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. Tackling Sports Concussions
Head On
Jeffrey Rosenberg MD
Sports Medicine
September 5, 2012

2. Traumatic Brain Injury
Concussions are one type
of TBI
Diffuse Injury, No Anatomic
Changes
Focal Brain Injury-More
Severe
 Subdural Hematoma,
Epidural Hematoma, Intra-
cerebral Hematoma
 Associated with Anatomical
Change-Blood, Fluid, Local
Damaged Tissue

3. Myth #1: 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

4. 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

5. Myth #2: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
Brain cell injury and dysfunction
No anatomic damage

6. 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

7. Myth #3: 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 scarey but
not permanent

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

9. 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

10. Myth #4: 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

11. Second Impact Syndrome
Continued symptoms sign that
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

12. Myth #5: '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

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 #6: 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 #7-'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. Brain Rest
If minimal sx ok to go to school monday
− Most athletes will need to miss some school
− Schools finally understanding and are
required to comply
Take to MD on monday or tuesday for
eval

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

20. 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

21. 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

22. 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

23. Myth #8: 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

24. Return to Play
All physical sx must be gone
IMPACT scores 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

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

26. Myth #9 (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

27. 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

Violent Suicide

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