Concussions
Current Concepts and Future Directions
Objectives
• Be able to identify signs and symptoms of concussive
and post concussive injuries
• Understand role for neurocognitive testing in
concussion management
• Be able to follow current concussion legislation and
latest guidelines
• Develop an appropriate treatment plan for youth with
concussions
Statistics
• 10% of all contact sport athletes sustain concussions
yearly
• 63% of all concussions occur in football
• Up to 20% of football players will sustain a
concussion per season
• An athlete that who sustains a concussion is 4-6 times
more likely to sustain a second concussion
• “Bell ringers” or mild concussions account for 75%
of all concussive injuries
• Effects of concussion injuries are cumulative
Signs/Symptoms of Concussion
• How do you know?
– Historically
• On field/sideline evaluation
• Follow post concussive symptoms
– Imaging Studies (Study structure not function)
• Do not detect subtle physiological changes in the concussed brain
Signs/Symptoms of Concussion
• Dazed
• Confused about play
• Answers questions
slowly
• Personality/Behavior
change
• Anterograde amnesia
• Loss of consciousness
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Headache
Nausea
Balance problems
Double vision
Photosensitivity
Feeling Sluggish
Feeling foggy
Change in sleep pattern
Cognitive changes
Sideline Evaluation
• SCAT-2
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Physical Signs
Glasgow Coma Scale
Maddock’s Questions
Cognitive Assessment
Balance Examination
Coordination
Examination
Risks of Premature Return To Play
• No athlete should return to play while experiencing
symptoms of concussion!
• Why? – risk of Second Impact Syndrome
Second Impact Syndrome
• Occurs in athletes with history of a prior concussion
– Second impact can be relatively minor
– Can occur up to 14 days after injury
– Athlete return to play before resolution of 1st concussion
symptoms
• Catastrophic increase in intracranial pressure
– Vasomotor paralysis, edema, massive swelling, herniation,
death
• Most often occurs in athletes < 21 yrs old
– Appears to be due to neuro-chemical processes in the
developing brain
Post Concussive Syndrome
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Decreased Processing Speed
Short Term Memory Impairment
Concentration Deficit
Irritability/Depression
Fatigue/Sleep Disturbance
General Feeling of “Fogginess”
Academic Difficulties
How Do We Know When An Athlete
Can Return?
• Physical Exam
– Balance
– Cranial Nerves
– Coordination
• Neurocognitive Exam
– ImPACT
Clinical Assessment Tool
• Neurocognitive testing
– Pre-season Baseline
– Post Injury Testing
• ImPACT Test – clinically validated objective
measure
Impact Test
• Computer Test – Developed by clinical researchers at
the University of Pittsburgh Medical Center (UPMC)
• Developed to allow for an objective assessment of
concussion and recovery
• Baseline testing allows for individual differences in
cognitive ability and symptom reporting
• Provides a test that allows for collaboration between
athletic trainers, coaches, physicians, and
neuropsychologists
Current Users
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NFL
NHL
MLB
MLS
CHL
Rapid City Rush
Many colleges (SDSU)
Many high schools (STM, RC Stevens, RC Central,
Sturgis Brown)
What Does Impact Measure?
What Does Impact Measure?
• Demographic/Concussion Questionaire
• Concussion Symptom Scale (21 item scale)
• Neurocognitive Measures
– Memory, working memory, attention, reaction time, mental
speed, verbal memory, visual memory, reaction time,
processing speed
• Detailed clinical report
ImPACT Test Examples
ImPACT Test Report
Frequently Asked Questions
• Data is confidential
• Athletes baseline screens performed in schools
computer lab
• Data stored online – no server/equipment needed at
the school
• Sideline assessment by trainer, post concussion test
with 24-48 hours, then tested once a week until score
normalizes
• Return to play after evaluation by physician
If Used Correctly, ImPACT will …
• Help determine severity of concussion
• Provide valuable information to the athlete, parents,
athletic trainers, and physicians
• Provide information on academic deficits associated
with concussion
• Promote safe return to play
• Reduce liability for school districts
• Impact will not
– Prevent a concussion from happening
– Eliminate the risk of concussion
Return to Play
Return to Play
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Remove from play/practice/event
Sideline Evaluation – SCAT2
If indicated – physician/Emergency Room
Monitor post-concussive symptoms
Once symptoms resolved –
– Begin gradual return to play ladder
– Follow ImPACT test Scores
• Step-wise return to play
– No activity - rest until asymptomatic
– Light aerobic exercise
– Sport-specific training
– Non-contact drills
– Full-contact drills
– Game play
How Many Concussions Per Year?
• Cantu rules – 2 severe or 3 total concussions in a
calendar year
• If 3 concussions = sit out x 1 year or longer
How Many Concussions Per Career?
• Chronic Traumatic Encephalopathy (CTE)
– Degenerative Process
– Deposition of Tau Protein (stains dark)
• Boston University Center for the Study of Traumatic
Encephalopathy
Future Directions
New Diagnostic Tests
• U.S. Army, in partnership with the Alachua, Fla.based
company Banyan Biomarker
• Preliminary test (34 subjects), second phase 1200
patients
• Test identifies substances that spill into the blood from
injured brain tissue
– SBDP145 and SBDP120 proteins appear to enter the blood as a
result of damage to brain cell
• Severe brain injury patients had levels of a biomarker
called UCH-L1 that were 16 times the level found in
patients without brain injury
Neuroproteomics: A Biochemical Means to Discriminate the Extent and Modality
of Brain Injury. Ottens AK, Bustamante L, Golden EC, Yao C, Hayes RL, Wang
KK, Tortella FC, Dave JR. J Neurotrauma. 2010 Aug 10.
Functional MRI
• Purdue engineering students
• Collecting control data for concussion project
• During season/multiple hits to head lead to decline in
activity in the dorsolateral prefrontal cortex – area
responsible for visual memory
Helmets
• Studies looking at biomechanical properties of
concussions
• Accelerometers in helmets to detect g-forces in
athletes when they sustain concussion
• Inconsistent findings
– Occasionally expected threshold reached and no
concussion occurs
– Linear vs rotational forces
– Expect that hits causing greater than 80Gs would cause
concussion (heading soccer ball 20Gs)
Helmets
- Helmets intended to
prevent skull fractures
- No independent evidence
based study showing any
helmet type can prevent
concussions
Helmets
Riddell - $419.99
Xenith - $319.00
Cascade M11 Hockey Helmet
$149.00
Coaching
• Eliminate Hitting with head down
• Change in “toughness culture”
• Emphasis on proper technique
South Dakota Senate Bill 149
• Included are South Dakota State Activities
Association Coaches/Athletes
• A concussion information sheet will need to be
signed and returned prior to participation
• Education and training for coaches/parents/athletes
• Key Safety Components:
– Athlete is removed from play/practice as soon as they show
signs of concussion
– All signs/symptoms of concussion must have resolved
– Evaluation by licensed/certified health care provider
– Written clearance provided by health care provider
Rule Changes
Rule Changes
• NHL – Rule 48 – Illegal check to the Head A lateral or blind side hit to an opponent
where the head is targeted and/or the principal
point of contact is not permitted.
- NFL - New rules prohibit a player from
launching himself off the ground and using his
helmet to strike a player in a defenseless posture
in the head or neck. When a player loses his
helmet, the play is immediately whistled dead.
Education
• National Federation of High Schools
• Web based training program:
– Free
– 20 min training program
– www.nfhslearn.com/electiveDetail.aspx?courseID=15000
Return to Play
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Remove from play/practice/event
Sideline Evaluation – SCAT2
If indicated – physician/Emergency Room
Monitor post-concussive symptoms
Once symptoms resolved –
– Begin gradual return to play ladder
– Follow ImPACT test Scores
• Step-wise return to play
– No activity - rest until asymptomatic
– Light aerobic exercise
– Sport-specific training
– Non-contact drills
– Full-contact drills
– Game play