Mark J. Harary, MD

Primary Care Sports Medicine

St Charles Orthopedics, LLP

Facts, Definitions, etc

Appropriate Recognition

Comprehensive

Management

Treatment

Consequences of Concussions

Neurocognitive Testing

“Return to Play” Progression

1.5-4 million sports related concussions occur each year Concussions from non-sports related injuries are also

fairly common

Over 60% of concussions in high school sports are from football

Soccer is the leading sport for concussions in high school females

High school athletes who sustain a concussion are 3x more likely to sustain a second concussion

If not appropriately treated, a patient who sustains concussion is 4-6 times more likely to sustain a second Cumulative effects

A concussion is a Mild Traumatic Brain Injury.

“Concussus:” derived from the latin “to shake violently”

Concussions may range from “bell ringers” to prolonged loss of consciousness.

Loss of consciousness is not diagnostic or prognostic of concussion

Concussion typically results in the rapid onset of short-lived impairment of neurologic function.

Concussion results in a functional disturbance rather than a structural injury.

The “invisible” injury

Concussions common and more serious than previously recognized Old treatment guidelines

“Mild” initial symptoms may lead to long lasting symptoms

Media exposure High exposure athletes have played through concussions

and return to play quickly after concussions

Youth athletes are more at risk for bad outcomes than their “professional counterparts” given their vulnerable/developing brains

Symptoms Reported

• Headache

• Nausea

• Balance problems

• Double/fuzzy vision

• Sensitivity to noise/light

• Feeling sluggish

• Feeling “foggy”

• Change in sleep pattern

• Concentration/memory issues

Signs Observed

• Appears dazed

• Confused about play

• Answers question slowly

• Forgets plays, score, opponent

• Personality change

• Retrograde amnesia

• Anterograde amnesia

• Loss of consciousness

Not all concussions are associated with LOC.

Only about 10%

Not all concussions present with headache.

About 85%

Concussions cannot be diagnosed by an X-ray, CT scan or MRI

Concussion symptoms are secondary to a SUPPLY/DEMAND issue…

Energy/Metabolic Crisis secondary to decreased blood flow and increased demand for glucose

American Academy of Neurology (1997)

Graded concussions

Vienna Guidelines (2001)

Prague Guidelines (2004)

Simple versus Complex

Zurich Guidelines (2008)

No same day RTP

No simple versus complex

No grading scheme

All concussions should be TREATED

*Education Program*

(Baseline Neurocognitive Testing)

Appropriate recognition

Appropriate ER evaluations

Appropriate Treatment with Follow-up visits

Graduated Return to Activity

EDUCATION, EDUCATION, EDUCATION

That is why we are here!!

Coaching staff, referees, parents, athletes, medical providers should be able to recognize a concussion

Appropriate preventive measures in sports

No tolerance on poor technique (ie, spear tackling)

Injured players MUST have a return to play assessment with documentation by a medical practitioner well versed in concussion management

WEAR THEM! There is no “concussion” helmet or mouthguard All helmets should be refurbished after the season

and stamped with approval Before season, all helmets should be fit to athlete–

there should be no movement with head movement

This should be done again if the athlete has a change in his hairstyle

Before each wear, helmets should be checked for inflated bladder, cheek pad placement

Mouthguards should be molded to thepatient and NOT cut for comfort.

Patients with head injury should be seen in the ER if there is loss of consciousness or if there are any focal neurologic symptoms

Rule out more serious intracranial pathology

CT scan

MRI

No one should get a

clearance note from the

ER.

WHEN IN DOUBT, SIT THEM OUT!

If a player is removed from play for concussive symptoms with or without LOC

No return to play

Take away the athlete’s helmet, cleat, etc

Continue to monitor for worsening symptoms

An adult must be responsible for following the athlete

Decision whether to go to ER

Athlete’s with concerning symptoms should be taken out of play IMMEDIATELY.

There should be no same day return to play in the adolescent population

** Avoid re-injury **

Patient should be seen by a medical provider trained in concussion management.

REST

Cognitive and physical

“Return to play” protocol

6 step protocol to return to play is much more conservative in youth than in older athletes.

Increased sleep

Good sleep hygiene

Low threshold to start melatonin

Take naps when available

No sports, gym, cardiovascular conditioning, strength training

May need to be out of school/work to allow for appropriate rest

Reduced course/work load

“Accommodations”

Minimal TV, computers, texting, video gaming, etc

Avoid loud noise, bright lights, vibration, etc

No concerts, no “gigs”

Symptoms generally resolve completely in 7-10 days, but may be longer in youth and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of untreated concussion)

If not treated properly, the patient is at increased risk of long term effects

Post Concussive Syndrome

Second Impact Syndrome

Chronic Traumatic Encephalopathy [CTE]

Emotional Problems

ADHD/LD??

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

N=134 High School athletes Collins et al., 2006, Neurosurgery

It’s the law…

July 2012

NY is the 33rd state to pass such a law

1) Permission slips

2) Immediate removal from participation

3) Medical clearance before RTP

Long term effects…

PCS

Second impact syndrome

CTE

ADHD/LD

Depression

Anxiety

Chronic headaches

Fatigue

Sleep difficulties

Personality changes (e.g. increased irritability, emotionality)

Sensitivity to light or noise

Dizziness when standing quickly

Deficits in short-term memory, problem solving and general academic functioning

A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event.

Can result in devastating/catastrophic increase in intracranial pressure Vasomotor paralysis, edema, massive swelling, brain

herniation, death

This catastrophic demise is very rapid and carries a 50% mortality rate along with almost a 100% morbidity rate

Most common in the high school population secondary to poor auto-regulatory control of intracranial blood flow

Approximately 50 high school students have died since 1997

“Punch-drunk”

The condition, which occurs in people who have suffered multiple concussions or sub-concussive blows.

Thought to be caused by the loss of neurons, scarring of brain tissue, collection of senile plaques, diffuse axonal injury, neurofibrillarytangles and damage to the cerebellum.

Parkinsonian movements, signs of dementia, speech problems, paranoia, etc.

Neurocognitive Testing/Evaluation Evaluates attention/concentration, memory/recall,

processing speed, and reaction time

Ideal to have baseline vs. post-concussive information

Pen and Paper versions are time consuming and expensive

Computerized models have simplified this ImPACT, CogState, HeadMinder

Testing done in 30 minutes or less

Able to test large numbers of athletes to obtain baselines

Results available as soon as testing is over

*Education*Baseline

Testing

Concussion

* Post-Injury Testing

* Clinical Eval

0 1-3 Days 3+ Days

* Sideline Eval* ER Eval

* F/u Clinical

Asymptomatic at rest

“RTP” progression

1. Rest until asymptomatic (physical, mental) 2. Light to moderate aerobic activities with no weight

training Goal is to increase HR

3.Increased weight training and aerobic activities. Add plyometrics and balance/proprioceptive challenge. Sports-specific, aggressive non-contact training Goal is intense, noncontact activity

4. Full contact training Goal is to reintegrate into full contact practice

5. Return to contact competition (game play) Goal is to return to competition

Each stage is at least 24 hrs and return to previous stage if symptoms reoccur