concussion 101: myths & facts signs/symptoms& return to play guidelines

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Concussion 101: Concussion 101: Myths & Facts Myths & Facts Signs/Symptoms Signs/Symptoms & & Return to Play Return to Play Guidelines Guidelines

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Concussion 101: Concussion 101: Myths & FactsMyths & Facts

Signs/Symptoms Signs/Symptoms &&

Return to Play Return to Play Guidelines Guidelines

What is a Concussion?What is a Concussion?

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Concussion Definition: A complex pathophysiological process affecting the brain

No damage to brain anatomy - as far as we can tell

Disturbance in brain metabolism

Common features Direct blow to the head or body Loss of consciousness not necessary Rapid onset of symptoms (usually) Traditional medical tests usually normal (CT/MRI)

From, CISG, Vienna, 2001, Clinical Journal Sports Medicine, 2002

What is a Concussion?What is a Concussion?

• Exactly what happens to the brain during a concussion is not entirely understood. It appears to be a very complex injury affecting both the structure and function of the brain.

• The sudden movement of the brain causes stretching and tearing of brain cells, damaging the cells and creating chemical changes in the brain.

What is a Concussion?What is a Concussion?

• Once this injury occurs, the brain is vulnerable to further injury and very sensitive to any increased stress until it fully recovers.

• A concussion is caused by a bump, blow, or jolt to the head or body. Basically, any force that is transmitted to the head causes the brain to literally bounce around or twist within the skull.

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What is a Concussion?What is a Concussion?

• The terms “ding” and “bell-ringer.” are sometimes used to refer to minor head injuries and thought to be a normal part of sports.

• There is no such thing as a minor brain injury. Any suspected concussion must be taken seriously.

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Concussion SignsConcussion Signs•Appears dazed•Confused about play•Moves clumsily•Answers question slowly•Personality change•Forgets plays prior to hit

Retrograde amnesia•Forgets plays after hit

Anterograde amnesia•Loses Consciousness

Concussion SymptomsConcussion Symptoms•Headache•Nausea•Balance problems•Double vision•Photosensitivity•Feeling sluggish•Feeling foggy•Change in sleep pattern•Cognitive changes

Decreased Processing Speed

Short-Term Memory Impairment

Concentration Deficit

Irritability/Depression

Fatigue/Sleep Disturbance

General Feeling of “Fogginess”

Academic Difficulties

Later Signs of ConcussionLater Signs of ConcussionPost-Concussion SyndromePost-Concussion Syndrome

Mental Status Testing

• Orientation– What period/quarter/half are we in?– What city is this?– Who is the opposing team?– What month is it?– What day is it?

Mental Status Continued

• Anterograde Amnesia– Ask the athlete to repeat 3 words (E.g., Boy, Cat, Red)

• Retrograde (Post-traumatic) Amnesia– What do you remember just prior to the hit?

– What was the score of the game prior to the hit?

– Do you remember the hit?

Mental Status Continued

• Concentration/Memory– Repeat the days of the week backward (starting with

today).– Repeat the months of the year backward (starting with

December).– Repeat numbers in reverse order:– E.g., 37 (73 is correct), 917 (719 is correct), 3156 (6513

is correct)– Ask the athlete to repeat the same three words from

earlier. (Boy, Cat, Red)

Important Reminders

• Athlete should be removed from play and not returned contest if any positive signs and symptoms are determined.

• Any positive symptom or cluster of symptoms is serious.

• Athletes returned to contest were found in research studies to develop significant symptoms 3 hrs post and believed to take longer to recover.

• Continued monitoring is necessary

Neurological Screening

• Visual tracking

• Pupil reactivity and size

• Balance testing-Romberg

• Strength testing

• Motor programming

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1994NFL Establishes Concussion Program

Injury to well-known players Concern regarding long-term functioning of athletes

NFL Program Continued

• 12/2009 NFL adopts stricter statement on return-to-play following concussions– Concussed athletes should not return to practice or play in

same day he shows symptoms

– Athlete should not be considered for return to play until he is fully asymptomatic, both at rest and with exertion, has normal neurological evaluation, normal neuropsychological testing, and has been cleared to return to play by team physicians and an independent neurological consultant

1/3/2011 Texas Sports Medicine Center 9

The Average Person Knows More About The ACL Than the Brain

• Disabling

• Need to see a doctor

• MRI

• Surgery

• Long rehabilitation

But What About Brain Injury? Harris Poll

Low Public Awareness of Brain Injury• 1 in 3 adults over 18 were not familiar with the

term “brain injury”

• Only 56% thought that a concussion was a brain injury

Brain injury is the leading cause of death and disability in American youth

The Challenge:

Can we provide the same level of care for non-professional athletes that we do for the professional athletes?

Pressure to Play in Sports: Can We Trust What the Athlete Tells Us?Can We Trust What the Athlete Tells Us?

ConcussionConcussion Myths and FactsMyths and Facts

Myth #1

If you didn’t get knocked out, you don’t have a concussion.

Fact #1• Very few concussions are associated with a loss of

consciousness. Less than 10% of athletes actually lose consciousness with a concussion.

• Amnesia around the time of the injury is more important than loss of consciousness as a predictor of return to play.

• Any unconscious athlete should be thought to have a neck injury and treated as such.

Myth #2 Everyone with a concussion needs

a CT scan or MRI right away.

Fact #2• Concussion is primarily an injury that interferes with

how the brain works. While there is damage to brain cells, the damage is at a microscopic level and cannot be seen on MRI or CT scans. The brain looks normal on these tests, even though it has been seriously injured.

• Sometimes CT scans are needed to rule out other problems, like skull fractures or bleeding in the brain.

• A normal CT scan does not mean the athlete is OK.

Myth #3

Athletes with a concussion should not be allowed to fall asleep, because they might not wake up.

Fact #3

• Drowsiness is a very common concussion symptom.

• Allowing the athlete to sleep is perfectly fine.

• Rapidly declining level of consciousness is a very worrisome sign and needs to be evaluated in an emergency room.

Myth #4 You should not treat the headache from concussion

with any medications because you might mask some symptoms.

Fact #4• Over the counter pain relievers are perfectly fine to use.

Tylenol is probably the best recommendation.

• Many times over the counter medications do not provide any relief.

• Sometimes prescription medications are needed.

• Athletes should not return to play on preventative headache medication unless they were prescribed medication pre-injury.

• Medication management should be overseen by a physician.

Myth #5

He just got his bell rung, he is ok to return in the second half.

Fact #5• There is no such thing as a minor concussion.

• The adolescent brain is different from the adult brain and is more susceptible to injury. It must be protected with more care and concern.

• It is never OK to return to the same game if a concussion has occurred.

Myth #6

The CT scan was OK, and the ER doctor said I could return to play in a week.

I don’t need to do anything else.

Fact #6• The return to play cannot be determined at the

time of the injury.

• A normal CT scan cannot predict the amount of injury.

• All concussed athletes need to be evaluated by a medical professional and gradually return to sport when their concussion has healed.

Myth #7

Concussions only happen in contact sports like hockey and football.

Fact #7 Concussion can happen at any level of play

and in any sport.

Myth #8 An athlete is recovered if he(she) does not

feel any symptoms and there are no observable signs of concussion.

Fact #8

A concussed athlete may experience symptoms for several weeks although a small number of athletes may only have symptoms for the day of their injury. Even if an athlete is symptom free he(she) may still have neurocognitive deficits and be at risk for second impact syndrome.

Unique Contribution of Neurocognitive Testing to Concussion Management

VerbalMemory

VisualMemory

5055606570758085

9095

100

Symptomatic Asymptomatic Control

N=215, MANOVA p<.000000 (Lovell et al., 2004; in press)

Testing revealscognitive deficitsin asymptomaticathletes within 4 days post-concussion

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Processing Speed

Symptomatic Aysmptomatic Control

MANOVA p<.000000 (ImPACT Test Battery)

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Reaction Time

Symptomatic Asymptomatic Control

Unique Contribution of Neurocognitive Testing to Concussion Management

Myth #9 Every athlete recovers from concussion at

the same rate.

Fact #9

There are many pre-injury factors that can affect the rate of recovery:– Age – Gender– Psychological status – Learning history (ADD/ADHD,

Learning Disability)– Neurological disorder (seizures,

migraines)

Myth #10

Baseline and post-injury cognitive testing is time consuming and holds athletes out of play unnecessarily.

Fact #10

Comparison baseline and post injury data helps clinicians, athletic trainers, and coaches guide the recovery process. Provides objective information. May help predict return to activity or seriousness of injury. Can help determine recovery rather than relying solely on athlete self report. Computerized testing may take up to 30 minutes and is worth it when you are considering one’s life and future livelihood.

Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery (Developer)

Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery

Joseph Maroon, MD - UPMC Dept. of Neurological Surgery

Immediate Post-Concussion Assessment and Cognitive Testing

Computerized Neurocognitive Testing

What ImPACT Is and Isn’t:• IS a useful concussion screening/management program (used pre-injury & post-injury)

• IS validated with multiple published studies

• IS NOT a substitute for medical evaluation/treatment

•IS NOT a substitute for comprehensive neuropsychological assessment when needed

•IS NOT a recommended tool for just anyone to use

NFL Wide Receiver NFL Wide Receiver ImPACT Composite Percentile ScoresImPACT Composite Percentile Scores

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Baseline

Age/GenderPercentileScores

day 2

day 7

Verbal MemoryVerbal Memory Visual MemoryVisual MemoryReaction TimeReaction Time

day 14

Myth #11

You can only undergo post injury cognitive assessment if you have had a pre-injury baseline.

Fact #12

A pre-injury cognitive baseline certainly makes things easier for the clinician in returning an athlete back to their true cognitive status. However, it is recommended that athletes without baseline examinations still undergo post-injury cognitive assessment with a concussion specialist with assessment experience.

HIGH SCHOOL SOCCER PLAYERHIGH SCHOOL SOCCER PLAYERImPACT Composite Percentile ScoresImPACT Composite Percentile Scores

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Day 6

Age/GenderPercentileScores

Day 9

Day 16

Verbal MemoryVerbal Memory Visual MemoryVisual MemoryReaction TimeReaction Time

Myth #12

An athlete should retire after three concussions.

Fact #12

This recommendation is an opinion and not based on scientific fact. There is no identifiable number of how many concussion are too many.

Myth #13

There are no long term effects of concussion.

Fact #13

• Post-Concussion syndrome

• Neurocognitive Impairment

• Increased risk of early onset

dementia

• Depression and anxiety

• Chronic Traumatic

Encepholopathy (CTE)

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill mandates a Concussion Oversight Team chosen by each school district or charter school, headed by at least one physician with concussion management training. If the school district employs an athletic trainer, the athletic trainer must be a member of the district or charter school concussion oversight team.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill defines who the Licensed Health Care Professionals are that will participate in the development and implementation of the concussion oversight team in schools. This includes advanced practice nurses, athletic trainers, neuropsychologists, physicians or physician assistants.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill will require the UIL to provide a document, to be signed, to inform the students and parents of the dangers of sports concussions.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill requires students who are suspected of sustaining a concussion be removed from activity/play immediately.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The athlete must be evaluated for the suspected concussion by a physician of his/her choosing.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• When the student athlete is suspected of suffering a concussion; the student athlete, parents or guardian, and other appropriate school employees must receive a written copy of the concussion oversight team’s protocol for the student’s return to play and practice.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• Upon completion of the school district’s concussion oversight team’s return to play protocol, the treating physician must sign a written statement indicating that, in their professional judgment, it is safe for the student to return to play.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• If the school district or charter school employs an athletic trainer, he/she is responsible for the compliance of the athlete with the return to play protocol.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• A coach of an interscholastic athletics team may not authorize a student’s return to play.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill establishes concussion education for coaches must be met every two years. The UIL must approve the continuing education for coaches and the education must be at least two hours. Requirements in concussion management for athletic trainers which can be met in the two year cycle must be approved by The Department of State Health Services Advisory Board of Athletic Trainers. Concussion education is also required for licensed health care professionals and recommended for physicians.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• The bill provides for immunity from liability for school districts or members of the concussion oversight team complying with this act.

Highlights of HB 2038Highlights of HB 2038Natasha’s LawNatasha’s Law

• There should be no fiscal impact in the next biennium attached to the implementation of the bill.

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Methodist Concussion Center Return to Play Protocol

Athlete must show no signs of post-concussion symptoms for 2 consecutive days before return to play protocol begins. Each phase will occur in 24 hour intervals if athlete is symptom free.

Athlete activity progressions:Phase 1 - Light aerobic exercise with no resistance training 10-15 minutes (e.g., walking, stationary bike, and hand bike low intensity setting)

Phase 2 - Moderate aerobic activity with resistance training 20-25 minutes (e.g., running, light weights – No squat, dead lift or bench press)

Phase 3 - Sport specific activity and non-contact training drills Heavy exertion, at least 30 minutes (e.g., non-contact training or non-contact practice)

Phase 4 - Full practice including light contact activities (e.g., head balls in soccer, sleds in football)

Phase 5 - Full Practice – Full Contact

Phase 6 - Return to full participation (pending physician clearance)

Note – Return to play progression continues as long as athlete is asymptomatic at current level. If the athlete experiences any post concussion symptoms, stop physical activity until symptom free for at least 24 hours. Resume with phase or level in which they were previously asymptomatic.

Methodist Concussion Center Recommendations for

Sports-Concussion Management

• Decreased cognitive activity– May need to miss school– Attend ½ days– Academic accommodations

• Un-timed tests, no examinations, pre-printed class notes, tutoring, modified homework assignments, frequent breaks, etc.

• Limit video games, texting, etc.• May need to restrict driving

Sports and Arts Affiliations

The Methodist Hospital System is the official health care provider for the Houston Texans, Houston Astros, Houston

Dynamo, Rice Athletics, Houston Ballet, Houston Grand Opera and Houston Symphony.

Summer D. Ott, Psy.D.

Methodist ConcussionCenterwww.methodistconcussioncenter.com

713.441.8277

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ImPACT™ and associated logos are trademarks of ImPACT Applications, Inc.

ImPACT™ and the ImPACT aretrademarks of ImPACT Applications, Inc.and are used herein with the expresswritten permission of ImPACTApplications, Inc. and may not beduplicated, removed or altered withoutImPACT Applications, Inc.’s writtenconsent. 

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Used with Permission.

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