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SPORTS CONCUSSION
EDUCATION SEMINAR
For Parents, Coaches, and School
Administrators
Presented by the
Vanderbilt Sports Concussion Center
Vanderbilt University Medical Center
Nashville, TN
What is the Vanderbilt Sports
Concussion Center?
• Collaborative effort among VUMC sports medicine
providers to standardize diagnosis, treatment, and
management of concussed athletes using state of
the art, evidence-based care while advancing the
current standard of care throughout the community
through public and provider education and the
discovery of new knowledge.
VSCC – Scope of Care
• Middle and high school athletes
– All Nashville metro and Williamson county high schools and several
private schools
• “Club” sports teams – lacrosse, soccer, hockey
• College teams
– Vanderbilt University, Belmont University
• Professional teams
– Nashville Predators (NHL), Nashville Sounds (AAA baseball)
• US Olympic Equestrian team and elite riders (USEF)
• Many individual athletes of all levels
•
•
•
•
•
VSCC - Providers
Primary care sports medicine
Neurosurgery
Neuropsychology
Certified athletic trainers
Affiliated consultants – neuroradiology,
neurology, pediatrics, ENT, rehab services,
psychiatry, counseling, physical and
occupational therapists
• Only comprehensive sports concussion center
in the region
VSCC – Locations
• Campus - Vanderbilt Sports Medicine (VOI),
Children’s Hospital, Neurosurgery (VAV)
• One Hundred Oaks
• Cool Springs – Orthopedics and Neurosurgery
• Vanderbilt Bone and Joint Clinic, Franklin
• Brentwood Primary Care
• Outreach clinics – Murray, KY; Mt. Juliet, TN
VSCC - services
• Team coverage
– Comprehensive concussion plan
– Coach/parent/athlete education
– Individual preseason baseline testing (history,
cognitive, and balance)
– Injury assessment and evaluation
– Supervised return to play
– Access to all resources for complex or refractory
cases
VSCC - education
• Many resources on our website:
– www.vanderbiltsportsconcussion.com
•
•
•
•
“Quick facts” brochures
In-services for ATCs and staff
Annual CME updates
Numerous outreach seminars and courses for
physicians, trainers, and other providers
Why are we here today?
• Data shows that an overwhelming majority of youth
sports concussions occur in practices or games
where no athletic trainer or physician is present
• We want to educate coaches, parents and school
officials about basic concussion diagnosis and
treatment so that these important injuries are
recognized and more severe injuries are prevented
But we are NOT here to…
• Get rid of football (or any other sport)
• Frighten everyone that all sports are
dangerous and cause long term brain damage
• Turn everyone into a concussion expert or
brain surgeon in 2 hours
Program objectives
• Understand what is a concussion and what
are common signs and symptoms
• Discuss initial treatment and transport
• Outline how we return someone to play after
injury
• Review baseline testing
• Describe current evidence about long term
outcomes
• Update prevention strategies
Unrestricted Educational Grant
Robert Parish, CEO
April 30, 2013: Nashville
Concussion: Definition,
Demographics, Signs &
Symptoms
Andrew Gregory, MD, FAAP, FACSM
Associate Professor Orthopedics &
Pediatrics
Team Physician, Vanderbilt & Belmont
Universities
Is this a concussion?
• 11 yo was swinging on a tree limb, fell 5-6’
and hit the back of his head on the ground
• Loses consciousness for one min according to
other kids
• Then has headaches and blurry vision
• Vomits twice
Is this a concussion?
• Seen at the Emergency Room - “normal
exam”, CT Scan negative
• Goes back to school with headaches needing
Ibuprofen
• Headaches get worse with physical activity
(including practicing with his travel baseball
team)
Self Reported Symptoms
•
•
•
•
•
•
•
Headache – 3/6
Trouble Sleeping – 3/6
Drowsiness – 2/6
Sensitivity to light – 2/6
Feeling like “in a fog” – 1/6
Difficulty concentrating – 1/6
All others - 0/6
Did this child have a concussion?
What is a Concussion?
• Lots of terms
– Ding, bell rung, shaking off the
cobwebs, closed head injury,
mild traumatic brain injury
(mTBI)
• “A trauma induced
alteration in mental status
that may or may not involve
loss of consciousness”
—AAN 1997
• Headache plus…
• Transient Neurological
Phenomenon
Definition of Concussion
1. Caused either by a direct blow to the head, face, neck or
elsewhere on the body with a resultant force transmitted to
the brain.
2. Typically results in the rapid onset of short-lived changes in
neurological function that resolves spontaneously.
3. May result in structural brain changes, but the symptoms
largely reflect a functional disturbance rather than a structural
injury.
4. Usually follows a progressive course of improvement
5. Imaging studies (brain CT/MRI) are usually normal.
Signs and Symptoms of Concussion
Signs
•
•
•
•
•
•
•
•
•
•
Appears dazed or stunned
Confused about assignment
Forgets plays
Is unsure of game, score, or
opponent
Moves clumsily
Answers questions slowly
Loses consciousness
Shows behavior or personality
change
Forgets events prior to play
(retrograde)
Forgets events after hit
(posttraumatic)
Symptoms
•
•
•
•
•
•
•
•
Headache
Nausea
Balance problems or dizziness
Double vision
Sensitivity to light or noise
Feeling sluggish
Feeling “foggy”
Concentration or memory
problems
• Change in sleep pattern (appears
later)
• Feeling fatigued
Common symptoms of concussion from a series
of injured high school athletes
•
Three most common symptoms:
1. Headaches (55%)
2. Dizziness (42%)
3. Blurred vision (16%)
•
•
46% experienced either cognitive or memory
problems
9% had loss of consciousness (“knocked
out”)
Do you have to be “knocked out”
to have a concussion?
• NO!!!!!
• In fact, only a SMALL number of concussed athletes were
“knocked out”
• Many studies have now shown that amnesia (inability to
remember) is a much more common sign of concussion and
ALWAYS indicates that a brain injury has occurred
What are the “Grades” of a
concussion?
• In the past concussions were often classified
into grade 1, 2, or 3 based on the severity and
duration of symptoms at the time of injury
• Many research studies have showed that
these grading scales were useless in predicting
the severity of injury or how long to recover
• Grading scales are no longer used
If you have a history of a previous
concussion are you more likely to have a
longer duration of symptoms?
• Available research says “yes”
Does having a concussion increase your
chances for a future concussion?
• Some research says “yes”
• 92% of the in-season repeat concussions occurred
within 7-10 days of first
Epidemiology of Concussion
• 1.5-3.8 million reported cases
of brain injury per year in the US
(CDC)
• 20% (300,000-760,000) are
sports-related
• 53,000 deaths each year
• 70-90,000 permanently disabled
• Highest sports incidence: ages 1524
• Cost estimated at > $60 billion
annually
HS RIO™ Injury
Surveillance System
• Internet-based high school sports-related injury surveillance
system
• Weekly data capture 2005 - 2010 academic years
• Representative sample of 100 US high schools
– Geography (4 US census regions)
– Size (≤1,000 vs >1,000 students)
• 20 sports
– Boys’ - football, soccer, basketball, wrestling, baseball, lacrosse, ice
hockey, swimming & diving, track & field, volleyball
– Girls’ - volleyball, soccer, basketball, softball, lacrosse, field hockey,
gymnastics , swimming & diving, track & field, cheerleading
26
Concussion Rates,
2005- 2010
Rates per 1,000 Athletic
Exposures
# of
Concussion
s
National
Estimate
s
Practice
Competition
Overall
Football
1392
357,114
1.3
11.4
2.9
B Soccer
182
89,237
0.3
3.0
1.1
G Soccer
243
132,062
0.3
4.6
1.6
G Vball
54
17,326
0.2
0.6
0.3
B Bball
111
27,404
0.2
1.3
0.6
G Bball
184
47,439
0.4
2.7
1.1
Wrestling
152
33,979
0.6
1.9
1.0
Baseball
32
9,569
0.1
0.4
0.2
Softball
66
23,692
0.4
0.8
0.5
Sport
Includes concussions resulting in <1 day time loss (non time
loss = 2% of all concussions)
27
Concussion Severity
2005-2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Football
B Soccer
Sport
G Soccer
G Volleyball
B Basketball
G Basketball
Wrestling
Baseball
Softball
Time lost
(days)
1-2 days
3-6 days
7-9 days
10-21 days
Time lost means days missed from sport due to concussion
22 Days +
28
Concussion Mechanisms 2005-2010
Includes only time loss concussions
29
Activity Associated with
Concussions,
Soccer 2005-2010
Boys’ soccer
Girls’ soccer
Heading ball
36%
30%
Goaltending
17%
13%
General play
10%
11%
Defending
9%
17%
Chasing loose ball
11%
15%
Ball
handling/dribbling
6%
5%
Receiving pass
6%
3%
Activity
Includes only time loss concussions
30
Activity Associations Basketball 2005 - 2010
Boys’ basketball
Girls’ Basketball
Rebounding
30%
21%
Chasing loose ball
17%
17%
Defending
20%
27%
General play
14%
7%
Shooting
10%
6%
Ball
handling/dribbling
6%
10%
Receiving pass
1%
7%
Activity
Includes only time loss concussions
31
Activity Associations Baseball/Softball 2005 -2010
Activity
Baseball
Softball
Batting
37%
8%
Running
bases
22%
4%
Fielding
15%
25%
Pitching
6%
5%
Catching
6%
33%
Sliding
12%
5%
* Includes only time loss concussions
32
Football Concussions 2010

Concussions resulting from player-to-player contact




Type of contact: head to head (66%), head to other
body site (26%), head to playing surface (8%)
Position of head during contact: head-up (38%), headdown (25%), no flexion (4%), unknown (33%)
Direction of impact: front (45%), side (22%), top
(8%), back (5%), unknown (20%)
Did athlete see impact coming: yes (37%), no (27%),
unknown (37%)
33
Girls’ Soccer Concussions 2010

Concussions resulting from player-to-player contact




Type of contact: head to head (48%), head to other
body site (45%), head to playing surface (7%)
Position of head during contact: head-up (21%), headdown (26%), no flexion (7%), unknown (46%)
Direction of impact: front (24%), side (43%), top
(3%), back (14%), unknown (16%)
Did athlete see impact coming: yes (55%), no (25%),
unknown (20%)
34
Summary
• Concussion is a temporary disruption of ANY function of the
brain caused by trauma
• All coaches and parents should become familiar with common
signs and symptoms of concussion and be alert for them
• No return to play if concussion is suspected
• Grading scales are no longer used
• ANY athlete in ANY sport at ANY age is at risk for concussion
Sports Concussion: Immediate, short-and
long-term effects on the brain
Gary Solomon, Ph.D., FACPN
Associate Professor of Neurological Surgery, Psychiatry,
and Orthopaedic Surgery & Rehabilitation
Co-Director, Vanderbilt Sports Concussion Center
Team Neuropsychologist, Nashville Predators
Consulting Neuropsychologist, Tennessee Titans
Disclosures/Competing Interests
• I receive royalties from book sales.
• I receive consulting fees from the Nashville Predators and
Tennessee Titans.
• I am involved in beta testing a new version of ImPACT and receive
free use of the test during the testing; I am a member of the
ImPACT Professional Advisory Board and am reimbursed for travel
expenses to Board meetings
• This presentation is not endorsed by any organization with which I
am affiliated.
Objectives:
1. Overview of the brain
2. What happens in the brain during a concussion--immediate, short, and long-term effects
3. How long it takes for the brain to recover from a concussion
4. Potential long-term effects
a. Post-Concussion Syndrome (PCS)
b. Chronic Traumatic Encephalopathy (CTE)
Average Adult Human Brain
Weight = 1350 g (~3 lbs.)
Width = 140 mm (5.6”)
Length = 167 mm (6.68”)
Height = 93 mm
(3.72”)
Brain = 2% of Total Body Weight
Average Adolescent Brain is Smaller
We can think of the brain as a computer
it is composed of hardware (structure)
and software (function)
Hardware (Structure) = brain tissue
Software (Function) = Electrical and chemical processes ongoing
within the brain tissue that allows us to sense, think, feel, and act
Sports related concussions rarely cause a hardware problem (structural
injury)
When structural injuries do occur, they are usually due to tearing of a
blood vessel (resulting in an epidural or subdural hematoma) or in
some cases, tearing of nerve cells (traumatic axonal injury)
However, these structural injuries are extremely rare in sports.
This is why the structural CT or MRI scan is normal 99+% of the time
after a sports concussion
Sports concussion usually causes a disruption in brain function
(software problem), which leads to the signs and symptoms described
previously
The disruption in brain function has
been termed “the chemical cascade”
The Chemical Cascade of Concussion
Blood flow to the brain is reduced immediately after a concussion
The brain operates on 2 kinds of fuel: glucose and oxygen
The brain gets glucose and oxygen from the blood supply
But because the brain is getting less blood flow after a concussion,
the brain is not getting the typical amount of fuel (energy)
The difference between the energy the brain is getting and what the
brain needs to operate fully results in an energy crisis and the
symptoms
PET Scans in Head Injury (Glucose)
Marvin Bergsneider, M.D., and David Hovda, Ph.D.
UCLA School of Medicine
fMRI Scan (Oxygen)
Drs. Mark Lovell and Micky Collins
University of Pittsburgh Medical Center
Drs. Victoria Morgan and Megan Strother, Vanderbilt
The short term effects of concussion are age- and
possibly gender dependent
Younger athletes take longer to recover than older athletes, probably
because the brain is not fully developed physically until about age 23
Many studies have indicated that females may take longer to recover
than males, although a recent VSCC study did not support this
Other factors affecting the duration and intensity of symptoms after a
concussion can include concussion history and co-existing disorders
such as ADHD, learning disabilities, sleep disorders, psychiatric illness,
and migraine headaches
To get back to the computer analogy, when we have a software
problem, we usually shut down the computer and re-boot it.
After a concussion the brain typically repairs (re-boots) itself.
But how long does it take?
First, there is no FDA-approved medication for concussion, although
many drugs are used to treat the symptoms of concussion
In general and on average, the short term effects of concussion
resolve within:
7 days for professional athletes
7-10 days for collegiate athletes
7-14 days for high school athletes
7-21 days for younger athletes
>90% of athletes with sport-related concussions
recover within a month
Second Impact Syndrome (SIS)
However, if an athlete does not recover fully from an initial concussion
and sustains another concussion before the first has cleared
completely, then he may be at risk for Second Impact Syndrome (SIS)
SIS is a very rare condition and typically occurs in teen aged males
SIS has never been reported in females or in professional athletes
SIS occurs when an athlete sustains an initial concussion that is
unrecognized, not reported, or has not fully healed,
SIS occurs when an athlete sustains an initial concussion that is
unrecognized, not reported, or has not fully healed
The brain remains in a vulnerable state from the initial concussion
(energy crisis)
The athlete then sustains a second concussion which causes additional
chemical changes in the brain that lead to severe brain swelling
The brain is encased in a hard skull and can only expand within certain
limits
SIS usually results in permanent disability or death
__________________________________________________________
Effective January 1, 2014
Sports Concussion: Long Term Effects
Post-Concussion Syndrome (PCS)
Chronic Traumatic Encephalopathy (CTE)
Post-Concussion Syndrome (PCS)
The term was first used by an article by Strauss and Savitsky in 1934
Multiple definitions abound and vary somewhat, but all involve a
constellation of symptoms after a blow to the head
Symptoms common to most definitions include a persistence of the
initial concussion symptoms, including headaches, dizziness, fatigue,
irritability, forgetfulness, poor concentration, blurred vision, sensitivity
to light and noise, frustration, sleep disturbance, difficulty thinking,
nausea, depression, increased emotionality
The diagnosis is made anywhere from 6 weeks to 3 months post-injury
Most of the scientific research on PCS has been done on civilians, and
more recently, on military personnel experiencing blast injuries
Studies of PCS in athletes are now being conducted
In general, less than 10% of athletes are diagnosed with PCS
Most of these athletes recover within 6-12 months, although there is a
small group that remains symptomatic longer
PCS typically involves multiple factors and usually requires
a multi-disciplinary treatment approach
Chronic Traumatic Encephalopathy (CTE)
• Punch-Drunk Syndrome (Martland, 1928, JAMA)
• Dementia Pugilistica (Millspaugh, 1937, US Navy Medical Bulletin)
• Psychopathic deterioration of pugilists (Courville, 1962, Bulletin Los
Angeles Neurological Society)
• Chronic traumatic encephalopathy (Miller, 1966, Proceedings of The
Royal Society of Medicine)
• Chronic traumatic brain injury
(Jordan et al., 1997, JAMA)
CTE has receive a resurgence of interest due to several professional
athletes (especially football players) being diagnosed with CTE after
death
The current definitions of CTE are somewhat different but common
elements include the appearance of a tau protein in brain tissue, found
on autopsy
Mood, behavioral, and cognitive changes occur prior
to death
CTE is an evolving area of study and merits close scientific
investigation with well designed, well controlled research
CTE, like most neurodegenerative disorders, is a multifaceted brain disease that involves a variety of genetic,
athletic exposure, and lifestyle factors
“…a cause and effect relationship has not yet been
demonstrated between CTE and concussions or exposure
to contact sports.”
Thanks to all of
you for being
here today, and
special thanks to
Rawlings for
their support
Concussion Baseline Testing
Tim Lee, MHA, MS, ATC
Coordinator, VSCC
What is baseline testing?
• Baseline testing is a
series of standardized
exams used to assess an
athlete’s balance, brain
function, and symptoms.
• Results of the baseline
test can be used to
compare to a follow-up
exam if the athlete has a
suspected concussion
What is included in VSCC baseline testing?
875-8722
•
•
•
•
Clinical Visit
Neurologic history
Symptoms Checklist
Modified Balance Error Scoring System (mBESS)
ImPACT (Immediate Post Concussion
Assessment and Cognitive Testing)Test
What is included in VSCC baseline testing?
• On-Site/Mass Testing
• Symptoms Checklist
• ImPACT (Immediate
Post Concussion
Assessment and
Cognitive Testing)Test
VSCC Neurological History
Symptoms Checklist
Consent Form
mBESS Testing
ImPACT Test
• Module 1: Word Discrimination
• Module 2: Design Memory
• Module 3: X’s and O’s
• Module 4: Symbol Matching
• Module 5: Color Match
• Module 6: Three Letter Memory
_______________________________________________
These subtests yield scores in Verbal Memory, Visual
Memory, Visual Motor (Processing) Speed, and Reaction
Time
When should an athlete be
baseline tested?
• Pre-season, before
contact
• Currently, ages 12
years old up.
How often should an athlete be baseline tested?
• Every 2 years
• Unless an athlete
has suffered a
concussion, has a
new diagnosis of
ADD/ADHD, or
learning disability
• mBESS and symptoms
checklists should be
performed yearly.
Who should administer the baseline test?
• A trained healthcare
professional (MD, DO,
ATC, PhD, PT)
• The testing
environment should
be quiet and free
from distractions
• Computer-based
testing should not be
performed at home or
anywhere without
supervision
Who should interpret the test results?
• A healthcare
professional
trained in
concussion
management
What are we
looking for in
these tests
after a
concussion?
• We are expecting that the
athlete’s test scores on all
the measures will have
returned to the baseline
values.
• This would indicate that the
athlete has most likely
recovered from the
concussion.
Concussion Baseline Testing for All Now Available
[email protected]
------------------------------------------------------------------------------A concussion is an urgent medical problem and we
strive to evaluate patients within 72 hours of injury.
Call us to make an appointment.
(615) 875-VSCC (8722)
Sports Concussion:
Sideline and Initial Management
Jim Fiechtl, MD
Assistant Professor: Depts. Of EM
and Orthopedics
Vanderbilt Bone and Joint Clinic
Vanderbilt Bone & Joint
Disclosures
• Unfortunately, I have no financial disclosures
to make, but I am always willing to listen.
Vanderbilt Bone & Joint
Objectives
•
•
•
•
How to recognize?
What we are doing on the sideline?
What to do in the first 48 hours?
What is this TSSAA form?
Vanderbilt Bone & Joint
Who is concussed?
http://i.cdn.turner.com/si/multimedia/photo_gallery/0910/cfb.impact.injuries/images/tim-tebow.3.jpg
Vanderbilt Bone & Joint
Who is concussed?
http://www.cbssports.com/mcc/blogs/entry/24156338/29747154
Vanderbilt Bone & Joint
Who is concussed?
http://theother87.files.wordpress.com/2011/05/youth-soccer.jpg
Vanderbilt Bone & Joint
Who does the evaluation?
• Anyone trained
– Means someone has
been trained
– Coach
– Certified Athletic Trainer
– Physician
– Team Parent
http://www.trophies2go.com/team-mom-trophy
Vanderbilt Bone & Joint
What are we looking for?
• Lying on the ground/slow to get up
– Are they unconscious?
•
•
•
•
Unsteady or wobbly
Grabbing their head
Dazed, blank look
Confused, running wrong plays
Pocket Concussion Recognition Tool™
Vanderbilt Bone & Joint
Lying Motionless
• If unconscious, assume
a cervical spine injury
– C-spine control
– Activate Emergency
Action Plan
• Take your time – ensure
safety
• Needs to go to
Emergency Department
http://mnhopper1s.files.wordpress.com/2011/10/spine.jpg?w=4
20&h=337
Vanderbilt Bone & Joint
Able to Move
•
•
•
•
Take your time – ensure safety
Move them to a ‘quiet’ area on the sideline
Give the player a few minutes to catch breath
Observe
Vanderbilt Bone & Joint
Sideline Assessment
• Maddocks’ Questions
– What city and stadium?
– Opponent?
– Month and day?
– Remember being injured, score of the game, the
play, etc
• Memory and Cognition
– Months, 3 objects, numbers backwards
Vanderbilt Bone & Joint
Sideline Assessment
• Brief Neuro Exam
–
–
–
–
Cranial nerves
Strength
Balance
Cerebellar
Vanderbilt Bone & Joint
When can they go back in?
They’re done for the day.
Vanderbilt Bone & Joint
Who needs a trip to the ER?
• Worsening headache or
symptoms
• Drowsy, hard to awaken
• Repeated vomiting
• Unusual behavior
• Seizures
• Weakness or numbness in arms
or legs
• Slurred speech, unsteady walking
Putukian. BJSM 2013;47:285-8.
Vanderbilt Bone & Joint
http://ia.mediaimdb.com/images/M/MV5BMjA0NjI0ODgzNF5BMl5BanBn
XkFtZTcwMDAxNDUyMQ@@._V1_SY317_CR20,0,214,317
Once in the ER…
• To Scan or Not To Scan
– Why not scan everyone?
• Multiple prediction
rules
Vanderbilt Bone & Joint
What Does this all Mean?
• Think about Headache Plus – the Sills Criteria
–
–
–
–
–
–
–
–
–
Worsening
Persistent Vomiting
Altered (GCS < 15)
Older (> 60)
Prolonged amnesia (> 2 hours)
Seizure
Fracture
Social Situation
Anticoagulants
Vanderbilt Bone & Joint
Now, what do we do –
Initial Management
• Rest, Rest, Rest
– Brain Rest: limit screen time, noises
– Physical Rest: no exertion
• Medications
– Acetaminophen over Ibuprofen, certainly over
Aspirin
• Let them sleep – Don’t awaken every 2 hours
• Symptoms can develop over 24-48 hours
Vanderbilt Bone & Joint
Post-injury Follow-up
• Who needs follow-up?
– Everyone will need medical clearance
– ED can not clear you back to sport
• Timing?
– Emergent v. Clinic
• School assistance
• Additional medications and/or specialty
referrals
Vanderbilt Bone & Joint
Summary
• Someone trained at every event
• Recognize and remove from the game
– No return to play on the same day
•
•
•
•
Remember what leads to an ER trip
Rest – brain and body
Can evolve over 24-48 hours
Needs medical clearance for return to play
– Provide additional resources, school help
Vanderbilt Bone & Joint
Post Injury
Management and
Rehab
Or, What do I do now?
Allen Sills, MD, FACS
Associate Professor of Neurosurgery,
Orthopedic Surgery and Rehabilitation
Co-Director, Vanderbilt Sports Concussion Center
Team Neurosurgeon - Nashville Predators
Consulting Neurosurgeon to:
Vanderbilt University Athletics
Belmont University Athletics
US Olympic Equestrian Team
Federation Equestrian Internationale (FEI)
Concussion in Sport Group
Outline
• What is a comprehensive concussion
plan and who should have one?
• How do we safely return someone to play
after a concussion?
• What does “return to learn” mean?
• When should ImPACT testing be
repeated?
• What to do when symptoms continue for
more than a few days?
Comprehensive
Concussion Plan
Comprehensive Concussion Plan
• Defines goals, key personnel, groups to
be served
• Discusses prevention and equipment
• Details baseline evaluations
• Delineates immediate management
• Identifies “red flags” for urgent medical
evaluation or transfer to ER
• Determines follow up care
• Return to Play (RTP) protocol
Concussion Plan
• Not a “rigid recipe” but rather a roadmap
to a common destination
– Allows for rest stops and sightseeing –
individual flexibility!
• But it is not OK to just “wing it”!
– Increases liability
– Decreases credibility
• No need to reinvent the wheel
Return to Play
“When can my boy get back out
there where he belongs?”
Return to Play - goals
• Return athlete to play as soon as possible
after brain injury has healed
• Emphasize actions and treatments that
enhance and promote recovery
• Avoid actions and treatments that hinder
recovery
• Return to play really begins as soon as
concussion is diagnosed
Same Day Return to Play
• Once any athlete at any age has been
diagnosed with any concussion they are
done for that day
–
–
–
–
No exceptions!
No such thing as a ding!
No grading scale
Be aware that some injuries may evolve over
time and symptoms may be delayed
– Serial evaluations are helpful
Acute treatment
• First 48 hrs
– Physical AND cognitive rest
– Avoid tasks which increase symptoms
• “overstimulation” of brain
• Simplify brain inputs
– “live like the Andy Griffith show”
– Some symptoms may evolve
• especially headache, concentration
Acute treatment
• First 48 hrs
– Encourage sleep
• Don’t need the every hour wakeup!
• “excessive” sleep probably OK
– School OK depending on tolerance
• Low threshold for absence – generally avoid until no
symptoms for 24 hours
– Meds – Tylenol usually adequate
– Red flags – immediate referral for medical eval
• Previous talk
– ER physician CANNOT CLEAR FOR RETURN
TO PLAY!!!
After 48 hours
• Reassess by practitioner trained in
concussion management
• NO role for ImPACT testing in this stage
– May increase symptoms
– Practice effect
– Does not change plan
• Once asymptomatic for 24 hrs can return
to class
– If symptoms in class may need to modify
schedule
Return to play stages
Return to Play progression
• After a concussion, we want to
GRADUALLY increase exertion in a
progressive manner to see if the athlete
has symtoms
– Athletes may have no symptoms at rest but
symptoms may emerge with exertion
– This means the brain has not fully healed from
the concussion
Return to Play progression
• Steps should be spelled out in your
concussion plan
• Should be overseen by someone trained
in concussion management
– Athletic trainer
– Physical therapist
– Physician (MD/DO), nurse practitioner (NP) or
physician’s assistant (PA) experienced in
athletic medicine and concussion care
Return to Play - stages
•
•
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•
•
Phase “0” – cognitive exertion
Phase 1 – aerobic exertion
Phase 2 – functional testing progression
Phase 3 – sport specific exertion
Phase 4 – limited drills and non-contact
practice
• Phase 5 – full participation without
restrictions
• For most athletes 24 hour minimum per
phase
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 0 – Cognitive Exertion
• No physical exertion until completion of
full school day and all academic work
with NO symptoms
• If no school – find other cognitive tasks
– Reading for comprehension
Courtesy of Tracy Campbell, ATC
• The athlete must be able to
“Return to Learn” BEFORE they
can begin the “Return to Play”
pathway
RTP Phase 1 – Aerobic Exertion
• Begin exertion to raise HR under
monitored conditions
• Example: Functional exertion test
– Bike 20 minutes @ 70 percent of predicted maximum heart
rate(PMHR)
– Rest for 15 minutes
– Monitor symptoms
– Incremental Treadmill Test 20 minutes
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 2 – Functional Testing
Progression
• More complex movements at higher pace, but
generally in a single plane
• Examples:
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Scissor step/quick step
Jogs
lateral shuffle
Backpedal
Sit-ups
Push-ups
Sprints
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 3 – Sport Specific Exertion
• Initial
– Moderate aerobic exercises specific to sport
– Duration approximately 10- 15 minutes with 5 minutes
rest post session
• Intermediate
– Progressively difficult aerobic exercises specific to sport
– Duration approximately 10- 15 minutes with 5 minutes
rest post session
–
• Advanced
– Demanding aerobic exercises specific to sport
– Duration approximately 10- 15 minutes with 5 minutes
rest post session
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 3 – Sport Specific Exertion Example
•
SPORTS SPECIFIC EXERCISES - BASKETBALL
•
Initial
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•
Intermediate
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•
10 laps around floor—sprint straight away/slide baseline
Sprints full court
Backpedal
lateral Shuffle
Defensive zigzag
Square drill
Shooting/post drills—timed
Advanced
–
Intervals 10 x 40 sec duration w/minute rest
•
•
•
•
•
•
Each interval contains various movements
Lateral shuffle
Sprints
Change of direction
Jumping
backpedal
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 4 – Return to Limited Drills and
Non-contact Practice
• Non-contact training drills dependent upon sport
• Athlete can practice with team but no contact
• Consult team physician for full clearance
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP Phase 5 – Return to Full Participation
without restrictions
• Full participation without restriction
• For collision sports will usually practice
full speed with contact before game action
(if available)
From the
Vanderbilt University Athletics
Mild Traumatic Brain Injury (mTBI)/Concussion Evaluation Guidelines (2012)
RTP – How NOT to do it
• “We didn’t let him practice all week and
he feels good today (Thursday) so we’re
gonna let him play Friday night.”
• “He rested for 3 days then I put him on
the bike today for 15 minutes and he did
fine so I let him go to practice today”
• “She felt bad all weekend but today she
just has a slight headache and seemed ok
in warmups so I let her go.”
RTP – “Pearls”
• If athlete has symptoms during one stage,
then should rest for 24 hours and go back
to previous stage
• Careful observation during and after final
stage / first game back
– EDUCATION of athlete!
• An extra few days in the RTP protocol
might save your athlete a month, a
season, or even a whole school year!
When should ImPACT testing be
repeated?
• Purpose of repeat test is to make sure
that brain function has returned to
baseline
– Especially if athlete is not being truthful about
their symptoms!
• NO reason to repeat test if athlete is still
having symptoms
When should ImPACT testing be
repeated?
• Can do test either prior to starting RTP
protocol or at any stage as long as athlete
is still without symptoms
• ImPACT test alone cannot “clear” an
athlete to return – it is a PART of an
overall assessment to be used by a
trained provider
Prolonged Recovery
JAE S. LEE / THE TENNESSEAN
Pathways to Recovery
• 2 general “pathways” to recovery have
been identified
– Standard (80 – 90%)
• all symptoms resolve in 7 to14 days
– Prolonged (10 – 20%)
• Symptoms for > 30 days
• This distinction appears over time and
initial treatment principles are same
Prolonged recovery
• Definition: more than 30 days of
symptoms
• Symptoms may not be specific to
concussion
– Require other management strategies
– Advanced imaging
– Formal neuropsych testing
Prolonged recovery
• All of these patients will benefit from
evaluation by a concussion specialist and
a multi-disciplinary approach
• Advanced interventions
– Treat sleep / mood problems
– Headache prophylaxis and treatment
– Vestibular assessment and rehab for balance
issues
– Cognitive evaluation and therapy for
persistent school problems
Vanderbilt Sports Concussion
Center
• (615) 875 – VSCC (8722)
• www.vanderbiltsportsconcussion.com
• Specialists in:
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Sports medicine, neurosurgery, neurology
Sports neuropsychology
Headache management
Sleep medicine
Balance and vestibular problems
Speech and cognitive therapy
Ear, nose and throat
Advanced MRI and imaging
Physical and occupational therapists
Supervised return to play
Prolonged recovery – what to avoid
• Avoid social and personal isolation for
prolonged periods of time
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No school
No sport
No social activities
No life!
Summary
• Everyone needs a concussion plan
– You need a trained provider to evaluate athletes who
sustain a concussion and to supervise their return to
play
• No RTP same day – no exceptions
• Physical and cognitive rest in first 48 hrs
• No physical exertion until asymptomatic
with brain exertion
• Stepwise RTP – be systematic
• Athletes with prolonged recovery are
unique and need specialist assessment
Thanks!
VSCC & Rawlings
Concussion Education Program
Prevention of Concussion: What Works,
What Doesn’t and What’s Next
April 30, 2013
Alex B. Diamond, D.O., M.P.H.
Assistant Professor of Orthopaedics and Rehabilitation
Assistant Professor of Pediatrics
Medical Director, Program for Injury Prevention in Youth Sports (PIPYS)
Vanderbilt University Medical Center
Team Physician
Vanderbilt & Belmont Universities
Nashville Sounds & Nashville Predators
Vanderbilt Sports Medicine
Injury Prevention 101
Vanderbilt Sports Medicine
Categories of Prevention
• Primary
– Preventing the injury from happening
• Secondary
– Reducing a possible injury’s severity
• Tertiary
– Working for the best outcome after an injury
Vanderbilt Sports Medicine
Injury Prevention is a Team Sport
Vanderbilt Sports Medicine
Emery CA et al. CJSM, 2006.
Safety cannot be delegated,
it is a shared
responsibility of…
• Parents
• Coaches
• Youth athletes
• Safety advocates
• Athletic trainers
• Schools
• Health professionals
Vanderbilt Sports Medicine
Approaches To Prevention
Clinical Care
Research
Vanderbilt Sports Medicine
Strategies for Concussion
Prevention
Vanderbilt Sports Medicine
Concussion Prevention: Equipment
• Football Helmets
• Mouth Guards
• Head Gear
Vanderbilt Sports Medicine
Virginia Tech National Impact Database. May 2012.
Football Helmet Ratings: STAR Evaluation System
• 5 Stars
Reduction in concussion risk
– Riddell 360
– Rawlings Quantum Plus
– Riddell Revolution Speed
• 4 Stars
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Schutt ION 4D
Schutt DNA Pro +
Rawlings Impulse
Xenith X1
Ridell Revolution
Rawlings Quantum
Riddell Revolution IQ
• 3 Stars
– Schutt Air XP
– Xenith X2
• 2 Stars
– Schutt Air Advantage
• 1 Star
– Riddell VSR4
• 0 Stars
– Adams A2000 Pro Elite
Vanderbilt Sports Medicine
Mouth Guards
• Effects of mouth guards on dental
injuries and concussion in college
basketball.
– Labella et al. MSSE, 2002. (LOE 2)
• Findings:
– No difference in concussion rate
– Significantly lower rate of dental
trauma
Vanderbilt Sports Medicine
Head Gear in Soccer
• Withnall et al. BJSM, 2005.
– Three equipment types tested
– No attenuation of mechanical
forces due to heading ball
– 33% reduction in acceleration
forces from direct head-to-head
contact
– Further evidence needed for
effect on injury or concussion
prevention
Vanderbilt Sports Medicine
Navarro RR. Curr Sports Med Reports, 2011.
Vanderbilt Sports Medicine
McIntosh AS et al. BJSM, 2011.
Summary of Helmet Benefits in Sports
Vanderbilt Sports Medicine
Headgear Fitting
• Important across sports
– A well maintained, properly fitted helmet required
to provide advertised level of protection to athlete
• Serious head injury (not concussion)
– Frequently inspect equipment for wear and tear
including cracks, defects and loss of proper fit
• Hands-on demonstration
– Rawlings
Vanderbilt Sports Medicine