(3) Lecture 18: Sport Related Concussions

Question 1

Sport Related Concussion

Answer 1

a traumatic brain injury induced by biomechanical forces

may be linear or rotational

Question 2

Linear injury

Answer 2

1. Injury at impact site
2. brain strikes skull on OPPOSITE side (contre-coup)

Question 3

Rotational injury

Answer 3

1. Brain strikes skull on other side
2. Brain rotates - stretches or tears structures/vessels as it shears on itself

CSF doesn’t help w/ rotational/shear injuries

Question 4

Common symptoms

Answer 4

• headaches, fatigue, and dizziness are common in youth
• difficulty concentrating
• “fogginess”
• dizziness
• light sensitivity
• visual blurring or double vision

NONE of these are always present

Question 5

Clinical Domains of SRC

Answer 5

1. Symptoms → Somatic (headache), Cognitive (fog) & Emotional (mood swings)
2. Physical signs → LOC, Amnesia, Neurological deficits
3. Balance impairment → gait unsteadiness
4. Behavioural changes → irritability
5. Cognitive impairment → slowed reaction times
6. Sleep/Wake disturbances → somnolence (feeling really tired)

Question 6

When should a SRC be suspected?

Answer 6

If symptoms or signs in any ONE or more of the clinical domains are present

Question 7

“I didn’t see him hit his head”

Answer 7

SRC can be caused either by
- direct blow to head, face, neck, OR
- blow elsewhere on body w/ an impulsive force TRANSMITTED to head (fwd-back movement)

Therefore, they don’t have to get hit in the head

Question 8

“He didn’t even get hit hard”

Answer 8

• NO agreed-on biomechanical threshold for injury
• force does NOT factor in on symptom severity

Therefore, they don’t have to be hit hard to be concussed

Question 9

“Needs better equipment”

Answer 9

• helmets were made to prevent catastrophic head injuries like skull fractures, not low impact/rotational forces
• evidence for mouthguard preventing SRC is mixed

Therefore, better equipment does not necessarily prevent SRC

Question 10

“Concussions are getting worse”

Answer 10

• No such thing as a minor, severe, Grade 1,2 or 3
• time missed is getting longer b/c we are getting smarter with how to deal with them (not b/c SRCs ae getting worse but we know to sit out longer)

Therefore, concussions are not getting worse, we’re getting smarter

Question 11

Acute medical management of SRCs

Answer 11

• disposition of player must be determined in a timely manner
• standard orientation Q’s (time, place, person) are unreliable when used in isolation
• diagnosis should combine subjective symptom reports + clinical exam
• a combo of sideline tests should be used (NOT in isolation) - combo of symptom eval, postural control on firm surface, neurocognitive screening = best

Question 12

Sideline tests

Answer 12

• modified balance error scoring system (mBESS)
• vestibular/ocular motor screening (VOMS)
• neurocognitive testing (SAC)
• post-concussion symptom scale (PCSS)

all part of SCAT-5 EXCEPT VOMS

Question 13

Test for postural stability

Answer 13

Modified balance error scoring system (mBESS)

part of SCAT-5

Question 14

Test for oculomotor function

Answer 14

Vestibular/ocular motor screening (VOMS)

Question 15

Test for neurocognitive functions

Answer 15

Standard assessment of concussion (SAC)

part of SCAT-5

Question 16

Test for SRC symptoms

Answer 16

Post-concussion symptom scale (PCSS)

part of SCAT-5

Question 17

SCAT 5

Answer 17

most well-established and developed instrument for sideline SRC assessment

• use the SCRIPT - be consistent
• SAC immediate and delayed word recall lists includes option to use 10 words to minimize ceiling effect
• rapid neuro screening
• SCAT5 utility appears to decrease significantly 3-5 days after injury

Question 18

Evaluation of SRC

Answer 18

• remember to RE-EVALUATE
• serial monitoring for deterioration is essential over initial few hours after injury

Red Flags = immediate hospital trip
- Person complains of neck pain
- Deteriorating conscious state
- Increasing confusion or irritability
- Severe or increasing headache
- Repeated vomiting
- Unusual behaviour change
- Seizure or convulsion
- Double vision
- Weakness or tingling/burning in arms or legs

Question 19

Return to Play

Answer 19

expected duration of symptoms in children is up to 4 weeks

Question 20

Children under 13 Return to Play

Answer 20

• evidence to suggest that the developing brain is MORE vulnerable to injury
• NEVER RETURN TO PLAY ON SAME DAY
• should not return until clinically completely symptom-free

WHEN IN DOUBT, SIT THEM OUT

Question 21

Neurometabolic Changes and Concussion

Answer 21

• at day of injury, glucose need increases and blood flow decreases = mismatch
• 1st 2 weeks – brain does NOT operate like it should = doesn’t get enough blood flow or glucose

Question 22

Second Impact Syndrome

Answer 22

• occurs up to 14 days post-injury
• occurs in athletes w/ prior concussion, who return to play before resolution of symptoms
• catastrophic increase in INTRACRANIAL PRESSURE following relatively minor second impact
• most often occurs in athletes < 21 years old

Question 23

Safe and Effective RTP People

Answer 23

Athlete
- everything is based on their subjective reports (must be honest and forthcoming)

Parent: often liaison btwn medical team and sport team

Medical: voice of reason (critical eye - communicate RTP stages)

Coach: plans practice (team culture)

MUST work together to idealize environment

Question 24

Return to Play Stages

Answer 24

1. Symptom-limited activity
   - goal: gradual reintroduction of work/school
2. Light aerobic exercises: walking, stat. bike at slow pace
   - NO resistance training
   - goal: increase HR
3. Sport-specific exercise: no head impact activities
   - goal: add movement
4. Non-contact training drill: harder training drills
   - may start progressive resistance training
   - goal: exercise, coordination + thinking
5. Full contact practice: participate in normal training
   - goal: restore confidence + assess functional skills by coaching staff
6. Return to sport: normal game play

player MUST HAVE 24 hrs SYMPTOM FREE BTWN STAGES
- if symptoms return, they go back to previous stage after 24hrs symptom free