Sports Medicine

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Sports Medicine
Sports Related Concussion
Susanna
Gadsby, RN, BSN, MBA, ONC
Sports Medicine Dartmouth
Hitchcock Medical Center
Return to Learn Return to Play
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Concussion 101
Sports Medicine
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Conflict of Interest Disclosure
Sports Medicine

• I and/or my spouse/legally recognized domestic
  partner have no financial interest/arrangements
  in any amount within the past 12 months with one
  or more organization(s), which could be perceived
  as a real or apparent conflict of interest and
  which would reasonably appear to influence my
  role as a potential faculty/committee member for
  any CME or CNE activity.

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Objectives
Sports Medicine

• 1) Define Sports Related Concussion.  
•  
• 2) Identify implications for personnel involved
  with student-athletes who may be exposed to
  possible injury.
•  
• 3) Identify 3 symptoms of sports related
  concussion
•  
• 4) Identify 2 potential catastrophic
  complications of sports related concussion

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Defining Concussion
Sports Medicine

• Incidence 1.6 to 3.8 million people sustain
  sport or recreation related concussions each
  year.
• Despite this number definitions and diagnostic
  criteria vary widely.
• Neuroanatomic and physiologic measures are
  non-existent.
• Functional vs. structural injury, can make it
  challenging for students to convince others they
  are really injured.

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Sports Medicine
MAY BE AS HIGH AS 3.9MILLION
75,000
45,000
30,000
Faul MX, L. et al. Traumatic Brain Injury in the
United States Emergency Department Visits,
Hospitalizations and Deaths 20022006. Centers
for Disease Control and Prevention, National
Center for Injury Prevention and Control.
2010Atlanta (GA).
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Sports Medicine
Signs and Symptoms
Cognitive Physical Emotional Sleep
Feeling slowed down Headache Irritability Sleeping more than usual
Difficulty concentrating Dizziness Sadness Trouble falling asleep
Mentally foggy Fatigue/drowsiness More Emotional Sleeping less than usual
Difficulty remembering Fuzzy or blurred vision Nervousness
Difficulty thinking clearly Sensitivity to noise or light Anxiety
Balance problems
Having no energy
Nausea or vomiting
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G Forces
Sports Medicine

• What a hit is made of

• Sport Science helmet to helmet collisions
• 1 g gravity
• 3 g space shuttle
• 5 g formula one race car
• 9-12 g fighter jet in 90 degree turn
• Football players 95-103 g
• Pop Warner players measured at 45g!

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Sports Medicine

• Recognition and proper management of concussions
  when they first occur can help prevent further
  injury or even death.
• Athletes should NEVER return to activity on the
  same day as a concussion.
• Keep the athlete out of play until a health care
  professional, experienced in evaluating for
  concussion, has clearer him/her to return to
  activity.
• WHEN IN DOUBT, SIT IT OUT!

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Second Impact Syndrome
Sports Medicine

• When an athlete returns to play, and sustains a
  second concussion before the first concussion has
  subsided.
• Because the brain is more vulnerable, only a
  minimal force is needed to cause irreversible
  damage.
• Although SIS is rare, it is most often deadly.

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Newsworthy
Sports Medicine

• Chronic Traumatic Encephalopathy
• Head Games

• Not a new term
• punch drunk (Dr. Harrison Martland
  (pathologist), 1928)
• dementia pugalistica (US Navy Surgeon, Dr. J.A.
  Millspaugh, 1937)
• chronic traumatic encephalopathy of boxers (Dr.
  MacDonald Critchley, 1957)
• parkinsonian pugalistica (Mohammed Ali)

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How to get better
Sports Medicine

• Physical rest avoid physical activity including
  gym class, after school play, sports, etc.
• Mental rest avoid tests, computer use,
  television, video games, texting, reading,
  studying, etc.
• Emotional rest
• Get plenty of sleep at night,
• and rest during the day.
• Ask your doctor if you can
• drive a car.

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Sleep Hygiene
Sports Medicine

• Consistent bedtime and wake-up time
• Avoid excessive daytime napping
• Dim lights, calm atmosphere
• Avoid computers, TV, and texting for one hour
  prior to bedtime
• Sleep-promoting environment
• No exercise 3 hrs prior to bedtime
• Mornings with bright light, breakfast, and
  activities

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Healing time
Sports Medicine

• Unfortunately there is no way to tell how long it
  will take to heal from a concussion.
• Recovery depends on numerous factors
• How severe the concussion was
• Age of the athlete
• How healthy the athlete was before the
  concussion
• How the athlete takes care of themselves after
  the injury
• History of previous concussions
• Individual biology

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Children are not plastic
Sports Medicine

• Recovery times longer than previously thought
• Higher incidence for long-term physical,
  cognitive and emotional sequelae when not managed
  appropriately.
• Medical management necessary to ensure
  appropriate school-based treatment planning
• Developing skills such as executive control
  processes are particularly vulnerable.
• Some parents may find it hard to access
  appropriate care, no ATC, access to doctor who is
  knowledgeable in sports concussion management
• Girls may be more susceptible (theory of weaker
  neck muscles)

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Assessing Executive Function in Younger
Student-Athletes
Sports Medicine

1. Keeping track of time and finishing work on time
   have homework done in an hour
2. Meaningfully include past knowledge in
   discussions remember when we went to the park
   and we saw that dog
3. Evaluate ideas and reflect on work coloring,
   making a sand castle, playing with blocks
4. Change our minds and make mid-course corrections
   while thinking, reading, and writing do you want
   popcorn or chocolate at the movies, what movie to
   see, deciding what to have for dinner, or wear to
   school on a cold or warm day
5. Engage in group dynamics play group, watching TV
   with family
6. Asking for help or seek more information when
   needed where is the bathroom, cant tie shoe
   laces.

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Return to learnbefore Return to play!
Sports Medicine
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Students must be back to school fully before
being allowed back to play.
Sports Medicine

• School accommodations

• Extended time to turn in assignments
• Workload reduction
• Systematic plan with support and supervision
• Note takers
• Reduce multi-tasking
• Allow for breaks and quiet time
• Extend test time
• Testing in quiet environment
• Fewer and shorter tests
• Defer standardized or high-stakes tests
• No more than one test per day
• Multiple choice or cueing, rather than free
  response format

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Incidence (www.cdc.gov)
Sports Medicine

• During the last decade, Emergency Department (ED)
  visits for sports/recreation-related TBIs,
  including concussions, among children and
  adolescents increased by 60.
• Overall, the activities associated with the
  greatest number of TBI-related ED visits included
  bicycling, football, playground activities,
  basketball, and soccer.
• 71 of all sports/recreation-related TBI ED
  visits were males.
• 70 of sports/recreation-related TBI ED visits
  were persons aged 10-19 years.
• For males aged 10-19 years, sports- and
  recreation-related TBIs occurred most often while
  playing football or bicycling.
• Females aged 10-19 years sustained sports- and
  recreation-related TBIs most often while playing
  soccer or basketball or while bicycling.

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Sports Medicine
Return to Play How to know if the Doctor is up
to date?

• Mild, Moderate, or Severe.
• Grade I, II, or III.
• Must have a loss of consciousness.
• Return to play after headache disappears.
• Sit out 7 days, then return to play.
• Repeatedly wake up the concussed person.
• Must have a MRI or CT scan.

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Sports Medicine
Support Resources
http//www.cdc.gov/concussion/ http//patients.da
rtmouth-hitchcock.org/ortho/sports_concussion_prog
ram.html www.impacttest.com Online Coaches
Training http//cdc.gov/concussion/HeadsUp/online
_training.html
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Sports Medicine
Red Flags!

• Weakness, numbness or decreased coordination.
• Repeated vomiting or nausea.
• Slurred speech.

• Go to an emergency department right away if
• Look very drowsy or cannot be awakened.
• Have one pupil (the black part in the middle of
  the eye) larger than the other.
• Have convulsions or seizures.
• Cannot recognize people or places.
• Getting increasingly confused, restless, or
  agitated, rapidly worsening headache.
• Have unusual behavior.
• Lose consciousness (a brief loss of consciousness
  should be taken seriously and the person should
  be carefully monitored).

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Pieces of the diagnostic puzzle
Sports Medicine

• Sideline recognition/on field assessment
• Neurocognitive screening (ImPACT)
• Vestibular assessment (balance)
• Physical exam with coordination assessment

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Sports Concussion Assessment Tool 2 (SCAT2)
Sports Medicine

• A standardized method of evaluating injured
  athletes for concussion and can be used in
  athletes aged from 10 years and older.
• Assessment Includes
• Symptoms 22 possible
• Cognitive Physical Assessment
• LOC?
• Glasgow coma scale eye, verbal, motor
• Orientation Month, Date, Day of the week, year,
  time?
• Immediate Memory recall 5 word recall (elbow,
  apple, carpet, saddle, bubble)
• Concentration
• Repeat Digits Backwards 3-9-7, 4-6-1-0,
  2-9-6-1-4
• Months of the year in reverse order
• Balance
• Coordination
• Now available to download as an app onto a smart
  phone.

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Sports Medicine
Immediate Post-Concussion Assessment and
Cognitive Testing

• ImPACT testing is a 30-45 minute neurocognitive
  test battery that has been scientifically
  validated to measure the effects of sports
  related concussion.
• ImPACT is available for athletes age 11 to 65
• All athletes should have a baseline test prior to
  playing sports
• Middle School High School test every two
  years
• College test once
• Professional athletes test once
• Athletes with no Baseline test Athletes should
  be retested within 24-72 hours of sustaining a
  possible concussion.
• Athletes with a Baseline test Athletes should be
  retested when they are completely symptom free.

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ImPACT test
Sports Medicine
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Sports Medicine
Balance Error Scoring System BESS

• Screening for postural stability
• Double Leg, non-dominant leg, tandem stance
• Eyes closed
• Hard floor surface foam surface
• Count errors or out of position moments
• Lifting hands off hips,
• opening eyes,
• step, stumble, or fall,
• more than 30 degrees abduction or flexion,
• lifting foot or heel,
• Normal ranges established

http//www.csmfoundation.org/Concussion_Balance_Te
sting.html (Collegiate Sports Medicine
Foundations)
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Videos
Sports Medicine
Physiology of a concussion 330 minutes Play
Smart Brain Injury Assoc. of Mass.
understanding sports concussion with Dr.
Cantu ADAM Concussion animation 20
seconds Concussion 101 white board 551
minutes ESPN Sport Science 128 shows g force in
helmet to helmet collisions College football 1
minute (endzone) Barcelona soccer player April
24, 2012 He got back up and continued to play.
Eight minutes later he signaled to the coaching
staff of the sidelines that he could no longer
play. He was removed from the game. He was
transported to a hospital where he was admitted
for observation. Sidney Crosby hit behind the
play 17 seconds Soccer player 47 seconds NHL
concussion epidemic starts at 529 approx 3
minutes long
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Sports Medicine
Thank-you for this opportunity.
concussion_at_hitchcock.org Susanna