Mark J. Harary, MD Primary Care Sports Medicine St Charles Orthopedics, LLP

Mark J. Harary, MD Primary Care Sports Medicine St Charles Orthopedics, LLP

Facts, Definitions, etc Appropriate Recognition Comprehensive Management Treatment Consequences of Concussions Neurocognitive Testing Return to Play Progression

1.5-4 million sports related concussions occur each year Concussions from non-sports related injuries are also fairly common Over 60% of concussions in high school sports are from football Soccer is the leading sport for concussions in high school females High school athletes who sustain a concussion are 3x more likely to sustain a second concussion If not appropriately treated, a patient who sustains concussion is 4-6 times more likely to sustain a second Cumulative effects

A concussion is a Mild Traumatic Brain Injury. Concussus: derived from the latin to shake violently Concussions may range from bell ringers to prolonged loss of consciousness. Loss of consciousness is not diagnostic or prognostic of concussion Concussion typically results in the rapid onset of short-lived impairment of neurologic function. Concussion results in a functional disturbance rather than a structural injury.

The invisible injury Concussions common and more serious than previously recognized Old treatment guidelines Mild initial symptoms may lead to long lasting symptoms Media exposure High exposure athletes have played through concussions and return to play quickly after concussions Youth athletes are more at risk for bad outcomes than their professional counterparts given their vulnerable/developing brains

Signs Observed Appears dazed Confused about play Answers question slowly Forgets plays, score, opponent Personality change Retrograde amnesia Anterograde amnesia Loss of consciousness Symptoms Reported Headache Nausea Balance problems Double/fuzzy vision Sensitivity to noise/light Feeling sluggish Feeling foggy Change in sleep pattern Concentration/memory issues

Not all concussions are associated with LOC. Only about 10% Not all concussions present with headache. About 85% Concussions cannot be diagnosed by an X-ray, CT scan or MRI Concussion symptoms are secondary to a SUPPLY/DEMAND issue Energy/Metabolic Crisis secondary to decreased blood flow and increased demand for glucose

American Academy of Neurology (1997) Graded concussions Vienna Guidelines (2001) Prague Guidelines (2004) Simple versus Complex Zurich Guidelines (2008) No same day RTP No simple versus complex No grading scheme All concussions should be TREATED

*Education Program* (Baseline Neurocognitive Testing) Appropriate recognition Appropriate ER evaluations Appropriate Treatment with Follow-up visits Graduated Return to Activity

EDUCATION, EDUCATION, EDUCATION That is why we are here!! Coaching staff, referees, parents, athletes, medical providers should be able to recognize a concussion Appropriate preventive measures in sports No tolerance on poor technique (ie, spear tackling) Injured players MUST have a return to play assessment with documentation by a medical practitioner well versed in concussion management

WEAR THEM! There is no concussion helmet or mouthguard All helmets should be refurbished after the season and stamped with approval Before season, all helmets should be fit to athlete there should be no movement with head movement This should be done again if the athlete has a change in his hairstyle Before each wear, helmets should be checked for inflated bladder, cheek pad placement Mouthguards should be molded to the patient and NOT cut for comfort.

Patients with head injury should be seen in the ER if there is loss of consciousness or if there are any focal neurologic symptoms Rule out more serious intracranial pathology CT scan MRI No one should get a clearance note from the ER.

WHEN IN DOUBT, SIT THEM OUT! If a player is removed from play for concussive symptoms with or without LOC No return to play Take away the athlete s helmet, cleat, etc Continue to monitor for worsening symptoms An adult must be responsible for following the athlete Decision whether to go to ER

Athlete s with concerning symptoms should be taken out of play IMMEDIATELY. There should be no same day return to play in the adolescent population ** Avoid re-injury ** Patient should be seen by a medical provider trained in concussion management. REST Cognitive and physical Return to play protocol 6 step protocol to return to play is much more conservative in youth than in older athletes.

Increased sleep Good sleep hygiene Low threshold to start melatonin Take naps when available No sports, gym, cardiovascular conditioning, strength training

May need to be out of school/work to allow for appropriate rest Reduced course/work load Accommodations Minimal TV, computers, texting, video gaming, etc Avoid loud noise, bright lights, vibration, etc No concerts, no gigs

Symptoms generally resolve completely in 7-10 days, but may be longer in youth and athletes with modifying risk factors (ie, ADHD, LD, migraine history, history of untreated concussion) If not treated properly, the patient is at increased risk of long term effects Post Concussive Syndrome Second Impact Syndrome Chronic Traumatic Encephalopathy [CTE] Emotional Problems ADHD/LD??

100 90 80 70 60 50 40 30 20 10 0 WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+ All Athletes No Previous Concussions 1 or More Previous Concussions N=134 High School athletes Collins et al., 2006, Neurosurgery

It s the law July 2012 NY is the 33 rd state to pass such a law 1) Permission slips 2) Immediate removal from participation 3) Medical clearance before RTP Long term effects PCS Second impact syndrome CTE ADHD/LD Depression Anxiety

Chronic headaches Fatigue Sleep difficulties Personality changes (e.g. increased irritability, emotionality) Sensitivity to light or noise Dizziness when standing quickly Deficits in short-term memory, problem solving and general academic functioning

A relatively minor second injury/impact that occurs prior to the resolution of a previous concussive event. Can result in devastating/catastrophic increase in intracranial pressure Vasomotor paralysis, edema, massive swelling, brain herniation, death This catastrophic demise is very rapid and carries a 50% mortality rate along with almost a 100% morbidity rate Most common in the high school population secondary to poor auto-regulatory control of intracranial blood flow Approximately 50 high school students have died since 1997

Punch-drunk The condition, which occurs in people who have suffered multiple concussions or subconcussive blows. Thought to be caused by the loss of neurons, scarring of brain tissue, collection of senile plaques, diffuse axonal injury, neurofibrillary tangles and damage to the cerebellum. Parkinsonian movements, signs of dementia, speech problems, paranoia, etc.

Neurocognitive Testing/Evaluation Evaluates attention/concentration, memory/recall, processing speed, and reaction time Ideal to have baseline vs. post-concussive information Pen and Paper versions are time consuming and expensive Computerized models have simplified this ImPACT, CogState, HeadMinder Testing done in 30 minutes or less Able to test large numbers of athletes to obtain baselines Results available as soon as testing is over

*Education *Baseline Testing * Post-Injury Testing * Clinical Eval Asymptomatic at rest Concussion * Sideline Eval * ER Eval 0 1-3 Days 3+ Days * F/u Clinical RTP progression

1. Rest until asymptomatic (physical, mental) 2. Light to moderate aerobic activities with no weight training Goal is to increase HR 3.Increased weight training and aerobic activities. Add plyometrics and balance/proprioceptive challenge. Sports-specific, aggressive non-contact training Goal is intense, noncontact activity 4. Full contact training Goal is to reintegrate into full contact practice 5. Return to contact competition (game play) Goal is to return to competition Each stage is at least 24 hrs and return to previous stage if symptoms reoccur