Alabama Association of School Nurses
Concussion
(and a quick mention of Neck Injuries)
Update and Review
June 1, 2011
ROBERT S. GILBERT, DO
AKA
PREMIER URGENT AND FAMILY CARE
4643 CAMP COLEMAN ROAD, SUITE 117
TRUSSVILLE, AL 35173
Position
“DR. BOB”
PREMIERURGENT@YAHOO.COM
OFFICE: (205) 655-4924
FAX: (205) 655-5059
Family Practice Physician
Professional Experience
04/2010 to Present
10/1997 to 04/2010
12/1997 to 07/2001
Premier Urgent and Family Care, Managing Partner
Emergency Department with over 25,000 clinical hours in level two and three facilities.
University of Alabama at Birmingham, Assistant Professor of Family Medicine
Education
10/1997 to Present
7/1994 to 6/1997
9/1990 to 5/1994
Board Certified in Family Medicine
The University of Alabama at Birmingham, Family Medicine Resident
New York College of Osteopathic Medicine
Certifications
Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Advanced Trauma Life Support,
Advanced Airway Management, Alabama Ems Online Director, Moderate Complexity Laboratory Director
Concussion Defined
The American Academy of Neurology
Concussion is a trauma-induced alteration in mental status that may or may not
be associated with loss of consciousness.
The Third International Conference on Concussion in Sport
Concussion is a complex pathophysiological process affecting the brain, induced
by traumatic biomechanical forces.
Zurich
z
Consensus Statement on Concussion In Sport – The 3rd International Conference on
Concussion in Sport, held in Zurich, November 2008
Who showed up?
Centre for Health, Exercise and Sports Medicine, University of Melbourne, Australia
Sport Medicine Centre, Faculty of Kinesiology and Department of Community Health
Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada
Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich, Switzerland
Ottawa Sport Medicine Centre, Ottawa, Canada
Huguenot House, Dublin, Ireland
Emerson Hospital, Concord, Massachusets, USA
Consensus Statement on Concussion in Sport – The 3rd International Conference on
Concussion in Sport, held in Zurich, November 2008
What was the plan?
Develop conceptual understanding of concussion in sport using a formal
consensus-based approach.
Develop guidelines for use by physicians, therapists, athletic trainers, health
professionals, coaches and other individuals involved in the care of injured
athletes, whether at the recreational, elite or professional level.
Just for kicks…
The Zurich consensus makes a distinction between Concussion and Mild
Traumatic Brain Injury (mTBI) and does not recommend they be used
interchangeably.
(Problem is… they didn’t define mTBI!)
Consensus Statement on Concussion in Sport – The 3rd International Conference on
Concussion in Sport, held in Zurich, November 2008
What did they come up with?
Concussion may be caused by a direct blow to the head, face, neck, or elsewhere
on the body with impulsive force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of
neurologic function that resolves spontaneously.
Concussion may result in neuropathological changes, but the acute clinical
symptoms largely reflect a functional disturbance rather than structural injury.
Concussion may result in a graded set of clinical syndromes that may or may not
involve LOC.
Resolution of the clinical and cognitive symptoms typically follows a sequential
course.
Post-concussive symptoms may be prolonged in a small percentage of cases.
Concussion shows no abnormality on standard structural neuroimaging studies.
Classification
What is it called?
The Old System – NO LONGER USED!
Grade 1:
Grade 2:
Grade 3:
Transient confusion, no loss of consciousness (LOC)
and all symptoms resolve within 15 min.
Transient confusion, no LOC, but symptoms or mental
status abnormalities persist longer than 15 min.
Any LOC, either brief (seconds) or prolonged (minutes).
Concussion grading based on the presence or absence and duration of loss
of consciousness, confusion, and posttraumatic amnesia have not been
shown to be clinically useful in the management of concussion.
Grading a concussion with the intent of then determining severity and to
return to play has been abandoned.
The severity of concussion in an individual athlete can only be ascertained
retrospectively after full clinical recovery has occurred.
Epidemiology
How often does it happen?
Annually there are approximately 2-4 million concussions in all age groups.
Approximately 300,000 head injuries occur yearly in high-school sports.
Concussions comprise 90% of head injuries.
Concussions comprise 8.9% of all high-school athletic injuries.
Concussion occurs at a rate of 6 to 25% of high school players per season.
Males account for 70%.
30% of high-school and collegiate athletes return to play the same day,
and 70% after 4 days.
80 – 90% of concussions resolve within 7 to 10 days.
Males account for 70%.
Epidemiology
Problem is…
Athletes may not report symptoms or head injury for fear of being excluded from
participation.
It is generally accepted the reported incidence of concussion is a gross
underestimate.
In a study of high-school football players with concussion:
47.3% reported their injury.
52.7% did not report their injury because:
66% did think their injuries were serious enough to report.
36% did not realize their symptoms were consistent with concussion.
41% did not want to be held out of play.
The highest number of concussions occur football, followed by ice hockey,
soccer, wrestling, basketball, field hockey, baseball and softball.
Athletes who have ever had a concussion are at increased risk for another
concussion.
Injuries are most often reported to Athletic Trainers.
Anatomy
Etiology
Why Did It Happen?
Concussion occurs as a result of sudden acceleration, deceleration, or rotational
forces imparted to the brain with or without direct impact.
Mechanism of injury may be subtle and not obvious.
Magnitude of impact does not correlate with clinical injury.
Concussion can also occur in noncontact sports.
Pathophysiology
What Happened?
Concussion is related to dysfunction of brain metabolism rather than structural
injury or damage.
Concussion on a cellular level is characterized by disruption, increased
permeability, and depolarization of neuronal cell membranes resulting in
neuronal suppression.
The increased cellular metabolic activity increases the need for energy and
glucose.
A complex cascade causes decreased blood flow to the brain creating a mismatch
between metabolic demands and supply.
This results in neuronal dysfunction that can last from 1 to 10 days or more
following the concussion, during which time the brain is more vulnerable to
further injury.
Second Impact Syndrome
A second concussion seen in an athlete who still has persistent symptoms or has not
clinically fully recovered from the previous concussion.
It is unclear whether Second Impact Syndrome represents a new brain injury or is a
complication of the initial injury.
Characterized by:
Rapidly progressive brain edema.
Brain stem herniation.
High mortality within minutes.
Signs and Symptoms
Mental Status Changes
Amnesia– Retrograde / Anterograde
Confusion
Concentration Difficulties
Disorientation
Easily Distracted
Excessive Drowsiness
Feeing Dinged, Stunned, or Foggy
Impaired Level of Consciousness
Inappropriate Play Behaviors
Loss of Consciousness
Poor Concentration and Attention
Seeing Stars or Flashing Lights
Slow to Answer Questions or Follow Directions
Loss of consciousness only occurs in 10% of concussions.
Signs and Symptoms
Physical or Somatic
Ataxia or Loss of Balance
Blurry vision / Double vision
Decreased performance or Playing Ability
Dizziness / Vertigo / Lightheadedness
Fatigue / Weakness
Headache
Insomnia / Hypersomnia
Nausea / Vomiting
Poor Coordination
Ringing in the Ears
Seizures
Slurred or Incoherent Speech
Vacant stare / Glassy Eyed
Vasovagal Syncope
Signs and Symptoms
A Word on Seizures…
A variety of immediate motor phenomena (e.g. tonic posturing) or convulsive
movements may accompany a concussion.
Although dramatic, these clinical features are generally benign and require no
specific management beyond the standard treatment of the underlying concussive
injury.
… Yeah, Whatever….
Signs and Symptoms
Behavioral or Psychosomatic
Anxiety / Nervousness
Depression (May be Long Term)
Emotional Lability
Irritability
Low Frustration Tolerance
Personality Changes
Signs and Symptoms
Warning Signs:
Amnesia
Headache That Gets Worse and/or Persistent
Loss of Consciousness > 1 Minute
Repeated Vomiting or Nausea
Slurred Speech
Weakness / Numbness / Decreased Coordination
Criteria
Prove It!
There are no tests to “prove” an individual has sustained a concussion.
Concussion implies a more severe injury, such as a brain contusion or bleed,
is not present.
Concussion is a diagnosis of exclusion.
Criteria
Common Concussion checklists include:
Concussion Resolution Index
Concussion Symptom Inventory
Head Injury Scale
McGill ACE Post-concussion Symptoms Scale
Pittsburgh Steelers Post-concussion Scale
Post Concussion Symptom Scale
Post-concussion Scale Revised
Standardized Assessment of Concussion (SAC)
Sports Concussion Assessment Tool 2 (SCAT2)
Concussed athletes scored 29% better on the SAC at the time of their injury
compared with their baseline evaluation.
English 101
Webster’s Dictionary
SCAT
Noun or Verb; perhaps from Greek skat-, skōr excrement
Definition:
An animal fecal dropping
Jazz singing with nonsense syllables
To go away quickly
To move fast
Assessment
What to look for?
Findings on neurologic examination should be normal with concussion,
other than the mental status or cognitive functions.
Abnormal or focal findings on neurologic examination prompt consideration of
intracranial pathology and emergent evaluation and management.
Children are particularly prone to drowsiness, vomiting, and irritability, which
are sometimes delayed for several hours after apparently minor injuries.
Assessment
Neurologic Examination
Eyes:
Extraocular Movements, Ocular Fundi, Pupil Reaction,
Visual Acuity, Visual Fields
Deep-tendon Reflexes
Finger-nose Test
Pronator Drift
Muscle Strength
Romberg Test
Tandem Gait
Speech
Postural stability has been shown to be a sensitive indicator of sensory-motor
dysfunction in concussion.
A variety of balance testing options are available including:
The Sensory Organization Test on the NeuroCom Smart Balance Master
System Balance Error Scoring System (BESS)
The Modified BESS
On-Field Evaluation
“WHEN IN DOUBT, SIT THEM OUT!”
Have an emergency action plan and concussion protocol in place.
ABCDE
AAOX3 is not reliable.
Glasgow Coma Scale
Sport Concussion Assessment Tool 2 (SCAT2)
Remember:
Sideline assessment tools are not designed to take the place of more
comprehensive evaluation or testing.
Some symptoms may appear right away, while others may not be
noticed for days or months.
On-Field Evaluation
Glasgow Coma Scale
I. Motor Response
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious stimuli
3 - Abnormal flexion, i.e. decorticate posturing
2 - Extensor response, i.e. decerebrate posturing
1 - No response
II. Verbal Response
5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words and jumbled phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds
III. Eye Opening
4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening
The final score is determined by adding the values of I+II+III.
Approximately 10% of patients with a GCS of 15 will have an acute lesion on
non contrast head CT.
On-Field Evaluation
On-Field Evaluation
On-Field Evaluation
Differential Diagnosis
Many symptoms of concussion are not specific to concussion.
This creates a difficult dilemma in making the diagnosis.
Differential Diagnosis in athletes include:
Heat-related Illness
Dehydration
Hypoglycemia
Acute Exertional Migraine
Referral
When to send?
Amnesia
Asymmetric Pupils
Drowsy or Cannot be Awakened
Headache That Gets Worse and/or Persistent
Increasing Confusion, Restless or Agitation
Loss of Consciousness > 1 Minute
Repeated Vomiting or Nausea
Secondary Injury
Seizures
Slurred Speech
Unusual Behavior
Weakness / Numbness / Decreased Coordination
Neurophysiologic Testing
Tests typically performed at least 24 to 48 hours after injury, when the athlete is
symptom free, and when compared with preseason baseline tests.
Neurophysiologic testing should be interpreted by a Neuropsychologist.
Computerized Testing
The advantage is the ability to test athletes without neuropsychologists having to
administer the tests.
The validity of computer-based neurophysiologic testing in sport-related
concussions remains unsettled.
The performance of computerized neurophysiologic tests seems to be variable,
but better than pencil-and-paper tests.
The same neurophysiologic test suite needs to be used for baseline and post
injury evaluation.
Neurophysiologic Testing
NeuANAM
(Automated Neuropsychological Assessment Metrics)
www.armymedicine.army.mil/prr/anam.html
Developed by the United States Department of Defense.
Assess how normal physical and cognitive performance might be affected by chemical warfare agents.
ANAM has been used for evaluation of other types of injuries, including concussion in athletes.
ANAM scores do not measure or indicate return to baseline after a concussion.
CogSport
www.cogstate.com
Measures psychomotor function, processing speed, visual attention, vigilance, visual learning, verbal learning, and memory.
The suite is sensitive to cognitive changes seen in sport-related concussions compared with baseline performance, which is necessary for the evaluation
of an athlete after concussion.
CRI
(Concussion Resolution Index)
www.headminder.com
Web-based test that includes measures of cognitive functions related to postconcussion syndrome.
Includes memory, reaction time, and speed of decision making and of information processing.
CRI was developed specifically to allow for comparison of an athlete’s baseline and postconcussion performance.
ImPACT
(Immediate Postconcussion Assessment and Cognitive Testing or Immediate Measurement of Performance and Cognitive Testing)
www.impacttest.com
Designed specifically to evaluate NP function in athletes at baseline and after concussive injury.
One of the most widely used test suites for evaluation of concussion in athletes, including professional players.
SAC, eSAC
(Standardized Assessment of Concussion)
www.csmisolutions.com
A brief examination intended for use at the sideline.
Based on the American Academy of Neurology’s 1997 Practice Parameter for management of sports-related concussion.
An electronic version operating on handheld personal digital assistants is available.
rophysiologic Testing
Management
What Now?
Following a concussion, complete physical and cognitive rest is recommended.
Educational accommodations for athletes recovering from concussion:
Reduce the number of work assignments
Allow more time to complete class work
Allow more time for tests
Outline and break complex tasks into simple steps
Provide written instructions
Provide distraction-free areas for work
Provide a note taker
Incorporate less stressful course work
Cognitive rest also implies limiting such activities as playing video games,
texting, and watching television during the recovery period.
Management
Return To Play
When?
There are NO accepted guidelines for return to play.
DO NOT follow the conventional return-to-play guidelines.
A more conservative RTP approach is now recommended because of the
different physiological response, longer recovery time, and specific risks
(e.g. diffuse cerebral swelling) during childhood and adolescence.
An individualized, stepwise plan for return to play is now the preferred practice.
Each athlete follows a variable time course to recovery from acute cerebral
concussion.
Any abnormality on CT or MRI scans should result in termination of the season,
and return to play at any future time should be discouraged.
Return To Play
Return To Play
The National Collegiate Athletic Association (NCAA) and
The National Federation of State High School Associations (NHFS)
mandate:
Removal from play once any signs or symptoms of concussion are present.
Cannot return to play the same day.
Immediate evaluation by a health care provider trained in concussion
management.
Evaluation by a physician or their designee before return to play.
Return To Play
Zurich
Most practitioners consider at least 7 to 10 days of rest before beginning the
Zurich recommendations.
This will protect vulnerable cells and axons by minimizing cerebral glucose
demands and avoiding additional strains on cerebral blood flow.
Before the athlete is allowed to start the return to play guidelines,
they must be:
Asymptomatic at rest.
Asymptomatic on exertion.
Examination must be normal.
Return To Play
The Zurich Conference Consensus Statement stepwise approach.
1. No activity; complete physical and cognitive rest
(e.g. scholastic work, video games, text messaging).
2. Light aerobic exercise
Walking, Swimming, Stationary Cycling.
Keep intensity <70% maximal predicted heart rate.
NO resistance training.
3. Sport-specific exercise.
Running
NO head impact activities.
4. Noncontact training drills with progression to more complex training drills.
Start resistance training.
5. Full-contact practice following medical clearance.
6. Return to unrestricted sport participation.
The athlete should continue to proceed to the next level if asymptomatic.
If symptoms recur, go back to the previous asymptomatic step and try to progress after 24
hours of rest.
Multiple Concussions
The adverse effects of repeated concussions on the brain are cumulative and
greater as the interval between successive concussions gets shorter.
Multiple concussions have been associated with cumulative effects on cerebral
function and cognition, including early onset of memory disturbances and even
dementia.
There is no agreement as to how many concussions in a given period of time
should disqualify the athlete from further participation in high-risk sports.
Some have suggested as few as three.
Concussion Management Program
Emergency Concussion Action Plan
These programs should include:
Concussion education programs for athletes, parents, and coaches focusing
on recognition, the recovery process, and return-to-play guidelines.
Guidelines for faculty, administrators, parents, and students to ensure
cognitive rest.
Concussion-prevention strategies including proper fit and maintenance of
protective equipment, teaching correct sport technique, and proper
maintenance of fields and facilities.
Baseline and post-concussion neurocognitive testing for student athletes.
Strict accident reporting protocol for coaching staff.
Resources
Cervical Spine Injuries
The mean incidence of catastrophic neurological injury over the past 30 years has
been approximately 0.5 per 100,000 participants at high school level and 1.5 per
100,000 at the collegiate level.
0.2 per 100,000 participants at the high school level and 2 per 100,000 participants
at the college level are diagnosed with cervical cord neuropraxia.
It has been reported to occur in 50-65% of players over a 4-year collegiate career.
The mechanism of catastrophic cervical injury is most often a forced hyperflexion
injury.
Cervical Spine Injuries
Stinger
The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s)
or brachial plexus and represents a reversible peripheral nerve injury.
Characterized by temporary pain, paraesthesias and/or motor weakness in
one or more extremity.
These 'stinger' or 'burner' injuries are characterized by unilateral burning
pain radiating from the neck, down the arm to the hand.
There is a rapid and complete resolution of symptoms and a normal
physical examination within 10 minutes to 48 hours after the initial injury.
On-Field Evaluation
911
ABCDE approach should be utilized.
Airway is first assessed while maintaining cervical spine stability
Breathing and ventilation
Circulation
Disability (neurological status)
Exposed for the secondary survey
The athlete's helmet and shoulder pads should remain in place with
immobilization of the cervical spine.
The helmet and shoulder pads serve to provide support and alignment to the
injured cervical spine.
On-Field Management
Immobilization
Collars
The hard collar does immobilizes the neck to a substantially greater degree than a
soft collar, but it is very poor at controlling rotational movement.
The range of flexion decreases from 35° in unrestrained volunteers to 24° in a
hard collar.
Backboards
Tape
Return to Play
No set of guidelines for return to play is agreed upon.
Relative contraindications to return to play include:
Recurrent episodes
Symptoms lasting >24 hours
Absolute contraindication to return to play
Spinal instability,
Ligamentous injury,
Persistent neck pain or loss of motion
Edema in the spinal cord
the athlete sustaining a stinger may return to play when the paraesthesias resolve
and full strength and painless full range of neck motion are appreciated.
The patient must be able to demonstrate a full, painless cervical range of motion
and have no evidence of neurological deficit prior to returning to play.
Conclusion
Q&A