Concussions

Question 1

Concussion is also known as?

Due to what?

Answer 1

• mild TBI
• may be due to direct blow, countercoup, or rotational/acceleration injury
• due to changes in brain physiology rather than structural changes

Question 2

Most concussion resolve over what time period?

Answer 2

• 80-90% resolve in 7-10 days
• most HS athletes are fully recovered in 14-21 days
• may have long term, even fatal sequelae

Question 3

Coup - mech of injury
Countercoup?
rotational?
- do you need direct trauma to head?

Answer 3

• coup: direct blow-skull driven into brain
• countercoup: brain driven into far skull
• rotational: features of both
• can happen without direct trauma= deceleration injury

Question 4

PP of concussions?

Answer 4

• disruption in neuronal membrane and depolarization
• leads to release of excitatory NTs: K+ efflux and Ca2+ influx
• leads to impairment of glucose metabolism, cerebral blood flow, and axonal fxn
• structural changes are rare- CT, MRI, EEG usually normal
• concussive effects are cumulative!!!

Question 5

How do you dx a concussion?

Answer 5

• based on hx, signs, sxs, exam findings, neurocog testing, balance testing
• neuroimaging usually normal, not reqd for dx (MRI for persistent/disabling sxs to R/O other causes)
• simple or complex?
• LOC - seen in 10%: presence of amnesia more predictive of sxs and neurocog deficits than LOC (retrograde amnesia correlates more with injury)

Question 6

Cognitive sxs of a concussion?

Answer 6

• fellings dinged, foggy or dazed, just not with it
• inability to focus attention - easily distracted
• cognitive slowing, confusion, amnesia
• memory dysfxn: disorientation - repeatedly asking the same ?
• inappropriate emotions: sadness, irritability, anger
• fatigue

Question 7

Physical sxs of a concussion?

Answer 7

• double vision, seeing stars, light sensitivity
• HAs, ringing in ears, nausea
• balance problems and dizziness
• difficulty falling asleep or sleeping less than usual

Question 8

Physical signs of a concussion?

Answer 8

• vacant stare
• poor coordination or unsteady gait
• slow to answer ?s or follow commands
• poor concentration
• slurred or incoherent speech
• behavior or personality changes
• diminished ability or reckless playing behavior
• LOC or seizure

Question 9

What is included in the initial eval for concussion?

Answer 9

mental status testing:

• orientation: time, place, person, situation
• concentration: subtraction or months backwards
• memory: details of contest, recent newsworthy events

gait assessment and balance:

• have pt walk away and back -ataxia?
• tandem gait
• romberg sign

Question 10

What are signs that demand emergency action?

Answer 10

• increasing HA, N/V
• progressive impairment of consciousness
• gradual rise in BP
• diminution of pulse rate
• blown pupil
• disorientation

Question 11

What signs and sxs warrant a emergent referral?

Answer 11

• suspicion for hematoma
• C-spine injury
• worsening LOC
• focal motor weakness
• transient quadriparesis
• seizure

Question 12

What signs and sxs warrant a refferal?

Answer 12

• persistent HA for longer than 7 days
• PCS lasting longer than 2 weeks
• abnorm neuropsych testing
• hx of mult high grade concussion
• clinical judgment

Question 13

What disorders can a concussion mimic?

Answer 13

• substance abuse/dependency
• intermittent explosive disorder
• suicidal ideation/tendencies
• depression
• mood disorder
• impulse control

Question 14

Severe brain injuries?

Answer 14

• focal neuro deficit
• IICP: HA, vomitng, papilledema, brain stem herniation (1 pupil dilated)
• skull fracture
• hematoma:
  epidural
  subdural
  subarachnoid
• spinal cord injury

Question 15

Correlation b/t athletes and concussions?

Answer 15

• head injuries are on the rise for athletes at all levels of play
• est 4-5 mill concussions annually
• increasing in middle school athletes, players are bigger, faster, stronger
• can occur in football, wrestling, soccer, cheerleading, hockey
• many don’t realize that have concussion
• coaches don’t recognize injury either
• mild injury can be sig: up to 15% can have long term sequelae

Question 16

What is a part of on field evaluations?

Answer 16

• ABCs first!
• any LOC, tx as cervical spine injury (C-spone precautons and immobilization)
• any signs of neuro deficits = immediate transfer to ER

Question 17

Sideline eval?

Answer 17

• signs, sxs
• mental status: orientation, concentration, memory
• gait assessment and balance

Question 18

• problems with sideline eval:

Answer 18

• players/coaches/parents know consequences of concussion - no play
• can happen on all plays, injury may not be seen
• concussions don’t only happen on big hits
• dx difficult if athlete doesn’t report and changes are not noted
• coaches and athletes reluctant to report sxs
• if any sxs reported, suspect concussion

Question 19

Post game eval?

Answer 19

• similar to sideline
• can determine if add tesing needed - emergent or not
• should include take home instructions
• coord the care and f/u of injured athletes
• discuss status of athlete with parents, ATs, and coaching staff

Question 20

What are indications for transfer to ED?

Answer 20

• LOC
• poss cervical spine injury or skull fracture
• high risk for intra-cranial bleed
• post-traumatic seizure
• acute worsening of mental status

Question 21

What is impt to remember about young and adolescent athletes? (protocols and sx resolution)

Answer 21

• use a longer sx-free period b/f starting exertion protocols
• extend length of graded exertion protocol
• don’t return to play or practice same day
• consult trained neuropsychologists
• age specific phsyical and cognitive rest issues (no over stim: no txting, video games, tv)
• sx resolution may take longer

Question 22

Tx of mild concussions?

Answer 22

• while sx: rest, fluids, and good nutrition
• physical rest: sleep is good, no training, playing, exercise or chores for a week
• cog rest:
  no TV, video games, txting, music, studying spanish (lol)
• avoid NSAIDs first 48hrs ( increase bleeding risk)
• avoid recreational activities that have risk for head injury)

Question 23

When can a concussed athlete return to play?

Answer 23

• not until full recovered - varies
• must pass exertional tests w/o sxs
• is athlete eager to return or still not feeling it?
• consider protective equip.
• career ending: 2 or 3 high grade concussions

Question 24

What is the rule of 3’s?

Answer 24

• 1 concussion: out of game/full practive for 7-10 days
• 2 concussions: out for the season
• 3 concussions: out of sport

Question 25

steps of progression for return?

Answer 25

- recurrence of sxs at any pt - drop back - aerobic exercise: light walking, biking - sport specific activities w/o opponent: dribbling, shooting, throwing, kicking - non-contact drills - full-contact drills - return to game play

Question 26

What is secondary impact syndrome?

Answer 26

- second impact to brain during vulnerable metabolic cascade - sudden, severe swelling - this occurs following head injury/concussion - occurs prior to healing of initial injury - may be minor/incidental injury - can lead to worsening mental status and death - 30-40 deaths in high school aged athletes over last decade

Question 27

Prevention of sports related concussions?

Answer 27

- can't condition brain but can strengthen neck muscles - rule changes if there is clear cut cause - spearing in football - protective equipment may lead to more risky behavior - promote fair play and respect and develop team awareness - teach players to play under control, how to fall, how to protect themselves - helmets do decrease risk of skull fracture and intracranial hemorrhage - mouth guards decrease risk of dental and oral trauma

Question 28

What is imPACT? | downside of it?

Answer 28

- immediate post concussion assessment and cognitive thinking - compute based neurophysiologic testing - records players sxs - scores verbal and visual memory, processing speed, reaction time - need baseline testing q 2 yrs (SD2 - freshmen and juniors) - admin by trained personnel: usually ATs - random variation of forms to inhibit learning at the test - athletes can game the test - time and dollar costs are high

Question 29

other testing tools for concussions?

Answer 29

- SCAT2 (sport concussion assessment tool 2) - SAC (std assessment of concussion: test orientation, concentration, delayed recall, immediate memory, exertional maneuvers, neuro screening

Question 30

Consequences of repetitive injury? What are you more likely to develop?

Answer 30

- athletes 3-6x more likely to have 2nd concussion - 2nd impact syndrome - don't recover as quickly or fully from another concussion - add concussions tend to be more severe - 4-7x more likely to get knocked unconscious ``` - more likely to develop; PCS HAs and sleep disorders depression and dementia CTE ```

Question 31

What is PCS? (Post concussive syndrome)

Answer 31

- chronic cognitive and behavioral sxs following injury: may take months to resolve - HAs, fatigue, sleep difficulties, concentration issues, emotional problems, and dizziness - affect sport, academics, life - need physical and cognitive rest - PT may be helpful (balance and proprioception), canalith repositioning maneuvers - beware of depression - if injury heals, no indication of long term problems

Question 32

Link b/t concussions and depression in NFL players?

Answer 32

- 20% of football players who recalled sustaining 3 or more concussions were dx with depression - 3x rate of players without concussions

Question 33

What is CTE?

Answer 33

- progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury - linked to memory loss, confusion, impaired judgement, paranoia, impulse control problems, aggression, depression, and progressive dementia - can only be dx posthumously via autopsy - characteristic streaks of dark tau protein on brain

Question 34

Evolving concussion guidelines?

Answer 34

- Natl hockey association: 1997: baseline available, but not reqd 2011 - league bans head hits, baseline testing in diff room for players who sustained head hits - MLB: 2007: medical staff must eval player with suspected injury on field 2011: neurocognitive ImPACT baseline testing mandatory, players with dxd concussion on 7 day disabled list NFL: 2007 - eval on field, 2009 - baseline testing mandatory if injury suspected, only asx players can return to play

Question 35

What is dylan steiger's law?

Answer 35

- passed by Montana legislature in 2013 key provisions: - educate coaches, athletes, parents on dangers of concussions - may not play with signs, sxs, or behaviors of concussion - must get medical clearance b/f returning to play/practice - decreases chance of long term injury by allowing for full recovery (doesn't reduce number of concussions)