ESPN Outside the Lines Segment: November 2007

http://espn.go.com/video/clip?id=3651929

Startling Numbers………………. High School Football Facts: “Why Are Concussions Under-

reported?” 66% Did not think it was serious enough 41% Did not want to leave the game 36% Did not know it was a concussion 22% Did not want to let down teammates

College Football Facts 6.3% of players suffered concussions as observed by AT 70.4% of players reported concussion-like symptoms anonymously

in surveys after the season NFL Facts

1 in 1,000:  The chance a 30-49 year old man will receive a diagnosis of dementia, Alzheimer's, or another memory related disease

1 in 53:  The chance a NFL retiree aged 30 to 49 will get the same diagnosis

(http://kingdevicktest.com/)

Concussion

Head trauma-induced Head trauma-induced alteration in mental alteration in mental status that may or status that may or may not involve a may not involve a loss of consciousnessloss of consciousness

Frequency of Concussions 3.5 million sports related 3.5 million sports related

concussions per year concussions per year (CDC)(CDC)

1 in 5 (250,000) high school 1 in 5 (250,000) high school football players per year football players per year (Cantu 1986)(Cantu 1986)

300,000 sport-related 300,000 sport-related concussions per year concussions per year (Thurman et al., 1998)(Thurman et al., 1998)

Player is 3 times more likely to Player is 3 times more likely to sustain a 2sustain a 2ndnd concussion after the concussion after the 11st st (Guskiewicz 2000)(Guskiewicz 2000)

Only 1 in 100,000 high school Only 1 in 100,000 high school football players suffer football players suffer catastrophic injuries catastrophic injuries (Cantu 1999)(Cantu 1999)

HOT OFF THE PRESSES….

Followed 25 schools over 11 years 2,651 concussions over 10,926,892 exposures Concussion rate increased 4.2x over 11 years

15% annual increase Football accounted for half of concussions

Lacrosse #2 overall Girls soccer highest rate among girls sports

Girls 2x likely to suffer a concussion in similar sport

Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. (Jan 29, 2011). Trends in Concussion Incidence in HS Sports: A Prospective 11 year study. Am J Sports Med

Frequency of Football Fatalities

(Mueller, F.O. 2001).

It’s Getting Better …..or is it?

(Mueller, F.O., 2001).

Or is it? 18 deaths in 2008 and 2009 seasons alone. Between 2005-2009 there were 39 fatalities – more than any other 5 year period since Mueller began collecting data!

Types of Head Injuries in Sports

Cerebral Concussion

VS

Cerebral Hematoma

………and what about

2nd ImPact Syndrome?

Cause of Death?

(Mueller, F.O. 2001).

Second Impact Syndrome Athlete sustains 2Athlete sustains 2ndnd

concussion before 1concussion before 1stst has has resolvedresolved Occurs within 1 week of Occurs within 1 week of

initial injuryinitial injury Potential for occurrence with Potential for occurrence with

mild head injuriesmild head injuries Often 1Often 1stst concussion goes concussion goes

unreported/unrecognizedunreported/unrecognized Major consideration when Major consideration when

making return to play making return to play decisionsdecisions

Mortality rate 50%Mortality rate 50% Involves rapid brain Involves rapid brain

swelling and herniationswelling and herniation Causes rapid dilation of Causes rapid dilation of

pupils, loss of eye pupils, loss of eye movement, respiratory movement, respiratory failure, and comafailure, and coma

Brain stem failure Brain stem failure develops within 2-5 develops within 2-5 minutesminutes

Signs of Severe Brain Damage

•Damage above brain stem.

•Rigid extension of legs and flexion of the arms, wrist, and hands towards the chest

•Damage below brain stem

•Rigid extension of all 4 extremities with arms internally rotated and pronated

Check for Signs of Skull Fracture

Battle’s SignBattle’s Sign – posterior – posterior auricular hematomaauricular hematoma

Ottorrhea Ottorrhea – CSF – CSF draining from earsdraining from ears

RhinorrheaRhinorrhea – CSF – CSF draining from nosedraining from nose

Raccoon EyesRaccoon Eyes – – periorbital ecchymosis periorbital ecchymosis resulting from blood resulting from blood leaking from anterior leaking from anterior fossa of skullfossa of skull

Thorough Evaluation Before an Athlete Is Allowed to Return to Play Primary survey Primary survey

check ABC’scheck ABC’s Secondary surveySecondary survey

H.O.P.S. protocolH.O.P.S. protocol Sideline vs Ambulance???Sideline vs Ambulance???

Rule Out More Serious Head Rule Out More Serious Head InjuriesInjuries

**Often there is no “player **Often there is no “player down” assessment**down” assessment**

Initial Assessment

Obtain information about any loss of consciousness, Obtain information about any loss of consciousness, mental confusion, and amnesiamental confusion, and amnesia Unconscious: assume a cervical spine injury exists, Unconscious: assume a cervical spine injury exists,

athlete spine boarded sent to ER; If conscious ask if he athlete spine boarded sent to ER; If conscious ask if he has any tingling, numbness, or neck pain. Also, can he has any tingling, numbness, or neck pain. Also, can he move his fingers and toes?move his fingers and toes?

Confusion: dazed, stunned, or glassy-eyed facial Confusion: dazed, stunned, or glassy-eyed facial expression; behaviors like running to the wrong huddleexpression; behaviors like running to the wrong huddle

Amnesia: test for post-traumatic amnesia by asking Amnesia: test for post-traumatic amnesia by asking what he remember about the last play; test for what he remember about the last play; test for retrograde amnesia by asking name, date, placeretrograde amnesia by asking name, date, place

Initial Assessment (con’t)

Ask athlete if “his ears’ are ringing”, he has blurry Ask athlete if “his ears’ are ringing”, he has blurry vision, or nauseavision, or nausea

Check for any facial abnormalitiesCheck for any facial abnormalities While asking questions, observe speech patterns, While asking questions, observe speech patterns,

respirations, and movement of the extremitiesrespirations, and movement of the extremities Palpate the athlete’s cervical spine and skull to Palpate the athlete’s cervical spine and skull to

rule out fracture, assuming neck injury has been rule out fracture, assuming neck injury has been ruled outruled out

Walk to sideline for further assessmentWalk to sideline for further assessment

Check Vital Signs

Increased pulse, Increased pulse, increased systolic increased systolic blood pressure, and a blood pressure, and a decreasing diastolic decreasing diastolic blood pressure blood pressure indicates increasing indicates increasing intracranial pressureintracranial pressure

A decrease in systolic A decrease in systolic bp denotes shockbp denotes shock

Symptoms of a Concussion HeadacheHeadache Nausea/vomitingNausea/vomiting DizzinessDizziness Poor balancePoor balance Sensitivity to noise/ lightSensitivity to noise/ light Ringing in the earsRinging in the ears Blurred visionBlurred vision Poor concentrationPoor concentration Memory problemsMemory problems Trouble sleepingTrouble sleeping Sleepiness / fatigueSleepiness / fatigue DepressionDepression IrritabilityIrritability LOCLOC

Only 8.9% result in a loss of Only 8.9% result in a loss of consciousness consciousness (Guskiewicz et al., 2000)(Guskiewicz et al., 2000)

Gold Standard for Concussion Assessment &

Management

The Resulting Paper

A New Concussion Assessment Tool

Recommendations from Zurich

Role of Diagnostic Testing

Recommendations from Zurich

Recommendations from Zurich

Recommendations from Zurich

Recommendations from Zurich

Part of Zurich Consensus Statement Provides a quantitative score

Scored out of 100 possible points Can be used to monitor

improvement Symptom evaluation Combines assessments for

orientation, consciousness, concentration, immediate and delayed memory, balance, and coordination into one assessment

SCAT2 Overall

Score

Daily Symptom Score Report

Computer-based neurocognitive test NFL, MLB, NBA, NHL, many major colleges Athletes administered a pretest in computer lab to establish a baseline

score and are retested in the event of a concussion Includes injury history and symptom assessment Similar to computer games where memory, concentration, motor speed, and

reaction time are assessed Takes about 30 minutes

Post-injury tests are conducted after asymptomatic Testing may be done 48 post injury in some cases

Impact scores must be “back to normal” before an athlete may RTP Pelion High School began testing in 2008

As of November 2010 almost 300 PHS athletes have been baseline-tested with post-injury tests conducted for 26 athletes sustaining a concussion

Currently 15 SC high schools test www.impacttest.com

ImPact Report #1

ImPact Report #2

ImPact Report #3

How long do symptoms linger?

(Guskiewicz, K. M. et al., 2001)

Post Concussion Syndrome

Graduated Return To Play

Stepwise protocol increasing level of exertion over several days Begins once asymptomatic and clean ImPact scores Pelion High School Protocol (based on Zurich/SCAT2)

Day 1: light aerobic exercise Ex: Bike 20 minutes & 1 mile jog

Day 2: intense exercise with sport-specific drills Day 3: Non-contact drills in practice Day 4: Full-contact practice Day 5: Return to competition

If symptoms return, go back to Day 1 after 24 hours

ESPN Outside the Lines Segment: November 24, 2010

http://search.espn.go.com/outside-the-lines-2nd-impact-syndrome/

NCAA-required Written Concussion Plan

4 Key Components Required Educate athletes & require

acknowledgement of their responsibility to report

Athletes with concussion-like symptoms must be removed and evaluated by a healthcare professional

No same day RTP Medical clearance required for RTP

Athlete Education/Awareness Video

NCAA Video: Report It, Don’t Hide It, Take Time to Recoverhttp://web1.ncaa.org/web_video/health_and_safety/concussion/concussion.html

Recommended Resources

http://www.cdc.gov/concussion/

http://www.cdc.gov/concussion/HeadsUp/youth.html

NCAA Concussion in Sport Webpage

http://www.cdc.gov/concussion/sports/index.html?source=govdelivery

A Better Helmet?

The Gladiator has padding on the outside, then hard plastic, then more padding inside to distribute the energy of impact. The face mask is mounted on flexible plastic to absorb blows.

Concussion Legislation: Zackery Lystedt Law 1st passed in Washington State. This law requires medical clearance of

youth athletes suspected of sustaining a concussion, before RTP. Requirements:

Athletes who are suspected of sustaining a concussion or head injury be removed from play. "When in doubt, sit them out"

School districts & Washington Interscholastic Activities Association (WIAA) develop information/policies on educating coaches, athletes, & parents about the nature &risk of concussion, including the dangers of RTP after a concussion/head injury.

All student athletes & parents/guardians sign an information sheet about concussion/head injury prior to participation.

Youth athletes who have been removed from play must receive written medical clearance prior to RTP from a licensed health-care provider trained in the evaluation & management of concussion.

Private, nonprofit youth sports associations wanting to use publicly owned playf-ields comply with this law.

Since passage of The Zackery Lystedt Law 8 other states, and the City of Chicago have passed similar laws.

ReferencesGuskiewicz, K.M., Weaver, N.L., Padua, D.A., Garrett, W.E. (2000). Epidemiology of concussion in collegiate and high

school football players. American Journal of Sports Medicine, 28, 643-650.

Guskiewicz, K.M., Ross S.E., Marshall, S. W. (2001). Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training. 36 (3), 263-273.

Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. (Jan 29, 2011). Trends in Concussion Incidence in HS Sports: A Prospective 11 year study. Am J Sports Med

McCorvy P, Meeuwisse W, Johnston K, Dvorak, Aubry M, Cantu R. (2009). Consensus Statement on Concussion in Sport: the 3rd International Concussion on Concussion in Sport held in Zuirch, November 2008.

McCrea, M, Kelly, J.P., Kluge, J., Ackley, B., and Randolph, C. (1997). Standardized assessment of concussion in football players. Neurology, 48, (3), 586-588.

Mueller, F.O. (2001). Catastrophic head injuries in high school and collegiate sports. Journal of Athletic Training 36, (3), 312-315.

Oliaro, S., Anderson S., and Hooker, D. (2001). Management of cerebral concussion in sports: the athletic trainer’s perspective. Journal of Athletic Training, 36, (3), 257-262.

Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1st Ed., pp.345-371). Human Kinetics. Champaign IL.

Thurman, J.D., Branche C.M., Sniezek, J.E. (1998). The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. Journal of Head Trauma Rehabilitation, 13, 1-8.

Winters, J.E. (2001). Commentary: Role of properly fitted mouthguards in prevention of sport-related concussion. Journal of Athletic Training, 36 (3), 339-341.

www.cdc.gov/concussion

www.ImPacttest.com

http://kingdevicktest.com/

www.ncaa.org/wps/portal/ncaahome?WCM_GLOBAL_CONTEXT=/ncaa/ncaa/academics+and+athletes/personal+welfare/health+and+safety/concussion

www.nfhslearn.com

http://search.espn.go.com/outside-the-lines-concussion/