Athletes (and non athletes as well) are increasingly reporting concussions to parents, coaches, and school nurses. How can you recognize a concussion? We will review the diagnosis and treatments for concussions, review dangers of multiple concussions and discuss the use of computerized neuropsychological testing prior to “return to play”.

1. Concussion in Sports
Jeffrey Rosenberg MD
Sports Medicine
October 6, 2013

2. Traumatic Brain Injury

Concussions are one type of
TBI

Diffuse Injury, No Anatomic
Changes

Focal Brain Injury-More
Severe

3. High School Football Player Dies After Helmet-to-
Helmet Collision
Damon Janes, a 16-year-old junior running back for the Brocton (N.Y.) High School varsity
football team, died on Monday, Sept. 16 as a result of injuries suffered from a helmet-to-
helmet hit

4. Family of Montclair High
School football player
Ryne Dougherty who died
in 2008 settles lawsuit for
$2.8 million
Montclair High School football
player Ryne Dougherty died on Oct.
15, 2008, two days after collapsing
in a junior varsity game against Don
Bosco Prep.

5. Myth: Only Football Players Get
Concussions
 >170,000 Sports and Recreations
TBI/year from birth to 19 yo
 ER visits increased by 60%
 Birth to 9 yo: Playground and
Bicycle Related Injury
 9% of all sports related injuries
 Male 10-19 yo: Football, Bicycling
 Female 10-19 yo:
Soccer, Basketball, Bicycling

6. Silent Epidemic
 Up to 50% of concussions not
reported
 Athletes hide symptoms, don't
report any problems
 Coaches want the players to play
Athletic Trainer, not coach has the
final say
 Parents play down severity to let the
athlete participate
 More difficult to ignore in NJ as of
2011 regulations

7. Myth :Can only get Concussion if
Hit in the Head
 Direct blow most common
Helmet to Helmet; Head to
other Body Part
Ground
 Indirect Forces
 Linear or rotational forces
 Getting hit from the side in
the body

8. Brain Injury
 Trauma causes brain tissue to release
chemicals: Calcium/Glutamate
Increases need for blood flow for metabolism
to recover from injury
Unfortunately, the arteries are constricted
 Imbalance between metabolic needs and
blood flow into the brain

9. Myth : Can't be a concussion if you
aren't knocked out
 Only 10% of concussions have LOC
 “Got my Bell Rung”
If any symptoms, this is a concussion as
well
 Symptoms may not start immediately
after the hit
 Seizure activity at injury very scary
but not permanent

10. Loss of Consciousness
 If LOC continues, need to start ABC
protocol
 Assume cervical spine injury
 Usually LOC is seconds only

11. Confusion
 Hallmark symptom of TBI is confusion
 Eyes glassy, loss of focus
 Incoherent speech
 Going to wrong team's huddle
 Memory Loss
Loss of memory prior to event-retrograde
amnesia
Loss of future memory-anterograde amnesia

12. Second Impact Syndrome
 Continued symptoms-- brain
metabolism not yet normal
 With additional injury (even mild)
the blood vessels open wide which
increases the pressure in the brain
Coma, Death
10-15 die a year <19 yo
Younger the brain, more susceptible
 This is why conservative in youth
sports, JH, HS sports

13. Sideline Assessment
 Assess symptoms:
headache, confusion, nausea, vision
 Neurological Exam
Pupillary Response
ROM/Strength
Balance/Coordination
 SCAT
Orientation
Memory
Confusion

14. Sideline Assessment
 Take Helmet
 Done for the day
 ATC or MD will re-evaluate every 15-20
mins to make sure things are worsening
If so, off to the ER
 In New Jersey, coaches, refs have duty to
make athletes sit if any concern

15. Red Flag Symptoms
Headaches that worsen
Look very drowsy, can’t be awakened
Can’t recognize people or places
Unusual behavior change
Seizures
Repeated vomiting
Increasing confusion
Increasing irritability
Neck pain
Slurred speech
Weakness or numbness in arms or legs
Loss of consciousness

16. Myth : We need to go to the ER!
 Generally not needed
 If significant LOC, confusion, or worsening
mental state
CT and MRI are always normal by definition
If neurological status worsens must be imaged to
r/o bleed
 No longer recommend waking up athlete every
hour over night
Observe for unusual breathing patterns or
atypical movements
(jerking, tremor, convulsions)

17. Myth -'Captain looks fine' so he didn't have a
concussion
 Unlike physical injury, its hard to 'see' the
injury
No post game activities
 Treatment of concussion
Rest, Rest, Rest
Brain Rest, Physical Rest
Quite, Dark
NSAIDs/Tylenol for headache
No
electronics, phones, texting, computers, etc

18. Myth 'Johnny' will be ready by next
week
 Each concussion is different, hard to predict
 Longer recovery with repeated concussions
 Younger patients typically need more time
 None the less, most better with 5-7 days
 Same day return to play no longer
recommended for youth sports
If College athlete or Pro, maybe

19. Post Concussion
 Every patient has different set of symptoms
 Physical
Headaches, N/V, FATIGUE, Balance, Sensitivity
 Thinking
Mentally Foggy, Concentration, Memory, Slow
 Emotional
Irritability, Sadness, Nervous, More Emotional
 Sleep
Drowsiness, Sleep more or Less, Difficult
sleeping

20. Myth : Of course he can play doc next
week, he only has a concussion
 Loss of consciousness, Amnesia, Confusion
used to be used to 'grade concussions'
These 'grades' would determine return to play
 No data to support the grading systems
15 different systems
No longer used
 Treat each concussion individually
Symptoms must completely resolve prior to
return to activities
 Ding's matter

21. Brain Rest
 If minimal sx ok to go to school monday
Many athletes need to miss some school
Schools finally understanding and are
required to comply
 Take to MD on monday or tuesday for eval

22. Post Concussion
 Let the child sleep, Daytime Naps
recommended at the beginning
 Eat and stay hydrated
 Limit Activities requiring thinking or
concentrating
Read, TV, Computer, etc
 Watch the grass grow
 Do not attend anything with flying objects
or potential for repeated injury

23. Complications to Recovery
 Concussion
History
 Headache History
 Developmental
History
 Psychiatric History

24. Post Concussion
 Not much the parents can do to help other
than provide emotional support, interact
with school nurse and administration
 Frustration can kick in
 School provide tutoring > 5 days
 Returning to school can be gradual
Part time
No gym or sports
Breaks in nurses station
Lunch in quiet place

25. Myth : There are no treatment for
concussions
 Insomnia-Melatonin
 Emotional symptoms
Role for amitriptyline/SSRI
 Physical symptoms
Balance can improve with vestibular therapy
 Concentration
ADHD medications
 Amantidine
 Nuvigil

26. Return to Play
 All physical sx must be gone
 IMPACT scores and Balance
return to baseline
 Medical clearance
 5-7 day return to play
protocol
Start with minimal exertion
Progress daily
If symptoms reoccur must
return to previous step

27. ImPACT Testing
 Focused
neuropsychiatric, computer
based test
 Memory, Coordination, Conce
ntration
 Preseason Testing Optimal
 @2 days post injury can
provide prognosis
 When symptoms are gone to
confirm brain function normal

28. Myth (from the NFL/NHL)
No long term risk from concussions
 With each concussion, repeated injuries
occur with less force, symptoms last
longer, more difficult to return to sport
 Symptoms may be life long
 Retire from sports

29. Chronic Traumatic Encephalopathy
 Pathological changes in
brain from
multiple, usually
mild, injuries (even
'dings')
Deposits of protein
similar to Alzheimer's
 Collision sports
 Substance abuse
 Dementia, Depression,
Death

30. Chronic Traumatic Encephalopathy
 Families of NFL
players donating
brain tissue after
suicide/death
 18/19 had CTE
 Huge lawsuits in
future