Concussion. Concussion is a disturbance of brain function caused by a direct or indirect force to the head.

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2 Concussion Concussion is a disturbance of brain function caused by a direct or indirect force to the head. Disturbances of brain tissue is largely related to neurometabolic dysfunction rather then structural injuries. Concussions are functional injuries, not structural.

3 Incidence Most common in male adolescents. CDC estimates there are 3.8 million sports and recreational concussions annually in the United States. Risk is 4-6X higher with players who have experienced a previous concussion.

4 Participation in Football NFL 1,800 Most Research College 54,000 High School > 1,000,000 Most Participation Youth Unknown

5 Most Coverage Least Coverage Elite Sports Youth Sports

6 Catastrophic Head Injuries In the past 10 years catastrophic head injuries in high school and college football; 59% had a history of previous concussions. 71% had a previous concussion the in the same season. 39% where playing with residual symptoms for a prior concussion. Herring, M.D.

7 Brain Trauma The Skull protects the brain against trauma, however it does not absorb the outside forces. During a concussion the brain rotates and twists inside the skull which results in tissue damage.

8 Brain MRI

9 There are Two Primary Mechanisms Linear or deceleration forces such as a fall to the ground and the head hits the ground. Rotational forces occurs from a hit from the side. The brain rotates and twists inside the skull causing twisting and tearing of the the axons (brain tissue) ** Most damaging Helmets do a great job at preventing skull fractures or focal injuries from direct blow. They do not slow acceleration of the brain.

10 Diffuse Tensor Imaging (DTI) DTI is a type of imaging that uses MRI to analyze the fiber tracks of the brain and correlate the findings with neurocognitive findings.

11 DTI Image

12 Removing an Athlete From Play If there is doubt, they are out. If you pulled they out take their helmet and put it out of their reach. Re evaluate the athlete every 15 minutes. Any progression of symptoms send to ER. Provide parent with written instructions which should include, Follow up with their heath care provider or ER, monitoring the athlete and what they should look for, and a signature. Home care should include rest and avoidance to meds unless approved by their MD.

13 Home Care Avoidance to medication unless approved by their MD. Rest (Does not have to be bed rest). Resume daily activities as tolerated Avoid activities that increase symptoms which can include school work

14 Special Testing Concussions are function injuries, not structural. Therefore CT s, MRI s and X-rays have little value to diagnose. They are helpful to rule out bleeds such as subdural and epidural hematomas. Future is hopeful with new testing such as DTI

15 Post Concussion Syndrome Lingering symptoms and continued cognitive deficit following a concussion. Usually reported as fatigue (sluggish or hazy / Just do not feel right), headaches, equilibrium disturbances, difficulty concentrating, intolerance to bright lights and noise, difficulty with sleep, vision difficulties, nausea and or vomiting. May occur for weeks to months after the initial injury.

16 Second Impact Syndrome All the guidelines focus on the question of when it is safe for an athlete to return to play following a concussion. There are several risk associated with premature return, the most serious is second impact syndrome. When an a second insult to the brain occurs before the first is completely resolved ( even a very minor hit ) can result in disruption of the auto regulation of the brains blood supply. Vascular engorgement can occur resulting in an increased intracranial pressure forcing brain herniation which almost always results in death. Developing brain are most at risk. (MC < 21 yrs)

17 Subdural Hematoma A cerebral contusion resulting in a venous bleed. Blood gathers within the meningeal layers which creates and increased intracranial pressure. The pressure will cause damage to the brain tissue. Treatment is surgical decompression.

18 Subdural Hematoma

19 Epidural Hematoma A cerebral contusion resulting in an arterial bleed in which the blood gathers between the Dura and the skull. As with an subdural the result is an increased intracranial pressure resulting in brain tissue damage. Treatment is surgical decompression.

20 Long Term Affects Chronic traumatic encephalopathy (CTE) A progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injuries. Memory loss, violent outbursts, mood disturbances, cognitive decline, eventual movement dysfunctions.

21 Concussion Guidelines Management of concussions including determination of when an athlete can return to play remains a controversy. There are over 16 guidelines, and over the past few years the SCAT 2 assessment has been the tool of choice.

22 Return to Play (RTP) An athlete should never be allowed to return to play if concussion symptoms are still present. If an athlete is removed from a game it is good practice to take their helmet so they do no return accidently either on their part or the coaches. As a coach you need a letter of approval to return from their heath care provider. Neurocogative testing return to base line. Test them and make sure they are symptom free both with and without exertion.

23 Recovery from Concussion What we do know is that recovery from concussions varies with age. The brain developed differently at various ages. (4-7, 8-12, 13-18). Youth take longer then high school and HS take longer then college.

24 Neuropsychological Testing and Management ImPact Vital signs Balance Error Scoring Test (BESS) Standardized Assessment of Concussion (SAC) Sports concussion assessment tool (SCAT2)

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