Lecture 16: Sport Related Concussions

What are the 13 Rs of concussions?

Recognize - What is a concussion Remove –Player from competition Refer – to those with specialized knowledge

Re-evaluate– Follow-up Assessment

Rest & Exercise -Strict rest not better Rehabilitate – Neck pain and headaches Recover – Symptoms and signs

Return to Learn/Play Reconsider – Long-term Effects

Residual Effects- Second Impact Retire – Education and Alternatives Refine – Parasport/Pediatrics Reduce – Rules/Training

What is a concussion?

Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities.*

What does a concussion initiate?

Initiates a neurotransmitter and metabolic cascade

- possible axonal injury, blood flow change and inflammation affecting the brain.

When may signs and symptoms present?

Symptoms and signs may present immediately, or evolve over minutes or hours

- MOI is your first sign

- commonly resolve within days, but may be prolonged.

What is the use of CT or MRI and Concussions?

No abnormality is seen on standard structural neuroimaging studies such as CT or MRI

What are the physiological changes with a concussion?

• Injury promotes release of Glutamate causing an efflux of K+

• Causes ↑ glycolytic activity at the onset of injury which lasts several hours

• ↓cerebral blood flow and ↑ glucose demand leads to cellular energy crisis • This can lead to neuronal injury/death • Dysregulation may persist up to 10 days • Unrestricted Ca+ causes excitotoxic environment...triggers/maintains inflammation

• Athletes displaying few to no signs/symptoms may be vulnerable to brain injury for some time due to the ongoing impaired glucose metabolism.

What is second Impact Syndrome?

• Occurs primarily in young athletes and there are uncertainties about its pathophysiology

• Many clinicians never encounter a case, with some experts doubting its existence.

• Usually after previous, recent brain injury(s) (concussion) followed by a second brain injury

What is there to know about swelling and second impact syndrome?

• The second injury is usually more severe and can lead to brain swelling

• It is not known why the brain swelling occurs so rapidly and profoundly.

• Hypothesized to be of acute loss of autoregulation and alteration of the blood-brain barrier.

• This causes major neurological decline. • May be fatal

What happens in most cases of Second Impact Syndrome?

Most cases die, but some survive because of emergency neurosurgical decompression providing extra space for the swollen brain

• SIS is preventable by preventing the second blow to the brain.

What are sports related concussion caused by?

SRC is caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain

"60% from head impacts"

What are concussion impacts like?

- Impacts of 100-190 g

- 20 mph with deceleration of 14 mph

- No agreed-on Biomechanical threshold for injury (60-168g)

- Force does NOT factor in on symptom severity

What is the inherent design of helmets?

The inherent material design of helmets are ideal for preventing high energy impact forces associated with catastrophic head injuries, but less ideal for reducing the lower impact/rotational forces to which concussions are typically related

What is the evidence of SRC and Helmets?

The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in many sports.

- There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in skiing/snowboarding

- 28% reduction in concussion rate with mouthguard use in ice hockey across all age groups

• mouthguards should be mandated in child and adolescent ice hockey and supported at all levels

- We need to continue to evaluate headgear in non-helmeted contact and collision sport to help inform headgear recommendations in the future

Are concussions getting worse?

• Over 30 concussion severity scales have been presented

• None have been scientifically validated

• No such thing as a minor, severe, Grade 1,2 or 3

• Reason time missed is getting longer is because we are getting smarter with how we deal with them

What is the Acute medical management of SRC?

Assuming no issues with ABCs/Unconscious, C-spine or other significant injury What we know

• The appropriate disposition of the player must be determined in a timely manner.

• Standard orientation questions (eg, time, place, person) used in isolation, are unreliable in the sporting situation when compared with memory assessment. • Diagnosis of concussion should be based on a combination of subjective symptom reports and clinical examination

What are the observable signs for immediate removal from game?

• Actual/suspect Loss of consciousness

• Seizure

• Tonic posturing

• Ataxia (muscle coordination/control)

• Poor balance

• Confusion

• Behavioral Changes

• Amnesia

What does the multiodal evaluation for SRC include?

- Symptoms

- Physical Signs

- Balance Impairment

- Balance Impairment

- Cognitive impairment

What are the symptoms of SRC?

- Somatic, Cognitive and Emotional

- Headache Fog and Mood Swings

What are Physical signs of SRC?

LOC, Amnesia, Neurological deficits. Watch out for Red Flags

What are balance impairments of SRC?

Modified BESS double leg, tandem stance and single leg

What are gait changes of SRC?

Gait unsteadiness/ slowed Tested using Tandem Gait

What are cogitive impairments of SRC?

Immediate memory- word lists Concentration- Digits backwards and months in reverse order

What are some sideline tests?

modified balance error scoring system (mBESS); vestibular/ocular motor screening (VOMS), neurocognitive testing (SAC), and post-concussion symptom scale (PCSS).

• NONE of these have demonstrated effectiveness in isolation at the necessary level to replace the clinical examination as the diagnostic standard

• A combination of symptom evaluation, postural control on a firm surface, and neurocognitive screening offered the best overall performance in quantifying acute post-concussion functioning.

What are the common symptoms in high school/university?

• Headache (78.5%)

• Fatigue (69.2%)

• Feeling slowed down (67%)

• Difficulty concentrating (66%) • "Fogginess" (62.3%) • Dizziness (61%)

• Light sensitivity (53%)

• Visual blurring or double vision (29.6%)

What are the common symptoms in Children 7-13?

• Headaches, fatigue and dizziness are especially common in youth

• No data available with regard to how the early signs and symptoms of concussion differ in younger children as compared with older children or adolescents.

What is the SCAT 6/Child SCAT 6?

• The SCAT6 (ChildSCAT6) currently represents the most current and rigorously developed instrument available for sideline assessment.

• Be consistent. Use the script

• SAC immediate and delayed word recall lists include only a 10 word list now

• Months backwards is now timed

• Optional duel-task test and balance on foam

• Neuro screen flow chart now included.

• SCAT6 utility appears have optimal utility in the first 72 hours up to 1 week

• If greater than 7 days- use the SCOAT (Sport Concussion Office Assessment Tool)

What do you need to remember?

• Remember to re- evaluate

• Athlete should not be left alone after the injury.

• Send the athlete home with a responsible adult

• Serial monitoring for deterioration/Red flags is essential over the initial few hours after injury.

• Red Flag = Immediate Emergency Medical Referral

What are Red Flags in SRC?

• Neck pain or tenderness

• Seizure or convulsion

• Double vision

• Loss of consciousness

• Weakness or tingling/burning in more than 1 arm or in the legs

• Deteriorating conscious state

• Vomiting

• Severe or increasing headache • Increasingly restless, agitated or combative

• GCS <15 • Visible deformity of the skull

What is the evolving and delayed onset symptoms of SRC?

are well documented and highlight the need to consider follow-up evaluation after a suspected SRC regardless of a negative sideline screening test or normal early evaluation.

• The recognition of suspected SRC is therefore best approached using multimodel testing guided via expert consensus.

• The SCAT6 (ChildSCAT6) currently represents the most recent and rigorously developed instrument available for sideline assessment.

What is is SRC and Pediatrics (Child 5-12 and Adolescents 13-18)?

• Brain development in young athletes necessitate paradigm shifts

• More focus needed on prevention

• Rule changes and contact limitations have decreased concussion rates

• Use Child SCAT6 8-12 YOs and SCAT6 for 13+

• Baseline testing is of limited - use for this age group

• NEVER RETURN TO PLAY ON SAME DAY!

• Full return to learn is recommended before full return to sport, but the two can progress in parallel

- When in doubt , sit them out!

What is SRC and high school athletes?

• The ''ding'' or "very mild" concussion was examined in high school athletes aged 13 to 17 years.

• High school athletes with <15 minutes of on-field symptoms required at least 7 days before full neurocognitive and symptom recovery.

• These findings suggest that all high school aged athletes displaying even short-term symptoms be removed from play.

What is ParaSport and SRC?

• Para athlete population estimated at 15-25% of global population • Commonly used SRC tools are not validated in this population

1. This population may benefit from baseline testing, due to potential varying nature of presentation

2. Those with history of CNS injury (CP, Stroke, etc) may require longer initial rest rest period, following concussion 3. Testing may require use of alternate or specialized equipment (UBE)

4. RTP must be tailored to include the individual's adaptive equipment

What is Return to Learn/ Play and SRC?

• Each person must be treated individually

• 93% of all ages returned to learn with no additional supports by 10 days

• Unrestricted return to sport typically occurs within 1 month in children, adolescents and adults

What is a safe and effective return to play?

• Athlete - Everything based on their subjective reports!

• Must be honest and forthcoming

• Parent - Will often be a liaison between medical team and sport team/school

• Medical - Voice of reason - Critical Eye - Communicate RTP stages

• Coach - Practice planning -Team culture

Must work together to idealize environment

What is rest and Exercise for SRC?

• Recommending strict rest until complete recovery is NOT beneficial

• Recommend early return to PA as tolerated

• Reduced screen time for the first 48 hours is warranted

• PA can advance provided there is no more than mild (2 point increase/10) and brief (<1 hour) exacerbation of their concussion related symptoms

What are the stages of RTP?

Must have 24 hours symptom free between stages. If symptoms return, go back to the previous stage after 24 hours symptom free

What are the practical sideline tips?

• Know your athletes •Take time to find out their daily baseline

• Ask how they are

• Be prepared

• educate

• Assess

• Communicate

• Idealize the environment

• Remember that concussions may evolve and delayed-onset symptoms of SRC are well documented. There may be need for re-evaluation