Concussion in Sport Coach/Parent/Athlete Education

Melinda Roalstad, MS, PACThink Head First

8 May 2012

Discussion Today….

• What is Concussion?• Why the recent Interest?• Legislation Nationwide• What is really happening

with this injury?• Best Practices-Management• Return to daily activities,

school and sport

Concussion – Current Definition

” Sports concussion is defined as a complex pathophysiological process

affecting the brain, induced by traumatic biomechanical forces”

1st International Symposium on Concussion in Sport, Vienna 2001 CISG

Br J Sports Med. 2005 Apr;39(4):196-204.

Features involved with Mild Traumatic Brain Injury (MTBI)

Vienna 2001 CISG

• Any direct blow to the head OR body causing “impulsive” force transmitted to the Brain

• Transient impairment in brain function• NO damage to brain anatomy• Disturbance in normal neurometabolism• Clinical s/s reflect functional NOT structural

Cognitive Symptoms• Attention Problems• Memory dysfunction• “Fogginess”• Fatigue• Cognitive slowing

Physical Symptoms• Visual Problems• Dizziness• Balance Difficulties• Headaches• Noise/Light Sensitivity• Nausea

Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins, 2004)N=327, High School and University Athletes Within 7 Days of Concussion

The Many FacesOf Concussion

Emotionality• More emotional• Sadness• Nervousness• Irritability

Sleep Disturbance•Difficulty falling asleep•Sleeping less than usual

Why the Fuss?• Major Public Health Problem - $$• 2.5-3.8 million mTBI / year • # Kids, 14-19 yo’s in organized

sports w/ ED visit for concussion has doubled since 1997

• > 90% associated with NO LOC• 30-50% go Undiagnosed• Mismanagement –> Catastrophic

“Silent Epidemic”

Concussion Facts and Stats

• 10% of all contact sport athletes sustain concussions annually

• >62,000 HS athletes concussed/yr• Football is Highest Risk in HS – 63% • Ice Hockey, Soccer, Lacrosse – High Risk• An athlete with one concussion is 4-6X more

likely to sustain a second concussion• High School proportionally > College

Journal Athl Train 2007;42(4):495–503

High School vs College Athletes

Historical Evolution in Guidelines

Guidelines Grade 1 Grade 2 Grade 3

Cantu5No LOC Post-traumatic amnesia for fewer than 30 minutes

LOC < 5 minutes Post-traumatic amnesia for more than 30 mins

LOC > 5 minutesPost-traumatic amnesia for more than 24 hours

Colorado Medical Society6

No LOC No post-traumatic amnesia / Confusion

No LOC+ Post-traumatic amnesia / Confusion

LOC of any duration

American Academy of Neurology7

No LOC Concussion symptoms for fewer than 15 minutes

No LOC Symptoms for more than 15 minutes

LOC of any duration

Management Concerns - Previously

• Grading systems ineffective/not data driven• CT/MRI not sensitive to subtleties of injury• Self report of symptoms not reliable• Variable clinician recommendations• Lack of education/awareness for injury –

contributes to misunderstanding for proper management

Cultural Shift in Perception• Scientific basis for guidelines• Enormous amount of research past 15-20 years• Evolutionary process of understanding• Management has become more conservative

because of what we DO NOT know and problems that can arise in recovery process

Concussion is a complicated injuryALL Concussions are Serious

What we have learned….

• Lack of Awareness & Education at all levels• Mild Injury -> Severe w/ poor management

• Each Injury is INDIVIDUAL• Different biomechanics -> different symptoms• Physical AND Cognitive exertion affect recovery• Risk Factors for delayed recovery

– Age, gender, migraines, learning disability

Increased Media Attention…

Utah Legislation“Protection of Athletes with Head Injuries”

• Sports organizations must have policy for head injury• Parent, Athlete, Coach Education• Removal from Sport if suspected to have a concussion• Prohibits athlete to return to sport/play until cleared by

qualified healthcare provider “trained in evaluation & management of concussion”

UHSAA Form

What is actually happening inside the brain with injury?

Pathophysiology of MTBI• Injury -> Neuronal Membrane Disruption• K+ leaks out / Ca2+ in Dysfunction• Na/K Pumps activated -> Require ENERGY• Glucose Demand High for Energy Coupled with

decreased Blood Flow• Impaired Oxidative Metabolism for 2-4 weeks• Lactate Accumulation Axonal Injury• Impaired Neuronal transmission

“Metabolic Mismatch”

Periods of Vulnerability• Glycolysis/Blood Flow Mismatch

• Resolve in 7-10 days in rat models / Humans 2-4 weeks

• Impaired neurotransmission• May persist for up to 1 week in rat models• Other cellular mechanisms postulated to be involved in

learning/memory may be impaired for up to 8 weeks

• Additional injury during this period may lead to additional damage

• “Double concussion” model in rats supports this idea

• Overstimulation / ‘cognitive demand’ on the brain may also ‘tip the scales’

Giza and Hovda, 2001

Management – What do you do?

Management RecommendationsCISG

• No more grading scales for concussion• ANY s/s – Remove from activity• Neurocognitive Testing “cornerstone” for proper

management of injury• Systematic progression in exertion to RTS

ASYMPTOMATIC at Rest & Exertion

Top Ten Reported SymptomsHigh School/College Athletes w/in 3 days of injury

SYMPTOM PERCENT

#1 Headache 71%

#2 Feeling Slowed Down 58%

#3 Difficulty Concentrating 57%

#4 Dizziness 55%

#5 Fogginess 53%

#6 Fatigue 50%

#7 Visual Blurring/double vision 49%

#8 Light Sensitivity 47%

#9 Memory Dysfunction 43%

#10 Balance Problems 43%

Lovell, Collins et al., 2004; N = 215

WHY use Neurocognitive Testing ??

• Quantifies injury Provides OBJECTIVE data for athlete, parents, coaches, clinicians

• Help determine severity of concussion • Prevents cumulative effects• Provide information on academic deficits

associated with concussion• Protects Athlete Promotes safe RTS

It is an additional “Tool”

Contribution of ImPACT Testing to Management of Concussion

Testing revealsCognitive impairmentin athletes reporting to be “Asymptomatic” within 4 days post-concussion

Best Practices Approach

• Adopt Program Policy – USSA• Program specific protocol / RTS Criteria • Develop local resources for support• Education -> Coaches, Athletes, Parents• Multidisciplinary approach for recovery• Collaboration / Coordination

Most mild concussions resolve successfully if well managed within the 1st 3-4 weeks

Education

• What Must an Athlete Know:– Protocol, S/S, Importance to Report, Rest

• What should Coaches Know: – Protocol, recognize, remove, when to call 911,

notify parent, refer for evaluation, rest, RTS• What Parents need to Know:

– Policy/Protocol, S/S, proper evaluation, when to go to ED, physical/cognitive/social REST for Recovery

Back to Baseline

BASELINETESTING

PRE-SEASON

Clearance to begin Progression into

Sport

RTSPlan

INJURY

Remove from Play

1 - Parent Notification 2 – Medical Evaluation 3 – Symptom Resolution

Observe Signs

Symptoms

Best Practices - Action Plan

Why Baseline Testing? • Individual variation in how

they perform on testing• Should injury occur, the

best comparison post injury is the individual pre injury status

**Educational Opportunity**

When Injury Occurs…

• Acute Triage – Identify Medical Emergencies• Prevent Second Impact Syndrome• Avoid Cumulative Effects

– Lowered Threshold to injury– Additive Post Concussive Symptoms

• Prevent Post Concussive Syndrome

Ideal Recovery Process

• Early Intervention – Rest,Rest,Rest• Medical/Clinical Evaluation • Post Injury Neurocognitive evaluation• Education Manage ALL Stressors• Create a PLAN for return to daily activity,

return to academic loads and return to sport participation

Return to School Recommendations

• Initial Excused Absence – control symptoms• Progressive Core Attendance with planned Rest• Reduce Volume of Workload - Prioritize • Assistance in planning work to be done • Testing – postpone/shorter test/allow more time • Attention issues – lights/noise/distractions

Support of family, teachers, peers is crit ical

Return to Sport Criteria

• Asymptomatic Rest• Symptom Free with School• Balance and Cognitive

function at Baseline• Return to conditioning

w/no increased symptoms• Sport Specific, non-risk

training w/no symptoms

Cognitive Recovery – How Long??

Collins, Lovell et al., 2005

Who will be your more complicated

recovery?• Age• Migraine History• Psychological Issues• Learning Difficulties• Repetitive Injury• Mechanism of Injury• Gender?

Recovery takes a Village• Collaborative Recovery Team

– PCP’s, PMR, Neuropsychologists, ATC’s, physical, occupational, speech and vestibular therapists

– Family support unit– School – counselors, teachers, school nurses, peers– Sport – coaches, team members

• Coordination of community support resources

Early Education / Intervention is crit ical to Recovery

In Summary

• Education at all levels• On-site awareness/assessment critical • Should an athlete return that day NO• Neurocognitive testing provides additional tool• MULTIDISCIPLINARY approach to recovery with

clear plan communicated to all parties involved • Good management is key to successful recovery

When in doubt sit them out! Think Head First!

Web Sites• CDC.gov/concussion• NFHS.org• impacttest.com• Brainline.org• thinkheadfirst.com• Lumosity.com• Sportconcussion.org