Updated – Concussion Management

NEW Updated Concussion Guidelines

from the American Academy of Neurology

Background information:

Concussion is a mild traumatic brain injury that occurs when a blow or jolt to the head disrupts the normal functioning of the brain.

Symptoms include persistent headache, problems with memory and communication, personality changes, and depression.

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Concussion can occur from a blow to the head/body, such as helmet to helmet contact, or contact with the ground or another object.

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More than a million Americans sustain a concussion each year.

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A concussion does not always “knock you out”.

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Symptoms of a concussion can last, hours, days, weeks, or even months.

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Why is this important?

Repeated concussion can lead to permanent brain damage, affecting academics, internships, social interactions, and athletics.

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Athletes who continue to play after sustaining a concussion, may take longer to recover and are at an increased risk for developing Second Impact Syndrome or a more prolonged Post-Concussion Syndrome.

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Numerous studies in professional boxers have shown that repeated brain injury can lead to permanent brain damage (dementia), sometimes referred to as “punch drunk” syndrome or dementia pugilistica.

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Autopsy studies have shown similar brain changes in former professional football players who experienced multiple concussions.

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Recent studies of college football players showed an association between multiple concussions and reduced cognitive performance.

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Guidelines for concussion evaluation and management

New American Academy of Neurology guidelines suggest the following management of concussion:

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Suspected Concussion:

Any athlete with suspected concussion should be closely observed and undergo repeated “side line assessments” for at least 30 minutes:

concussion screen

The presence of one or more of these symptoms and signs indicates concussion, that athlete should be removed from play, and referred to an emergency room or experienced concussion program for more detailed assessment.

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Brain Imaging Studies

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Any athlete who sustains a head injury who has unconsciousness, persistently altered mentation, or progressive deterioration on the screening tool (above) over time should be sent to the emergency room for a brain imaging study to rule out a skull fracture or intracerberbral hemorrhage.

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Follow-up Care at a Concussion Center

All athletes with concussion, whether they did not need to go the emergency room, or whether seen in the emergency room and sent home, should be evaluated by a health care provider experienced in managing concussion or a concussion center.  They should be prohibited from return to play or practice (contact risk activity) until the concussion has resolved and they are asymptomatic off medications.

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The concussion center uses clinical assessment of symptoms, computerized cognitive testing and balance testing to follow an athlete’s concussion, and determine when it has resolved.

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Computerized testing:

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Immediate Post-Concussion Assessment and Cognitive Testing (or ImPACT ) is used at many centers to help assess the severity of concussive brain injury and determine when it safe for athletes to resume sporting activities.

The test is computerized and lasts approximately twenty minutes.

Ideally, athletes should take a baseline test at the beginning of the season.

The test should then be repeated within 24-72 hrs after a concussion. The scores are compared to that athlete’s baseline to identify any residual change in verbal and visual memory, processing speed, and reaction time.

ImPACT testing can then be repeated to look for improvement, once the symptoms have cleared, or 7-10 days after the first post-concussion test.

This information can assist with decisions regarding when a player may return to action.

It should be noted that the widespread application of ImPACT testing has been criticized by some authorities.

ImPACT testing can be helpful, but is only part of the neurologic evaluation of athletes with concussion, and should not be the only factor used to determine when that athlete can return to sporting activities.

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Balance Testing:

The Balance error scoring system (BESS) is a clinical assessment of postural stability that is administered in the concussion center and contributes to the diagnosis of concussion.

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Recovery from concussion

Most athletes recover fully from a concussion, but it can take weeks, months, and even years.

School attendance, student work load and other activities may need to be modified according to the individual’s symptoms.

The athlete’s symptoms should be closely monitored until they feel symptom free.

Once the athlete is symptom free, and they have been cleared through ImPACT, they may begin a progressive return to their sport.

A progressive return involves gradually increasing the level and intensity of the activity, while closely monitoring the athlete for any return of symptoms

Day 1: Walking or easy biking for 20-30 min.

Day 2: Jogging or moderate biking for 20-30 min.

Day 3: Running or heavy biking for 20-30 min.

Day 4: Sport specific drills/practice (non-contact)

Day 5: Return to contact sports

If symptoms return at any point during the progression the activity should be stopped. The athlete should return to rest and must be symptom free for at least 24 hrs before starting the progression again.

Recovery may take longer in those with a previous history of concussion, learning disability, or attention disorder.

It must be stressed to athletes, parents and athletic trainers that these guideline are important, and must be followed to minimize the risk of permanent brain injury.

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Retirement from play

Health care professionals in a concussion center may suggest that athletes who have experienced multiple concussions and have persistent neurobehavioral problems permanently retire from contact sports.

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Download the AAN Concussion App

Download a concussion quick check app specially developed for coaches and parents directly to your ipad or droid device.

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