Sports Related Sports Related ConcussionConcussion

Current Trends and Current Trends and Evidence Based MedicineEvidence Based Medicine

ObjectivesObjectives

Defining and Recognizing ConcussionDefining and Recognizing ConcussionLatest evidenceLatest evidence

Management of ConcussionsManagement of ConcussionsClinical Evaluation – Sideline/AT ClinicClinical Evaluation – Sideline/AT Clinic

Referral DecisionsReferral DecisionsConcussion Assessment ToolsConcussion Assessment ToolsReturn to PlayReturn to PlayHome CareHome Care

International Conference on International Conference on Concussion in SportConcussion in Sport

Complex pathophysiological process Complex pathophysiological process affecting the brain, induced by traumatic affecting the brain, induced by traumatic biomechanical forces.biomechanical forces.Struck player more likely to receiveStruck player more likely to receiveFunctional disturbance rather than a structural Functional disturbance rather than a structural

injuryinjuryBiochemical, metabolic, and gene expressionBiochemical, metabolic, and gene expression

Symptom clusterSymptom clusterSomatic, Emotional, Cognitive, Sleep DisturbancesSomatic, Emotional, Cognitive, Sleep Disturbances

Symptom ClusterSymptom Cluster

Emotions•More Emotional•Sadness•Nervousness•Irritability

Sleep Disturbances•More sleep•Less sleep•Can’t fall asleep or stay asleep

Somatic•Visual•Dizziness•Balance Problems•Headaches•Light Sensitivity•Nausea

Cognitive•Attention Problems•Memory Dysfunction•Fogginess•Fatigue•Cognitive Slowing

Research about S/SResearch about S/S

LOC only in 9%, Amnesia only in 27%LOC only in 9%, Amnesia only in 27%No association between LOC and amnesia No association between LOC and amnesia

and the duration of S/Sand the duration of S/SSignificant association between S/S Significant association between S/S

severity and total durationseverity and total durationCan have lucid period followed by S/SCan have lucid period followed by S/S

15-20 minutes athlete should sit15-20 minutes athlete should sit

International Conference on International Conference on Concussion in SportConcussion in Sport

Simple vs. Complex ConcussionSimple vs. Complex ConcussionSIMPLESIMPLE

Injury progressively resolves without complications Injury progressively resolves without complications over 7-10 days.over 7-10 days.

Management = rest until all S/S resolved, graded Management = rest until all S/S resolved, graded return to sport, and evaluated by physician.return to sport, and evaluated by physician.

COMPLEXCOMPLEXInjury results in persistent symptomsInjury results in persistent symptomsAthlete receives multiple concussionsAthlete receives multiple concussionsManagement = same as above with more formal Management = same as above with more formal

evaluation by team of specialistsevaluation by team of specialists

To grade or not to grade?To grade or not to grade?

Current approachesCurrent approaches1.1. Time of injuryTime of injury

2.2. Based on Presence and duration of Based on Presence and duration of symptomssymptoms

3.3. NOT to grade at all – focus on recoveryNOT to grade at all – focus on recovery The medical community does not agree The medical community does not agree

on a system – but is leaning towards #3on a system – but is leaning towards #3

Grading Scales (#1)Grading Scales (#1)

Cantu Grading System Grade 1 (mild)Grade 1 (mild)

No LOC; PTA < 30 minsNo LOC; PTA < 30 mins Grade 2 (moderate)Grade 2 (moderate)

LOC < 5 min LOC < 5 min oror PTA PTA >> 30 30 minsmins

Grade 3 (severe)Grade 3 (severe) LOC LOC >> 5 min 5 min oror PTA PTA >> 24 24

hrshrs

American Academy of Neurology

Grade I No LOC; S/S < 15 mins

Grade 2 No LOC; S/S > 15 mins

Grade 3 Any LOC

Most recent grading (#2)Most recent grading (#2)Note: Takes place after symptoms have resolvedNote: Takes place after symptoms have resolved

Cantu Evidence Based Grading System Grade 1 (mild)Grade 1 (mild)

No LOC; PTA < 30 mins; No LOC; PTA < 30 mins; PCS < 24 hrsPCS < 24 hrs Grade 2 (moderate)Grade 2 (moderate)

LOC < 1 min LOC < 1 min oror PTA PTA >> 30 mins but < 24 hrs 30 mins but < 24 hrs oror PCS PCS >> 24 hrs but 24 hrs but < 7 days< 7 days

Grade 3 (severe)Grade 3 (severe) LOC LOC >> 1 min 1 min oror PTA PTA >> 24 hrs 24 hrs oror PCS PCS >> 7 days 7 days

#3

Cornerstones of ManagementCornerstones of Management

Removal of symptomatic athletes from Removal of symptomatic athletes from playplay

Restriction from play while symptomaticRestriction from play while symptomaticGraduated return to playGraduated return to playRecognition of differences in childrenRecognition of differences in children

Brains don’t absorb shock the sameBrains don’t absorb shock the sameBe more conservativeBe more conservative

Neurocognitive testing is recommendedNeurocognitive testing is recommended

Management of ConcussionsManagement of Concussions

Stepwise ProcessStepwise ProcessImmediate history/palpationImmediate history/palpationRule out immediate life threatening Rule out immediate life threatening

injuriesinjuriesClinical Evaluation of SymptomsClinical Evaluation of Symptoms

S/S scalesS/S scalesNeuropsychological TestingNeuropsychological Testing

Obtain detailed concussion historyObtain detailed concussion history

Clinical EvaluationClinical Evaluation

Where do you begin? Just Observe!Where do you begin? Just Observe! AVPU Scoring– alert, verbal, pain, or unresponsiveAVPU Scoring– alert, verbal, pain, or unresponsive

Level of consciousnessLevel of consciousness

Oriented X 3 – person, place, and timeOriented X 3 – person, place, and time Do you know where you are and what happened?Do you know where you are and what happened? Is there a blank or vacant stare? Can the athlete keep their Is there a blank or vacant stare? Can the athlete keep their

eyes open?eyes open?

Is there slurred speech or incoherent speech?Is there slurred speech or incoherent speech? Are there delayed verbal and motor responses?Are there delayed verbal and motor responses? Gross disturbances to coordination?Gross disturbances to coordination?

Decision TreeDecision Tree

Immediate Immediate History/PalpationHistory/Palpation

Common questionsCommon questionsCan you remember who we played last week? Can you remember who we played last week?

(retrograde amnesia)(retrograde amnesia)Can you remember walking off the field? Can you remember walking off the field?

(anterograde amnesia)(anterograde amnesia)Does your head hurt?Does your head hurt?

Palpate head, face, neck vertebraePalpate head, face, neck vertebraeDo you have pain in your neck?Do you have pain in your neck?Can you feel and move your hands and feet?Can you feel and move your hands and feet?

Rule out these injuries before Rule out these injuries before proceedingproceeding

Most head injuries in athletics are mild:Most head injuries in athletics are mild:However, …However, …

Breathing or Heart MalfunctionBreathing or Heart MalfunctionDon’t respond to questionsDon’t respond to questions

C-Spine Fracture/DislocationC-Spine Fracture/DislocationPain in neck, inability to feel or move hands and feetPain in neck, inability to feel or move hands and feet

Skull FractureSkull FractureHead hurts at site of impactHead hurts at site of impact

Intracranial BleedingIntracranial BleedingMemory issues/Lucid and then rapid deteriorationMemory issues/Lucid and then rapid deterioration

Skull FracturesSkull Fractures

Fx. at trauma site or away from siteFx. at trauma site or away from siteGeneral S/S: skin cool and moist, pulse and General S/S: skin cool and moist, pulse and

breathing changes, and pupil discrepanciesbreathing changes, and pupil discrepanciesSpecific S/S: Specific S/S: ‘raccoon eyes’, ‘battle’s sign’,

goose egg, cerebrospinal fluid – otorrhea or rhinorrhea

Testing for Cerebrospinal fluid (CSF)Testing for Cerebrospinal fluid (CSF)Bull’s eye test/Halo testBull’s eye test/Halo test

Cranial BleedingCranial Bleeding

Intracranial BleedingIntracranial Bleeding Progressive declineProgressive decline

Epidural HematomaEpidural Hematoma Rapid deteriorationRapid deterioration

Subdural HematomaSubdural Hematoma Slow deteriorationSlow deterioration

Signs of increasing Signs of increasing cranial pressure from cranial pressure from bleedingbleeding Progressive headacheProgressive headache Excessive drowsinessExcessive drowsiness Nausea/vomitingNausea/vomiting Unequal/Unreactive pupilsUnequal/Unreactive pupils DisorientationDisorientation Cranial Nerve DysfunctionCranial Nerve Dysfunction Increase BPIncrease BP Decrease in pulseDecrease in pulse Loss of ConsciousnessLoss of ConsciousnessMedical Medical

EmergencyEmergency

Cranial BleedingCranial Bleeding

Intracranial BleedingIntracranial Bleeding Bleeding in sinus Bleeding in sinus

separating two separating two hemisphereshemispheres

Progressive decline – 24-Progressive decline – 24-48 hours48 hours

Epidural HematomaEpidural Hematoma Between dura mater and Between dura mater and

skullskull Arterial bleeding – rapid Arterial bleeding – rapid

accumulation of bloodaccumulation of blood Lucid period followed by a Lucid period followed by a

rapidrapid deterioration deterioration 10-60 mins.10-60 mins.

Unilaterally dilated pupil is Unilaterally dilated pupil is most common early signmost common early sign

Cranial BleedingCranial Bleeding

Subdural HematomaSubdural Hematoma Between the dura and archnoid Between the dura and archnoid

matermater Arterial and venous bleedingArterial and venous bleeding

Within 48 hoursWithin 48 hours Slow venous bleedingSlow venous bleeding

Days to weeksDays to weeks Lucid period followed by gradual Lucid period followed by gradual

deteriorationdeterioration Headaches, confusion, and Headaches, confusion, and

declining consciousnessdeclining consciousness This is why home instructions are This is why home instructions are

so importantso important

Clinical EvaluationClinical Evaluation

If new signs and symptoms appear ORIf new signs and symptoms appear OR If any of these signs and symptoms are If any of these signs and symptoms are

severe or persist ORsevere or persist ORBegin to deteriorate then this warrants Begin to deteriorate then this warrants

immediateimmediate……

REFERRAL REFERRAL

Referral DecisionsReferral Decisions When do you refer a concussion?When do you refer a concussion?

Day of referral and Delayed referralDay of referral and Delayed referral KEYS:KEYS:

LOC or deterioration of consciousnessLOC or deterioration of consciousness Amnesia longer than 15 minsAmnesia longer than 15 mins Eye signsEye signs Vasomotor signsVasomotor signs Mental status changesMental status changes Cranial nerve deficitCranial nerve deficit Motor, Balance, or Sensory deficitMotor, Balance, or Sensory deficit Normal life is adversely affected.Normal life is adversely affected.

Clinical EvaluationClinical Evaluation

Special TestsSpecial TestsEyes Eyes Neurological StatusNeurological Status

Concussion Assessment ToolsConcussion Assessment ToolsCognitionCognition

Standardized Concussion Assessment (SAC)Standardized Concussion Assessment (SAC)

BalanceBalanceBalance Error Scoring System (BESS)Balance Error Scoring System (BESS)

Special TestsSpecial Tests

““Eyes are the great revealer”Eyes are the great revealer”Eye functionEye function

Pupils equal and reactive to light (PEARL)Pupils equal and reactive to light (PEARL) Dilated or irregular pupilsDilated or irregular pupils Ability of pupils to accommodate to light varianceAbility of pupils to accommodate to light variance

Eye tracking - smooth or unstable (nystagmus, Eye tracking - smooth or unstable (nystagmus, which may indicate cerebral involvement)which may indicate cerebral involvement)

Dynamic Visual AcuityDynamic Visual AcuityBlurred visionBlurred visionPhotophobiaPhotophobiaDiplopiaDiplopia

Standardized Assessment of Standardized Assessment of Concussion (SAC)Concussion (SAC)

5 - 10 minute test; 30 point scale5 - 10 minute test; 30 point scaleOrientationOrientation Immediate memoryImmediate memoryConcentrationConcentrationDelayed recallDelayed recall

Neurological Screening – not scoredNeurological Screening – not scoredExertional Manuevers – not scoredExertional Manuevers – not scored

www.upmc.com and www.impacttest.com

Balance and CoordinationBalance and Coordination

Rhombery Sway and Tandem RhombergRhombery Sway and Tandem Rhomberg Singleton’s TestSingleton’s Test Finger to NoseFinger to Nose Balance Error Scoring SystemBalance Error Scoring System

(BESS)(BESS) Two surfaces – firm and foamTwo surfaces – firm and foam Three positions – double, single, tandemThree positions – double, single, tandem Errors committed in 20 seconds with eyes closed.Errors committed in 20 seconds with eyes closed.

Eyes open, hands off, foot down, moving too muchEyes open, hands off, foot down, moving too much Reliable and ValidReliable and Valid

Neurological StatusNeurological Status What does a diminished reflex indicate?What does a diminished reflex indicate? How about hypo- or hypersensitivity of the skinHow about hypo- or hypersensitivity of the skin Cranial NervesCranial Nerves

I-XIII-XII On Old Olympic Towering Tops A Finn And German On Old Olympic Towering Tops A Finn And German

Vault and HopVault and Hop Olfactory(I), Optic (II), Oculomotor(III), Trochlear(IV), Olfactory(I), Optic (II), Oculomotor(III), Trochlear(IV),

Trigeminal(V), Abducens(VI), Facial(VII), Auditory(VIII) Trigeminal(V), Abducens(VI), Facial(VII), Auditory(VIII) (Vestibulococchlear), Glossopharyngeal(IX), Vagus(X), (Vestibulococchlear), Glossopharyngeal(IX), Vagus(X), Accessory(XI), Hypoglossal(XII)Accessory(XI), Hypoglossal(XII)

http://www.gwc.maricopa.edu/class/bio201/cn/cranial.htm

Cranial NervesCranial NervesCNN # Name Function

I Olfactory Special Sensory: Smell

II Optic Special Sensory: Sight

III Oculomotor

Somatic Motor: Superior, Medial, Inferior Rectus, Inferior Oblique  Visceral Motor: Sphincter Pupillae 

IV TrochlearSomatic Motor: Superior Oblique

V Trigeminal

Somatic Sensory: Face  Somatic Motor: Mastication, Tensor Tympani, Tensor Palati 

VI AbducensSomatic Motor: Lateral Rectus

VII Facial

Somatic sensory: Posterior External Ear Canal  Special Sensory: Taste (Anterior 2/3 Tongue)  Somatic Motor: Muscles Of Facial Expression Visceral Motor: Salivary Glands, Lacrimal Glands

VIII VestibuloCochlearSpecial Sensory: Auditory/Balance

IX Glossopharyngeal

Somatic Sensory: Posterior 1/3 Tongue, Middle Ear  Special Sensory: Taste (Posterior 1/3 Tongue)  Somatic Motor: Stylopharyngeus  Visceral Motor: Parotid Gland

X Vagus

Somatic Sensory: External Ear  Somatic Motor: Soft Palate, Pharynx, Larynx (Vocalization and Swallowing)  Visceral Motor: Bronchoconstriction, Peristalsis, Bradycardia, Vomitting

XI Spinal AccessorySomatic Motor: Trapezius, Sternocleidomastoid

XII Hypoglossal Somatic Motor: Tongue

Immediate RTP DecisionsImmediate RTP Decisions

Any LOC, neurological changes, or Any LOC, neurological changes, or persistent symptomspersistent symptomsNO play that day!NO play that day!

Golden rules:Golden rules: ““If you were out, you are out”If you were out, you are out” ““If you sway you do not play”If you sway you do not play” ““When in doubt, sit them out”When in doubt, sit them out”

15-20 minute “rule”15-20 minute “rule”

Immediate RTP DecisionsImmediate RTP Decisions

Must NOT have extensive concussion Must NOT have extensive concussion historyhistory

Must be symptom free at rest and exertionMust be symptom free at rest and exertionAthlete must meet 4 criteriaAthlete must meet 4 criteria

Normal neurological - – physiological and cognitiveNormal neurological - – physiological and cognitiveNormal vasomotor – BP and pulseNormal vasomotor – BP and pulseFree of headaches, dizziness, fatigue, & impaired Free of headaches, dizziness, fatigue, & impaired

orientationorientationIncrease in activity doesn’t make S/S worseIncrease in activity doesn’t make S/S worse

40 yd dash, sit-ups, push-ups, deep knee bends40 yd dash, sit-ups, push-ups, deep knee bends

Immediate RTP DecisionsImmediate RTP Decisions

StatisticsStatistics30% of concussions RTP on same day30% of concussions RTP on same day70% = 4 or more days70% = 4 or more days

Why is it important to continue to monitor Why is it important to continue to monitor symptoms even when they return to play symptoms even when they return to play that day?that day?33% of same day returners experienced 33% of same day returners experienced

delayed onset of symptomsdelayed onset of symptoms12% of non-returners experienced delayed 12% of non-returners experienced delayed

onset of symptoms onset of symptoms

Importance of Concussion Importance of Concussion HistoryHistory

Must get a DETAILED HistoryMust get a DETAILED HistoryPrevious head injuriesPrevious head injuries

NumberNumberCharacteristics – MOICharacteristics – MOIAll S/S and deficitsAll S/S and deficitsTime out of practiceTime out of practiceTime out from competitionTime out from competition

Neurocognitive TestingNeurocognitive Testing

Inability to focus attention and easily distracted? Inability to focus attention and easily distracted? Memory deficit? Memory deficit?

Retrograde vs. AnterogradeRetrograde vs. Anterograde Short term and Long termShort term and Long term

Does the athlete have normal concentration?Does the athlete have normal concentration? Normal emotional response?Normal emotional response?

How long were the athlete’s emotions abnormal?How long were the athlete’s emotions abnormal?

ImPACT™ Testing

Immediate Post-Concussion Assessment and Cognitive Testing

Computerized TestingComputerized Testing NOT to diagnose but to measure recoveryNOT to diagnose but to measure recovery There are varietiesThere are varieties

Need interpretation and normsNeed interpretation and norms Risk of False NegativesRisk of False Negatives CostCost

ImPACTImPACT™ Testing (www.impacttest.com) Testing (www.impacttest.com) Verbal MemoryVerbal Memory Visual MemoryVisual Memory Information Processing SpeedInformation Processing Speed Reaction TimeReaction Time Impulse ControlImpulse Control

Neurocognitive TestingNeurocognitive Testing

Neurocognitive TestingNeurocognitive Testing

Return to Play (RTP)Return to Play (RTP)

• Athletes should complete the following step-wise process prior to Athletes should complete the following step-wise process prior to return to play following concussion. return to play following concussion.

• Removal from contest following any signs / symptoms of concussion Removal from contest following any signs / symptoms of concussion • No return to play in current game No return to play in current game • Medical evaluation following injury Medical evaluation following injury • Rule out more serious intracranial pathology Rule out more serious intracranial pathology

• Step-wise return to play Step-wise return to play • No activity - rest until asymptomatic No activity - rest until asymptomatic • Light aerobic exercise Light aerobic exercise • Sport-specific training Sport-specific training • Non-contact drills Non-contact drills • Full-contact drills Full-contact drills • Game play Game play

Prague Concussion Prague Concussion Conference Conference RecommendationsRecommendations

Future Return to Play DecisionsFuture Return to Play Decisions Depends on both the athlete’s current condition and Depends on both the athlete’s current condition and

the athlete’s past concussions.the athlete’s past concussions. Should follow a progression that begins once the athlete is Should follow a progression that begins once the athlete is

fully symptom freefully symptom free No magic number of concussions – After 3…significant No magic number of concussions – After 3…significant

changes in neurocognitive functionchanges in neurocognitive function

Current recommendations:Current recommendations: Fully symptom freeFully symptom free for at least 7 days at rest and during for at least 7 days at rest and during

exertionexertion Why 7 days? Why 7 days?

Research studiesResearch studies Remember time frame gets bigger if athlete has had more than one Remember time frame gets bigger if athlete has had more than one

concussionconcussion

Threat of Multiple ConcussionsThreat of Multiple Concussions

This is your brain:This is your brain: This might be your This might be your brain after multiple brain after multiple concussions:concussions:

ReassessmentReassessment

What timeline should you use?What timeline should you use?Who is involved?Who is involved?

This may be the time to grade the concussionThis may be the time to grade the concussionYou have more data – You have more data – severity of symptomsseverity of symptoms and and

total durationtotal durationHOWEVER, do not place too much emphasis on HOWEVER, do not place too much emphasis on

the grading system…FOCUS on whether the the grading system…FOCUS on whether the athlete is symptom freeathlete is symptom freeUse the 4 criteria of RTPUse the 4 criteria of RTP

Home Care InstructionsHome Care Instructions

Instructions on medicine, rest, food, alcohol, S/S Instructions on medicine, rest, food, alcohol, S/S monitoring, and when to be reassessed.monitoring, and when to be reassessed. Why are these so important?Why are these so important? What should an athlete know about their concussion?What should an athlete know about their concussion?

Should a concussed athlete be awakened Should a concussed athlete be awakened throughout the night?throughout the night?

What would you write on your athletic training What would you write on your athletic training room’s Home Care Instructions?room’s Home Care Instructions?

SecondSecond ImpactImpact SyndromeSyndrome

Second Impact Syndrome (SIS)Second Impact Syndrome (SIS) Athlete returns to play while still experiencing S/S of Athlete returns to play while still experiencing S/S of

previous concussion, then receives another blow previous concussion, then receives another blow (even minor).(even minor).

Loss of vascular autoregulation causes vascular Loss of vascular autoregulation causes vascular engorgementengorgement

Catastrophic swelling in brain with increase in intracranial Catastrophic swelling in brain with increase in intracranial pressurepressure

SecondSecond ImpactImpact SyndromeSyndrome

May initially display S/S of Grade I concussion May initially display S/S of Grade I concussion but then quickly collapses into a but then quickly collapses into a semicomatose statesemicomatose stateDilated pupils, Unresponsive pupils, Loss of eye Dilated pupils, Unresponsive pupils, Loss of eye

motionmotionResponsiveness diminishes – eyes open but Responsiveness diminishes – eyes open but

unresponsive to commandsunresponsive to commandsRespiratory distress secondary to phrenic nerve Respiratory distress secondary to phrenic nerve

disruptiondisruption

SecondSecond ImpactImpact SyndromeSyndrome

DON’T push for early return to play.DON’T push for early return to play.Concussions are cumulative!!Concussions are cumulative!!

The previous one is NOT erasedThe previous one is NOT erased

Permanent damage Permanent damage 50% chance that SIS will result in death or 50% chance that SIS will result in death or

vegetative statevegetative state

How do you prevent if athlete doesn’t report How do you prevent if athlete doesn’t report lingering symptoms?lingering symptoms?Neuropsychological and cognitive testing is Neuropsychological and cognitive testing is

importantimportant

Post Concussion SyndromePost Concussion Syndrome

Post-concussion SyndromePost-concussion Syndrome Continued disability due to one or more Continued disability due to one or more

concussions. concussions. i.e. Al Toon, Meryl Hodges, Chris Miller, Brett Lindros, Pat i.e. Al Toon, Meryl Hodges, Chris Miller, Brett Lindros, Pat

LaFontaine, Stan Humphries, Steve Young, Troy AikmanLaFontaine, Stan Humphries, Steve Young, Troy Aikman

S/S: S/S: Early: disorientation, headaches, dizziness, Early: disorientation, headaches, dizziness,

nausea, sleep disturbances, light sensitivity, and nausea, sleep disturbances, light sensitivity, and blurred vision.blurred vision.

Late: Poor memory, lack of concentration, Late: Poor memory, lack of concentration, depression, irritability, anxiety, fatigue, depression, irritability, anxiety, fatigue, headaches, and sleep disturbancesheadaches, and sleep disturbances

In ConclusionIn Conclusion

Work as a sports medicine teamWork as a sports medicine teamATC, Dr., athlete (parents), coachATC, Dr., athlete (parents), coach

No 2 concussions are the same !!!No 2 concussions are the same !!!Each athlete should be considered Each athlete should be considered

individuallyindividuallyThe negative consequences of early return The negative consequences of early return

by far outweigh the inconvenience of time by far outweigh the inconvenience of time lost in a seasonlost in a season