| Concussion |
| Definition - A concussion is an alteration of mental status due to biomechanical forces affecting the brain. A concussion may or may not cause loss of consciousness. Facts About Concussion - Centers for Disease Control and Prevention (CDC) estimates 300,000 sports-related concussions occur per year (100,000 in football alone) - An estimated 900 sports-related traumatic brain injury deaths occur per year - Concussion occurs most often in males and children, adolescents and young adults - Risk of concussion in football is 4-6 times higher in players with a previous concussion - Concussions per every 100,000 games and/or practices at the collegiate level o Football; 27 o Ice Hockey; 25 o Men’s soccer; 25 o Women’s soccer; 24 o Wrestling; 20 o Women’s basketball; 15 o Men’s basketball; 12 (Head and Neck Injury in Sports, R.W. Dick) Anatomy of Concussion - The brain is a jello-like substance vulnerable to outside trauma. Cranium protects the brain against trauma, but does not absorb impact forces. o During concussion, the brain rotates and twists inside the skull, causing damage to brain tissue - Cervical spine allows the head to rotate to avoid blunt trauma - However, rotational forces can be the most damaging during concussion Vulnerable Tissues - Gray Matter of the Brain o Neurons, residing in the gray matter, are single cells that use chemical reactions to create electrical currents to carry out activities o The gray matter is the site of processing, integration and memory - White Matter of the Brain o Nerve cells are connected by axons (long projections of nerve cells resembling insulated wiring) which connect neurons to other neurons Two Primary Mechanisms of Concussion - Linear o Example; A quarterback falls to the ground and hits the back of his head. The falling motion propels the brain in a straight line downward - Rotational o Example; When a football player is tackled, his head may strike an opponent’s knee; this contact to the head can cause a rotational motion Immediate Signs of Concussion (occurring within seconds to minutes) - Impaired attention – vacant stare, delayed responses, inability to focus - Slurred or incoherent speech - Gross incoordination - Disorientation - Emotional reactions out of proportion - Memory deficits - Any loss of consciousness Later Signs of Concussion (occurring within hours to days) - Persistent headache - Dizziness/vertigo - Poor attention and concentration - Memory dysfunction - Nausea or vomiting - Fatigue easily - Irritability - Intolerance of bright lights - Intolerance of loud noises - Anxiety and/or depression - Sleep disturbances Post Concussion Syndrome - Lingering symptoms and continuing cognitive deficit following a concussion injury o May occur for weeks or months after injury o Associated with concussion Grades 2 &3 Second Impact Syndrome - Second concussion occurs while still symptomatic & healing from previous injury days or weeks earlier - Loss of consciousness not required - Second impact more likely to cause brain swelling and other widespread damage - Can be fatal – 50% mortality rate in most severe cases - Higher risk of long-term cognitive dysfunction Related Brain Tissue Injuries - Hematoma – blood clot - Contusion --- brain bruises - Brain swelling and diminished blood flow to sensitive brain tissues How is Concussion Assessed? - AAN guidelines for sideline evaluation - Standardized Assessment of Concussion (SAC) for sideline use - Standard neuropsychological tests - Computerized reaction time tests ANN Sideline Evaluation - Mental status testing o Orientation, concentration, memory - Exertional provocative tests o 40-yd. Dash, push-ups, knee-bends - Neurological tests o Strength, coordination/agility, sensation SAC (Standardized Assessment of Concussion) - Assesses orientation, memory and concentration - Developed for sideline use - Developed for nonmedical personnel - Easy to administer - Can use for objective comparisons (e.g., preseason vs. post injury) Grade 1 Concussion - Transient confusion - NO loss of consciousness - Concussion symptoms or mental status abnormalities resolve in less than 15 minutes Management Recommendations Grade 1 - Remove from contest - Examine immediately and at 5-minute intervals for the development of mental status abnormalities or post- concussive syndrome at rest and with exertion - May return to contest if mental status abnormalities or post-concussive symptoms clear within 15 minutes Grade 2 Concussion - Transient confusion - NO loss of consciousness - Concussion symptoms or mental status abnormalities last more than 15 minutes Management Recommendations Grade 2 - Remove from contest; disallow return that day - Examine on-site frequently for signs of evolving intracranial pathology - A trained person should re-examine the athlete the following day - A physician should perform a neurologic exam to clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion Grade 3 Concussion - Any loss of consciousness, either brief (seconds) or prolonged (minutes) Management Recommendations Grade 3 - Transport from the field to the nearest emergency department by ambulance if still unconscious or worrisome signs are detected (with cervical spine immobilization, if indicated) - A thorough neurologic evaluation should be performed emergently, including neuroimaging procedures when indicated - Admit to hospital if any signs of pathology are detected or if the mental status remains abnormal When to Return to Play |
| Grade of concussion Grade 1 Multiple grade 1 Grade 2 Multiple grade 2 Grade 3- w/ prolonged loss of consciousness Multiple grade 3 |
| Return to play only after asymptomatic with normal neurologic assessment at rest and with exertion 15 minutes or less 1 week 1 week 2 weeks 2 weeks 1 month or longer |
| Treatment - The treating physician can utilize a variety of treatment options including; o Analgesics for pain o Sleeping medication o Muscle relaxants o Rehabilitation therapies Case Study - 17-year-old high school football player - Suffered concussion without loss of consciousness during a varsity game - Complained of headache throughout the next week - Received no further injuries and did not seek medical attention - Next game o A week after first concussion - While carrying the ball, he was struck on the left side of his helmet by the helmet of his tackler - He was stunned, but mental functions appeared to clear quickly during a brief time out on the field - He was given the ball during the next play - His helmet made only slight contact with one of several tacklers during the play - He arose from the pile of players under his own power then fell unconscious into the arms of a teammate - He arrived at the local hospital totally unresponsive, pupils fixed and dilated - All treatment efforts were unsuccessful - Brain pressure rose stopping blood flow to the brain - 15 hours after his loss of consciousness he was pronounced dead Prevention Goals - Identification - Implementing sideline evaluation & treatment recommendations o Recognize and treat post concussion syndrome o Prevent second impact syndrome o Prevent further morbidity o Prevent fatal injury Prevention Tools - Rule changes o Play smart, keep the head safe by making penalties tougher - Use helmet and other protective equipment - Design changes for protective equipment - Ongoing research o Education, risk factors, early detection of concussion using SAC Goals for the Future - Eliminate fatalities – second impact syndrome - Prevent morbidity – post concussion syndrome - Preserve brain function – enable young players to reach their full potential in life! - Make sports safer - Increase awareness about sports-related concussions |