Concussion
Sports Medicine - Mr. Riego
West Hills High School
Mind Blowing!!!
“Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.”
Concussion Defined
“Injury to the brain or spinal cord, accompanied by loss of neural function, resulting from a blow to the head or a fall (Clover, 359).”
“Clinical syndrome characterized by immediate and transient posttraumatic impairment of neural functions, such as alterations of consciousness, disturbance of vision, loss of equilibrium, etc. (Prentice/Arnheim, 542).”
“A concussion is a type of traumatic brain injury (TBI), caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussion can also occur from a blow to the body that causes the head to rapidly move back and forth (CDC, 2013).”
Consensus Statement
http://www.thinkfirst.ca/downloads/concussion/consensus-statement-2013.pdf
* Definition:
- Concussion is a brain injury and is defined as a
complex pathophysiological process affecting the
brain, induced by biomechanical forces.
* Stepwise Progression RTP Protocol
New Consensus Statement
Brain Function
* Brain Stem: respiration, heart rate
* Cerebellum: coordination, balance, motor learning
* Frontal Lobe: emotional control, personality, language, judgement, impulse control
* Parietal Lobe: sensation, perception
* Occipital Lobe: visual center
* Temporal Lobe: auditory, memory, language, sexual behavior
Types of Injury (MOI)
* Coup Injury
- Stationary head hit by moving force (linear acceleration).
→ Injury to the impact site = altered coordination, posture, and equil.
* Countercoup Injury
- Moving head hits a stationary object (deceleration)
→ injury to the opposite side
* Rotational Acceleration
- Causes twisting of the brain-stem, carotid artery and vertebral artery
Coup, Countercoup, Rotational
http://www.braininjury.com/images/injured01.gif
http://kin450-neurophysiology.wikispaces.com/file/view/Cerebral_concussion.jpg/189385993/Cerebral_concussion.jpg
Level of Consciousness
* Alert (Awareness)
- Oriented, fully aware of surrounding
* Confusion
- Impaired memory, disoriented
* Lethargy
- Drowsy, sluggish, inattentive, responds to name but loses train of
thought, slow response
Levels of Consciousness
* Stupor
- Semicoma, groans, has reflexes, responds to painful stimuli with
withdrawal
* Coma (Amnesia)
- No response to painful stimuli
* Delirium
- Experiencing hallucination, restlessness, incoherent
On-Field Head Injury Evaluation
* Primary Survey
- ABC
* R/O C-Spine Injury
* Determine whether EMS needs to be activated
* Glasgow Coma Scale
Glasgow Coma Scale
Decerebrate and Decorticate
Observation
* Halo Sign → Look for Cerebral Spinal Fluid
* Battle Sign → Temporal or base of skull fx
* Raccoon Eyes → Orbit or base of skull fx
*** Can take a few hours to develop, so it’s an emergency
Observation
Signs and Symptoms
* Blurred Vision - Nervousness
* Depression - Poor Balance
* Dizziness - Poor Concentration
* Drowsiness - Ringing in the ears (Tinnitus)
* Fatigue - Seeing stars
* Feeling “in a fog” - Sensitivity to light
* Headache - Sensitivity to noise
* Irritable - Sleep disturbances
* Memory Problems - Vomiting
* Nausea
Grading Concussion
DO WE GRADE CONCUSSIONS??????
NO!!!
A concussion is a concussion, and any signs and symptoms will be handled very seriously!!!
Same day RTP
“It was unanimously agreed that no RTP on the day of concussive injury should occur. There are data demonstrating that at the collegiate and high school levels, athletes allowed to RTP on the same day may demonstrate NP deficits postinjury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms”
Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
AB 25 - Hayashi: Concussions and Head Injuries
“... to immediately remove from a school-sponsored athletic activity for the remainder of the day an athlete who is suspected of sustaining a concussion or head injury during that activity , and . The bill would prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from, a licensed health care provider, as specified...”
CA Education Code 49475
(a) If a school district, charter school, or private school elects to offer an athletic program, the school district, charter school, or private school shall comply with both of the following (1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the athletic activity for the remainder of the day, and shall not be permitted to return to the athletic activity until he or she is evaluated by a licensed health care provider. The athlete shall not be permitted to return to the athletic activity until he or she receives written clearance to return to the athletic activity from a licensed health care provider. If the licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete shall also complete a graduated return-to-play protocol of no less than seven days in duration under the supervision of a licensed health care provider. The California Interscholastic Federation is urged to work in consultation with the American Academy of Pediatrics and the American Medical Society for Sports Medicine to develop and adopt rules and protocols to implement this paragraph. (2) On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the athlete and the athlete's�parent or guardian before the athlete initiates practice or competition. (b) As used in this section, "licensed health care provider" means a licensed health care provider who is trained in the management of concussions and is acting within the scope of his or her practice. (c) This section does not apply to an athlete engaging in an athletic activity during the regular schoolday or as part of a physical education course required pursuant to subdivision (d) of Section 51220.
Acute/ Long Term Effects
* Second Impact Syndrome (SIS)
* Epidural/ Subdural Hematoma
* Parkinsons
* Alzheimers
* Lou Gehrig’s
Heads-Up Video
Assessment
* Cranial Nerves
- Olfactory, Optic, Oculomotor, Trochlear, Trigeminal,
Abducens, Facial, Vestibulocochlear, Glossopharyngeal,
Vagus, Accessory, Hypoglossal
- Mnemonic: (O)h, (O)h, (O)h, (T)o, (T)ape, (A)nd, (F)ilm, (V)ideos, (G)igantic, (V)eins, (A)nd, (H)earts
Cranial Nerves (The type of nerve)
* Mnemonic:
- (S)ome, (S)ay, (M)oney, (M)atters, (B)ut,
(M)y, (B)rother, (S)ays, (B)ig, (B)rains,
(M)atter, (M)ost
S = Sensory M = Motor B = Both
Cranial Nerves
1. Olfactory = Smell → not usually tested
2. Optic = Vision → have subject read something
3. Oculomotor = Eyeball movement → H-Test (look for nystagmus)
4. Trochlear = Turns eye downward and lat → H-Test
5. Trigeminal = Chewing, Face and mouth touch/pain → Bite Test
6. Abducens = Turns eye laterally → H-Test
7. Facial = controls most facial expressions → Smile
8. Vestibulocochlear = Hearing, Equilibrium, Sensation → Stork Stand, snaps next to ear
9. Glossopharyngeal = Taste, senses carotid blood pressure → Say “AHH”
10. Vagus = Senses aortic blood pressure, slows heart rate → Same as IX
11. (Spinal) Accessory = Controls Trapezius & Sternocleidomastoid, Swallowing → Swallow
12. Hypoglossal = Controls tongue movements → Stick tongue out and wiggle it around
Activity
* Students will study the cranial nerves and create their own mnemonic to remember the cranial nerves.
* Students will also get the chance to evaluate their partner
Standardized Assessment of Concussion (SAC)
* What is it?
- Measures:
→ Orientation, Immediate Memory,
Concentration, Delayed Recall
- Total of 30 points
- Drop of one point from baseline is significant
SAC Administration
* Orientation (5 points)
- month, date, day of the week, year, time (< 1hr)
* Immediate Memory (15 points)
- 5 words, repeated, three trials
- Do not tell the subject that a delayed recall will be administered
SAC Administration
* Neurological Screening (not scored)
- Dermatome (C1-T1 & L2-S1)
- Myotome (C1-T1 & L2-S1)
- Progressive Romberg
→ stand feet together, eyes closed, then lift arms,
touch nose, tilt head back
- Coordination
→ Heel-to-toe walk (min of 5 steps); finger-to-nose
SAC Administration
* Concentration (5 points)� - Recite digits backwards
- All correct, go on; Incorrect, read trial 2
- Months in reverse order, must get all correct to get one point
* Exertional Maneuvers
- Done when appropriate
- 10 jumping jacks, sprint, push-ups, sit-ups, squats
SAC Administration
* Delayed Recall
- One point for each word remembered
** One point lower than baseline is significant
** 25 or above is standard cut-off. BUT higher score does not mean normal brain function. SAC does not look at symptoms, so it must be combined with graded symptom checklist
Balance Error Scoring System
* BESS
- hold position for 20 secs
- record errors
- 3 stances, 2 difference surfaces
Activity
* Students will now have the chance to practice taking each other’s Baseline SAC and GSC
- Orientation - Exertional Maneuver
- Immediate Memory - Delayed Recall
- Neurological
- Concentration
Sources
Clover, Jim. Sports Medicine Essentials: Core Concepts in Athletic Training & Fitness Instruction. Australia: Thomson Delmar
Learning, 2007. Print.
"Concussion and Mild TBI." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 15 Aug.
2013. Web. 14 Dec. 2013.
Prentice, William E. Essentials of Athletic Injury Management. Boston: McGraw-Hill, 2008. Print.