Anatomy Of An

Adolescent Concussion:

It’s Not Child’s Play

Vicki Galliher, ATC, VATL, ACSM

By The Numbers• Concussions account for 1 in every

10 sports injuries according to the Centers For Disease Control & Prevention

• Concussions send 1.7 million individuals to the emergency room (ER) each year

• Nearly half of those ER visits are for children 14 years of age and younger

Thinking … then and now

• Severity of concussion is only indirectly related to the physical force of the impact

• Brain has no pain receptors – impact can only be perceived indirectly, as a headache or loss of consciousness

• No clear threshold for concussive injury

Thinking … then and now

• Less than 5% of all concussions are accompanied by loss of consciousness.

• Football ranks only slightly higher than girls’ soccer for incidence of youth concussions. Youth ice hockey and wrestling are trending close behind.

• There is no helmet that can prevent an athlete from sustaining a concussion.

A concussion is the most complicated injury to the most complicated organ

ofthe body

Brain Function Mapping

Not In Question• A concussion IS a traumatic brain

injury (TBI). About 75% of TBIs that occur each year are concussions.

• TBIs can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions

• TBIs can cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age

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Power Up Electrical Surge Lost Equilibrium

Fall OutAltered Brain Function

• Cognitive• Visual

• Emotional

What happens to your brain?

Power up … • The brain consists of billions of

nerve cells which communicate with distant nerve cells via long nerve fibers called axons

• Severe sudden twisting or torquing of the brain - as occurs in sudden acceleration/deceleration motion - stretch, twist, and shear the delicate axon fibers

Electrical Surge … “Fire in the brain”• The nerve cells fire simultaneously,

causing a mini-seizure. As they fire, K+ rushes out of the cells as Ca+ rushes in, clogging the neurons’ mitochondria.

• To fuel the absorption of new K+, the neurons consume glucose (sugar).

• Metabolization (breaking down) of glucose creates lactic acid. Lactic acid damages cell walls.

Milliseconds after concussion …

Fire in the brain

Lost equilibrium …• The calcium-clogged mitochondria do

not get essential oxygen. This causes a neuronal energy crisis.

• Blood flow diminishes and brain cells begin to die.

• Brain cells in the adolescent brain are still developing. Cell death is devastating to the present & future functioning and growth of the adolescent brain.

Fall Out … “Post-Concussion Syndrome”

• Physical symptoms can arise almost immediately to within 4 weeks from the initial concussive injury

• The predominant physical symptoms include: headache, dizziness, moderate-to-extreme fatigue, insomnia, and irritability

• Predominant cognitive symptoms include: memory loss (retrograde amnesia, anterograde amnesia), difficulty concentrating, impairment of higher level cognitive/executive functioning

In the aftermath …• The brain remains extremely

fragile – healing must be uninterrupted by subsequent injury

• Neurons are still starved for energy

• Even a minor “secondary impact” can unleash a devastating molecular cascade

In the aftermath …• If healing is interrupted, brain cells that seemed to be regaining their balance begin committing suicide - end result is massive loss of neurons.

• No one knows why this loss occurs, but the loss is permanent.

• Youth are particularly susceptible – brain is still developing. Even slight cell loss can alter the trajectory of brain growth.

Second Impact Syndrome - Video

• Dr. Jeffrey Barth, PhD, ABPP-CN

• Director, Brain Injury & Sports Concussion Institute

• University of Virginia School of Medicine

http://bcove.me/50uubwlm

Second Impact Syndrome

• Preston Plevretes – Life after tragedy

• ESPN: E-60 Second Impact

http://espn.go.com/video/clip?id=5163151

The Road To Recovery …

You only get one opportunity to manage the concussion recovery process the right way

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Immediate Intervention Comprehensive medical

assessment

Physical safeguards

Cognitive safeguards

Team Approach

• Health care professionals

• Family support• School support

Immediate Intervention …• Remove from play

• Initial assessment & observation

• Refer for medical evaluation

Comprehensive medical assessment

• Medical evaluation

• Diagnostic imaging

• Neuropsychological testing & follow-up

Physical safeguards …

• No physical activity at school or home

• No sports participation – must be extra vigilant with younger players who are more likely to be injured

• Careful observation & monitoring of symptoms

Cognitive safeguards …

Cognitive rest is the most often neglected aspect of concussion management

Cognitive safeguards …

• Symptom exacerbation, or re-emergence of symptoms in the wake of cognitive or physical exertion, is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits

• Neurometabolic activity can interfere with concussion recovery

• Current research has demonstrated that a significant degree of symptom exacerbation follows cognitive exertion

Cognitive safeguards …• Cognitive rest !!!!!!!!!!!!• Minimize brain stimulation – cognitive &

visual

• Turn it off !!

Computer Video Games Texting

Reading Puzzles Music Lighting

Audio Books Board & Card Games

It’s Your BRAIN !

• Be patient• Be honest

• Don’t rush back

D

C

B

A

A

B

C

D Slow and steady

Physical progression

Cognitive progression

Symptom resolution

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• Cumulative Effects• Diagnostic Imaging

• Baseline Testing• Technology

Current Research & Trends

CumulativeEffects

Cumulative Effects of Multiple Concussions

(Athletes with 3 or more prior concussions)• More likely to experience loss of consciousness,

prolonged post-injury mental status changes and greater severity of post-injury symptoms

• Exhibit impaired memory – short & long term

• Longer recovery time with each subsequent concussion

• Score significantly lower on auditory processing tasks

• Exhibit slower cognitive & visual processing speed

Diagnostic Imaging

Diagnostic Imaging

• X-rays

• CT Scan

• MRI (Functional / Resting State)

• EEG (Electroencephalograph)

• PET Scan (Positive Emission Tomography)

• DTI Scan (Diffusion Tensor Imaging)

Diffusion Tensor Imaging (DTI)

DTI Image of Concussed Brain

Baseline Testing

IMPACT Testing

• Immediate Post-Concussion Assessment & Cognitive Testing (IMPACT)

• Pre-season testing is essential in establishing baseline cognitive & visual processing values for the student-athlete

• Re-establish baseline values following concussion recovery

Technology

Technology

• Helmet design – force & acceleration sensors

• Mouthguard design

• Playing equipment

Thoughts from those living the reality of an adolescent

concussion

It’s not easy …

• Can I do this? … No! Well, can I do that? … No! What about? … No!

• But I’m BORED !!!

• It’s like being under HOUSE ARREST !!!

Final thoughts & questions …

Thank you …

• Vicki Galliher, ATC, VATL, ACSM

• Athletic Training Coordinator, GMHS

• galliherv@fccps.org

• 571-722-6331 (Office Cell)

• 703-248-5500 Ext 5583 (Office Phone)