Concussions

• Concussion

  Brain injury resulting in a complex pathophysiological response induced by biomechanical forces. Leads to temporary loss of normal brain function
• Mild Traumatic Brain Injury (mTBI)


  Term often used to describe concussions in non-athletic settings
• Both the terms "concussions" and "mTBI" are misleading as they redirect the attention from the essence of this condition, namely a "brain injury"
• Signs


  An objective, observable phenomenon that can be identified by another person (e.g. vomiting)
• Symptoms

  A subjective experience that cannot be identified by anyone but the person who feels it (e.g. nausea)
• Overall, football represents 44% of all concussions in high school sports and about 2/3 happen in practice
• Concussions are the 3rd most common injury in high school tackle football, representing 12.5% of all injuries in the sport
• All 50 States and the District of Columbia in the United States have some form of concussion legislation, including immediate removal from play and criteria for return to play
• Ontario, Canada has Rowan's law, which includes requirements for sports organizations, school boards, and medical professionals
• Concussion Recognition Tool

  A useful tool to help beginners identify concussions
• Sport Concussion Assessment Tool 5 (SCAT6)


  Health care professionals are more commonly using this tool
• Concussions have the same injury mechanism as severe head/brain traumatic injury (head impact and whiplash)
• Multiple concussions in a short period of time can lead to a deadly brain injury known as second impact syndrome
• Delayed recognition and removal can lead to poor recovery and/or disability, and even death
• Second impact syndrome occurs when an individual suffers a symptomatic head injury resulting in concussion symptoms, then before recovering sustains a second impact, developing altered mental status and sometimes loss of consciousness within seconds to minutes of the second hit
• All 17 cases of second impact syndrome reported in a literature review were males, with an age range of 13-23, and 10 out of the 17 were from American tackle football
• Outcomes of second impact syndrome include 4 deaths, 8 major disabilities, and 5 cases of minor impairments, with all but one being younger than 19
• Approximately 1/3 of children experience concussion symptoms lasting more than 1 month, which can have a negative impact on school, mental health, physical health, social isolation, and quality of life
• Additional exposure to head impact while symptomatic increases the risk of persistent post-concussion syndrome
• Delayed reporting and removal from sports after a concussion predicts prolonged recovery
• Immediate removal from sport participation after a concussion to reduce the risk of additional impact or prevent the brain from post-concussion exertion has been demonstrated to promote shorter recoveries and less severe symptoms
• Delayed referral for specialty care is associated with prolonged recovery
• Recognize and Remove

  1 head acceleration (head or body impact or whiplash) + ≥ 1 sign or symptom of concussion = removal from activity
• At least 50% of concussions go unreported
• Challenges to Recognition and Removal

  • Lack of objectivity and specificity of symptoms
  • Athletes' willingness to disclose injury
  • Desire to remain in the game
  • Interpersonal dynamics among the athlete, teammates, and coaches
  • Emphasis on winning games
  • Parents' financial interest or alternative agenda
• Presence of health care professional and improved if consistent HCP can develop a relationship based on trust with student-athletes, parents, coaches, and administrators facilitates recognition and removal
• Concussion recovery is complex and requires a multidisciplinary approach and the collaboration of every stakeholder involved in the care of student-athletes
• Clearance for unrestricted return to play must be done by a credentialed health care professional
• Clinical care for concussion

  Should be provided by a health care professional with expertise and experience in concussion management, and should be undertaken as soon as possible to limit risk of persistent symptoms
• Characteristics of appropriate clinics for concussion care

  • Has a physician in-house, or recommends to consult with one
  • Multidisciplinary and multifactorial approach
  • Teams of various health care professionals
  • Assess contributing factors to persistence of symptoms: neck, autonomic response, balance, oculomotor, and affective
  • Evidence-informed clinical practice
  • Up-to-date on most recent recommendations
• Return to play should be done under the supervision of a credentialed health care professional
• Elements of a concussion protocol

  • Culture
  • Roles and responsibilities of various stakeholders
  • Education
  • Communication
  • Yearly review
• Head impacts and whiplash can also result in significant neck injuries, and the athlete should be immobilized and the ambulance should be called if there are certain signs and symptoms: altered/loss of consciousness, neck pain, numbness/tingling in extremities, inability to move, restlessness/agitation, loss of bladder/bowel controls
• Conventional imaging performed in hospitals cannot detect a concussion, and imaging is only pertinent when a moderate-severe traumatic brain injury is suspected
• Athletes with a suspected concussion should be monitored by a responsible adult for the first 2 hours following impact, & they can rest or sleep as much as they need during the first 48 hours
• No medication should be given during the first 24 hours after a suspected concussion since it could mask symptoms & prevent detection of red flags. Any medication after that should be approved by a physician or pharmacist
• Things to advocate for to improve the safety of sport participants

  • Sport organisations or teams promoting a culture of overall health, safety, and personal growth over performance alone
  • Coaches that promotes this culture
  • Coaches knowledgeable about the risk of concussion in their sports and how to reduce it
  • Limited practices with contact
  • Written policies and procedures and organization specific concussion protocol
  • Credentialed health care professionals present at practices and games
  • Support from the organization to obtain adequate care
  • Partnerships with local clinics or health care professionals to promote early intervention
  • If school sports, support for return-to-learn and academic accommodations
  • Enforced rules and regulations
• Red flags requiring immediate call to 911

  • Neck pain or tenderness
  • Double vision
  • Weakness or tingling in arms or legs
  • Severe or increasing headache
  • Seizure or convulsion
  • Loss of consciousness
  • Deterioration conscious state
  • Vomiting more than once
  • Increasingly restless, agitative, combative
• Medical Definition of Concussion

  Clinical syndrome characterized by immediate & transient alteration in brain function, including alteration of mental status or level of consciousness, that results from mechanical force or trauma. (AAN)
• No Red Flags Present After Head Impact

  • Monitor for 30 minutes
  • Provide necessary information for next steps if no red flags appear
  • Notify parents, coaches, & other stakeholders as per concussion protocol
  • Refer to knowledgeable health care professional for in-depth evaluation