Kevin Avilla
DPT, ATC, CSCS

Clinical Doctorate Physical Therapy – Northeastern
University

MS in Exercise Science UMASS-Amherst

BS in Athletic Training - Northeastern University

Adjunct Professor /Teaching Assistant
 Lasell College –
Athletic Training Education Program
 Northeastern University - Athletic Training Education Program
Physical Therapy Department

NATA Certified Athletic Trainer 12 years
 Division I / II /III University and College Settings

Inside the Numbers

Defining Concussion/MTBI

Symptomatic Profile

Anatomy and Mechanism of Injury

Management / Return to Play

Complications /Long term concerns

Role of Protective Equipment
 MTBI (Mild Traumatic Brain Injury) / Concussion
▪ WHY???
 Use this term when explaining to parents, and
athletes
 Sound harsh ………………but that is reality

TERMINOLOGY!!!TERMINOLOGY!!!

Speed
 Fast moving players
 Fast moving objects

Surfaces
 Ice
 Boards

Contact
 Mechanisms
What’s the Injury
Yellow
Card
Syndrome

207,830 patients with Sports Related TBIs were treated in
U.S. Emergency annually
(CDC 2001-2005)

A previous national estimate of 300,000 SR-related TBIs
included only those TBIs involving loss of consciousness
 studies have reported that only 8%--19% of SR-related
TBIs involve loss of consciousness.
 Researchers have suggested that 1.6--3.8 million SRrelated TBIs occur each year, including those not treated
by a health-care provider.

Ages 5--18 years account for an estimated 65% of ED visits for
SR-related TBIs.

CDC Research
 Ages15 to 24 years, sports are the second leading cause of traumatic
brain injury behind only motor vehicle crashes
 2001 -2009 the number of ED visits increased 62%
 Estimated incidence rates rose from
▪ 190 per 100,000 up to 298 per 100,000
▪ 9.7 % of “Hockey Related” injuries were TBIs**

The Sports Concussion Institute estimates that 10% of athletes in
contact sports suffer a concussion each season.

A 2007 Study Journal of Athletic Training found (OSU
Ohio State and Nationwide Children’s Hospital)
 8.9% of all injuries to high school athletes
▪ 9 sports studied
▪ boy’s football, soccer, basketball, wrestling and baseball and girl’s
soccer, volleyball, basketball and softball
 Increased 5.5% reported a decade earlier.

Concussion rates are increasing in high school sports
 2006 - 92,000 cases of concussions in American high school
sports.
 1999 - 62,000 cases
▪ Why??

In sports both sexes played in, high school
girls had higher rates of concussion than boys.
 also seen among college athletes.

Proposed Rationale:
 Females may be more honest in reporting
symptoms
 Neck muscular strength
 Smaller head mass

Comprehensive Review* - (1985 -2000) American football,
boxing, ice hockey, judo, karate, tae kwon do, rugby, and
soccer
 “ice hockey athletes demonstrated the highest incidence of
concussion (3.6 per 1000 athlete-exposures) [AEs]”
 “At the professional level, similar concussion incidence
rates were found in both ice hockey and rugby.”
▪ (6.5 per 1000 player-games, 95% CI 4.8–8.6) ▪ (9.05 per 1000 player-games, 95% CI 4.1–17.1) -
Ice Hockey
Rugby
*Journal of Athletic Training 2006;41(4):470–472 Contact Sport Concussion Incidence

Data collected from 8 teams in a Division I athletic
conference for 1 season using a standardized form:
 113 injuries in 23,096 athlete exposures.
 65% of injuries occurred during games
 Concussion (18.6%) was the most common injury, followed
by knee MCL sprains, AC joint injuries, and ankle sprains.
*Flik et al. The American Journal of Sports Medicine Vol. 33, No. 2, 2005 American Collegiate
Men’s Ice Hockey Injuries

Game injury rates 5 times higher than the injury rate in
practices
(12.6 versus 2.5 injuries per 1000 athlete-exposures, rate ratio = 5.0, 95% confidence interval
= 4.2, 6.1, P < .01).

Concussions were the most common injury in both games
(21.6%) and practices (13.2%).
Agel et al. Journal of Athletic Training 2()07:42(2):249-254Descriptive Epidemiology of Collegiate Women's Ice Hockey
Injuries: National Collegiate Athletic Association Injury Surveillance System,2000-2001 Through 2003-2004

Studies indicate 1 in 20 collegiate level
hockey players will experience a
concussion during their college careers

Nonfatal catastrophic spinal cord and
brain injury rates in HS athlets:
 2.6 per 100,000 hockey players
 0.7 per 100,000 football players

Each season 10%–12% of minor league
hockey players 9–17 years report a head
injury

MTBI incidence rates
97/98 -07/08 seasons




HIGH 1.81/1000 athlete exposures in 1998-99
LOW 1.04/1000 athlete exposures in 2005-06.
downward trend in the number of concussions reported
time lost from play per concussion increased over the
same period (p<0.0005).
 Forwards suffered a disproportionately high percentage
of concussions (p<0.0001).
The Canadian Journal Of Neurological Sciences 2008 Nov; Vol. 35 (5), pp. 647-51.

CMAJ 2011Study -1997 – 2004

Team physicians reported 559 concussions

1.8 concussions per 1000 player-hours.

Varied post-concussion symptoms

Time loss (in days) increased 2.25 times for every subsequent
concussion sustained during study

A clinical syndrome occurring as the result of
trauma to the head and characterized by
immediate and transient impairment of neural
function.

A brain injury


Trauma to the brain (Concussion)=dysfunction of
the brain
Resulting Symptoms:
•Alteration in motor
patterns
•Unusual behavior /
mood changes
•Changes in cognitive
ability
•Disorientation
•Changes in memory
(amnesia)
•Visual Changes
•Vomiting
•Splitting headache,
intense pain, or
pressure
Example- dislocation of the shoulder

Understand that
 trauma = dysfunction

Trauma = shoulder is out of normal alignment

Resulting Dysfunction
 ↓ Range of Motion
 Swelling
 Pain
 ↓ Strength
 ↓ Functional ability

Force and impact ≠ Severity of
Concussion
 With each concussion the relative
force required is diminished

Large and small forces alike
can cause prolonged
concussion symptoms

Large impacts may appear
worse then they are, and vise
versa

Symptoms may arise
immediately after impact or
take some time to develop

A delayed onset of symptoms
may make it difficult to
recognize early in the injury
process, especially in “lower
grade” concussions

Symptoms are unique to the
athlete and all concussions
present differently
 The concussive forces may cause
confusion, amnesia, either
immediately or shortly after
impact.
50
40
30
20
▪ Often times recognized by other athletes
▪ Major Symptoms may be day(s) later
 The alteration in function is
secondary to trauma on the brain
10
0
Day 1
Day 8
Day 11
Symptoms scores via Impact
Testing
(Former UMASS Athlete)

Brain is essentially free
floating with the skull
surrounded by a layer of
protective fluid

Within the skull the brain
has some ability to move

Similar to an egg yolk
within an eggshell

How concussion occur:
 2 main mechanism
▪ Coup and Countrecoup
▪ Coup Mechanism –
Direct Trauma Occurs
when a moving head hits
a stationary objects:
▪ The brain has direct
contact with the skull at
the site of impact


Head hitting the ice after a fall
Head hitting the boards

Countrecoup Mechanism
 Injury to the brain occurs in the
opposite direction of the initial
force or impact
 Generally seen when the head
and neck accelerate and
decelerate quickly
 “whiplash effect”

Can have combo type
concussions
 Coup-countrecoup Injuries
 Collision with “whip lashing”
and the head hitting the ice
afterwards

A number of grading scales exist with the implication that a
higher grade = greater severity.
Symptoms
Gra
de I
Grade II
Grade III
L. O . C
None
No L.O.C
LOC up to 5 minutes*
L.O.C secs – mins
> 5 minutes*
Altered Mental State
Limite
d,
<15mi
nutes
> 15 minutes
RTP Criteria
Upon
resolut
ion of
Sympt
oms
Medical Authority
1 week asymptomatic
Medical Authority
Notes:
Often
not
report
ed
-LOC treat as cervical spine injury
-LOC treat as cervical
spine injury
-Transport via medical
advanced medical
services

Treat athlete based on symptoms, grading scales can be
deceiving.

Loss of consciousness does not necessarily indicate the
seriousness

Continue to stress to athletes and parents that these are brain
issues

Utilize Coaches Card
 A tool for management
 Some inherent problems if sole basis of decision

Avoid alcohol as symptoms may be masked

Appropriate adjustments to academic coursework

Avoid stimulating environments
 video games
 Theaters
 Concerts
''I was the captain of a team, the father of three, and
all of a sudden I was having trouble taking a
shower,'' LaFontaine said. ''There was depression,
emotional issues. I could not watch a hockey
game on television. It was too fast for me.''

If an athlete become unconscious after a head
injury or fall – Cervical Spine Injury
 Athlete should not be moved


What is your action plan?
Has it been practiced?
 Things to consider
▪ CPR /AED Certification – readily available??
▪ Ambulance – entrance, designate coach, manager
▪ The injured athlete???
Monitor symptoms
 Athlete’s condition can worsen ma be
larger medical concern
▪ Sub-dural hematoma
▪ Epi-dural hematoma
▪ pressure on the brain, resulting in
bruising (hematoma) injuring brain
tissue
▪ a progressive decline in function and
increase in the severity of symptoms

Occur acutely, but recent research has shows
more likely when RTP to soon from a head
injury and sustaining another

Using Subjective and Objective Measures
 Many organizations are utilizing computer based assessments to
evaluate the athletes function
 IMPACT Testing
▪ Computer based assessment
▪ Baseline measure – post concussion measures
▪ Measures a number of variables
 Visual memory
 Verbal memory
 Reaction time
 Recall
▪ A tool in the overall management of concussions
▪ Often will show significant decrease in function even though reported symptoms
appear to be improving

A Stepwise progression
 Can only move through progression 1 day at a time
 Any manifestations of previous symptoms athlete move to previous level
▪ 1-Asymptomatic Rest
▪ 2-Light activity to stimulate an increase in HR
(no jarring of the head)
▪ 3-Sports-Specific Tasks- Skating
▪ 4-Non-contact practice
▪ 5-Full contact training with medical clearance
▪ 6-Return to competition
*Younger athletes will need more to time to heal



Never in the same game if concussion suspected
Who makes the decision?
 -League Policies??
 Signed Documentation
 State Mandates:
Zak Lysted Bill

105 CMR 201.000 ~Head Injuries and Concussions in Extracurricular
Athletic Activities.
 All parties must participate in yearly training
 Student removed form competition not allow to return same day
 Must have documented clearance to RTP
▪ Only the following professional can designate RTP:
▪ A duly licensed physician; certified athletic trainer, nurse
practitioner in consultation with a licensed physician; or
neuropsychologist
 From this policy and required documentaiton,
statistical database will be generated

A catastrophic event when a second concussion occurs while the
athlete is still symptomatic from the first

The second concussion causes additional swelling and greater
damage to the brain tissue

SIS is fatal

Widespread damage can result in many changes within brain’s
functioning, resulting in permanent brain damage

In general athletes who have sustained a concussion are 3xmore
likely to sustain a second concussion than those with no history of
head injury

Athletes who are still symptomatic from a previous concussion
should always be Dq’d with SIS in mind

Generally as the number of total concussions increase so does the
likelihood of PCS (Post-Concussion Syndrome)

PCS-is a set of disorders that affect many brain functions including:
emotions, behavior and cognitive ability

Just as repeated soft tissues become cumulative, so do injuries to the brain
 Only problem the brain cannot be repaired surgically at the end of the
season

Can last for weeks, months, and even years

Generally PCS is the reason you hear athletes retiring early

''I can't remember that day, I can't
remember what happened,'' …..''I got
knocked out. It took me about three
weeks before I could start eating
normally, before I could start
remembering a lot of things.'‘
- Jeremy Stevenson

“Dimentia Pugilista”

Repeated concussions have been linked to
Alzheimer's disease, clinical depression

Also implicated in Parkinson's
 Example: Muhammad Ali

Patients with a history of brain injuries have
been shown to exhibit Alzheimer’s related
symptoms at an average of 8 years younger
than patient with no associated history

A study of more than 2,500 retired NFL
players found that those who had at least three
concussions during their careers had triple the
risk of clinical depression as those who had no
concussions.

Chronic Traumatic
Encephalopaty
 Receiving much attention in
the mainstream media
 BU Center for Traumatic
Encephalopathy
 Research is supporting the
links between several
conditions and repeated head
trauma

Concussions in contact sports will always occur

However numbers can be limited with proper fitting
equipment
 Proper Helmet fitting
▪ Use of HECC certified helmet
▪ Constant review of “snugness" of the helmet
 What’s the best type of Helmet?

Enforcement of current rules structure

Facial protection showed a statistically significant (p<0.05)
reduction in the number and type of facial injuries

(FFP) versus half facial protection (HFP), FFP offered a significantly
higher level of protection against facial injuries and lacerations than HFP
(relative risk (RR) 2.31, CI 1.53 to 3.48)

There was no significant difference in the rate of concussion or neck
injury (CI 0.43 to 3.16) between full and partial protection.

In those who sustained concussion players with FFP returned to practice
or games sooner than players with partial facial protection (PFP)

Facial protection and head injuries in ice hockey: a systematic review. Authors: Asplund C; Bettcher
S; Borchers J Affiliation: The Ohio State University Sports Medicine Center, 2050 Kenny Road, Suite
3100, Columbus, OH 43221, USA. chad.asplund@osumc.edu. Source: British Journal of Sports Medicine
(BR J SPORTS MED), 2009 Dec; 43(13): 993-9

2005 Study –
 University male football (394) and university males (129)
and female (123) rugby athletes reporting to 2003 fall
training camps.
 Primary Measure Concussion Symptoms based on
American Academy of Neurology Concussion
 Secondary endpoints included the incidence of dental
trauma events and observed concussion symptoms.
 Experimental Groups Specific Type II Mouth Guard
 Control Group – allowed to used mouth guard of choice.
Barbic et. al. Comparison of Mouth Guard Designs and Concussion Prevention in
Contact Sports: A Multicenter Randomized Controlled Trial Clinical J Sport
Med Volume 15, Number 5, September 2005

“This trial found no benefit in
concussion prevention when
using the WIPSS Brain-Pad
mouth guard when compared
with other mouth guards in
standard use by athletes
participating in football and
rugby at 5 Canadian
universities”
“There is currently insufficient evidence to
determine whether mouth guards offer
protection against concussion injury, and more
work of good methodological quality is
needed. Mouth guard use should be promoted
in sports activities where there is a significant
risk of orofacial injury”
Mouth guards in Sport Activities History, Physical Properties and Injury Prevention
Effectiveness. Sports Med 2007; 37 (2): 117-144

“no advantage in wearing a custom-made mouth
guard over a boil-and-bite mouth guard to reduce the
rise of cerebral concussion in athletes. However,
ATCs and coaches should mandate the regular use of
mouth guards because a properly fitted mouth guard,
with no alterations such as cutting off the back part,
is of great value in protecting the teeth and
preventing fractures and avulsions that could require
many years of expensive dental care.”
CDC (Center for Disease Control and Prevention) Heads Up Campaign
Coaches Tool Kit
http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
http://www.biausa.org/
IMPACT Testing Home Page
http://www.impacttest.com



Discussion
Questions
Comments
 Kevin Avilla
▪ kevinavilla@gmail.com