Sports Medicine
Susanna Gadsby, RN, BSN, MBA, ONC
Sports Medicine
Concussion 101
Sports Medicine
Conflict of Interest
Disclosure
I and/or my spouse/legally recognized domestic
partner have no financial
interest/arrangements in any amount within the
past 12 months with one or more organization(s),
which could be perceived as a real or apparent
conflict of interest and which would reasonably
appear to influence my role as a potential
faculty/committee member for any CME or CNE
activity.
Sports Medicine
Objectives
1) Define Sports Related Concussion.
2) Identify implications for personnel involved with studentathletes who may be exposed to possible injury.
3) Identify 3 symptoms of sports related concussion
4) Identify 2 potential catastrophic complications of sports
related concussion
Sports Medicine
Defining
Concussion
Incidence: 1.6 to 3.8 million people sustain sport or recreation
related concussions each year.
Despite this number definitions and diagnostic criteria vary widely.
Neuroanatomic and physiologic measures are non-existent.
Functional vs. structural injury, can make it challenging for students
to convince others they are really injured.
Sports Medicine
75,000
45,000
30,000
Faul MX, L. et al. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and
Control. 2010;Atlanta (GA).
Sports Medicine
Signs and
Symptoms:
Cognitive
Physical
Emotional
Sleep
Feeling slowed
down
Headache
Irritability
Sleeping more than
usual
Difficulty
concentrating
Dizziness
Sadness
Trouble falling asleep
Mentally foggy
Fatigue/drowsiness
More Emotional
Sleeping less than
usual
Difficulty
remembering
Fuzzy or blurred
vision
Nervousness
Difficulty thinking
clearly
Sensitivity to noise
or light
Anxiety
Balance problems
Having no energy
Nausea or vomiting
Sports Medicine
WHAT A HIT IS MADE OF…
G Forces
Sport Science helmet to helmet collisions
1 g = gravity
3 g = space shuttle
5 g = formula one race car
9-12 g = fighter jet in 90 degree turn
Football players = 95-103 g
Pop Warner players measured at 45g!
Sports Medicine
•
•
•
Recognition and proper management
of concussions when they first occur
can help prevent further injury or even
death.
Athletes should NEVER return to
activity on the same day as a
concussion.
Keep the athlete out of play until a
health care professional, experienced in
evaluating for concussion, has clearer
him/her to return to activity.
WHEN IN DOUBT, SIT IT OUT!
Sports Medicine
Second Impact Syndrome:
• When an athlete returns to play, and sustains a
second concussion before the first concussion
has subsided.
• Because the brain is more vulnerable, only a
minimal force is needed to cause irreversible
damage.
• Although SIS is rare, it is most often deadly.
Sports Medicine
Newsworthy
• Chronic Traumatic Encephalopathy
• Head Games
•
Not a new term
• “punch drunk” (Dr. Harrison Martland (pathologist),
1928)
•“dementia pugalistica” (US Navy Surgeon, Dr. J.A.
Millspaugh, 1937)
•“chronic traumatic encephalopathy of boxers” (Dr.
MacDonald Critchley, 1957)
•“parkinsonian pugalistica” (Mohammed Ali)
Sports Medicine
How to get better:
• Physical rest; avoid physical activity including
gym class, after school play, sports, etc.
• Mental rest; avoid tests, computer use,
television, video games, texting, reading,
studying, etc.
• Emotional rest
• Get plenty of sleep at night,
and rest during the day.
• Ask your doctor if you can
Sports Medicine
Sleep Hygiene
 Consistent bedtime and wake-up time
 Avoid excessive daytime napping
 Dim lights, calm atmosphere
 Avoid computers, TV, and texting for one hour
prior to bedtime
 Sleep-promoting environment
 No exercise 3 hrs prior to bedtime
 Mornings with bright light, breakfast, and
Sports Medicine
Healing time:
Unfortunately there is no way to tell how long
it will take to heal from a concussion.
Recovery depends on numerous factors:
How severe the concussion was
Age of the athlete
How healthy the athlete was before the concussion
How the athlete takes care of themselves after the injury
History of previous concussions
Individual biology
Sports Medicine
Children are not plastic…
• Recovery times longer than previously thought
• Higher incidence for long-term physical,
cognitive and emotional sequelae when not
managed appropriately.
• Medical management necessary to ensure
appropriate school-based treatment planning
• Developing skills such as executive control
processes are particularly vulnerable.
• Some parents may find it hard to access
appropriate care, no ATC, access to doctor who
is knowledgeable in sports concussion
management
• Girls may be more susceptible (theory of
weaker neck muscles)
Sports Medicine
Assessing Executive Function in Younger StudentAthletes
1)
2)
3)
4)
5)
6)
Keeping track of time and finishing work on
time: have homework done in an hour
Meaningfully include past knowledge in
discussions: remember when we went to the
park and we saw that dog
Evaluate ideas and reflect on work: coloring,
making a sand castle, playing with blocks
Change our minds and make mid-course
corrections while thinking, reading, and writing:
do you want popcorn or chocolate at the
movies, what movie to see, deciding what to
have for dinner, or wear to school on a cold or
warm day
Engage in group dynamics: play group,
watching TV with family
Asking for help or seek more information when
needed: where is the bathroom, can’t tie shoe
laces.
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Return to learn
before
Return to play!
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SCHOOL ACCOMMODATIONS
Students must be back to school fully before being allowed
back to play.
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Extended time to turn in assignments
Workload reduction
Systematic plan with support and supervision
Note takers
Reduce multi-tasking
Allow for breaks and quiet time
Extend test time
Testing in quiet environment
Fewer and shorter tests
Defer standardized or high-stakes tests
No more than one test per day
Multiple choice or cueing, rather than free response format
Sports Medicine
Incidence
(www.cdc.gov)
•
During the last decade, Emergency Department (ED) visits for sports/recreationrelated TBIs, including concussions, among children and adolescents increased
by 60%.
•
Overall, the activities associated with the greatest number of TBI-related ED visits
included bicycling, football, playground activities, basketball, and soccer.
•
71% of all sports/recreation-related TBI ED visits were males.
•
70% of sports/recreation-related TBI ED visits were persons aged 10-19 years.
•
For males aged 10-19 years, sports- and recreation-related TBIs occurred most
often while playing football or bicycling.
•
Females aged 10-19 years sustained sports- and recreation-related TBIs most
often while playing soccer or basketball or while bicycling.
Sports Medicine
•
•
•
•
•
•
•
Mild, Moderate, or Severe.
Grade I, II, or III.
Must have a loss of consciousness.
Return to play after headache disappears.
Sit out 7 days, then return to play.
Repeatedly wake up the concussed person.
Must have a MRI or CT scan.
Sports Medicine
Support & Resources
http://www.cdc.gov/concussion/
http://patients.dartmouth-hitchcock.org/ortho/sports_concussion_program.html
www.impacttest.com
Online Coaches Training:
http://cdc.gov/concussion/HeadsUp/online_training.html
Sports Medicine
Red Flags!
Go to an emergency department
right away if:
•Look very drowsy or cannot be
awakened.
•Have one pupil (the black part in the
middle of the eye) larger than the
other.
•Have convulsions or seizures.
•Cannot recognize people or places.
•Getting increasingly confused,
restless, or agitated, rapidly
worsening headache.
•Have unusual behavior.
•Lose consciousness (a brief loss of
consciousness should be taken
seriously and the person should be
carefully monitored).
•Weakness, numbness or decreased
coordination.
•Repeated vomiting or nausea.
•Slurred speech.
Sports Medicine
Pieces of the diagnostic
puzzle:
•
•
•
•
Sideline recognition/on field assessment
Neurocognitive screening (ImPACT)
Vestibular assessment (balance)
Physical exam with coordination assessment
Sports Medicine
Sports Concussion Assessment Tool 2
(SCAT2):
A standardized method of evaluating injured athletes for concussion and can be used
in athletes aged from 10 years and older.
Assessment Includes:
Symptoms: 22 possible
Cognitive & Physical Assessment
LOC?
Glasgow coma scale: eye, verbal, motor
Orientation: Month, Date, Day of the week, year, time?
Immediate Memory recall:
5 word recall: (elbow, apple, carpet,
saddle, bubble)
Concentration:
Repeat Digits Backwards: 3-9-7, 4-6-1-0, 2-9-6-1-4
Months of the year in reverse order
Balance
Coordination
*Now available to download as an app onto a smart phone.
Sports Medicine
Immediate Post-Concussion
Assessment and Cognitive Testing
ImPACT testing is a 30-45 minute neurocognitive test battery that
has been scientifically validated to measure the effects of sports
related concussion.
ImPACT is available for athletes age 11 to 65
All athletes should have a baseline test prior to playing sports:
Middle School & High School: test every two years
College: test once
Professional athletes: test once
Athletes with no Baseline test: Athletes should be retested within 2472 hours of sustaining a possible concussion.
Athletes with a Baseline test: Athletes should be retested when they
are completely symptom free.
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ImPACT test:
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Balance Error Scoring System
BESS
Screening for postural stability:
•Double Leg, non-dominant leg, tandem stance
•Eyes closed
•Hard floor surface & foam surface
•Count “errors” or out of position moments:
•Lifting hands off hips,
•opening eyes,
•step, stumble, or fall,
•more than 30 degrees abduction or flexion,
•lifting foot or heel,
•Normal ranges established
http://www.csmfoundation.org/Concussion_Balance_Testing.ht
ml (Collegiate Sports Medicine Foundations)
Sports Medicine
Videos:
Physiology of a concussion: 3:30 minutes
Play Smart: Brain Injury Assoc. of Mass.: understanding sports concussion with
Dr. Cantu
ADAM Concussion animation: 20 seconds
Concussion 101 white board: 5:51 minutes
ESPN Sport Science: 1:28 shows g force in helmet to helmet collisions
College football: 1 minute (endzone)
Barcelona soccer player: April 24, 2012: He got back up and continued to play.
Eight minutes later he signaled to the coaching staff of the sidelines that he
could no longer play. He was removed from the game. He was transported to a
hospital where he was admitted for observation.
Sidney Crosby hit behind the play: 17 seconds
Soccer player: 47 seconds
NHL concussion epidemic: starts at 5:29 approx 3 minutes long
Sports Medicine
Thank-you for this opportunity.
concussion@hitchcock.org
Susanna