UCSC
Salisbury
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
What’s New In Concussions:
Prevention and Management
ACHA Annual Meeting,
San Francisco
May 2009
Page 1
UCSC
Salisbury
Presenters
Dr. James MacDonald, MD, FAAFP
University of California – Santa Cruz
Santa Cruz, CA
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Dr. Lori Dewald, EdD, ATC, CHES, F-AAHE
Salisbury University
Salisbury, MD
Page 2
UCSC
Salisbury
Background….UCSC
•Our clinic
•Our student population
•Mostly Young
•Mostly Healthy
•Very Active!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 3
UCSC
Salisbury
UCSC Division III Sports
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
men’s tennis
women’s tennis
men’s basketball
women’s basketball
men’s soccer
women’s soccer
men’s volleyball
women’s volleyball
men’s water polo
women’s water polo
women’s cross-country
women’s golf
men’s and women’s swimming and diving
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UCSC
Salisbury
…..And More
Club Sports
 Rugby, Ultimate, Baseball, Lacrosse,
Cheerleading, Dance and more
Activities and Classes
 Jiu Jitsu, Capoeira, Biking, Lifting, Swimming,
Skating, Snowboarding, Surfing……….
Our Campus!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 5
UCSC
Salisbury
Background….Salisbury University
8000 students.
One of the most successful Division III athletic
departments in the country.
Multiple national championships in multiple
sports annually.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 6
UCSC
Salisbury
Salisbury University*
NCAA Division III
Our sports
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Women’s Field Hockey
Women’s Soccer
Women’s Cross Country
Women’s Basketball
Women’s Lacrosse
Women’s Softball
Women’s Track/Field
Women’s Tennis
Women’s Swimming
Women’s Volleyball
Men’s Football
Men’s Soccer
Men’s Cross Country
Men’s Basketball
Men’s Lacrosse
Men’s Baseball
Men’s Track/Field
Men’s Tennis
Men’s Swimming
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UCSC
Salisbury
Athletics does not deal with…
Club sports
Other activities (i.e. dancers, theatre, etc.)
These are dealt with by the student health center!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 8
UCSC
Salisbury
What’s New In Concussion
A move away from consensus “grading” to a
binary diagnosis scheme: simple vs. complex
A move away from arbitrary days, and a move
toward symptom-based protocol for return to play
A move toward more objective assessment of
recovery (quantifying symptoms,
neuropsychological performance, balance)
Increasing research!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 9
UCSC
Salisbury
Ever Increasing Research and
Awareness
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 10
UCSC
Salisbury
Brain Anatomy
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 11
UCSC
Salisbury
Concussion—A Definition
Diffuse, reversible brain injury associated with
trauma. Functional not structural!!
Caused by inertial forces from trauma that lead to
shear strain.
Concussion is a metabolic injury: injury results in
increased energy demands as repair begins.
Hallmark: Mental Status changes, including
confusion, amnesia, even loss of consciousness.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 12
UCSC
Salisbury
Epidemiology
CDC estimate: more than 1.6 million/year/USA.
300,000+ are sports related.
This means that 1.3 million occur in other
ways….such as alcohol-related stunts, etc.
92% of repeat concussions occur within 10 days of
the first!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Kevin Guskierwicz 2000
Page 13
UCSC
Salisbury
YouTube Video
This is the way your students might get this in a
“non athletic” way
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 14
UCSC
Salisbury
Concussion—a metabolic injury
Increased demand for glucose
coupled with decreased cerebral
blood flow.
Can be seen on PET, fMRI
imaging (not clinically useful).
Vasoconstrictive effects are due
to local accumulations of
calcium in endothelium of
cerebral vasculature.
http://www.nytimes.com/library
/sports/other/concussion.swf
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 15
UCSC
Salisbury
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 16
UCSC
Salisbury
How lay people understand it
A “Ding”.
Getting Your Bell
Rung.
“Just shake it off and
get back in the game”.
The difference
between injury and
pain.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 17
UCSC
Salisbury
The reality….
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Concussus—Latin:”to shake violently”.
Traumatic functional brain injury.
With rapid onset of short lived neurological deficits!!!!!!
No two concussions have the same signs or symptoms.
Student health centers see more concussions than athletic
trainers, because you have the entire student body as your
patients.
Intramural sports, accidents, general student body, physical
education classes, and weekend warriors experience more
concussions annually.
Page 18
UCSC
Salisbury
What it’s not!
Epidural hematoma
Subdural hematoma
Brain contusion
Cervical Spine injury
Transient quadriplegia
Facial fracture
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 19
UCSC
Salisbury
Concussion--Signs
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Appears “dazed and confused”.
Forgets Plays.
Unsure of game, score, opponent.
Moves clumsily.
Answers questions slowly.
Loss of consciousness.
Personality changes.
Amnesia—both retrograde and antegrade.
No “localizing signs” on neurological exam.
Imbalance.
Seizure.
Inappropriate emotions.
Page 20
UCSC
Salisbury
Concussion--Symptoms
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Headache, nausea. , vomiting
Dizziness.
Blurry Vision.
Light, sound sensitivity.
Feels sluggish or slow.
Feels groggy or foggy.
Concentration problems.
Difficulty balancing
Tinnitus
Sadness or finding everything funny
Hallucinations
Page 21
UCSC
Salisbury
SCAT 2
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 22
UCSC
Salisbury
Testing
Monitoring of the following critical domains
 Neuropsychological (Standardized Assessment
of Concussion, SAC)
 Balance (Balance Error Scoring System, BESS)
 Symptoms (Graded Symptom Checklist)
These can all be found in the newly released
SCAT2 widely distributed now on the internet
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 23
UCSC
Salisbury
Concussion—Associated Sports
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
All sports have the potential for
concussions!
Football
Soccer
Rugby
Wrestling
Boxing
Martial Arts
Skiing
Snowboarding
Lacrosse
“I like to believe that my best hits border on felonious assault.”
~Jack Tatum
“Float like a butterfly, sting like a bee.” ~Muhammad Ali
Page 24
UCSC
Salisbury
Concussion--diagnosis
Best done on the field or shortly thereafter.
Neurological examination, including mental status
testing.
Grade I (Mild): <30 min. amnesia, no LOC.
Grade II (Moderate): 30 min to 24 hours of
amnesia, and/or < 5 min. of LOC.
Grade III (Severe): >24hr amnesia and/or >5 min
LOC.
NO!!!!!
“LOC” means “loss of consciousness”
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 25
UCSC
Salisbury
On field mental status
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Orientation and evaluation of retrograde amnesia.
 Who are we playing?
 Which goal is ours?
 Who is winning?
 Who scored last?
 Who did we play last week?
 Did we win last week?
 Are your parents at this game?
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UCSC
Salisbury
Mental Status--continued
Concentration.
 Months backwards.
 Digits or Name backwards.
Evaluate antegrade amnesia: three to five word
recall.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 27
UCSC
Salisbury
Additional considerations
Brains appear “normal” on CAT scans, x-rays, and MRI’s.
PET, SPECT, and “functional” MRI’s are the preferred
imaging. Especially to be used immediately after the injury
and then as a comparative tool for determining concussion
recovery. Difficult to find though.
The effects of concussions are cumulative!
The adolescents and teens are more vulnerable to
concussions than adults…but researchers still do not know
exactly why this is. Girls possibly, too.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 28
UCSC
Salisbury
Recent research
Study by Collins et al. revealed that the presence
of amnesia and not LOC was most predictive of
post injury difficulties at three days post injury.
Studies by Erlanger et al. found that LOC was not
predictive of deficits following sports related
concussion.
Women appear at higher risk for concussions:
why?
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 29
UCSC
Salisbury
Cantu’s Guidelines for return to play
First
Concussion
Second
Concussion
Third
Concussion
Grade I
Return to play if
asymptomatic for
one week
Return to play in
two weeks if
asymptomatic at
that time for one
week
Terminate season;
may return to play
next season if
asymptomatic
Grade II
Return to play if
asymptomatic for
one week
Return to play if
asymptomatic one
month; consider
terminating season
Terminate season;
may return to play
next season if
asymptomatic
Grade III
Return to play if
asymptomatic one
month
Terminate season;
may return to play
next season if
asymptomatic
NO!!!!!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 30
UCSC
Salisbury
Step Wise Return to Play Protocol
1.
2.
3.
4.
5.
6.
No activity; complete rest. Once asymptomatic, proceed
to level (2), and so on…
Light aerobic exercise such as walking/cycling.
Sports specific training—e.g. running in rugby or skating
in hockey.
Non-contact training drills.
Full contact training.
Game play.
With this stepwise progression, athlete should continue to next level if
asymptomatic at current level. If symptoms develop, drop back to previous
asymptomatic level and try to progress again after 24 hours.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 31
UCSC
Salisbury
Disqualifying considerations
Disqualifying for a game or practice.
Disqualifying for the season.
Disqualifying for a career.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 32
UCSC
Salisbury
Second Impact Syndrome
This dreaded complication occurs when athlete is
still symptomatic from initial head injury and
sustains a second head injury.
Second injury shear force causes enough damage
to result in cerebral edema leading to brain stem
herniation.
Signs: fixed, dilated pupils; slowing and then
stopping of respiration; a rigid, abnormal posture.
Rare, but becoming more common!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 33
UCSC
Salisbury
Post-concussion Syndrome
By definition what is seen in a complex
concussion
Prolonged
 Inattention
 Affective symptoms
 Difficulty Concentrating
 Headaches
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 34
UCSC
Salisbury
Long term complications
Long term deficits have
been observed from a
single concussive event.
More events = higher risk
of long term deficits; but
how much is too many?
Dementia pugilistica—is
this secondary to
concussion or multiple
lower level traumatic
events to the brain?
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 35
UCSC
Salisbury
Chris Nowinski
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 36
UCSC
Salisbury
Encephalopathy
Increasingly
researched.
Anecdotal information
mounting.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 37
UCSC
Salisbury
Athletes to donate brains for
concussion study
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 38
UCSC
Salisbury
Long Term Complications, Cont.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Center for the Study of Retired Athletes,
Univ. of North Carolina
Page 39
UCSC
Salisbury
Retirement?
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
No evidence based recommendations guide
practitioner.
Anecdotal cases of athletes with poor outcomes
dictate many decisions.
Some evidence that certain preconditions (ApoE
gene; associated learning disabilities) are
associated with higher risk.
Having a frank discussion with the athlete about
risks/benefits seems appropriate course at this
current juncture.
Page 40
UCSC
Salisbury
Concussion—How to avoid it
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Customized mouthguard is a
must…..for teeth protection!
Head protection.
 Avoiding sports at risk.
 Pre-season neck
strengthening?
 Wearing
appropriate/advanced, sport
specific head gear.
 Not wearing head gear????
 “Minding your manners” if
you’ve had a concussion.
 Correct tackling, etc.
 Turf?
Page 41
UCSC
Salisbury
What’s New?
Grading of concussions is simplified: there are
simple and complex concussions.
Return to play/work decisions are simplified:
functional assessment as opposed to old criteria.
Increasing recognition of impact in the school room
and not just the playing field.
Increasing recognition of longer term consequences.
Increasing Awareness!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 42
UCSC
Salisbury
What’s new continued
Neuropsychometric testing
preseason, after trauma, and
postseason.
Genetic testing for apolipoprotein
E (ApoE) gene.
Sport specific differences.
Gender specific differences.
 Females more susceptible than
males.
Age specific differences.
Handheld device that is taped to the
forehead and reads the brain’s
electrical activity immediately after
the possible concussion and
compares it immediately to normal
brain function.
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 43
UCSC
Salisbury
Increasing Awareness
CDC “Heads Up”
Program
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 44
UCSC
Salisbury
National Athletic Trainers’ Association
Position Statement on
Sport-Related Concussions
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 45
UCSC
Salisbury
Another Video! This time from the
CDC
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 46
UCSC
Salisbury
Suggestions
QI
In service
 Readings
 Track Diagnosis
code
 Chart Review
 Feedback

Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 47
UCSC
Salisbury
Summary
A functional, not a structural injury.
Be comfortable with return to play/work
progression.
Consider additional injuries and rule out/treat as
indicated.
Consider referral for complex concussions.
Students will present just as likely as athletes
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Practice Pearl!!!
Page 48
UCSC
Salisbury
Resources
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
NATA Position Statement on Concussions (available at
http://www.nata.org/statements/position/concussion.pdf)
Pediatrics Vol. 123 No. 1 January 2009, pp. 114-123
Review Article on Concussions
British Journal of Sports Medicine (the entire May 2009
issue).
www.chrisnowinski.com
CDC’s “Head’s Up” program, at
http://www.cdc.gov/ConcussionInYouthSports/
 The 3rd International Conference on Concussion in Sport,
Zurich, 2008 (being widely distributed)
Page 49
UCSC
Salisbury
Thanks, From
UCSC and Salisbury!
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 50
UCSC
Salisbury
Questions?
Lori Dewald,
ATC, ED.D.
James
MacDonald, MD
Page 51