Recognizing and Managing Sports ConcussionBrian P Rieger, PhDChief Psychologist & Clinical Assistant ProfessorDepartment of Physical Medicine & RehabilitationSUNY Upstate Medical University

Director, UPSTATE Concussion CenterNYSPHSAA Concussion Team & Safety CommitteeNYS TBI Coordinating Council Public Education Committee

June 2014

Concussion A Hot TopicGrowing concern about the effects of concussions and of repeated head traumaRecognition of the need for more education, and to treat concussion more seriouslyProper management of concussion can make a differenceAll 50 states have passed sports concussion laws

ConcussionWhat are the risks?Athletes who return to play while still symptomatic from a concussion are at increased risk of . . .Another concussionMore severe symptomsProlonged recovery, with associated medical, psychological, and academic difficulties

ConcussionWhat are the risks?Athletes who suffer multiple concussions are at increased risk of . . .Another concussion (increasing concussability)More severe symptoms or prolonged recoveryPermanent problemsHeadacheCognitive problemsDepression

Whats the big deal?The hidden nature of the signs and symptoms of concussion often make detecting this injury challenging. Moreover, at younger competitive levels there is often limited medical coverage, which often places increased responsibility on coaches for addressing any medical issues that may arise. Therefore, it is important that individuals involved in youth sports, coaches in particular, be aware of the signs and symptoms of concussion and know how to respond if a concussion is suspected.Covassin et al. 2012

Epidemiology1.6 to 3.8 million sports concussions each year in the United StatesFootball, hockey, and lacrosse are the riskiest male team sports Soccer and lacrosse are the riskiest female team sportsIn H.S. sports played by both sexes with the same rules, girls have a higher rate of concussion

Concussion in H.S. SportsGuerriero et al. 2012Lincoln et al. 2011

Boys High School LacrosseConcussion Video Analysis518 games 86 concussions 34 analyzedPlayer-to-player contact was the mechanism for all concussionsMost often, injured players were unaware of the pending contact, and the striking player used his head to initiate contactEducation of coaches and officials and enforcement of rules designed to prevent intentional head-to-head contact is warrantedLincoln et al. 2013

Concussion inMens LacrosseNCAA data 1988 - 20048.6% of game injuries3.6% of practice injuries3% of severe injuries (10+ days out)80% due to contact or collision with another playerDick et al. 2007

Concussion inWomens LacrosseNCAA data 1988 - 20049.8 % of game injuries4.6 % of practice injuries5 times more likely in game vs. practice56% of head and neck injuries due to stick, and 20% due to ballDick et al. 2007

Pediatric ER DataPediatric ER data 1990 - 2003Young children (ages 2-9) were twice as likely to sustain an injury to the head and face than older children (10-18)Most facial injuries in female lacrosse occur away from the eye and mouth

Yard & Comstock 2006

What is a concussion?Mild traumatic brain injuryA disruption in normal brain function due to a blow or jolt to the headCT or MRI is almost always normalInvisible injury

Mechanisms of InjuryComplex physiological processsudden chemical changestraumatic axonal injuryaltered cerebral blood flow

Common Physical SymptomsHeadacheNausea and vomitingFatigue and lack of energyClumsiness and poor balanceDizziness and lightheadednessBlurred vision and light sensitivitySleep problems

Common Emotional SymptomsIrritabilityAnxiety or depressionExtreme moodsEasily overwhelmedPersonality changeLack of motivationEmotional outbursts

Common Cognitive SymptomsFeeling dazed or foggy or fuzzyEasily confusedSlowed processingEasily distracted Memory problemsTrouble readingPoor mental stamina

Exertion effectsSymptoms are worsened by . . . mental effort environmental stimulation emotional stress physical activity

Zurich 2012 GuidelinesNo grading of injury Treat every concussion seriously

4th International Conference on Concussion in Sport

FIFA IOC IIHF

Zurich Concussion GuidelinesAny athlete who show ANY symptoms or signs of a concussion:athlete should not return-to-play in the current game or practiceAthlete should be monitored for deterioration for 24 hoursreturn-to-play must follow a medically supervised stepwise processathlete must be symptom-free at rest and after exertionWhen in doubt sit em out

Medical ProtocolAny athlete who suffers a concussion should undergo medical evaluation within 24 hoursAnyone with loss of consciousness should be evaluated that dayIf confused or not fully conscious, transport by EMS with immobilizationFollow athlete until asymptomaticFirst medical clearance is to begin return- to-play progressionIf no return of symptoms with exertion, then final clearance for game play

Zurich Return to Play ProgressionNo activity, complete restLight aerobic exercise but no resistance trainingSport specific exercise and progressive addition of resistance trainingNon-contact training drillsFull contact training and scrimmage after medical clearanceGame playAlso should be symptom-free after mental exertion and have normal neruocognitive test results

Sideline EvaluationStandardized tools availableSCAT 3SACSigns & symptomsEvaluation of cognition is an essential componentStandard orientation questions are unreliable Postural stability testing is a valid addition to assessmentSerial testing recommended

NYSPHSAAConcussion ChecklistFirst completed by coach or trainer on the sidelineFollows athlete until cleared to RTPReviewed by trainer and school medical director after doctor clearanceImproves communicationEnforces proper protocol

Full recovery in 7-10 days. . .in most casesSymptoms can last weeks or monthsSymptoms can significantly disrupt academic abilitiesRisk of depression and anxietyRecovery from Concussiona miserable minority experience persistent symptoms

Preventing ConcussionDont tolerate dangerous playLate and unprotected hitsChecks to the headHelmet properly fitted and worn

Recommendations for coachesEducate players, parents and staffZero tolerance for hiding symptomsIf youre suspicious of concussion, pull the player off the field for evaluationHave a plan (e.g., who will evaluate the player, and how ?)Clear communication with athlete, parents, other coaching staff, etc.No return to play without proper clearanceWhen in doubt sit em out

Heads UpHigh School Soccer Players With Concussion Education Are More Likely to Notify Their Coach of a Suspected ConcussionBramley et al. 2012 Clinical Pediatrics

72% of athletes who had acknowledged receiving concussion training responded that they would always notify their coach of concussion symptoms, as compared with 36% of the players who reported having no such training (P = .01)

Managing Complex ConcussionConsider referral to specialized provider or program if . . .History of multiple concussions or other risk factorsProlonged recovery (> 2 weeks)Worsening symptoms

Guidelines for Return to Schoolafter ConcussionOut of school at first if necessary, and then gradual re-entry as toleratedAvoid re-injury in sports, gym classs and crowded hallways or stairwellsProvide academic accommodationsCommunicate and Educate

Academic AccommodationsRest breaks during school in a quiet location (not always the nurses office)Reduced course and work loadDecrease homeworkAvoid over-stimulation, (e.g., cafeteria or noisy hallways)Extra time and a quiet location for tests

Provide reassurance and support

ResourcesFree Educational MaterialsSafe Kids USA www.safekids.org/sportsCDC Heads up in High School Sports kitsNFHS-CDC web-based training video for coachesSUNY Upstate Concussion in the Classroom video and brochure on-line

SummaryCDC now recognizes sports concussion as a significant public health issueProper recognition and management of concussion can prevent serious problemsAvoid re-injury and over-exertion until recoveredNo return to play until symptom-free and cleared by a trained professionalEveryone involved in sports needs to be educated about concussion

Thanks !

upstate.edu/concussion

riegerb@upstate.edu

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