Definitions

A concussion is defined as a “traumatically induced alteration in mental status.”

Amnesia - loss of memory - times vary.

The Head The head is not as

forgiving as an arm, leg etc.

The brain does not like changes in blood flow or pH levels.

The brain has a different blood flow than the rest of the body.

Concussions

This is the most common “brain” injury in sport.

Ranges from a minor “ding” with short periods of symptoms, to a prolonged loss of consciousness with persistent cognitive effects.

Concussions

Memory Loss Can be associated

with amnesia which may occur immediately or develop several minutes later.

There are two kinds of amnesia:

Concussions

1. Retrograde Amnesia - loss of memory for events that occurred before injury (breakfast, score, team playing, etc).

Concussions

2. Anterograde Amnesia - is defined as a loss of memory for events that occurred after the injury.

Concussions - Problem??? With this possibility of

“delayed development of symptoms”…

This greatly increases the need for careful evaluation and observation before the athlete is allowed to play.

Concussions

Causes of Concussions:

Direct blow to the head

Landing on your butt!!

Whiplash mechanism.

ConcussionsContracoup Injury This is a type of

movement of the brain inside the skull…

When you get hit in the front of the head, the brain shifts (backwards) and pain will be felt at the back of the head (opposite side of injury).

ConcussionsObserved Features ofConcussions: Headache Vacant stare Confusion Tinitis (ringing in ears) Nausea/vomitting Blurred vision Dizziness

ConcussionsOther more serioussymptoms: Altered

Consciousness Memory deficits Lack of

coordination/balance Disorientation Emotions Pupil size***Eyes are

poor indicator of concussion on sport field

Classification of Concussions:

GRADE 1

Transient confusion(inattention inability to maintain a coherent stream of thought and carry out goal directed movements.

No loss of consciousness

Concussion symptoms or mental status abnormalities resolve in less than 15 min.

GRADE 2

Transient confusionAmnesia possible

No loss of consciousness

Concussion symptoms or mental status abnormalities (including amnesia) upon examination last more than 15 min.

GRADE 3

Any loss of consciousness, it can be brief (seconds) or prolonged (minutes).

Concussions

Grade 1 Concussion: Remove from contest Player should be re-

evaluated every 5 minutes for at least 15 minutes for signs of amnesia and other mental status changes.

Management Recommendations:

Concussions

Grade 2 Concussion

With grade 2 injury, the athlete should be removed from play for the remainder of event (day).

Continue to assess any inter-crainial* pathology.

*inter-crainial - inside the head (brain).

Management Recommendations:

ConcussionsGrade 2 cont.d A trained person

should evaluate the person next day.

A physician should perform a neurologic examination to clear the athlete after 1 full asymptomatic week.

Concussion

Grade 3 Concussion As with any loss of

consciousness, the athlete should be transferred to an Emergency Department (hospital) for further observation by a doctor.

Management Recommendations:

Concussions

Grade 3 cont.d A thorough

neurologic assessment is indicated. (CT scan, MRI)

Keep casualty in the hospital if any pathology is indicated

Return to play Grade of Concussion Return to play only after

asymptomatic time.

Grade 1 15 minutes or less

Multiple grade 1 1 week

Grade 2 1 week

Multiple grade 2 2 weeks

Grade 3, brief LOC 1 week

Grade 3 prolonged LOC 2 weeks

Multiple grade 3 1 month or longer, based on decision of evaluating physician, usually season terminator

Concussions

Sideline EvaluationThese are some of the tests that you can do with anathlete on the sidelines (grade 1) or later on (grade2,3):

Mental Status Testing Orientation – to time, place, injury Concentration – digits backward, numbers etc. Memory – details of contest, names of teams,

recall 3 of 3 words, objects at 5 min. intervals

Concussion

Exertional Tests 40 m sprint 5 push ups 5 sit ups 5 burpies

Neurologic tests Strength Coordination Sensations Balance

Check associated symptoms – headaches, dizziness, blurred vision, nausea, concentration, photophobia (sunlight)

Sideline Evaluation cont.d

Concussions

Second ImpactSyndrome This condition occurs when

the athlete returns to play to fast.

Another concussion is suffered before the symptoms of the first are resolved.

Loss of conciousness is not required.

ConcussionsSIS The hit does not need

to be as hard or traumatic as the first.

After suffering a second hit, the player may seem fine, but within seconds or minutes SIS may occur.

Concussions

SIS Previously

observed features, but after SIS we may be looking at an extremely debilitating or life a threatening head injury.

Concussions

Apart from SIS, this is another syndrome we need to be aware of.

As each person is different, the brain will react different to a concussion differently

Post Concussion Syndrome

Concussions

PCS The following may

occasionally persist after concussions:

Gait and Balance abnormality

Exertional headache: When they do any

physical activity they get a headache

Concussions

PCS Emotional Lability

Altered emotions, crying/agitation

Sleep disturbances Neurotransmitters in

the brain are not functioning correctly

Cognitive impairment Reflexes, coordiation

Concussions

PCS Athletes with

these symptoms are not ready to return to sport.

See next slide for return to play for these athletes:

ConcussionsReturn to Play – Post Concussion Step 1 – no activity, complete rest, once

asymptomatic proceed to step 2 Step 2 – Light aerobic exercise (walking,

stationary biking) if asymptomatic proceed to step three, if not go back to 1

Step 3 – Sport specific training. Once asymptomatic proceed to step four, if not go back to 2

ConcussionsReturn to play – Post

concussion Step 4 – Non-contact drills, once

asymptomatic proceed to step five, if not go back to 3

Step 5 – Full contact after medical clearance. Once asymptomatic proceed to step six, if not go back to 4

Step 6 – GAME PLAY!!!

ConcussionsSome Sportsattempting to

decreaseConcussions.2. Football:

Equipment: Mandatory mouthguards Helmets safety checked

each season Padding on all goal posts.

ConcussionsFootball Cont.Rule Changes

No spearing (tackling with head)

No face masking No late hits Free catch Rules to protect

quarterback and kicker

Concussions2. Hockey

Equipment Mandatory helmets Mouthgaurds –

highly recommended

Breakaway goal posts

Padding around benches, glass

Absorbing boards

ConcussionsHockey cont.d No hitting from

behind Rules to deter

fighting No high sticking Goalie protection Longer

suspensions

Concussions3. Rugby Equipment: not

too much here!!! Mandatory mouth

guards Scrum caps are

recommended Padding around

goal posts No hard

equipment

Concussions

Rugby cont.d Rules:

No high tackles No late hits No stomping Mark catches No blocking Wrap person when

tackling