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


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

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

  • 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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

Brain Function Damage Long Term
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

Brain Function Damage Long Term
  • CTE signs
  • Impulse control problems
  • Aggression
  • Depression
  • Progressive dementia

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

  • 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

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

  • 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

  • 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

  • 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

  • Vienna Concussion Conference return to play
  • 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)

  • 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

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

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

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

Studies Examining Relevance of Bell Ringers
in High School AthletesLovell, Collins, Iverson,
Field, Podell, Cantu, Fu J Neurosurgery
  • 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

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
  • Findings contrary to most grading systems (AAN)
  • Recovery from concussion may not be linear
  • Replication needed with college/professional
  • Should HS athletes return to competition in same

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

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

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

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

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
  • 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

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

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

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

Headache Study
  • Headache
  • Type of pain throbbing concussion, sharp
  • 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

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

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

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

  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.

  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.

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

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