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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury What’s New In Concussions: Prevention and Management

ACHA Annual Meeting,San Francisco

May 2009

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Presenters

Dr. James MacDonald, MD, FAAFP

University of California – Santa Cruz

Santa Cruz, CA

Dr. Lori Dewald, EdD, ATC, CHES, F-AAHE

Salisbury University

Salisbury, MD

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Background….UCSC

•Our clinic

•Our student population•Mostly Young•Mostly Healthy•Very Active!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

UCSC Division III Sports

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

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

8000 students.

One of the most successful Division III athletic departments in the country.

Multiple national championships in multiple sports annually.

Background….Salisbury University

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury Salisbury University*NCAA Division III

Our sportsWomen’s Field Hockey Men’s Football

Women’s Soccer Men’s Soccer

Women’s Cross Country Men’s Cross Country

Women’s Basketball Men’s Basketball

Women’s Lacrosse Men’s Lacrosse

Women’s Softball Men’s Baseball

Women’s Track/Field Men’s Track/Field

Women’s Tennis Men’s Tennis

Women’s Swimming Men’s Swimming

Women’s Volleyball

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Athletics does not deal with…

Club sports

Other activities (i.e. dancers, theatre, etc.)

These are dealt with by the student health center!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury Ever Increasing Research and Awareness

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Brain Anatomy

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!

Kevin Guskierwicz 2000

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

YouTube Video

This is the way your students might get this in a “non athletic” way

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

The reality….

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

What it’s not!

Epidural hematoma

Subdural hematoma

Brain contusion

Cervical Spine injury

Transient quadriplegia

Facial fracture

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Concussion--Signs

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Concussion--Symptoms

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

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

SCAT 2

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Concussion—Associated Sports

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

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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.“LOC” means “loss of consciousness”

NO!!!!!NO!!!!!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

On field mental status

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

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Mental Status--continued

Concentration. Months backwards. Digits or Name backwards.

Evaluate antegrade amnesia: three to five word recall.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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?

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!!!!!NO!!!!!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Step Wise Return to Play Protocol

1. No activity; complete rest. Once asymptomatic, proceed to level (2), and so on…

2. Light aerobic exercise such as walking/cycling.3. Sports specific training—e.g. running in rugby or skating

in hockey.4. Non-contact training drills.5. Full contact training.6. 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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Disqualifying considerations

Disqualifying for a game or practice.

Disqualifying for the season.

Disqualifying for a career.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Post-concussion Syndrome

By definition what is seen in a complex concussion

Prolonged Inattention Affective symptoms Difficulty Concentrating Headaches

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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?

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Chris Nowinski

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Encephalopathy

Increasingly researched.

Anecdotal information mounting.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Athletes to donate brains for concussion study

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Long Term Complications, Cont.

Center for the Study of Retired Athletes, Univ. of North Carolina

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Retirement?

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Concussion—How to avoid it

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?

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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.

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Increasing Awareness

CDC “Heads Up” Program

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

National Athletic Trainers’ Association Position Statement on

Sport-Related Concussions

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury Another Video! This time from the CDC

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Suggestions

QI In service Readings Track Diagnosis

code Chart Review Feedback

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

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

Practice Pearl!!!Practice Pearl!!!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

ResourcesNATA 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)

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury Thanks, From UCSC and Salisbury!

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UCSC

Lori Dewald, ATC, ED.D.James MacDonald, MD

Salisbury

Questions?