Brain Injuries in Athletics

ObjectivesDefine and explain these terms:

◦Concussion◦MTBI◦Second-Impact Syndrome◦Post-Concussion Syndrome◦Intracranial hemorrhage◦Mortality◦Morbidity

Continued….

Objectives Define and explain these terms:

◦ GSC◦ SAC◦ BESS◦ IMPACT◦ ISS◦ HITS

Be familiar with the incidence of head injury in sport

Explain the various mechanisms of head injury

Understand assessment procedures for head injuries

Be familiar with current management practices for head injury

Cardinal PrinciplesTreat every unconscious athlete

as if she/he has a cervical spine injury until proven otherwise!

No athlete should return to participation while symptomatic!

CONCUSSION/MTBI (MILD TRAUMATIC BRAIN INJURY)

An injury of transient physiologic dysfunction resulting from biomechanical forces acting on the brain. It does not necessarily involve loss of consciousness (LOC)

Incidence of concussion Has been vastly underreported in the past, due to outdated

definition.

Fewer than 9% of collegiate concussions occurred with LOC (loss of consciousness).

47% of high school football concussions go unreported (McCrea, Hammeka, Olsen, Leo, Guskiewicz, 2004). BIG PROBLEM!!!

Current estimate is 1.6-3.8 million per year (Langlois, Rutlan-Brown, Wald, 2006)

Accounts for 9% of all high school athletic injuries (Langlois, Rutlan-Brown, Wald)

Long-term effects are just starting to become known

Why is the brain so susceptible to injury??

Mechanisms of MTBICoupContrecoup

MTBI Signs and Symptoms*

*+ HEADACHEPossible nausea, tinnitis, photophobia

AmnesiaRetrogradeAnterograde

Signs vs. Symptoms?

Assessment of ConcussionImmediate, on-fieldFollow-upLong-term

All include both physical and neurocognitive testing

Immediate AssessmentNote time of injury/initial

assessment

MTBI Signs and Symptoms*

*+ HEADACHEPossible nausea, tinnitis, photophobia

ASSESSMENT OF CONCUSSION

Graded Symptom Checklist (GSC)

ASSESSMENT OF CONCUSSION

Standardized Assessment of Concussion (SAC)

ASSESSMENT OF CONCUSSION

Balance Error Scoring System (BESS)

ASSESSMENT OF CONCUSSION

1130 NATA 2005 CASE STUDIES 2[1].PDF

Head Impact Telemetry System

3 Important Things for the ClinicianRecognizing the injury and its

severity

Determining if the athlete requires additional attention and/or assessment

Deciding when it is safe for the athlete to return to sports activity

Management of the Concussed Athlete

Play or no-play??No LOC, no amnesia, other

symptoms clear quickly (<15 minutes) – may return

New NFL policy – any athlete demonstrating signs of concussion is out at least for the remainder of that day

Out of collision activities at least 6 symptom-free days – WHY??

Second-Impact Syndrome (SIS)Estimates of 3-6x greater liklihood of

sustaining a second concussion if returns too early (i.e. non-resolution of symptoms = NOT symptom-free)

Brain is much more sensitive, and not as great an impact is required to cause substantial trauma

50% mortality rate/100% morbidity rate

Post-Concussion SyndromePersistence of concussion

symptoms◦May persist forever

Must have continual follow-up to document signs and symptoms

Repeated MTBICumulative effect of multiple

concussions over time◦Just beginning to see the effects of

this

The Dangers of ConcussionSecond-Impact SyndromeDon’t yet know the effects of

cumulative MTBIAnd…

Intracranial HemorrhageIntracerebral

hemorrhage (right)

Cerebral hematoma

Epidural hematoma

Subdural hematoma

Intracranial Hemorrhage Signs and Symptoms*

*+ HEADACHEPossible nausea, tinnitis, photophobia

Indicators that things are heading SouthSlowing pulseSlow increase in blood pressureMental status changes (for the

worse)

Initiate Emergency Action Plan

Epidural HematomaOccurs as a result of acceleration-

deceleration mechanismRapidly developing

◦Deteriorating status begins 10 minutes to 2 hours post-ictal

◦“Lucid Interval” PhenomenonAlways check for associated skull

fracture (common)Immediate surgery required

Subdural HematomaBlow to the headMuch more insidious onset

◦Why?

3 Important Things for the ClinicianRecognizing the injury and its severity

◦ Sideline evaluation◦ Serial follow-up evaluations◦ Patient and family education

Determining if the athlete requires additional attention and/or assessment◦ Progression of symptoms

Deciding when it is safe for the athlete to return to sports activity◦ Symptom-free!◦ Neurocognitive testing within baseline limits

References Corvassin, T, Elbin, R., Stiller-Ostrowski, J. and Kontos, A. (2009).

Immediate post-concussion assessment and cognitive testing (ImPACT) practices of sports medicine professionals. Journal of Athletic Training, 44(6), 639-44.

Broglio, SP and Guskiewicz, KM (2009). Concussion in sports: the sideline assessment. Sports Health, 1(5), 361-369.

Kutcher, J. (2010). Management of the complicated sports concussion patient. Sports Health, 2(3), 197-202.

www.nata.org/health

Questions?