Concussions Traumatic Brain Injuries (TBI) in Sports Presented By: Corey Dean, MD, FAAP, FACP, CAQ Sports Medicine Team Physician for Concordia University, Saline and Ypsilanti-Lincoln High Schools IHA Physician for Neighborhood Family Health Center Associate Program Director of St. Joseph Mercy Internal Medicine Residency Program Site Medical Director of AIM Center Date: August 4, 2018
The Scope of the Concussion (TBI) Problem According to the National Council of Youth Sports, more than 44 million youth take part in sports annually. An estimated 2.8+ million concussions were reported in 2017, double what was reported in 2002. Researchers also found that 0.5 to 1.2 million concussions are not reported to health-care providers (2016). Athletes want to Stay in the Game!! 2
Sports Concussion Statistics 1 in 5 high school athletes will sustain a sports concussion during the season Every 3 minutes a sports concussion is evaluated in the Emergency Department Concussions are more likely in competition (67%) than in practice (33%) Source: Center for Disease Control Statistics, 2017 3
The Scary Statistics With multiple concussions(?#), there is a 39% increased risk in permanent neurologic disability later in life. Chronic Traumatic Encephalopathy (CTE)-like most neurodegenerative disorders, CTE can only be definitively diagnosed at autopsy. Clinical signs of CTE=intractable headaches, mood disorders, and memory loss. 5.3 Million disabled individuals Source: Center for Disease Control Statistics, 2017 4
Who Gets Concussions? Risk factors for concussion Sport and recreational activities, particularly contact and collision sports Falls Motor vehicle accidents Concussion history ADHD, depression, anxiety and learning difficulties (children) 5
Definition of a Concussion or TBI Sports related concussion is a traumatic brain injury (TBI) induced by biomechanical forces. Concussions may be caused either by a direct blow to the head, face, neck or elsewhere on the body by an impulsive force transmitted to the head. These typically result in the rapid onset of shortlived impairment of the neurologic function that resolves over time. 6
How a Concussion Occurs Concussion caused by transmitted impulsive forces to the brain Head trauma Blow to the body Sudden transfer of force to the head Angular rotational forces: important cause of injury Direct trauma to head not necessary for concussion Indirect forces transmitted to the head from an impact to the body (whiplash) can also cause concussion 7
Typical Symptoms of Concussion (TBI) 8
Red Flag Symptoms of Concussion Red flags Neck pain or tenderness Double vision Weakness or tingling/burning in arms or legs Severe or increasing headache Seizure or convulsion Loss of consciousness Deteriorating conscious state Vomiting Increasingly restless, agitated or combative 9
Michigan State Law The Michigan Concussion Law (2012) Introduced by Senators Proos, Brandenburg, Marleau, Hansen and Jones ENROLLED SENATE BILL No. 1122 Bottom line: SANCTIONS FOR NON-COMPLIANCE WITH CONCUSSION MANAGEMENT POLICY A concussed student is ineligible to return to any athletic meet or contest on the same day the concussion is sustained. A concussed student is ineligible to return to competition in a meet or contest on a subsequent day without the written authorization of an MD or DO. Consequences: Game forfeiture and MHSAA Tournament DQ 10
Emergency Room Evaluation CT and Blood Markers CT of the head is rarely needed in the evaluation of concussion Blood markers: lack of evidence for diagnosis of concussion - Serum glial fibrillary acid protein (GFAP) - a marker for brain bleed (hemorrhage) - Research on Neuron-specific enolase and apo-e gene 11
Evaluation and Management Clinical Interview Vestibular-Ocular Screening and complete neurologic exam Return to Learn and Play Neurocognitive Testing 12
Evidence Based Management Clinical diagnosis-imaging rarely needed Medications are not needed beyond NSAIDs/Tylenol (stop before return to play) Multidisciplinary personnel may be involved in the continuum of care (Athletic Trainers, Primary care physician, PT, OT, and Neurologists) Direct therapy toward specific symptoms and deficits Balance and dizziness problems: Vestibular rehabilitation Exercise intolerance: Aerobic rehabilitation Vision problems that persist 3 months: formal binocular vision rehabilitation Cognitive deficits in children: temporary modification and support of school activities may sufficiently improve Post-concussive Syndrome-Concussion > 3-4 weeks in duration; Referral to Neurologist and concussion specialty team 13
Return to Learn/Work Cognitive rest: No school or work, homework, texting, video games, or computer work for up to 48 h, plenty of sleep (9-10 hours) and increased fluids to minimize symptom exacerbation and allow symptom abatement Relative rest: Reintroduce short periods (5 15 min) of activities that do not trigger severe symptom exacerbation (stretching, walking, etc.) Homework/work at home: Longer periods of cognitive activity (20 30 min) to build stamina, avoiding severe symptom exacerbation (screens: 30:30 rule) Return to school/work: Partial day of school/work with accommodations after tolerating 1 2 cumulative hours of homework at home Ramp up to full day: With accommodations for full workload, limited makeup work Full return to school/work: Full day/workload, all work made up 14
Return to Play Stage Activity Objective 1. No activity Complete physical rest-no symptoms at rest before advance RTP 2. Light aerobic exercise Walking, swimming, aerobic exercise up to 70% max predicted HR, no resistance training 3. Sport-specific exercise Sport-specific exercise such as skating and running drills, no head impacts 4. Noncontact training drills Progress to complex drills; add resistance training 5. Full contact practice Normal practice after cleared by medical personnel Recovery Allow stretching and walking, light activity (not couch potato) Increase Heart Rate Add movement Exercise coordination, add cognitive load Restore confidence and timing, allow assessment of functional skills Return to play Normal game play Full return to play Source: Halstead, M, et al, Return to Learning Following Concussion, Pediatrics, October 2013.
Neurocognitive Testing Pros More objective measure of testing Baseline data before concussion Recovery and Return to Play can be decided more objectively Cons Gaming the system Cost Time Training need specialized training to perform reliably
Post-concussion syndrome: Resources Stephen Bloom, DO, PM&R Traumatic Brain Injury Rehabilitation St. Joseph Mercy Hospital, Reichert Health Center 5333 McAuley Drive, Suite 2009 Ypsilanti, MI 48197 (734) 712-0072 Jeff Kutcher, MD The Sports Neurology Clinic 8273 Grand River Ave, Suite 210 Brighton, MI 48114 810-522-6080 NeuroSport Clinic Domino Farms Lobby A, Suite 1000 24 Frank Lloyd Wright Dr. Ann Arbor, MI 48106 734-930-7400 17
How Can a Concussion be Prevented? Reduce or minimize activities with injury risk Primary prevention Protective equipment (sports helmets, mouth guard) Rule changes (raising body-checking age in ice hockey) Education and awareness Secondary prevention Culture change an education of athletes and athletic personnel After concussion, delay exposure until clinically recovered Second concussion soon after initial may prolong recovery 18
Community Connectedness and Education Team of Providers High School Administration and Athletic Directors Certified Athletic Trainers Coaches Parents Athletes Team Physicians Healthcare Providers Concussion Preparation PRE-SEASON - Educational Seminar - Baseline Testing - Emergency Protocol Setup - MHSAA requirements Communication with all providers on concussion plan of care 19
Family Resources Rocket Blades App 20
After the Hit Bio-psycho-social aspects of a concussion Suffering from a concussion can be frustrating, especially when athletes are temporarily removed from their social environments (i.e. sports and school). But it s important to remind the athlete that they are not alone, and that they should take time to recognize their support systems, be it parents, siblings, physicians, coaches, trainers, teammates, or friends. Stay connected. The collective goal is to get the athlete better and back to their sport (and everyday life!) symptom-free. 21
Contact Information Corey_Dean@ihacares.com St. Joseph Mercy Neighborhood Family Health Center 111 N. Huron St., Suite 200 Ypsilanti, MI 48197 Telephone: 734-547-7977 22