SPORTS CONCUSSION EDUCATION SEMINAR · VSCC – Scope of Care • Middle and high school athletes...

SPORTS CONCUSSION

EDUCATION SEMINAR

For Parents, Coaches, and School Administrators

Presented by the

Vanderbilt Sports Concussion Center Vanderbilt University Medical Center

Nashville, TN

http://supertremendous.com/Galleries/Funny/The-100-Funniest-Sports-Photos-Of-All-Time/FunnySportsAccidents002-194.html

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

http://www.vanderbiltsportsconcussion.com/

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 15-

24

• 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

Rates per 1,000 Athletic

Exposures

Sport

# 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

Concussion Rates, 2005- 2010

27

Includes concussions resulting in <1 day time loss (non time loss = 2% of all concussions)

Concussion Severity 2005-2010

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Football

B Soccer

G Soccer

G Volleyball

B Basketball

G Basketball

Wrestling

Baseball

Softball

Sp

ort

1-2 days 3-6 days 7-9 days 10-21 days 22 Days +

Time lost (days)

28 Time lost means days missed from sport due to concussion

Concussion Mechanisms 2005-2010

29 Includes only time loss concussions

Activity Associated with Concussions,

Soccer 2005-2010

Activity 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%

30 Includes only time loss concussions

Activity Associations Basketball 2005 - 2010

31

Activity 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%

Includes only time loss concussions

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%

32 * Includes only time loss concussions

Football Concussions 2010

33

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%), head-down (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%)

Girls’ Soccer Concussions 2010

34

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%), head-down (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%)

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

• 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.

Disclosures/Competing Interests

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 multi-faceted 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

Tim Lee, MHA, MS, ATC

Coordinator, VSCC

Concussion Baseline Testing

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.


Objectives

• How to recognize?

• What we are doing on the sideline?

• What to do in the first 48 hours?

• What is this TSSAA form?


Who is concussed?


http://i.cdn.turner.com/si/multimedia/photo_gallery/0910/cfb.impact.injuries/images/tim-tebow.3.jpg

Who is concussed?


http://www.cbssports.com/mcc/blogs/entry/24156338/29747154

Who is concussed?


http://theother87.files.wordpress.com/2011/05/youth-soccer.jpg

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

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™

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=420&h=337

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


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


Sideline Assessment • Brief Neuro Exam

– Cranial nerves

– Strength

– Balance

– Cerebellar


When can they go back in?

They’re done for the day.


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


http://ia.media-imdb.com/images/M/MV5BMjA0NjI0ODgzNF5BMl5BanBnXkFtZTcwMDAxNDUyMQ@@._V1_SY317_CR20,0,214,317_.jpg

Putukian. BJSM 2013;47:285-8.

Once in the ER…

• To Scan or Not To Scan

– Why not scan everyone?

• Multiple prediction rules


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


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


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


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


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

mailto:[email protected]










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

• 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


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



RTP Phase 2 – Functional Testing

Progression

• More complex movements at higher pace, but

generally in a single plane

• Examples: – Scissor step/quick step

– Jogs

– lateral shuffle

– Backpedal

– Sit-ups

– Push-ups

– Sprints

From the



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


rest post session

–

• Advanced

– Demanding aerobic exercises specific to sport


rest post session

From the



RTP Phase 3 – Sport Specific Exertion Example

• SPORTS SPECIFIC EXERCISES - BASKETBALL

• Initial

– 10 laps around floor—sprint straight away/slide baseline

– Sprints full court

– Backpedal

– lateral Shuffle

• Intermediate

– 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



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



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



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: – 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

http://www.vanderbiltsportsconcussion.com/

Prolonged recovery – what to avoid

• Avoid social and personal isolation for

prolonged periods of time

– 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!

Vanderbilt Sports Medicine

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

VSCC & Rawlings

Concussion Education Program


Injury Prevention 101


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


Injury Prevention is a Team Sport


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


Clinical Care Research

Approaches To Prevention


Strategies for Concussion Prevention


Concussion Prevention: Equipment

• Football Helmets

• Mouth Guards

• Head Gear


Football Helmet Ratings: STAR Evaluation System

• 5 Stars – Riddell 360 – Rawlings Quantum Plus – Riddell Revolution Speed

• 4 Stars – 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

Virginia Tech National Impact Database. May 2012.

Reduction in concussion risk


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


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


Navarro RR. Curr Sports Med Reports, 2011.


Summary of Helmet Benefits in Sports McIntosh AS et al. BJSM, 2011.


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

SPORTS CONCUSSION EDUCATION SEMINAR · VSCC – Scope of Care • Middle and high school athletes...

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