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Concussion Presentation, Management, and Prevention Brandon D. Larkin, M.D. Primary Care Sports Medicine St. Peters Bone and Joint Surgery What is a concussion? A brain injury Caused by a bump or blow to the head or body, even if mild May result from a fall or from players colliding with each other or with obstacles Changes the way the brain normally works What is a concussion? Can’t see it. May be referred to as – “Ding” – “Bell rung” Signs and symptoms may be noticed – Right after the injury – Days or weeks later What is a concussion? Can occur without loss of consciousness. Can occur in any sport, during games or practices, or during unorganized activity. Statistics Up to 3.8 million sports- and recreationrelated concussions per year. 1/10 of sports-related injuries require hospitalization. 20% of high school and 40% of college football players will sustain a head injury. 2 to 4 times greater risk of recurrence. High High Risk Risk Sports Sports Football/Rugby Gymnastics Hockey Wrestling Lacrosse Equestrian Sports Martial Arts/Boxing Signs of a Concussion Appears dazed or stunned Is confused about assignment or position Forgets an instruction Is unsure of game, score, opponent Moves clumsily Signs of a Concussion Answers questions slowly Loses consciousness Shows behavior or personality changes Can’t recall events prior to hit or fall Can’t recall events after hit or fall Symptoms Reported by Athlete Headache or “pressure” in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Does not “feel right” Symptom Explanations “I’ve gone from HD to standard definition.” “I feel like I’m underwater.” “I feel one step behind the rest of the world.” What should you do when you suspect a concussion? Keep the athlete out of play. – “When in doubt, take them out.” – Should never return while symptomatic. – Concussions take time to heal. – Returning too early increases the risk of a second concussion. What should you do when you suspect a concussion? Seek medical attention right away. – Coaches and parents should not judge the severity of the injury themselves. – A professional experienced in evaluating concussion should guide return to play. Important Information for the Physician Cause of injury and force of the hit or blow to the head Any loss of consciousness Any memory loss immediately following the injury Any seizures immediately following the injury Number of previous concussions What should you do when you suspect a concussion? Open lines of communication. – Athletes should tell parents and coaches. – OK to tattle on teammates. – Parents should be advised to have child seen by a physician. – Coaches should be told if a child has had a recent concussion in any sport. What should you do when you suspect a concussion? Allow the athlete to return only with permission from a health care professional with experience in evaluating for concussion. – Emergency room physicians cannot clear an athlete to return. – Dire consequences with early return. Current Protocol Evaluation of injured athlete on the sideline or in the athletic training room. Clearance by a physician once symptoms have resolved. Graduated return to play protocol. SCAT2 Sport Concussion Assessment Tool Utilized by FIFA, IOC, International Ice Hockey Federation Combines signs, symptoms, memory, cognitive and neurologic function to guide management Sport Concussion Assessment Tool GCS GCS Scaled 3-15 13-15 MBI (Minimal Brain Injury) 9-12 Moderate Injury <8 Severe Injury Neuropsychological Testing In most cases, cognitive recovery overlaps with the time course of symptom recovery. Commonly follows symptom resolution. Suggests that NP testing should be used in RTP protocols. ImPACT is a sophisticated, research-based computer test developed to help clinicians evaluate recovery following concussion. ImPACT is a 20-minute test battery that can be administered in the pre-season for a baseline and post-injury to track a concussion. ImPACT promotes an athlete’s full recovery from injury and assists clinicians in making a safe return-to-play decision and reducing the chance of follow-up concussions. ImPACT’s technology assesses eight key neurocognitive domains. – – – – – – – – – Impulse Control Sustained Attention Visuomotor Processing Speed Visual and Verbal Memory (immediate/delayed) Working Memory Selective Attention Reaction Time Response Variability Pediatric and Adolescent Concussion Longer recovery May require modifications for cognitive rest Limit ALL activities that require concentration and attention More cautious RTP Complications Postconcussive syndrome – Prolonged symptoms Decreased memory and attention span Decreased mental processing Irritability Fatigue Sleep problems Headaches “Foggy” feeling Complications Decreased mental function – Requires testing by neuropsychologist – Repeated concussions may have a cumulative effect – May lead to permanent problems Complications Second impact syndrome – Brain swelling – Likely to result in significant brain damage and death – May be caused by a mild second injury in a symptomatic athlete Follow -up Care Follow-up Care Avoid contact activities Avoid sedating medications – Narcotics, antihistamines May note difficulty with reading, homework, and testing Ice, Tylenol, light diet What to watch for after a head injury Should not be left alone Awaken every 2-3 hours? Normal signs in the first 2 days – Fatigue and desire for extra sleep – Headache – Nausea and vomiting – Problems with thinking, concentration, attention span Seek immediate medical attention! Marked change in personality – Confusion – Irritability Worsening headache, especially with nausea and vomiting Numbness, tingling, or weakness in arms or legs, changes in breathing patterns, or seizure Eye and vision changes – – – Double vision Blurred vision Unequal-sized pupils Prevention Safety First! – Follow the rules of the game – Encourage good sportsmanship – Teach safe playing technique – Protective equipment that is properly fitted, well maintained, and worn at all times – Never return a symptomatic athlete to play Prevention Education – Talk with athletes, parents, and coaches about the dangers and potential longterm consequences of concussion – cdc.gov/concussioninyouthsports Prevention Teach athletes, parents, and coaches that it’s not smart to play with a concussion. – “Playing hurt shows strength and courage” – No pressure to return – Don’t allow athletes to persuade coaches and parents that they are “just fine” Prevention Prevent long-term problems – Repeat injury may slow recovery or increase risk of long-term problems – Don’t forget the second impact syndrome – Have players evaluated before returning – “It’s better to miss one game than the whole season.” Quiz Time! 1. A concussion is a brain injury. TRUE 2. Concussions can occur in any organized or unorganized recreational sport or activity. TRUE 3. You can’t see a concussion and some athletes may not experience and/or report symptoms until hours or days after the injury. TRUE 4. Following a coach’s rules for safety and the rules of the sport, practicing good sportsmanship at all times, and using proper sports equipment are all ways that athletes can prevent a concussion. TRUE 5. Concussions are caused by a fall or by a bump or blow to the head or body. TRUE 6. Concussion can happen even if the athlete hasn’t been knocked out or lost consciousness. TRUE 7. Nausea, headaches, sensitivity to light or noise, and difficulty concentrating are some of the symptoms of concussions. TRUE 8. Athletes who have a concussion should not return to play until they are symptom-free and have received approval from a doctor or health care professional. TRUE 9. A repeat concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems. TRUE