Concussion Facts & Stats

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1 Jeffrey Liang, MD

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3 Concussion Facts & Stats 10% of all contact sport athletes sustain concussions yearly. 63% of all concussions occur in football. Estimated that up to 20% of football players will sustain a concussion per season.

4 Concussion Facts & Stats An athlete who sustains a concussion is 4-6 times more likely to sustain a second concussion. Effects of concussions are cumulative in athletes who return to play prior to complete recovery. The best way to prevent problems with concussions is to manage them effectively when they occur.

5 Concussion Webster Dictionary: Pronunciation: kən-'kŭsh-ən Function: noun a:a stunning, damaging, or shattering effect from a hard blow; especially : a jarring injury of the brain resulting in disturbance of cerebral function b:a hard blow or collision Source:

6 Concussion Bell Ringer Dinger Mild Traumatic Brain Injury A trauma induced alteration in mental status that may or may not be accompanied by a loss of consciousness

7 Concussion (As defined by the Second International Conference on Concussion in Sport, Prague 2004) Sports concussion is defined as a complex pathophysiological process affecting the brain, induce by traumatic biomechanical forces. Several common features that incorporate clinical pathological, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head. 2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury. 4. Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness (LOC). Resolution of the clinical and cognitive symptoms typically follows a sequential course. 5. Concussion is typically associated with grossly normal structural neuroimaging studies. Sources: Course of neurological Surgeons, Committee on Head Injury Nomenclature: Glossary of Head Injury. (1966). Clinical Neurosurgery, 12, Johnson, K.N., McCrory P., Mohtadi, N.G., et al. (2001). Evidence-based review of sport-related concussion: clinical science. Clinical Journal of Sport Medicine, 11,

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10 On-Field Signs / Symptoms of Concussion Concussion Signs Appears dazed Confused about play Answers questions slowly Personality / behavior change Retrograde amnesia Forgets play after hit Anterograde amnesia Loss of consciousness Concussion Symptoms Headache Nausea Balance problems Double vision Photosensitivity Feeling sluggish Feeling foggy Change in sleep pattern Cognitive changes

11 Concussion Severity Grading scales Loss of consciousness Amnesia Simple vs. Complex

12 Later Signs of Concussion Decreased Processing Speed Short-Term Memory Impairment Concentration Deficit Irritability / Depression Fatigue / Sleep Disturbance General Feeling of Fogginess Academic Difficulties

13 Second Impact Syndrome Occurs in athletes with prior concussion following relatively minor second impact Second impact has been shown to occur up to 14 days post-injury Athlete returns to competition before resolution of symptoms Catastrophic increase in intracranial pressure Vasomotor paralysis, edema, massive swelling, herniation, death Most often occurs in athletes <21 years old Neuro-chemical processes appear to differ in developing brain

14 Second Impact Syndrome

15 Sports-Related Concussion: Topics of Concern Return to play Current guidelines are not data driven. CT and MRI insensitive to subtleties of injury. CAT scans and standard MRI scans do not indicate if there are physiological changes in the concussed brain since these instruments study structure and not FUNCTION. Self-report determines management directives. Variability in physician recommendations.

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17 Currently Available Computer Based Testing Programs Cogsport Headminders (CRI) ANAM ImPACT

18 ImPACT: A Tool for Evaluating Concussion (Immediate Post-Concussion Assessment and Cognitive Testing) Computerized test developed by clinical researchers at the University of Pittsburg Medical Center (UPMC) Developed to allow for a more objective assessment of concussion and recovery Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing Provides a common metric which allows for effective collaboration between athletic trainers, coaches, physicians, and neuropsychologists in concussion management Utilized throughout professional and amateur sports across the country and internationally

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20 Current Users of ImPACT Computer-Based Testing 22 NFL Teams IRL, F1, CHAMP Car NASCAR USA Olympic Hockey USA Hockey 60 Neuropsych Clinics 60 Sports Medicine Clinics in US Pro Boxing USA Ski Team USA Soccer Junior Team Ontario Hockey League Australian Rugby New Zealand Rugby South African Rugby World Cup Soccer 150+ Universities in US 500+ High Schools in US Statewide Program in Nevada High Schools Statewide Initiatives underway in CT, WA, PA

21 Examining Relevance of Bell Ringers in High School Athletes 64 athletes with a mild concussion Two groups compared in terms of outcome Athletes with < 5 minutes of signs / symptoms Athletes with 5-15 minutes of signs / symptoms No athletes in sample sustained LOC All athletes met AAN Grade 1 criteria No athlete returned to contest ImPACT evaluation obtained a baseline, day 2, day 4, day 7 post-injury Sources: Lovell, Collins, Iverson, Podell, Cantu, Fu. (2003). Journal of Neurosurgery. 98, Lovell, Collins, Iverson, Johnston, Bradley. (2004). American Journal of Sports Medicine. 32,

22 ImPACT Memory Composite Scores Brief vs. Prolonged On-Field Mental Status Changes 5-15 min < 5 min NS N = 64 High School Athletes P <.02 P <.01 P < P <.003 P < Baseline Day 2 Day 4 Day 7 ImPACT Memory-Percent Correct Sources: Lovell, Collins, Iverson, Podell, Cantu, Fu. (2003). Journal of Neurosurgery. 98, Lovell, Collins, Iverson, Johnston, Bradley. (2004). American Journal of Sports Medicine. 32,

23 ImPACT Symptom Scale Scores Brief vs. Prolonged On-Field Mental Status Changes 5-15 min < 5 min N = 64 High School Athletes Baseline Day 2 Day 4 Day 7 Sources: Lovell, Collins, Iverson, Podell, Cantu, Fu. (2003). Journal of Neurosurgery. 98, Lovell, Collins, Iverson, Johnston, Bradley. (2004). American Journal of Sports Medicine. 32,

24 Steelers Pre-Game Show

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26 Return to Play Protocol Athletes should not return to play the same day of injury. When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. For example: 1. Rest until asymptomatic (physical and mental rest) 2. Light aerobic exercise (e.g. stationary bike) 3. Sport-specific exercise 4. Non-contact training drills (start light resistance training) 5. Full contact training after medical clearance 6. Return to competition (game play) Source: McCrory, P., Johnson, K., Meeuwisse, W., et al. (2005). Clinical Journal of Sport Medicine. 15,

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29 Thank You!!