drowsiness – 2/6 • Sensitivity to light – 2/6 • Feeling like “in a fog” – 1/6 • Difficulty concentrating – 1/6 • All others - 0/6

Did this child have a concussion?

What is a Concussion? • Lots of terms • Ding, bell rung, shaking off the cobwebs, closed head injury, mild traumatic brain injury (mTBI) • “A trauma induced alteration in mental status that may or may not involve loss of consciousness” —AAN 1997 • Headache plus… • Transient Neurological Phenomenon

Definition of Concussion 1. Caused either by a direct blow to the head, face, neck or elsewhere on the body with a resultant force transmitted to the brain. 2. Typically results in the rapid onset of short-lived changes in neurological function that resolves spontaneously. 3. May result in structural brain changes, but the symptoms largely reflect a functional disturbance rather than a structural injury. 4. Usually follows a progressive course of improvement 5. Imaging studies (brain CT/MRI) are usually normal.

Symptoms Headache Nausea Balance problems or dizziness Double vision Sensitivity to light or noise Feeling sluggish Feeling “foggy” Concentration or memory problems Change in sleep pattern (appears later) Feeling fatigued Signs and Symptoms of Concussion Signs • Appears dazed or stunned • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly • Loses consciousness • Shows behavior or personality change • Forgets events prior to play (retrograde) • Forgets events after hit (posttraumatic)

Common symptoms of concussion from a series of injured high school athletes • Three most common symptoms: • Headaches (55%) • Dizziness (42%) • Blurred vision (16%) • 46% experienced either cognitive or memory problems • 9% had loss of consciousness (“knocked out”)

Do you have to be “knocked out” to have a concussion? • NO!!!!! • In fact, only a SMALL number of concussed athletes were “knocked out” • Many studies have now shown that amnesia (inability to remember) is a much more common sign of concussion and ALWAYS indicates that a brain injury has occurred

What are the “Grades” of a concussion? • In the past concussions were often classified into grade 1, 2, or 3 based on the severity and duration of symptoms at the time of injury • Many research studies have showed that these grading scales were useless in predicting the severity of injury or how long to recover • Grading scales are no longer used

If you have a history of a previous concussion are you more likely to have a longer duration of symptoms? • Available research says “yes”

Does having a concussion increase your chances for a future concussion? • Some research says “yes” • 92% of the in-season repeat concussions occurred within 7-10 days of first

Epidemiology of Concussion 1.5-3.8 million reported cases of brain injury per year in the US (CDC) 20% (300,000-760,000) are sports-related 53,000 deaths each year 70-90,000 permanently disabled Highest sports incidence: ages 15-24 Cost estimated at > $60 billion annually

HS RIO™ Injury Surveillance System Internet-based high school sports-related injury surveillance system Weekly data capture 2005 - 2010 academic years Representative sample of 100 US high schools Geography (4 US census regions) Size (≤1,000 vs >1,000 students) 20 sports Boys’ - football, soccer, basketball, wrestling, baseball, lacrosse, ice hockey, swimming & diving, track & field, volleyball Girls’ - volleyball, soccer, basketball, softball, lacrosse, field hockey, gymnastics , swimming & diving, track & field, cheerleading 16

Concussion Rates, 2005- 2010 Includes concussions resulting in <1 day time loss (non time loss = 2% of all concussions) 17

Concussion Severity 2005-2010 Time lost (days) Time lost means days missed from sport due to concussion 18

Concussion Mechanisms 2005-2010 Includes only time loss concussions 19

Activity Associated with Concussions, Soccer 2005-2010 Includes only time loss concussions 20

Activity Associations Basketball 2005 - 2010 Includes only time loss concussions 21

Activity Associations Baseball/Softball 2005 -2010 * Includes only time loss concussions 22

Football Concussions 2010 • Concussions resulting from player-to-player contact • Type of contact: head to head (66%), head to other body site (26%), head to playing surface (8%) • Position of head during contact: head-up (38%), head-down (25%), no flexion (4%), unknown (33%) • Direction of impact: front (45%), side (22%), top (8%), back (5%), unknown (20%) • Did athlete see impact coming: yes (37%), no (27%), unknown (37%) 23

Girls’ Soccer Concussions 2010 • Concussions resulting from player-to-player contact • Type of contact: head to head (48%), head to other body site (45%), head to playing surface (7%) • Position of head during contact: head-up (21%), head-down (26%), no flexion (7%), unknown (46%) • Direction of impact: front (24%), side (43%), top (3%), back (14%), unknown (16%) • Did athlete see impact coming: yes (55%), no (25%), unknown (20%) 24

Summary • Concussion is a temporary disruption of ANY function of the brain caused by trauma • All coaches and parents should become familiar with common signs and symptoms of concussion and be alert for them • No return to play if concussion is suspected • Grading scales are no longer used • ANY athlete in ANY sport at ANY age is at risk for concussion

Concussion: Definition, Demographics, Signs & Symptoms