Concussion in Sports

Sports Injury ManagementSession 4

“ He got his bell rung.”

He got “ dinged”.

What is the big deal about concussions?

• A concussion is a functional injury to the brain.• Silent epidemic• Multiple injuries have cumulative effects• Over 50% of concussions go unreported – – 1.6 – 3.8 TBIs reported account for 10% of sports

injuries• Athletes can / WILL hide symptoms• YOU are the first line of defense!

How do I evaluate a concussion?

1- Primary SurveyABC’s to determine if life-threatening or limb-threatening

2- Secondary SurveyNormal injury evaluations concentrating on neurological deficits

RESULTS FROM ONE TEST SHOULD NOT SUPERSEDE ANOTHER!

REMEMBER: No direct blow is necessary for a concussion.(whiplash, shaken baby syndrome)

A HELMET WILL NOT PREVENT A CONCUSSION!

The following information is on a sticker on every helmet worn by high school football players in North Carolina.

WARNING 

Do not strike an opponent with any part of this helmet or facemask.  This is a violation of football rules and may cause you to suffer severe brain 

damage or neck injury including paralysis or death. 

Severe brain injury may occur accidentally while playing football. 

NO HELMET CAN PROTECT SUCH INJURIES. 

YOU USE THIS HELMET AT YOUR OWN RISK.

ASSESSMENT PROTOCOL

• History• Observation• Palpation• AROM / PROM• Strength Tests• Stress Tests• Functional Tests

HISTORY• What happened? What were you doing when it occurred? What

position were you playing when it occurred?

• SYMPTOMS: headache, blurred vision, tinnitus,numbness/weakness, nausea, photophobia,

dizzinessSYMPTOMOLOGY: asymptomatic or symptomatic – no longer “graded”

• LEVEL OF CONSCIOUSNESS: alert, lethargic, stuporous,semicomatose, comatose

IF SEMICOMATOSE OR COMATOSE, CALL 911!

OBSERVATION• Watch the athlete closely during the

observation.- Aphasia: difficulty finding / saying the right words- Obvious deformities / abnormalities- Coordination- Pupillary signs: PEARRL, size, response to light, eye

movement, tracking- Respirations- Overall demeanor

PALPATION

• PULSE: could / should be somewhat elevated,a decrease may indicate a brain bleed

• BLOOD PRESSURE: sideline check, need to know what is normal for that athlete

• PALPATE: for signs of trauma; painful areas, deformities, swelling, crepitus (especially in the C-spine area → C-spine fx?)

ROM and Strength

• AROM / PROM: neck and any other suspect area

• Strength: neck and any other suspect area

• Dermatomes / Myotomes: to check for nervedamage

Stress Tests

• 3 C’s- Cognition- Coordination- Cranial Nerves

Stress Tests: Cognition

• 3 word recall• Serial 7s• Recite months of year in reverse order• Recite days of week in reverse order• Mental status testing (more later)

• Neuropsychological testing (more later)

Cognition: Mental Status Testing

• Standard Assessment of Concussion (SAC)- Orientation- Immediate memory- Exertional maneuvers- Neurological screening- Concentration- Delayed recall- Total score is computed

(Handout included at the end of this section.)

Cognition: Neuropsychological Testing

• Assess cognitive factors such as memory, concentration, impulse control, and reaction time

• Paper and Pencil Tests- GOOD: a lot of normative data exists- BAD: time consuming, inability to access reaction time

• Computerized NP tests- GOOD: trained administrators may not be needed,

test multiple subjects at once, reaction time can be assessed

- BAD: expensive (start-up costs, copyrighted program)

COORDINATION

• Heel to opposite knee• Finger to nose• Postural control

• Used to use Romberg test, no longer used, replaced with BESS

COORDINATION: Postural Control• BALANCE ERROR SCORING SYSTEM (BESS)

Dr. Kevin Guskiewicz

- Clinical Test Battery• 6 20 sec. trials• Uses 3 different stances• Uses 2 different surfaces• All performed with eyes closed

- Recorded errors * hands lifted off iliac crests * opening eyes * step, stumble, fall * moving into > 30° of hip flexion or abduction * remaining of test position for > 5 sec.

Handout includedat the end of this

section.

CRANIAL NERVES

II – Optic Nerve, III – Oculomotor, IV – Trochlear,VII – Facial

II - Optic Nerve: visual acuityIII - Oculomotor: pupil reactionIV - Trochlear: eye movementVII - Facial: smile, grimace

CRANIAL NERVESUpper Extremity Clearing Exam

• C1 & C2 – Neck Flexion• C3 – Neck Side Flexion• C4 – Shoulder Elevation• C5 – Shoulder Abduction• C6 – Elbow Flexion / Wrist Extension• C7 – Elbow Extension / Wrist Flexion• C8 – Thumb extension / Ulnar Deviation

CUE: “Don’t let me move you.”

CRANIAL NERVESLower Extremity Clearing Exam

• L2 – Hip flexion• L3 – Knee Extension• L4 – Ankle Dorsiflexion• L5 – Toe Extension• S1 – Ankle Plantar Flexion• S1 – Ankle Eversion

CUE: “Don’t let me move you.”

FUNCTIONAL TESTING

• Exertional tests performed to seek evidence of early post-concussion symptoms or an increase in symptomatic severity

- Valsalva Maneuver: situps- Biking, jogging, or short sprints- Progress to sport specific activities

CONSIDERATION FOR RETURN TO PLAY

• New ruling by the North Carolina High School Athletic Association (NCHSAA)- High school and youth activities: NO RETURN

TO PLAY SAME DAY• NCHSAA Sports Medicine Advisory Committee• A RTP (Return to Play) form is being designed– Must be signed by a PHYSICIAN licensed to practice

medicine in NC before an athlete with a suspected concussion may return to practice or play

NCHSAA Concussion Return to Play Form

SERIAL EVALUATIONS• TOI (time of injury): clinical evaluation and symptoms checklist• 1-3 hrs. after injury: symptoms checklist• 24 hrs. after injury: follow-up clinical evaluation and symptoms

checklist

• RED FLAGS!!!!!!!!– s/sx that last > 7 – 10 days– Extensive LOC (loss of consciousness)– Deterioration over time– Personality changes

(A subdural hematoma has a 7 – 10 day incubation period.)

SERIAL EVALUATION – con’t.

• Once the athlete is ASYMPTOMATIC– Where is athlete relative to baseline scores

(provided you were able to do baseline scores)– When athlete returns to baseline on ALL SCORES• Another 48 hrs. rest, then reassess• If after 48 hrs. rest, performs to baseline or better,

conduct exertional tests– If ASYMPTOMATIC for 24 hrs. after exertional tests, can RTP– If becomes SYMPTOMATIC within 24 hrs. after exertional tests,

NO RTP until athlete returns to baseline, then reassess again

What is Second Impact Syndrome?

• Occurs when an athlete sustains a 2nd head injury before the symptoms of the 1st injury have resolved. (Cantu & Voy, 1995)

• It is thought to be a problem with auto-regulation of blood flow in the brain.

Is brief LOC an isolated marker of severity?

• LOC is not associated with total number of symptoms at follow-up or overall duration of symptoms.

• LOC is not predictive of NP deficits at follow-up.• LOC is not associated with neuroimaging or

electrophysiological abnormalities.

(McCrory et al., 2000; Collins et al., 2003; Erlanger et al,. 2003; Guskiewicz et. al., 2007; Lovell et al., 1999; Guskiewicz et al., 2001; Johnston et al., 2001, Dupuis et al., 2003.)

Can amnesia be an isolated marker?

• Duration of PTA (post traumatic amnesia) was found to be correlated with the severity and outcome of severe TBI (traumatic brain injury).

• Earlier studies suggest that amnesia is NOT a prognostic marker following mild TBI.

• More recent studies suggest amnesia is predictive of symptoms and NP deficits following concussion in athletes.

(Levin et al., 1979, 1982; Sciarra et al., 1984; Fisher et al., 1966; Gronwall et al., 1980; Yarnell et al., 1973; Maddocks et al., 1995; Guskiewicz et al., 2001; Lovell et al., 1999; Erlanger et al., 2003; Collins et al., 2003)

Do cumulative effects last?• Depression (Guskiewicz 2007)• Memory and concentration problems• Delayed recovery following subsequent

concussion• Increased likelihood of sustaining additional

concussions (Guskiewicz 2003)Hx of 1 concussion: 1.5 x more likely to sustain repeat concussionHx of 2 concussions: 2.8 x more likely to sustain repeat concussionHx of 3 concussions: 3.5 x more likely to sustain repeat concussion

In North Carolina, 3 reported concussions = end of athletic career in contact sports.

Are there cumulative risks for children?

• Increased time for exposure.

• Developing brain

• Under-reporting

Managing Functional Academic DeficitsNEUROLOGICAL DEFICIT FUNCTIONAL SCHOOL 

PROBLEMMANAGEMENT STRATEGY

Attention / Concentration Short focus on lecture, classwork, homework

Shorter assignments, break down tasks, lighter work load

“Working” Memory Holding instructions in mind, reading comprehension, math calculations, writing

Repetition, written instructions, use of calculator, short reading passages

Memory Consolidation / Retrieval

Retaining new information, accessing learned information when needed

Smaller chunks to learning, recognition cues

Processing Speed Keep pace with work demand, process verbal information effectively

Extended time, slow down verbal information, comprehension techniques

Fatigue Decreased arousal / activation to engage basic attention, working memory

Rest breaks

COMPUTERIZED PROGRAMS AVAILABLE

• ANAM - Automated Neuropsychological Assessment Metrics

• Used with military subjects• GOOD: very inexpensive, possibly no cost to schools• BAD: no comparative data for < 18 y/o

• ImPACT – Immediate Post-concussion Assessment and Cognitive

Testing• GOOD: comparative data for males and females < 18 y/o• BAD: may be cost prohibitive

REFERENCES

• NFHS Sports Medicine Handbook, 3rd Ed.

• Kevin Guskiewicz, PhD., ATC; University of North Carolina; Evaluation of Concussion in Sport; NCATA 32nd Annual Clinical Symposium & Business Meeting; March 6-8, 2009, Concord, NC.

• Spencer Elliott, MA, LAT, ATC; Carolinas Medical Center, Concord, NC; Tools of the Trade: Concussion Assessment; NCATA 32nd Annual Clinical Symposium & Business Meeting; March 6-8, 2009; Concord, NC.