oaa concussion seminar scot brayford ms, otr/l, pa-c division of sports medicine orthopaedic...

OAA Concussion SeminarOAA Concussion Seminar

Scot Brayford MS, OTR/L, PA-CScot Brayford MS, OTR/L, PA-C

Division of Sports Medicine Division of Sports Medicine

Orthopaedic Associates of AllentownOrthopaedic Associates of Allentown

OAA Concussion Seminar

October 6, 2011 PennsylvaniaOctober 6, 2011 Pennsylvania’’s Lystedt Law passess Lystedt Law passes3030thth state to adopt legislation state to adopt legislation

Initial legislation introduction would have been 4Initial legislation introduction would have been 4 thth state state

2006 Zach Lystedt suffered brain injury upon return to 2006 Zach Lystedt suffered brain injury upon return to MS football game. Washington was first state legislature MS football game. Washington was first state legislature to pass lawto pass law

Lystedt Law highlightsLystedt Law highlights Educational materials for parentsEducational materials for parents Information meeting with parents in pre seasonInformation meeting with parents in pre season Mandates removal from play(coach/ATC/MD) on day of injuryMandates removal from play(coach/ATC/MD) on day of injury Coaches will have concussion course once/yearCoaches will have concussion course once/year


GoalsGoalsDefine concussionDefine concussionEpidemiologyEpidemiologyPathoanatomy Pathoanatomy Address the FAQ of concussionAddress the FAQ of concussion Challenge the common stereotypes of Challenge the common stereotypes of

concussionconcussion Give brief foundation of current eventsGive brief foundation of current eventsImPACT overviewImPACT overview


What is a concussion?American Academy of Neurology

A trauma induced alteration in mental status that may or may not involve loss of consciousness

Centers for Disease Control A disruption in brain function due to a blow or jolt to the head

Zurich 2008 Consensus statement A complex pathophysiologic process affecting the brain, induced by

traumatic biomechanical forces

The definitions highlight the functional changes that occur, not the structural changes, nor the mechanism


What is a concussion?

May or may not be caused by a direct blow to the head

Rotational component is important

Rapid onset impairment in neurologic function Symptoms may be short lived vs. long lasting

Neuroimaging studies grossly normal


What is the pathoanatomy of concussion?What is the pathoanatomy of concussion?Generally a coup vs. contrecoup from sudden acceleration- coup vs. contrecoup from sudden acceleration-deceleration mechanismdeceleration mechanism

Insult to head causes a flood of neurotransmitters (glutamate) Insult to head causes a flood of neurotransmitters (glutamate) causing neurons to firecausing neurons to fire

Calcium goes into neuronCalcium goes into neuron Potassium goes outPotassium goes out

Neurons continue to fire, requiring more energy, but calcium Neurons continue to fire, requiring more energy, but calcium in the cell and potassium outside restricts cells ability to get in the cell and potassium outside restricts cells ability to get energyenergy

At itAt it’’s basic core, concussion is an energy crisis of the brains basic core, concussion is an energy crisis of the brain Energy crisis causes symptomsEnergy crisis causes symptoms Activities which exacerbate energy crisis can cause symptomsActivities which exacerbate energy crisis can cause symptoms


Why do our definitions of concussion keep changing?Concussion is a complicated injury that has multiple presentations

Approximately 90% of the concussion research has been completed in the last 10 years

Our understanding of concussion is far from complete

**At present there are approximately 19 different concussion guideline/classification measures, none have been proven to have inter-rater and intra-rater reliability, thus no consensus on rating system

OAA Concussion SeminarOAA Concussion SeminarConcussion Epidemiology

Most common head injury

1.4 million per year in United States Incidence of concussion in > 75y/o and older only demo higher

than 15-24 y/o demographic

300,000 sports related concussions/year Approximately 60,000 in high school sports 63% from football, 7% from ice hockey

15-20% of football players annually 34% of college football players have had at least one concussion

90% of concussions are mild, with symptoms resolving in <10 days


Concussion Epidemiology (weird facts)Concussion Epidemiology (weird facts)Concussion is the leading cause for missed games for Concussion is the leading cause for missed games for Canadian youth ice hockey playersCanadian youth ice hockey players

Approximately 6% of cheerleaders will experience a Approximately 6% of cheerleaders will experience a concussion during their cheer careerconcussion during their cheer career

82% at experienced at practice82% at experienced at practice

From 1988 through 2004 the rate of incidence of From 1988 through 2004 the rate of incidence of concussions for field hockey and ice hockey was actually concussions for field hockey and ice hockey was actually higher than footballhigher than football

800,000 participants compared to 35 million800,000 participants compared to 35 million


LOC

Amnesia

Poor coordination

Slowed responses

Memory problems Repetitive questions Forget play/opponent

Irritable/emotional

Headache

Foggy

Dizziness

Lightheadedness

Photophobia

Tired/sleepy

What are the signs/symptoms of concussion?


Who warrants an urgent referral to ER?Who warrants an urgent referral to ER?

Loss of consciousness on the field/court lasting greater than 30 secondsDeterioration of neurological functionDecreasing level of consciousnessAbnormally unequal, dilated, or unreactive pupilsAny signs or symptoms of associated head/neck injuries, spine or skull fractures, or bleedingMental status changes: lethargy, difficulty maintaining arousal, confusion, or agitationWeakness or numbnessSlurring of speechHeadaches that are worsening over timeCranial nerve deficits

Released to care of parents with post concussion instructions


Common misconceptions/stereotypes

The athlete says he/she feels “fine”.75% of athletes surveyed report not knowing the signs/symptoms of concussion (Kaut 2003)

50% of high school football concussions go unreported (McCrea 2004)

“Symptoms not serious enough to report” Did not want to let team/players down Did not want to be removed from play

Anecdotal evidence from practice at OAA

OAA Concussion SeminarOAA Concussion SeminarI thought the helmet would prevent concussions

In 1960’s helmets initiated to decrease incidence of dental injuries, facial lacerations and severe head injuries (depressed fractures, hematoma, fatalities)

Fractures, hematomas and fatalities exceedingly rare NOCSAE (National Operating Committee on Standards for Athletic

Equipment) was established Still have not established standard to decrease concussionStill have not established standard to decrease concussion

Virginia Tech Helmet Study (May 2011)Virginia Tech Helmet Study (May 2011) Established STAR rating systemEstablished STAR rating system

Riddell Revolution Speed top performerRiddell Revolution Speed top performerRiddell VSR4 second lowest performer; Adams 2000 lowestRiddell VSR4 second lowest performer; Adams 2000 lowest

Not available for sale since 2010; company recommends alternativesNot available for sale since 2010; company recommends alternatives Most popular football helmet in use for all levelsMost popular football helmet in use for all levels Revo decreased likelihood of concussion by 30% from VSR4Revo decreased likelihood of concussion by 30% from VSR4

Rothlisberger and Rodgers had concussions in 2010 in VSR4Rothlisberger and Rodgers had concussions in 2010 in VSR4Even top performer only decreased incidence by 30%Even top performer only decreased incidence by 30%

HELMETS ARE NOT THE MAGIC BULLETHELMETS ARE NOT THE MAGIC BULLET


I thought the helmet would prevent concussions

2010 University of North Carolina study demonstrates number of impacts/year in football players

QB’s = 5900; OL/DL = 89000!

2010 Purdue study followed 21 players from a HS football team Accelorometer study over course of season

11 players identified due to severity or number of hits taken 3 diagnosed with concussion 4 showed no changes; 4 showed significant neuro-cognitive slowing WHILE

DISPLAYING ASYMPTOMATIC BEHAVIOR

Four STAR rated: Shutt ION 4D, Schutt DNA Pro+, Xenith X1, Riddell Revolution, and Riddell Revolution IQ


The CT scan was negative, so he/she can be cleared from concussion

Likely the largest misconception in concussion management

CT scan negative in +90% of all concussions Concussion a functional change, not a structural change If intracranial injury can be excluded, CT likely not indicated

Medical-legal implications for NOT CT

Parental expectations

Easier to check a box than to do necessary education


CT in recent years has expandedCT in recent years has expanded Risk vs. benefit rewardRisk vs. benefit reward

Rule out epidural, subdural, hematoma, skull fracture – life threatening conditionsRule out epidural, subdural, hematoma, skull fracture – life threatening conditions Natasha Richardson – subduralNatasha Richardson – subdural

If CT scan is positive, it is NOT concussionIf CT scan is positive, it is NOT concussion

One CT scan equals 200-250 x-raysOne CT scan equals 200-250 x-rays

One out of 5000 10y/o; One out of 10000 adolescents will develop lethal One out of 5000 10y/o; One out of 10000 adolescents will develop lethal malignancy from CT scanmalignancy from CT scan

If CT scan is negative, this is concussionIf CT scan is negative, this is concussion Does not eliminate possibility of prolonged recoveryDoes not eliminate possibility of prolonged recovery

MRI may have limited role in protracted symptomsMRI may have limited role in protracted symptoms Functional MRI is likely future, potentially 10 years away from being clinically Functional MRI is likely future, potentially 10 years away from being clinically

beneficialbeneficial


The Emergency Room doctor said I could return to play in one week

Likely the second most common misconceptionER doctors have likely ruled out life threatening injuries

Unlikely to have taken the time or effort to do a full evaluation for concussionApproximately 30-40% of concussions will be recovered enough to return to Approximately 30-40% of concussions will be recovered enough to return to play in one weekplay in one week

Approximately 50-60% in two weeksApproximately 50-60% in two weeks Approximately 80% in three weeksApproximately 80% in three weeks Prolonged recovery has some hallmarksProlonged recovery has some hallmarks

Retrograde amnesia is 10x more likelyRetrograde amnesia is 10x more likelyAnterograde amnesia is 4x more likelyAnterograde amnesia is 4x more likelyDizziness as a initial presenting symptom is 4x more likelyDizziness as a initial presenting symptom is 4x more likelyFogginess as primary complaint in office evaluation is 6x more likelyFogginess as primary complaint in office evaluation is 6x more likelyVestibular or balance issues that arenVestibular or balance issues that aren’’t improving with brain rest alonet improving with brain rest alone

Note LOC not listedNote LOC not listedCollege and pro athletes may recover quickerCollege and pro athletes may recover quicker

Mature brains, better initial recognition?, quicker/daily access to rehabMature brains, better initial recognition?, quicker/daily access to rehab


His/her head didn’t even get hit, so it can’t be concussion OR it shouldn’t take long to recover

Coup vs. Contrecoup mechanismRisk factor consideration

Age <14 y/o Migraine history

Consideration of family history of migraine Potential start of post-traumatic migraine

Female > male Concussion history? History of learning disability or ADHD?

Neck strength a factor? Research theorizes a correlation with greater neck strength and the

ability to absorb greater accelerations/forces No definitive study at present. No clear training regime outlined.

OAA Concussion SeminarHe/she says she is asymptomatic.

Players want desperately to return to play Culture of sport; role coaches play in creating an environment of

self reporting and acceptance of return to play guides are important

Time to be a parent vs. be a fan Be an informed advocate When in doubt, keep in them out

Conservative steps for high school; even more conservative for Junior High


Benefits of baseline testing ImPACT – Immediate Post Concussion Assessment

and Cognitive TestingUniversity of Pittsburgh – Lovell, Collins & Maroon

How the brain functions at baseline compared to functioning after concussion

Demographic questionnaire 21 Item Likert symptom scale 8 neurocogitive measures


Jim ThorpeJim Thorpe’’s Concussion Program s Concussion Program Player suspected of head injury remove from play and not be Player suspected of head injury remove from play and not be

returnedreturned Physical exam by ATCPhysical exam by ATC Evaluation by ER?Evaluation by ER?

24-72 hour ImPACT24-72 hour ImPACT Academic accommodations Academic accommodations Communication with concussion providerCommunication with concussion provider

Office evaluationOffice evaluation

Return to play on ZurichReturn to play on Zurich

Thank youThank you

oaa concussion seminar scot brayford ms, otr/l, pa-c division of sports medicine orthopaedic...

Documents

definitions of concussion

pathoanatomy of concussion

concussion research

brain injury

ms football game

football players annually34

college football players

brain function