Is it a Concussion or Did I Get My Bell Rung?

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Is it a Concussion or Did I Get My Bell Rung?

• Steve Pritchard MS, AT
• Southwest General Sports Medicine
• Head Athletic Trainer Strongsville High School
• B.S. Bowling Green State University
• M.S. Syracuse University

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Introduction

• Researchers are continually studying the effects
  of concussion and the best way to treat this
  potentially serious injury
• The University of Pittsburgh Medical Center and
  Boston University researchers are two of many
  groups who focus on concussion
• What new knowledge have they and others acquired?

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Topics of Discussion

• Concussion
• Definition, mechanisms, pathophysiology,
  signs/symptoms, brain function damage
• Concussion assessment
• Concussion management
• Neuropsychological testing
• Studies

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Concussion Definition

• An injury affecting the brain, induced by
  traumatic biomechanical forces
• No damage to brain anatomy
• Disturbance in brain metabolism
• Important facts
• No loss of consciousness necessary
• Recovery usually within days to weeks
• Traditional medical tests not helpful (CT, MRI)
• Poor management can result in serious injury

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Concussion Mechanisms

• Rotational
• Brain rotates on axis causing stretching/tearing
  of axons
• Stretching/tearing of blood vessels results in
  hematoma
• Brain strikes skull causing contusion

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Concussion Mechanisms

• Deceleration (linear)
• Brain moves forward in skull
• Frontal lobes strike inside of skull (coup)
• Rebound (contracoup) injury to occipital lobe
• Can cause a stretching/tearing of neurons in
  brainstem and throughout brain

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Concussion Mechanisms

• Direct blow (coup) can cause injury to the
  corresponding area of the brain blow to the back
  of the head causes biochemical changes to the
  occipital lobe

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Concussion Pathophysiology

• Studies on mice have demonstrated
• Increased energy demand within the brain due to
  ionic shifts with increased sodium and potassium
  activation with resultant hyperglycolysis
• Decreased cerebral blood flow
• Creates a mismatch of energy demand and delivery

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Concussion Pathophysiology

• The brain strives for homeostasis but these
  changes prevent it
• Rodent models have indicated this dysfunction can
  last up to 2 weeks, or theoretically longer in
  human models

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Concussion Signs and Symptoms

• Concussion signs
• Appears dazed
• Confused about play
• Moves clumsily
• Answers questions slowly
• Personality/behavior change
• Forgets plays prior to hit retrograde amnesia
• Forgets plays after hit anterograde amnesia
• Loses consciousness

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Concussion Signs and Symptoms

• Concussion Symptoms
• Headache
• Nausea
• Balance problems
• Double vision
• Photosensitivity
• Feeling sluggish
• Feeling foggy
• Change in sleep pattern
• Cognitive changes

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Concussion Signs and Symptoms

• Commonly Reported S/S from HS/Collegiate athletes
  within 3 days of injury
• Headache 71
• Feeling slowed down 58
• Difficulty concentrating 57
• Dizziness 55
• Fogginess 53

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Concussion Signs and Symptoms

• Commonly Reported S/S cont
• Fatigue 50
• Visual blurring or double vision - 49
• Light sensitivity 47
• Memory dysfunction 43
• Balance problems 43

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Brain Function Damage

• Injury to certain brain structures will cause
  specific symptoms
• Frontal lobe injury personality changes change
  in moral and/or social attitudes HA difficulty
  with memory
• Temporal lobe injury amnesia difficulty
  understanding written or oral requests

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Brain Function Damage

• Lt. Temporal lobe injury retrograde amnesia
  word memory difficulties
• Rt. Temporal lobe injury design memory
  difficulties

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Brain Function Damage

• Occipital lobe injury vision difficulties and
  reticular activating system problems fatigue is
  common and reaction time is adversely affected

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Brain Function Damage Long Term

• Chronic Traumatic Encephalopathy (CTE) a
  progressive degenerative disease of the brain
  found in athletes (and others) with a history of
  repetitive brain trauma, which can include
  symptomatic concussions or asymptomatic hits to
  the head.

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Brain Function Damage Long Term

• First noted in boxers beginning in the 1920s
• Recently noted in retired football players or
  athletes with a history of repetitive head trauma
• The trauma triggers a progressive degeneration of
  the brain tissue, including the build-up of an
  abnormal protein called tau.

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Brain Function Damage Long Term
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Brain Function Damage Long Term

• These brain changes can begin months, years or
  even decades after the last brain injury or
  athletic involvement
• Changes can cause
• Memory loss
• Confusion,
• Impaired judgement

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Brain Function Damage Long Term

• CTE signs
• Impulse control problems
• Aggression
• Depression
• Progressive dementia

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Assessment

• Cards
• Consistent questions
• What is the first thing you remember after the
  injury?
• What is the last thing you remember prior to the
  injury?
• Describe your HA throbbing, sharp, dull time
  of day?

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Assessment

• Classification and grading systems Cantu,
  Colorado, American Academy of Neurology
• Advantages of concussion guidelines
• Led to better recognition and awareness of injury
• Promoted use of uniform terminology
• Promoted research for more data-driven management
  principles

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Assessment

• Disadvantages
• Tremendous variability 19 current scales
  available
• Poor job distinguishing mild concussion
• Assigns too much importance to LOC
• May be useful to grade concussion once symptoms
  resolve (Vienna/Prague meetings)

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Assessment

• On-field
• Signs/symptoms evaluation
• Neurologic examination
• Mental status testing orientation,
  concentration, anterograde/retrograde amnesia
• Symptoms may worsen with exertion or over time
• Serial evaluation necessary
• Any positive findings preclude return to play

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Management

• Areas of focus
• Rule out a more serious intracranial pathology
  CT, MRI, neurologic examination primary
  diagnostic tests
• Prevent second impact syndrome
• Prevent against cumulative effects
• Cumulative neurobehavioral deficits
• Lowered threshold to injury
• Prevent presence of post-concussion syndrome

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Management

• Concussion should be case and data driven
• CT MRI are typically unremarkable post
  concussion and should be used when a structural
  lesion is suspected
• Return to play
• Symptom free at rest
• Symptom free with exertion
• Normal ImPACT test or another type of
  neuropsychologcal test

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Management

• Vienna Concussion Conference return to play
  recommendations
• Removal from contest following any signs/symptoms
  of concussion
• No return to play in current game
• Medical evaluation following injury
• r/o more serious intracranial pathology
• Neuropsychologic testing (considered cornerstone
  of proper post-injury assessment)

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Management

• Vienna Conference cont.
• Stepwise return to play
• No activity and rest until asymptomatic
• Light aerobic exercise
• Sport-specific training i.e. skate/run
• Non-contact drills
• Full contact drills
• Game play

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Neuropsychologic Testing

• Paper and pencil tests
• Computer based testing
• Cogsport Australian
• Headminders (CRI) NY
• ANAM
• ImPACT Pittsburgh, PA
• Concussionsentinel.com

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Neuropsychologic testing

• What is ImPACT
• Demographic/concussion history questionnaire
• Concussion symptom scale
• 21 item Likert scale (i.e. headache, dizziness,
  nausea, etc)
• Eight neurocognitive measures
• Measures domains of memory, working memory,
  attention, reaction time, mental speed

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Neuropsychologic testing

• Verbal memory, visual memory, reaction time,
  processing speed, summary scores
• Detailed clinical report
• Outlines demographic, symptom, neurocognitive
  data
• Automatically computer scored
• Components of validity
• Criterion-related validity several studies
• Construct validity several studies

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Studies Examining Relevance of Bell Ringers
in High School AthletesLovell, Collins, Iverson,
Field, Podell, Cantu, Fu J Neurosurgery
98296-301,2003

• 64 high school athletes with mild concussion
• Two groups compared in terms of outcome
• No athlete in sample sustained LOC
• All athletes met AAN grade 1 criteria
• No athlete returned to contest
• ImPACT evaluation obtained at baseline, day 2,
  day 4, and day 7 post-injury

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Bell Ringers Study

• Summary First study to challenge assumption
  that grade 1 or mild concussion in high school
  athletes in associated with rapid and complete
  recovery
• Findings contrary to most grading systems (AAN)
• Recovery from concussion may not be linear
  process
• Replication needed with college/professional
  athletes
• Should HS athletes return to competition in same
  contest?

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Studies Recovery from Concussion in High School
Athletes How Long Does it Take?Collins,
Lovell, Iverson, Ide, Maroon et al, 2005

• 3 year study with 2,141 athletes
• 134 athletes with diagnosis of concussion (6.2)
• All athletes received baseline ImPACT and follow
  up evals until complete recovery
• Recovery was return to baseline on ImPACT summary
  and symptom scores

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Recovery Study

• Summary
• Approximately 40 return in 1 week
• Approximately 60 return in 2 weeks
• Approximately 80 return in 3 weeks

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Studies Does Age Make a Difference in Recovery
From Sports ConcussionField M, Collins M, Lovell
M, Maroon J J Pediatrics 63 921-927, 2003

• 39 high school athletes
• 11 experienced LOC
• 22 hx of one prior concussion
• 53 college athletes
• 34 experienced LOC
• 37 hx of one prior concussion
• Groups compared in terms of neurocognitive
  recovery

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Age Study

• Summary first study to compare recovery from
  concussion in high school and college athletes
• Suggests protracted recovery in high school
  athletes
• Symptoms resolve earlier than neurocognitive
  deficits
• Longer-term outcome studies needed
• Contradicts return to play guidelines which
  assume standard use for all age groups and
  playing levels

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Studies Which On-Field Markers of Concussion
Predict Poor Acute Outcome?Collins, Iverson,
Lovell, McKeag, Norwig, et al. Clinical J Sport
Med 2003 13 222-229

• 139 HS/College athletes with concussion
• All athletes received baseline ImPACT
• Athletes re-evaluated within 72 hours
  post-concussion
• good outcome in 44 athletes (ImPACT)
• poor outcome in 34 athletes (ImPACT)
• Groups compared to presence of on-field markers
  of concussion
• Anterograde/retrograde amnesia, LOC
• Documented by physicians/ATCs

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Markers Study

• Summary
• Athletes with on-field retrograde amnesia are 10x
  more likely to have poor acute outcome
• Athletes with on-field anterograde amnesia are
  4.2x more likely to have poor acute outcome
• Brief LOC not predictive of outcome

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Studies Relevance of Post-Concussion Headache
in High School AthletesCollins, Field, Lovell,
Maroon et al Am J Sports Med 2003 31 168-173

• 110 HS athletes with concussion
• 84 male 64 FB players
• Athletes evaluated via ImPACT day 7 post-injury
• 73 (66) reported no HA at follow-up
• 36 (34) reported presence of HA
• Groups compared on ImPACT composite and symptom
  scores at Day 7
• No baseline differences between groups

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Headache Study

• Summary first study to suggest lingering
  headache is associated with incomplete
  neurocognitive and symptom recovery
• Conservative management indicated
• Need for follow-up evaluation
• Careful interview should include quality of pain,
  location of headache, duration of headache, and
  relationship to exertion
• Need for further research on headache type and
  pattern onset

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Headache Study

• Headache
• Type of pain throbbing concussion, sharp
  musculoskeletal
• Time of day a.m. concussion HA, afternoon HA
  worsens into p.m. concussion HA
• Exertion HA pain increases concussion HA
• Concussion HA stays in same area

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Further Headache Information

• Athletes with a HA plus the following will take
  longer to recover
• Retrograde amnesia
• Phonophobia
• Photophobia
• Nausea

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Studies Do Multiple Prior Concussions Lead to
Lowered Threshold to Concussive Injury?Collins
MW, Lovell MR, Iverson GL, Cantu et al
Neurosurgery 51 1175-81 2002

• 173 HS concussed athletes
• Groups determined by concussion hx
• No concussion in past (45)
• Hx of 3 concussion (27)
• Compared presence of on-field LOC, retrograde
  amnesia, and anterograde amnesia following
  in-season concussion

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Cumulative Study

• Summary first study to suggest cumulative
  effects of concussion in high school athletes
• Two hypotheses
• Lowered threshold with each concussion?
• Increased vulnerability in select individuals?
• Unknown duration of symptoms or long-term outcome
• Need for further research
• Need to document management of previous injuries
• Longitudinal studies in college and pro athletes

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References

1. University of Pittsburgh Sports Medicine ImPACT
   Training Workshops for 2006 Lovell M, Collins
   M 1/20/06.
2. Collins M, Stump J, Lovell M New Developments
   in the Management of Sports Concussion. Curr.
   Opin Ortho 2004,15 100-107.

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References

1. Lovell M, Collins M, Bradley J Return to Play
   Following Sports-Related Concussion. Clinics in
   Sports Medicine 2004, 23 421-441.
2. Concussion in Sports (CIS) Group Johnston K
   (chair), et al Summary and Agreement Statement
   of the 1st International Symposium on Concussion
   in Sport, Vienna 2001. Clinical Journal of Sport
   Medicine 2002, 12 6-11.

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References

1. Collins M, Lovell M Data-Based Management of
   Sports Concussion Research and Clinical
   Application. University of Pittsburgh
   Physicians, Department of Orthopaedic Surgery,
   2005.
2. Dock, D Permanent Post Concussion Syndrome Dr.
   Daniel P. Dock 4529 E. Superior St. Duluth, MN
   55804, 2004.

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References

• 7. Boston University Center for the Study of
  Traumatic Encephalopathy. Boston University
  Medical Center. Boston, MA. 2009.