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Anatomy Of An Adolescent Concussion: It’s Not Child’s Play A presentation at George Mason High School, Falls Church, VA by Vicki Galliher, ATC, VATL, ACSM on 2/22/2012
Citation preview
Anatomy Of An
Adolescent Concussion:
It’s Not Child’s Play
Vicki Galliher, ATC, VATL, ACSM
By The Numbers• Concussions account for 1 in every
10 sports injuries according to the Centers For Disease Control & Prevention
• Concussions send 1.7 million individuals to the emergency room (ER) each year
• Nearly half of those ER visits are for children 14 years of age and younger
Thinking … then and now
• Severity of concussion is only indirectly related to the physical force of the impact
• Brain has no pain receptors – impact can only be perceived indirectly, as a headache or loss of consciousness
• No clear threshold for concussive injury
Thinking … then and now
• Less than 5% of all concussions are accompanied by loss of consciousness.
• Football ranks only slightly higher than girls’ soccer for incidence of youth concussions. Youth ice hockey and wrestling are trending close behind.
• There is no helmet that can prevent an athlete from sustaining a concussion.
A concussion is the most complicated injury to the most complicated organ
ofthe body
Brain Function Mapping
Not In Question• A concussion IS a traumatic brain
injury (TBI). About 75% of TBIs that occur each year are concussions.
• TBIs can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions
• TBIs can cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age
1 2 3 4
Power Up Electrical Surge Lost Equilibrium
Fall OutAltered Brain Function
• Cognitive• Visual
• Emotional
What happens to your brain?
Power up … • The brain consists of billions of
nerve cells which communicate with distant nerve cells via long nerve fibers called axons
• Severe sudden twisting or torquing of the brain - as occurs in sudden acceleration/deceleration motion - stretch, twist, and shear the delicate axon fibers
Electrical Surge … “Fire in the brain”• The nerve cells fire simultaneously,
causing a mini-seizure. As they fire, K+ rushes out of the cells as Ca+ rushes in, clogging the neurons’ mitochondria.
• To fuel the absorption of new K+, the neurons consume glucose (sugar).
• Metabolization (breaking down) of glucose creates lactic acid. Lactic acid damages cell walls.
Milliseconds after concussion …
Fire in the brain
Lost equilibrium …• The calcium-clogged mitochondria do
not get essential oxygen. This causes a neuronal energy crisis.
• Blood flow diminishes and brain cells begin to die.
• Brain cells in the adolescent brain are still developing. Cell death is devastating to the present & future functioning and growth of the adolescent brain.
Fall Out … “Post-Concussion Syndrome”
• Physical symptoms can arise almost immediately to within 4 weeks from the initial concussive injury
• The predominant physical symptoms include: headache, dizziness, moderate-to-extreme fatigue, insomnia, and irritability
• Predominant cognitive symptoms include: memory loss (retrograde amnesia, anterograde amnesia), difficulty concentrating, impairment of higher level cognitive/executive functioning
In the aftermath …• The brain remains extremely
fragile – healing must be uninterrupted by subsequent injury
• Neurons are still starved for energy
• Even a minor “secondary impact” can unleash a devastating molecular cascade
In the aftermath …• If healing is interrupted, brain cells that seemed to be regaining their balance begin committing suicide - end result is massive loss of neurons.
• No one knows why this loss occurs, but the loss is permanent.
• Youth are particularly susceptible – brain is still developing. Even slight cell loss can alter the trajectory of brain growth.
Second Impact Syndrome - Video
• Dr. Jeffrey Barth, PhD, ABPP-CN
• Director, Brain Injury & Sports Concussion Institute
• University of Virginia School of Medicine
http://bcove.me/50uubwlm
Second Impact Syndrome
• Preston Plevretes – Life after tragedy
• ESPN: E-60 Second Impact
http://espn.go.com/video/clip?id=5163151
The Road To Recovery …
You only get one opportunity to manage the concussion recovery process the right way
1 2
34
Immediate Intervention Comprehensive medical
assessment
Physical safeguards
Cognitive safeguards
Team Approach
• Health care professionals
• Family support• School support
Immediate Intervention …• Remove from play
• Initial assessment & observation
• Refer for medical evaluation
Comprehensive medical assessment
• Medical evaluation
• Diagnostic imaging
• Neuropsychological testing & follow-up
Physical safeguards …
• No physical activity at school or home
• No sports participation – must be extra vigilant with younger players who are more likely to be injured
• Careful observation & monitoring of symptoms
Cognitive safeguards …
Cognitive rest is the most often neglected aspect of concussion management
Cognitive safeguards …
• Symptom exacerbation, or re-emergence of symptoms in the wake of cognitive or physical exertion, is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits
• Neurometabolic activity can interfere with concussion recovery
• Current research has demonstrated that a significant degree of symptom exacerbation follows cognitive exertion
Cognitive safeguards …• Cognitive rest !!!!!!!!!!!!• Minimize brain stimulation – cognitive &
visual
• Turn it off !!
Computer Video Games Texting
Reading Puzzles Music Lighting
Audio Books Board & Card Games
It’s Your BRAIN !
• Be patient• Be honest
• Don’t rush back
D
C
B
A
A
B
C
D Slow and steady
Physical progression
Cognitive progression
Symptom resolution
1 23
4
• Cumulative Effects• Diagnostic Imaging
• Baseline Testing• Technology
Current Research & Trends
CumulativeEffects
Cumulative Effects of Multiple Concussions
(Athletes with 3 or more prior concussions)• More likely to experience loss of consciousness,
prolonged post-injury mental status changes and greater severity of post-injury symptoms
• Exhibit impaired memory – short & long term
• Longer recovery time with each subsequent concussion
• Score significantly lower on auditory processing tasks
• Exhibit slower cognitive & visual processing speed
Diagnostic Imaging
Diagnostic Imaging
• X-rays
• CT Scan
• MRI (Functional / Resting State)
• EEG (Electroencephalograph)
• PET Scan (Positive Emission Tomography)
• DTI Scan (Diffusion Tensor Imaging)
Diffusion Tensor Imaging (DTI)
DTI Image of Concussed Brain
Baseline Testing
IMPACT Testing
• Immediate Post-Concussion Assessment & Cognitive Testing (IMPACT)
• Pre-season testing is essential in establishing baseline cognitive & visual processing values for the student-athlete
• Re-establish baseline values following concussion recovery
Technology
Technology
• Helmet design – force & acceleration sensors
• Mouthguard design
• Playing equipment
Thoughts from those living the reality of an adolescent
concussion
It’s not easy …
• Can I do this? … No! Well, can I do that? … No! What about? … No!
• But I’m BORED !!!
• It’s like being under HOUSE ARREST !!!
Final thoughts & questions …
Thank you …
• Vicki Galliher, ATC, VATL, ACSM
• Athletic Training Coordinator, GMHS
• 571-722-6331 (Office Cell)
• 703-248-5500 Ext 5583 (Office Phone)