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Athletes (and non athletes as well) are increasingly reporting concussions to parents, coaches, and school nurses. How can you recognize a concussion? We will review the diagnosis and treatments for concussions, review dangers of multiple concussions and discuss the use of computerized neuropsychological testing prior to “return to play”.
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Tackling Sports Concussions Head On
Jeffrey Rosenberg MDSports Medicine
September 5, 2012
Traumatic Brain InjuryConcussions are one type of TBIDiffuse Injury, No Anatomic
Changes
Focal Brain Injury-More SevereSubdural Hematoma, Epidural Hematoma, Intra-cerebral Hematoma
Associated with Anatomical Change-Blood, Fluid, Local Damaged Tissue
Myth #1: Only Football Players Get Concussions
>170,000 Sports and Recreations TBI/year from birth to 19 yo
ER visits increased by 60%
Birth to 9 yo: Playground and Bicycle Related Injury
9% of all sports related injuries
Male 10-19 yo: Football, Bicycling
Female 10-19 yo: Soccer, Basketball, Bicycling
Silent EpidemicUp to 50% of concussions not
reportedAthletes hide symptoms, don't
report any problemsCoaches want the players to play
Athletic Trainer, not coach has the final say
Parents play down severity to let the athlete participate
More difficult to ignore in NJ as of 2011 regulations
Myth #2:Can only get Concussion if Hit in the Head
Direct blow most common Helmet to Helmet; Head to
other Body Part Ground
Indirect ForcesLinear or rotational forces
Getting hit from the side in the body
Brain cell injury and dysfunctionNo anatomic damage
Brain Injury
Trauma causes brain tissue to release chemicals: Calcium/Glutamate Increases need for blood flow for metabolism
to recover from injury Unfortunately, the arteries are constricted
Imbalance between metabolic needs and blood flow into the brain
Myth #3: Can't be a concussion if you aren't knocked out
Only 10% of concussions have LOC “Got my Bell Rung”
If any symptoms, this is a concussion as wellSymptoms may not start immediately
after the hitSeizure activity at injury very scarey but
not permanent
Loss of Consciousness
If LOC continues, need to start ABC protocol
Assume cervical spine injuryUsually LOC is seconds only
Confusion
Hallmark symptom of TBI is confusionEyes glassy, loss of focusIncoherent speechGoing to wrong team's huddleMemory Loss
Loss of memory prior to event-retrograde amnesia
Loss of future memory-anterograde amnesia
Myth #4: Of course he can play doc next week, he only has a concussion
Loss of consciousness, Amnesia, Confusion used to be used to 'grade concussions' These 'grades' would determine return to play
No data to support the grading systems 15 different systems No longer used
Treat each concussion individually Symptoms must completely resolve prior to
return to activitiesDing's matter
Second Impact Syndrome
Continued symptoms sign that brain metabolism not yet normal
With additional injury (even mild) the blood vessels open wide which increases the pressure in the brain Coma, Death 10-15 die a year <19 yo Younger the brain, more susceptible
This is why conservative in youth sports, JH, HS sports
Myth #5: 'Johnny' will be ready by next week
Each concussion is different, hard to predict
Longer recovery with repeated concussions
Younger patients typically need more time
None the less, most better with 5-7 daysSame day return to play no longer
recommended for youth sports If College athlete or Pro, maybe
Sideline Assessment
Assess symptoms: headache, confusion, nausea, vision
Neurological Exam Pupillary Response ROM/Strength Balance/Coordination
SCAT Orientation Memory Confusion
Sideline Assessment
Take HelmetDone for the dayATC or MD will re-evaluate every 15-20
mins to make sure things are worsening If so, off to the ER
In New Jersey, coaches, refs have duty to make athletes sit if any concern
Red Flag Symptoms Headaches that worsen Look very drowsy, can’t be awakened Can’t recognize people or places Unusual behavior change Seizures Repeated vomiting Increasing confusion Increasing irritability Neck pain Slurred speech Weakness or numbness in arms or legs Loss of consciousness
Myth #6: We need to go to the ER
Generally not neededIf significant LOC, confusion, or worsening
mental state CT and MRI are always normal by definition If neurological status worsens must be imaged to
r/o bleedNo longer recommend waking up athlete every
hour over night Observe for unusual breathing patterns or
atypical movements (jerking, tremor, convulsions)
Myth #7-'Captain looks fine' so he didn't have a concussion
Unlike physical injury, its hard to 'see' the injury No post game activities
Treatment of concussion Rest, Rest, Rest Brain Rest, Physical Rest Quite, Dark NSAIDs/Tylenol for headache No electronics, phones, texting, computers,
etc
Brain Rest
If minimal sx ok to go to school monday Most athletes will need to miss some school Schools finally understanding and are
required to complyTake to MD on monday or tuesday for
eval
Complications to Recovery
Concussion History
Headache HistoryDevelopmental
HistoryPsychiatric
History
Post Concussion
Every patient has different set of symptomsPhysical
Headaches, N/V, FATIGUE, Balance, SensitivityThinking
Mentally Foggy, Concentration, Memory, SlowEmotional
Irritability, Sadness, Nervous, More EmotionalSleep
Drowsiness, Sleep more or Less, Difficult sleeping
Post Concussion
Let the child sleep, Daytime Naps recommended at the beginning
Eat and stay hydratedLimit Activities requiring thinking or
concentrating Read, TV, Computer, etc
Watch the grass growDo not attend anything with flying objects
or potential for repeated injury
Post ConcussionNot much the parents can do to help
other than provide emotional support, interact with school nurse and administration
Frustration can kick inSchool provide tutoring > 5 daysReturning to school can be gradual
Part time No gym or sports Breaks in nurses station Lunch in quiet place
Myth #8: There are no treatment for concussions
Insomnia-MelatoninEmotional symptoms
Role for amitriptyline/SSRIPhysical symptoms
Balance can improve with vestibular therapyConcentration
ADHD medicationsAmantidineNuvigil
Return to Play
All physical sx must be goneIMPACT scores return to
baselineMedical clearance5-7 day return to play
protocol Start with minimal exertion Progress daily If symptoms reoccur must
return to previous step
ImPACT Testing
Focused neuropsychiatric, computer based test
Memory, Coordination, Concentration
Preseason Testing Optimal@2 days post injury can
provide prognosisWhen symptoms are gone to
confirm brain function normal
Myth #9 (from the NFL/NHL)
No long term risk from concussions
With each concussion, repeated injuries occur with less force, symptoms last longer, more difficult to return to sport
Symptoms may be life longRetire from sports
Chronic Traumatic Encephalopathy
Pathological changes in brain from multiple, usually mild, injuries (even 'dings') Deposits of protein similar
to Alzheimer's Collision sports Substance abuse Dementia, Depression,
Death Violent Suicide
Chronic Traumatic Encephalopathy
Families of NFL players donating brain tissue after suicide/death
18/19 had CTE
Huge lawsuits in future
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