(3) Lecture 18: Sport Related Concussions Flashcards
Sport Related Concussion
a traumatic brain injury induced by biomechanical forces
may be linear or rotational
Linear injury
- Injury at impact site
- brain strikes skull on OPPOSITE side (contre-coup)
Rotational injury
- Brain strikes skull on other side
- Brain rotates - stretches or tears structures/vessels as it shears on itself
CSF doesn’t help w/ rotational/shear injuries
Common symptoms
- 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
Clinical Domains of SRC
- Symptoms → Somatic (headache), Cognitive (fog) & Emotional (mood swings)
- Physical signs → LOC, Amnesia, Neurological deficits
- Balance impairment → gait unsteadiness
- Behavioural changes → irritability
- Cognitive impairment → slowed reaction times
- Sleep/Wake disturbances → somnolence (feeling really tired)
When should a SRC be suspected?
If symptoms or signs in any ONE or more of the clinical domains are present
“I didn’t see him hit his head”
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
“He didn’t even get hit hard”
- 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
“Needs better equipment”
- 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
“Concussions are getting worse”
- 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
Acute medical management of SRCs
- 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
Sideline tests
- 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
Test for postural stability
Modified balance error scoring system (mBESS)
part of SCAT-5
Test for oculomotor function
Vestibular/ocular motor screening (VOMS)
Test for neurocognitive functions
Standard assessment of concussion (SAC)
part of SCAT-5
Test for SRC symptoms
Post-concussion symptom scale (PCSS)
part of SCAT-5
SCAT 5
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
Evaluation of SRC
- 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
Return to Play
expected duration of symptoms in children is up to 4 weeks
Children under 13 Return to Play
- 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
Neurometabolic Changes and Concussion
- 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
Second Impact Syndrome
- 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
Safe and Effective RTP People
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
Return to Play Stages
- Symptom-limited activity
- goal: gradual reintroduction of work/school - Light aerobic exercises: walking, stat. bike at slow pace
- NO resistance training
- goal: increase HR - Sport-specific exercise: no head impact activities
- goal: add movement - Non-contact training drill: harder training drills
- may start progressive resistance training
- goal: exercise, coordination + thinking - Full contact practice: participate in normal training
- goal: restore confidence + assess functional skills by coaching staff - 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
