Concussion in Higher Education

Dr. Taryn Taylor, BKin, MSc, MD, CCFP (CAC SEM), Dip Sport Med

Make the CutNovember 16, 2016

What is a Concussion?

Signs & Symptoms

Gender Differences

Diagnosis of Concussion

Implications of Concussion

Initial treatment of Concussion

Return to Play

Return to Learn

1. A concussion only occurs as a result of a direct blow to the head.

2. A normal CT scan rules out a concussion.

3. A person who has been knocked unconscious will suffer a worse concussion.

4. Males sustain more concussions than females.

5. A grade 1 concussion is less serious than a grade 3 concussion.

6. The harder someone is hit, the worse the concussion.

7. Students/Athletes can tough through a concussion.

8. Concussions are the same for adults and children/adolescents.

9. Helmets prevent concussions.

10. A person who has had a concussion has the same likelihood of re-injury as a person who has never been concussed.

Concussion is a silent epidemic and a serious public health problem in North America.

An increase of 60% over the last decade.

CDC stats estimate 3.8 million concussions annually in the United States and 165,000 per year in Canada, the majority in children and young adults.

452 people suffer a brain injury every day in Canada which amounts to one TBI every 3 minutes.

One in three Canadians is directly impacted by brain injury in some way.

Concussion represents 9% of injuries reported in the National Surveillance in US high school sports.

A mild traumatic brain injury (mTBI) results in immediate & temporary alteration of mental functioning.

Concussion may be caused by either a direct blow to the head, face, neck or body with an impulsive force transmitted to the head.

Helmets are important but do not prevent concussions.

No loss of consciousness necessary.

No structural damage to the brain (No bleed or bruise of the brain).

vs.

Medical field abandoned the grading systems of concussions in 2001 (Gr3=LOC).

The majority of concussions (80-90%) resolve within 2 weeks, but may be longer in children & adolescents with developing brains.

Repetitive concussions decreases threshold for re-injury & may have major consequences on the brain.

A genetic predisposition has been suspected (ongoing studies)

Statements based on international conferences among leading concussion experts from around the globe:1st Vienna in 2001

2nd Prague in 2004

3rd Zurich 2008

4th Zurich 2012

5th Berlin 2016

Females have a higher rate of concussion compared to males when playing:◦ Soccer (2.1 x greater risk)

◦ Softball versus baseball (up to 3.2 x greater risk)

◦ Basketball (up to 1.7 x greater risk)

◦ Lacrosse (equal risk but noncontact!)

The concussion rate in NCAA women's ice hockey is 2.72 per 1,000 player hours. ◦ NCAA men's ice hockey rate is 1.47 per 1,000

◦ NCAA football rate is 2.34 per 1,000

Females at higher risk/prone to concussion Heads are smaller Neck muscles are less developed Females may not be as good at absorbing shock of impact Hormones (estrogen) increase susceptibility for migraine Cranio vascular differences Decreased perception visual field (tunnel vision, anticipation

on the field of play) Self-reported symptoms vary by gender As a result, concussed females suffer with greater

cognitive decline and slowed reaction time relative to males

Despite the media craze, concussions are often under-recognized, under-diagnosed & under-reported!!

Evaluation by a physician should occur within 1-2 days following a concussion unless there is concern of brain damage/bleed.

The diagnosis of a concussion is made CLINICALLY!

CT and MRI scans rarely have a role.

Functional injury NOT a Structural injury.

Headache/Dizziness

Neck Pain

Amnesia

Feels “dinged” or “dazed”

Sees stars or flashing lights

Ringing in the ears

Sleepiness/fatigue/drowsy

Low energy

Change in vision

Slurred speech

Stomach ache

Nausea/vomiting

Sensitivity to light & sound

Poor coordination or balance, moves clumsily

Blank stare/glassy eyed Confusion, poor focus Slow to answer questions

or follow directions Easily distracted Difficulty concentration Irritability Inappropriate emotions

(laughing, crying, anger) Poor memory Changes in sleep pattern Cognitive changes

Barriers include: ◦ Excess competitiveness◦ Fear of viewing injuries as a weakness◦ Fear of being removed from the competition◦ Fear of letting down/disappointing the team

Student/Athlete may not report the symptoms if they didn’t recognize it as a concussion!

Post Concussion Syndrome - Risk of prolonged or permanent symptoms if premature return to learn/activity occurs before full recovery.◦ Decreased processing speed

◦ Short-term memory impairment

◦ Poor attention & concentration

◦ Emotional Difficulties (Depression, Anxiety)

◦ Fatigue/sleep disturbance

◦ Academic difficulties

The recovery pattern may not always be smooth.

Concussed students with persistent symptoms are at high risk for depression due to:

◦ loss of identity

◦ loss of social interaction/isolation

◦ overwhelming course demands

◦ loss of scholarship/university acceptances due to poor marks

◦ Chronic pain/HA

Second impact syndrome results from a second concussive episode when the individual is still symptomatic from a concussion.

Although rare, devastating consequences can occur, especially in young athletes <21yr

Catastrophic increase in intracranial pressure causing paralysis, massive brain swelling, herniation, & Death

Mental/Cognitive Rest & Physical Rest

Subthreshold Activity

Physician may restrict scholastic activities that involve reading or work on the computer

Limit screen time (computer, smart board, video games, smart phones, television)

Concussions should be treated and managed on an individual basis.

No two concussions are exactly alike anymore than the brains of any two individuals are identical.

Exercise

1. No activity/Rest2. Light aerobic exercise3. Sport-specific training, non-contact training

drills (may start resistance training)4. Contact training drills, no scrimmage5. Full contact practice after medical clearance6. Return to play

Concussed students should not return to school until symptoms are improving.

When headache-free, students may try brief periods of reading or light studying at home.

Return to school when the student can tolerate a few hours of cognitive activity without return of concussion symptoms.

Important that student athletes have full return to academics BEFORE return to sport.

Concussion can cause mental fatigue and negatively affect the ability to participate, learn & perform in school:

◦ Difficulty with new learning◦ Decreased attention and memory◦ Slowed processing speed and

efficiency ◦ Slowed reaction time◦ Anxiety/nervousness can further impair cognitive

function, impact compliance◦ Emotional meltdowns & behavioural outbursts

Activities requiring concentration can worsen symptoms & prolong recovery.◦ “cognitive overexertion”

Academic adjustments & accommodations need to be individualized.

Stepwise increase in cognitive tasks◦ Cognitive rest◦ Period of school absence◦ Increase cognitive activities at home◦ Gradual return to school

Half-days initially, only attend some classes

Shortened day start later in the morning depending on the student’s peak time for symptoms

Accommodations in place

Pacing, Pacing, Pacing (Energy Conservation)◦ Full course load

Concussion management & supportive recovery requires a team approach!

Involvement of the student/athlete, parent/guardian, Student Support Centers, teachers/profs, coaches/trainers, therapists, counsellor/psychologist all in communication with the health care professional will be instrumental in supporting changes to the academic plan to facilitate successful RTL

1. A concussion only occurs as a result of a direct blow to the

head.

A concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body and the force is transmitted to the head.

2. A normal CT scan rules out a

concussion.

When an athlete is concussed, there is no structural injury, so an MRI/CT scan won't add any additional info. A normal MRI/CT scan is expected in concussion.

3. A player who has been knocked unconscious

will suffer a worse concussion than a player

who didn't lose consciousness.

A player doesn't have to be knocked out to sustain a serious concussion and the severity of the concussion might not be known for days or weeks.

4. Male athletes sustain more

concussions than female athletes.

Females have a higher rate of concussion compared to males when playing the same sport and are at higher risk of developing persistent symptoms.

5. A Grade 1 concussion is less

serious than a Grade 3 concussion.

We used to grade concussions (Grade 3= LOC), but we have learned there is no correlation with prognosis. It is difficult to accurately assess the severity of a concussion right away. We have to wait and see how the symptoms develop & resolve over time.

6. The harder someone is hit, the

worse the concussion.

It doesn't always take a big hit to produce a concussion. Any contact to the head or body that causes rapid head movement can cause a concussion. Several lower impacts over time might be more serious than a single collision of great force. For example, offensive linemen in football, who experience contact on almost every play, could be more at risk for permanent brain damage than a wide receiver who absorbs a single hard hit once in a game.

7. Athletes can tough through a

concussion.

Typically, it takes 1-2 weeks for concussion symptoms to resolve. It is never safe to return to play the same day after experiencing a concussion. The more you try to do, the worse you will feel & symptoms will be prolonged.

8. Concussions are the same for

adults and adolescents.

Adolescent brains are still developing. The effects of a concussion on young people are more dynamic than on mature brains and may take longer to recover.

9. Helmets prevent

concussions.

Helmets are designed to prevent skull fractures, not concussions. If a helmet is fitted properly, it might reduce the risk or severity of concussions, but no one helmet is capable of preventing a concussion.

10. A person who has had a concussion has the

same likelihood of re-injury as a person who

has never been concussed.

Once someone has experienced a concussion, it can decrease the threshold for sustaining another concussion.

Parachute Canada www.parachutecanada.org Think First Foundation of Canada

www.thinkfirst.ca

Hockey Canada www.hockeycanada.ca/apps Play it cool www.playitcoolhockey.com Stop Concussions www.stopconcussions.com

Centers for Disease Control and Prevention www.cdc.gov/concussion

Canadian Academy of Sport & Exercise Medicine www.casem.acmse.org

Carleton Sport Medicine Clinic www.carletonsportmed.com

Thank You!

Questions?

McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008. Journal of Clinical Neuroscience 16 (2009) 755–763.

Delaney S. Concussions Among University Football + Soccer Players. Clin J Sport Med, 12(6), Nov 2002

Gioia et al. BJSM 2009;43(suppl 1):i13-i22. Kirkwood et al. Acta Paediatrica 2009;98:1409-1411. McGrath N. J Ath Training 2010;45(5):492-498 Sady MD, Vaughan CG and Gioia GA. Phys Med Rehab Clin N

Am 22 (2011) 701-719 CDC. Returning to School After a Concussion: A Fact Sheet for

School Professionals Master et el. Ped Annals 2012;41:9:1-6