Recognition and Care of Concussion Seattle Sport Concussion Program: - - PowerPoint PPT Presentation

Enter department name here Orthopedics and Sports Medicine

Recognition and Care of Concussion

Seattle Sport Concussion Program: Philip D. Heywood MS, ATC, AT/L

Orthopedics and Sports Medicine

Objectives:

• Definition and Pathophysiology
• Concussion facts
• Recognizing Concussions
• Caring for the concussed athlete (RTP)
• Washington State Law

Orthopedics and Sports Medicine

What is a Concussion?

“A complex pathophysiological process affecting the brain, induced by biomechanical forces.”

• Zurich Concussion Statement 2012
• Complex – no “easy” concussions
• Pathophysiological – function and microscopic structure

problems

• Biomechanical forces – a direct blow to the head, face,

neck or elsewhere on the body with an “impulsive” force transmitted to the head

Orthopedics and Sports Medicine

What is a Concussion?

Common features of a concussion:

• Rapid onset of usually short-lived neurological

impairment which typically resolves spontaneously

• A range of clinical symptoms that may or may

not involve loss of consciousness (LOC).

Less than 10% of sports concussions involve loss of consciousness

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Pathophysiology of Concussions

• A concussion is a disturbance in brain function.
• Results in a variety of nonspecific symptoms
• Certain chemical levels are altered at the cellular level.
• Blood supply to the brain decreases.
• The brain’s demand for glucose increases.
• The result is a metabolic imbalance referred to as an

The result is a metabolic imbalance referred to as an “ “energy crisis. energy crisis.” ”

• This Energy crisis leaves neuronal tissue vulnerably
• The brain needs time to recover and heal

Orthopedics and Sports Medicine

Concussion Basics

• If the brain was like a computer a concussion would be a

software issue, not a major hardware problem

• Imaging (CT and MRI) shows structure, not function
• Routine Imaging will be normal in most cases
• Normal imaging does not equal normal function!

Normal imaging does not equal normal function!

Orthopedics and Sports Medicine

Concussion: Epidemiology

• 3.8 million recreation or sports

related concussions among children and adults

Langois et al, J Head Trauma Rehab, 2006

• 144,000 Emergency Department

visits for concussion in children 0-19 years of age annually

Meehan & Manix, J Peds 2010 and 2011

Orthopedics and Sports Medicine

Concussion: Epidemiology

• 8.9 % all high school athletic injuries
• 5.8 % all collegiate athletic injuries
• 16.8% had previous concussion (that

season or prior season)

• Sports Concussion Rates
• Football
• Girls soccer
• Boys soccer
• Girls basketball

High School Reporting Information Online & NCAA Injury Surveillance System (2005-2006)

Gessel et al, J Athl Trning 2007

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Concussion: Epidemiology in High School Athletes

• Concussion rate per 1000 athlete-exposures
• Football:

0.47

• Girl’s soccer:

0.36

• Boy’s soccer:

0.22

• Girl’s basketball: 0.21
• Boy’s basketball: 0.07

Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503

60% higher 300% higher

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Gender Comparable Sports

• Girls had a higher rate of concussions than boys
• Concussions represented a greater proportion of all

injuries in girls’ sports

• Girls had a greater proportion of concussions due to

player-playing surface contact and player-equipment contact

Marar,M et al. AJSM online 01/27/12

Orthopedics and Sports Medicine

Concussion: Epidemiology

• Risk for future sports concussion:
• 1 previous concussion: 1.5x risk
• 2 previous concussions: 2.8x risk
• 3+ previous concussions: 3.5x risk

Guskiewicz, JAMA 2003

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• Boden, AJSM 2007

Concussion: Epidemiology

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Concussion Symptom Resolution

Marar,M et al. AJSM online 01/27/12 25% had symptom resolution within one day 40% had symptom resolution within three days (except girl’s track and field and swimming

Orthopedics and Sports Medicine

Concussion Basics: Knowing your Athletes

• A concussion should be suspected in the

presence of ANY ONE OR MORE of the following:

• Symptoms

Symptoms (Headache, nausea, ringing in ears) (Headache, nausea, ringing in ears)

• Physical signs

Physical signs (unsteadiness, LOC, Appears dazed) (unsteadiness, LOC, Appears dazed)

• Impaired brain function

Impaired brain function (e.g. confusion, difficulty remembering) (e.g. confusion, difficulty remembering)

• Abnormal behavior

Abnormal behavior (e.g. severe anger, sadness) (e.g. severe anger, sadness)

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Treatment:

Immediate Response

• Any athlete with a suspected concussion should…

IMMEDIATELY BE REMOVED FROM PLAY IMMEDIATELY BE REMOVED FROM PLAY

• Should Not…

BE LEFT ALONE BE LEFT ALONE and should not drive a motor vehicle

• Seek Medical Attention right away if:

You notice any change in behavior/worsening worsening of symptoms

• f symptoms

Loss of consciousness more then 1 minute, Vomiting more Loss of consciousness more then 1 minute, Vomiting more then once then once, double vision, excessive drowsiness excessive drowsiness or inability to recognize familiar people.

• Seek Health Care Professional afterwards
• No Alcohol
• Do NOT use aspirin or anti-inflammatory medication

Orthopedics and Sports Medicine

Concussion Basics: Knowing your Athlete

• If you suspect a concussion remove athlete from play

and have them evaluated by a Licensed Health Care Provider trained in the evaluation and management of concussion:

• Medical Doctors (MD)
• Doctor of Osteopathy (DO)
• Advanced Registered Nurse Practitioner (ARNP)
• Physicians Assistant (PA)
• Licensed Certified Athletic Trainers (AT/L)
• As a coach what should I expect from my player’s

healthcare providers?

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What My Team’s Health Care Provider Should Know

SCAT3 SCAT3 Child Zurich Consensus Statement

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Recognizing when a concussion occurs SYMPTOMS

Symptoms may include one or more of the following:

Cognitive Somatic Affective Sleep

Confusion Post-traumatic amnesia (PTA) Retrograde amnesia (RGA) Loss of consciousness (LOC) Disorientation Feeling “in a fog” Vacant stare Inability to focus Delayed verbal and motor responses Slurred/incoherent speech Excessive drowsiness Headache Fatigue Disequilibrium, dizziness Nausea/vomiting Visual disturbances (photophobia, blurry/double vision) Phonophobia Emotional lability Irritability Drowsiness Sleeping less Sleeping more Trouble falling asleep

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Recognizing when a concussion occurs: Decreased Brain Function

Orientation

1 point for each correct answer What month is it? 1 What is the date today? 1 What is the day of the week? 1 What year is it? 1 What time is it right now? 0 1 Orientation score of _________of 5

Memory Function

Failure to have immediate/ delayed recall of words may suggest a concussion

• List 5 separate words and have athlete repeat them

immediately and after 5min Example: Candle, Paper, Sugar, Iron, Sunset

Concentration

• Months in Reverse Order

Ask the patient to state the months backwards starting from the current month. Circle omissions. Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan OR

• Days of the Week Backwards

Ask the patient to state the days of the week backwards starting from the current day. Circle omissions. Fri-Thur-Wed-Tue-Mon-Sun-Sat

Orthopedics and Sports Medicine

Recognizing when a concussion occurs: Balance Function

• Balance examination
• Balance testing is to be performed for 20 seconds each. Instruct the athlete to place the hands on

the hips and close the eyes.

• Dominant foot is defined as the “foot you kick with”
• (a) Double leg stance: The feet should be placed shoulder-width apart.
• (b) Single leg stance: The athlete should lift the dominant foot. The hip should be at 30 degrees of

flexion and the knee at 45 degrees of flexion.

• (c) Tandem stance: The dominant foot should be in the front.
• Balance testing: types of errors (max. 10 per trial)
• 1. Hands lifted off iliac crest
• 2. Opening eyes
• 3. Step, stumble, or fall
• 4. Moving hip into > 30 degrees abduction
• 5. Lifting forefoot or heel
• 6. Remaining out of test position > 5 seconds
• Which foot was tested? Left Right
• (i.e. which is the non-dominant foot)
• Total errors
• Double leg stance ____of 10
• Single leg stance (non-dominant foot) ____of 10
• Tandem stance ____of 10
• Balance examination score ________of 30

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Treatment:

until signs/symptoms clear

• DO NOT allow athlete

DO NOT allow athlete to run/jump, raise heart rate or put themselves in a raise heart rate or put themselves in a situation where they can get hit again situation where they can get hit again. This involves playing pickup ball, weight lifting, PE, or running down the street chasing their friends.

• Athlete may have a hard time with concentration

Athlete may have a hard time with concentration.

• If athlete complains of a severe headache or dizziness limit time at school, no TV and

Video Games!

• Allow athlete to rest and stay inactive until all signs and symptoms have cleared
• Do NOT engage in any physical activity until cleared by a Licenc

Do NOT engage in any physical activity until cleared by a Licenced ed Health Care Provider! Health Care Provider!

Orthopedics and Sports Medicine

Treatment:

Return to Play Guidelines

• Athlete will not be returned to play the same day of injury

Athlete will not be returned to play the same day of injury. .

• When returning athletes to play, they will then follow a stepwise

symptom-limited program, with stages of progression.

1.

Rest until asymptomatic

2.

Light aerobic exercise (running, biking)

3.

Sport-specific exercise

4.

Non-contact training drills

5.

Full contact training drills after medical clearance

6.

Return to competition (game play)

• Approximately 24 hours (or longer) for each stage.
• If symptoms return at any stage athlete should return to stage 1.
• MEDICAL CLEARANCE MUST BE GIVEN BEFORE RETURN

MEDICAL CLEARANCE MUST BE GIVEN BEFORE RETURN TO PLAY! TO PLAY!

Orthopedics and Sports Medicine

RTP In-depth

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Second Impact Syndrome

• Rare
• Limited to teenagers
• No cases in NFL/ NHL/ MLB

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Concussions in the News

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Zachery Lystedt Law: Engrossed House Bill 1824

• Washington State Legislature
• Develop guidelines and informative

hand outs for all athletes/families/coaches.

• Signed document stating they know

and understand the importance of this issue prior to participating in practice or competition.

• Updated Yearly

Updated Yearly

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Zachery Lystedt Law: Engrossed House Bill 1824

• An athlete who is suspected of sustaining a concussion in the

State of Washington

• MUST BE HELD OUT.

MUST BE HELD OUT.

• Once removed, no return until evaluated by a licensed

health care provider trained in the evaluation and management of concussion.

• Licensed Health Care Providers
• Medical Doctors (MD)
• Doctor of Osteopathy (DO)
• Advanced Registered Nurse Practitioner (ARNP)
• Physicians Assistant (PA)
• Licensed Certified Athletic Trainers (AT/L)

Research is currently being done to determine which other licensed health care providers may have sufficient training to qualify to authorize return to play. The WIAA will update schools and this website as this information becomes available.

• Must have written clearance to return to play!!!

Must have written clearance to return to play!!!

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Zachery Lystedt

http://www.nfl.com/videos/nfl- videos/09000d5d81c7a785/Part-three-The-Zackery-Lystedt- Youth-Sports-Concussion-Law-Meet-Zackery-Lystedt

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Concussion Legislation

• 49 states and District of Columbia currently have

49 states and District of Columbia currently have concussion legislation for young athletes concussion legislation for young athletes

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In Conclusion

• You know your athletes best
• RTP is key when keeping kids safe
• Promote honesty with your athletes, and set

clear expectations for your team

• Where applicable work with your ATC to

educate administrators, parents, and Student athletes

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In Conclusion

• Do not let a injured athlete back into practice or

games until they have been evaluated and cleared in writing by a licensed healthcare provider trained in the evaluation and management of concussions. This is not only the Law (in Washington State); It Is The Right Thing To Do!

Orthopedics and Sports Medicine

Helpful Resources

• Consensus Statement on

Concussion in Sport; 4th International Conference on Concussion in Sport, Zurich 2012

• SCAT 3
• Graduated Return to Play
• Zackery Lystedt Law
• CDC Heads Up Tool Kit
• WIAA website- Coaches’ video

Orthopedics and Sports Medicine

Seattle Sports Concussion Clinic

Appt: 206.744.8000 Appt: 206.987.2109