Evaluation and Management of Head Injuries in Sports George S. Wham Jr., M.S., A.T.,C., S.C.A.T.

Evaluation and Management of Head Injuries in Sports

George S. Wham Jr., M.S., A.T.,C., S.C.A.T.George S. Wham Jr., M.S., A.T.,C., S.C.A.T.

NATA Competencies concerning Head Injuries Recognize signs and symptoms of head trauma, Recognize signs and symptoms of head trauma,

including loss of consciousness, changes in including loss of consciousness, changes in neurological function, cranial nerve assessment, neurological function, cranial nerve assessment, and other symptoms that indicate brain injuryand other symptoms that indicate brain injury

Explain and interpret signs and symptoms Explain and interpret signs and symptoms associated with intracranial pressure associated with intracranial pressure

Define cerebral concussion and lists the signs and Define cerebral concussion and lists the signs and symptoms used to classify cerebral concussion to symptoms used to classify cerebral concussion to accepted grading scales: Cantu, Colorado, ANAaccepted grading scales: Cantu, Colorado, ANA

Assess a patient for possible closed-head traumaAssess a patient for possible closed-head trauma

Mechanisms of Injury

CoupCoup a forceful blow to resting a forceful blow to resting

head, producing maximal head, producing maximal injury beneath the point of injury beneath the point of impact impact

example: being hit with a example: being hit with a baseball or hockey puckbaseball or hockey puck

Mechanisms of Injury

ContrecoupContrecoup moving head hits an moving head hits an

unyielding object, unyielding object, producing maximal brain producing maximal brain injury opposite the site of injury opposite the site of impact as the brain impact as the brain bounces within the bounces within the cranium cranium

Example: head hits ground Example: head hits ground when being tackledwhen being tackled

Mechanisms of Injury

Repeated Sub-Repeated Sub-concussive Blowsconcussive Blows

Many nontraumatic Many nontraumatic blows overtimeblows overtime

Example: Soccer Example: Soccer players who head players who head the ball frequentlythe ball frequently

Types of Head Injuries in Sports

Cerebral ConcussionCerebral Concussion

Cerebral ContusionCerebral Contusion

Cerebral HematomaCerebral Hematoma

Cerebral Concussion

Head trauma-induced alteration in mental Head trauma-induced alteration in mental status that may or may not involve a loss of status that may or may not involve a loss of consciousnessconsciousness

Cerebral Contusion

A bruise of the brain resulting from an impact of A bruise of the brain resulting from an impact of the skull and an object causing bleeding from the skull and an object causing bleeding from injured vesselsinjured vessels

May be associated with partial paralysis, one sided May be associated with partial paralysis, one sided pupil dilation, and altered vital signspupil dilation, and altered vital signs

Progressive edema may further compromise brain Progressive edema may further compromise brain tissue not injured in original traumatissue not injured in original trauma

If basic life support, proper transport techniques, If basic life support, proper transport techniques, and prompt expert evaluation are delivered, no and prompt expert evaluation are delivered, no surgery is needed and prognosis is goodsurgery is needed and prognosis is good

Cerebral Hematoma

Blood clot in the tissue surrounding the Blood clot in the tissue surrounding the brain causes pressure on the brainbrain causes pressure on the brain

3 Types3 TypesEpiduralEpiduralSubduralSubduralIntercerebralIntercerebral

Epidural Hematoma

Results from a severe blow to the head that Results from a severe blow to the head that produces a skull fracture in the produces a skull fracture in the temporoparietal regiontemporoparietal region

Neurological status may not be evident for Neurological status may not be evident for 10 to 20 minutes after the injury10 to 20 minutes after the injury

Immediate surgery needed to decompress Immediate surgery needed to decompress the hematoma and control the bleeding the hematoma and control the bleeding arteryartery

Subdural Hematoma

A blow to the skull that causes subdural A blow to the skull that causes subdural blood vessels to tear resulting in venous blood vessels to tear resulting in venous bleeding and the slow formation of a clotbleeding and the slow formation of a clot

Symptoms may not appear for hours, days, Symptoms may not appear for hours, days, or even weeksor even weeks

Surgery is needed to drain the hematoma Surgery is needed to drain the hematoma and decompress the brainand decompress the brain

Intracerebral Hematoma

Bleeding from a torn artery collects within Bleeding from a torn artery collects within the brain itself the brain itself

Often results from a depressed fracture or Often results from a depressed fracture or penetrating woundpenetrating wound

No lucid interval after the injuryNo lucid interval after the injury Hematoma progresses rapidlyHematoma progresses rapidly Death occurs before the athlete can be Death occurs before the athlete can be

moved to an emergency facilitymoved to an emergency facility

Second Impact Syndrome

An athlete sustains a second concussion An athlete sustains a second concussion before an earlier one has resolvedbefore an earlier one has resolved

Potential for occurrence with mild head Potential for occurrence with mild head injuriesinjuries

Often the first concussion goes unreported Often the first concussion goes unreported or unrecognizedor unrecognized

A major consideration when making return A major consideration when making return to play decisionsto play decisions

Second Impact Syndrome (con’t)

Occurs within 1 week of initial injuryOccurs within 1 week of initial injury Involves rapid brain swelling and herniationInvolves rapid brain swelling and herniation Brain stem failure develops within 2-5 Brain stem failure develops within 2-5

minutesminutes Causes rapid dilation of pupils, loss of eye Causes rapid dilation of pupils, loss of eye

movement, respiratory failure, and comamovement, respiratory failure, and coma Athlete must be intubatedAthlete must be intubated Mortality rate 50%Mortality rate 50%

Frequency of Concussions

1 in 5 (250,000) high school 1 in 5 (250,000) high school football players per year (Cantu football players per year (Cantu 1986)1986)

300,000 sport-related 300,000 sport-related concussions per year (Thurman concussions per year (Thurman et al., 1998)et al., 1998)

Player is 3 times more likely to Player is 3 times more likely to sustain a 2sustain a 2ndnd concussion after concussion after the 1the 1st st (Guskiewicz 2000) (Guskiewicz 2000)

Only 1 in 100,000 high school Only 1 in 100,000 high school football players suffer football players suffer catastrophic injuries (Cantu catastrophic injuries (Cantu 1999)1999)

Who’s at Greatest Risk?

(Mueller, F.O. 2001).

Frequency of Head-Related Fatalities

(Mueller, F.O. 2001).

Cause of Death?

(Mueller, F.O. 2001).

It’s Getting Better …..

(Mueller, F.O., 2001).

OK, but isn’t it just football?.…

(Mueller, F.O., 2001).

Mouth Guards Decrease Concussions? How?

(Winters, J.E., 2001)

Grading Scales

Cantu (1984)Cantu (1984)

Colorado Medical Colorado Medical Society (1991)Society (1991)

American Academy of American Academy of Neurology (1997)Neurology (1997)

Cantu’s Scale (1984)

Grade 1 – no loss of consciousnessGrade 1 – no loss of consciousness Grade 2 – loss of consciousness < 5 minutesGrade 2 – loss of consciousness < 5 minutes Grade 3 – loss of consciousness > 5 minutesGrade 3 – loss of consciousness > 5 minutes

Revised in 1992

(Shultz et al., 2000)

Colorado Medical Society’s Scale

Grade 1 – confusion; no amnesia; no loss of Grade 1 – confusion; no amnesia; no loss of consciousnessconsciousness

Grade 2 – confusion; amnesia; no loss of Grade 2 – confusion; amnesia; no loss of consciousnessconsciousness

Grade 3 – any loss of consciousnessGrade 3 – any loss of consciousness

American Academy of Neurology’s Scale

Grade 1 – confusion less than 15 minutes, Grade 1 – confusion less than 15 minutes, no loss of consciousnessno loss of consciousness

Grade 2 – confusion greater than 15 Grade 2 – confusion greater than 15 minutes, no loss of consciousnessminutes, no loss of consciousness

Grade 3 – any loss of consciousnessGrade 3 – any loss of consciousness

A.A.N.’s Recommendations for Management of Concussions in Sports For a grade 1For a grade 1

Remove from activityRemove from activity Examine immediately and at 5 minute intervalsExamine immediately and at 5 minute intervals Allow to return only if post-concussive Allow to return only if post-concussive

symptoms resolve within 15 minutessymptoms resolve within 15 minutes If a 2If a 2ndnd grade 1 concussion occurs on the same grade 1 concussion occurs on the same

day then remove until asymptomatic for 1 weekday then remove until asymptomatic for 1 week

A.A.N.’s Recommendations for Management of Concussions in Sports For a Grade 2For a Grade 2

Remove from activityRemove from activity Examine frequently to assess the evolution of Examine frequently to assess the evolution of

symptoms, with more extensive diagnostic symptoms, with more extensive diagnostic evaluation if symptoms worsen or persist for evaluation if symptoms worsen or persist for more than 1 weekmore than 1 week

Athlete may return to play after 1 week Athlete may return to play after 1 week asymptomaticasymptomatic

A.A.N.’s Recommendations for Management of Concussions in Sports For a Grade 3For a Grade 3

Remove from activity for 1 week if loss of Remove from activity for 1 week if loss of consciousness is brief, or for 2 weeks if consciousness is brief, or for 2 weeks if prolongedprolonged

If unconscious at time of initial evaluation or if If unconscious at time of initial evaluation or if neurological signs are abnormal, the athlete neurological signs are abnormal, the athlete should be transported by ambulance to ERshould be transported by ambulance to ER

If a 2If a 2ndnd grade 3 occurs, the athlete should not grade 3 occurs, the athlete should not return to sport until asymptomatic for 1monthreturn to sport until asymptomatic for 1month

If any abnormality exists on the MRI or CT If any abnormality exists on the MRI or CT scan the athlete should be removed from scan the athlete should be removed from activity for the season and discouraged activity for the season and discouraged from a future return to contact sportsfrom a future return to contact sports

Another Classification Scale to Consider?

(Oliaro, S., et al. 2001).

(Oliaro, S., et al. 2001).

More Return to Play Guidelines

Evaluation

Signs of Severe Brain Damage

•Damage above brain stem.

•Rigid extension of legs and flexion of the arms, wrist, and hands towards the chest

•Damage below brain stem

•Rigid extension of all 4 extremities with arms internally rotated and pronated

Babinski Sign

Thorough Evaluation Before an Athlete Is Allowed to Return to Play

On-field On-field AssessmentAssessment

Primary SurveyPrimary SurveySecondary Secondary

SurveySurvey

Off –field Off –field AssessmentAssessment

On-field Assessment

Primary survey Primary survey check ABC’scheck ABC’s

Secondary surveySecondary survey H.O.P.S. protocolH.O.P.S. protocol determine if the athlete can go to the sideline determine if the athlete can go to the sideline

for further evaluation or needs an ambulancefor further evaluation or needs an ambulance

**Often there is no “player down” assessment****Often there is no “player down” assessment**

Check for Signs of Skull Fracture

Battle’s SignBattle’s Sign – posterior – posterior auricular hematomaauricular hematoma

Ottorrhea Ottorrhea – CSF – CSF draining from earsdraining from ears

RhinorrheaRhinorrhea – CSF – CSF draining from nosedraining from nose

Raccoon EyesRaccoon Eyes – – periorbital ecchymosis periorbital ecchymosis resulting from blood resulting from blood leaking from anterior leaking from anterior fossa of skullfossa of skull

Symptoms of a Concussion Headache, nausea, vomiting, Headache, nausea, vomiting,

dizziness, poor balance, dizziness, poor balance, sensitivity to noise or light, sensitivity to noise or light, ringing in the ears, blurred ringing in the ears, blurred vision, poor concentration, vision, poor concentration, memory problems, trouble memory problems, trouble sleeping, sleepiness, sleeping, sleepiness, depression, irritabilitydepression, irritability

Only 8.9% result in a loss of Only 8.9% result in a loss of consciousness consciousness (Guskiewicz et (Guskiewicz et al., 2000)al., 2000)

Method to Rate Severity of Signs & Sx

(Oliaro, S., et al. 2001).

Initial Assessment

Obtain information about mental confusion, any Obtain information about mental confusion, any loss of consciousness, and amnesialoss of consciousness, and amnesia Confusion: dazed, stunned, or glassy-eyed facial Confusion: dazed, stunned, or glassy-eyed facial

expression; behaviors like running to the wrong huddleexpression; behaviors like running to the wrong huddle Unconscious: assume a cervical spine injury exists, Unconscious: assume a cervical spine injury exists,

athlete spine boarded sent to ER; If conscious ask if he athlete spine boarded sent to ER; If conscious ask if he has any tingling, numbness, or neck pain. Also, can he has any tingling, numbness, or neck pain. Also, can he move his fingers and toes?move his fingers and toes?

Amnesia: test for post-traumatic amnesia by asking Amnesia: test for post-traumatic amnesia by asking what he remember about the last play; test for what he remember about the last play; test for retrograde amnesia by asking name, date, placeretrograde amnesia by asking name, date, place

Initial Assessment (con’t)

Ask athlete if “his ears’ are ringing”, he has blurry Ask athlete if “his ears’ are ringing”, he has blurry vision, or nauseavision, or nausea

Check for any facial abnormalitiesCheck for any facial abnormalities While asking questions, observe speech patterns, While asking questions, observe speech patterns,

respirations, and movement of the extremitiesrespirations, and movement of the extremities Palpate the athlete’s cervical spine and skull to Palpate the athlete’s cervical spine and skull to

rule out fracture, assuming neck injury has been rule out fracture, assuming neck injury has been ruled outruled out

Walk to sideline for further assessmentWalk to sideline for further assessment

Glasgow Coma Scale Used to assess Used to assess

level of level of consciousnessconsciousness

(Shultz et al., 2000)

Cranial Nerve Assessment Rule out problems with II, Rule out problems with II,

III, IV, VI firstIII, IV, VI first II – check vision by read II – check vision by read

scoreboard and fingersscoreboard and fingers III, IV, VI – check eye III, IV, VI – check eye

movement by asking athlete movement by asking athlete to track a moving object, to track a moving object, check pupils for equal size check pupils for equal size and light reactivity with a and light reactivity with a penlightpenlight

** problems indicate increased ** problems indicate increased intracranial pressure**intracranial pressure**

(Shultz et al., 2000)

Further Cranial Nerve Assessment

I – check smellI – check smell V – check by clinching jawV – check by clinching jaw VII – check by raising eyebrows, smilingVII – check by raising eyebrows, smiling VIII – check balance and hearingVIII – check balance and hearing IX and X – check by swallowingIX and X – check by swallowing XII – check by sticking out tongueXII – check by sticking out tongue XI – check by neck rotation/extension and XI – check by neck rotation/extension and

shoulder shrugshoulder shrug

(Shultz et al., 2000)

Test Sensory/Motor Function

Dermatome TestingDermatome Testing

Myotome TestingMyotome Testing

ROM TestingROM Testing

Strength TestingStrength Testing

Upper Extremity Dermatome Testing C1: Top of headC1: Top of head C2: Temporal, C2: Temporal,

OccipitalOccipital C3: Neck, Posterior C3: Neck, Posterior

CheckCheck C4: Superior ShoulderC4: Superior Shoulder C5: Deltoid patchC5: Deltoid patch

C6: Lateral forearm, C6: Lateral forearm, thumb, fore fingerthumb, fore finger

C7: posterior forearm, C7: posterior forearm, middle fingermiddle finger

C8: Lower medial C8: Lower medial forearm, 4forearm, 4thth and 5 and 5thth fingers fingers

T1: Medial forearmT1: Medial forearm

Upper Extremity Myotome Testing

C1/C2: Cervical flexionC1/C2: Cervical flexion C3: Lateral neck flexionC3: Lateral neck flexion C4: Shoulder ShrugC4: Shoulder Shrug C5: Shoulder AbductionC5: Shoulder Abduction C6: Elbow flexion, wrist extensionC6: Elbow flexion, wrist extension C7: Elbow extension, wrist flexionC7: Elbow extension, wrist flexion C8: Ulnar deviation, thumb extension, finger C8: Ulnar deviation, thumb extension, finger

flexion & abductionflexion & abduction T1: Finger abduction/adduction T1: Finger abduction/adduction

Check Vital Signs

Increased pulse, Increased pulse, increased systolic increased systolic blood pressure, and a blood pressure, and a decreasing diastolic decreasing diastolic blood pressure blood pressure indicates increasing indicates increasing intracranial pressureintracranial pressure

A decrease in systolic A decrease in systolic bp denotes shockbp denotes shock

Check for Post-traumatic Amnesia(Anterograde) Give the athlete 3 Give the athlete 3

unassociated words to unassociated words to remember, and remember, and periodically ask for periodically ask for recall recall

Example: Red, Example: Red, Explorer, ClemsonExplorer, Clemson

Check for Retrograde Amnesia

Ask questions likeAsk questions like Where are we Where are we

playing?playing? Which quarter is it?Which quarter is it? What did we have What did we have

for pre-game meal?for pre-game meal? Who did we play Who did we play

last week?last week?

Check for Concentration

Have athleteHave athlete Recite days of the Recite days of the

week or months of week or months of the year backwardthe year backward

Count backward Count backward from 100 by 7’s from 100 by 7’s (Serial 7’s)(Serial 7’s)

Multiple/Addition Multiple/Addition factsfacts

SAC (Standardized Assessment of Concussion) Designed to detect impaired concentrationDesigned to detect impaired concentration Sideline or follow-up evaluation toolSideline or follow-up evaluation tool Takes 5 minutes to assess:Takes 5 minutes to assess:

OrientationOrientation Immediate memoryImmediate memory Neurological fxnNeurological fxn ConcentrationConcentration Delayed recallDelayed recall Sx during exertional testing Sx during exertional testing

(McCrea et al., 1997)

Neurocognitive Assessments

Trail-Making Test B: (working memory and rapid visual processing) Connect circles containing letters (A-

L) to numbers (1-13) in alternating numeric fashion as fast as possible.

Wechsier Digit Span Test: (concentration and memory recall) Subjects presented w/ a series of

numbers and must repeat digits in same order or reverse order.

(Guskiewicz, K. M. et al., 2001)

Check Balance, Coordination, and Depth Perception

Romberg’s TestRomberg’s Test

Finger-to-Nose TestFinger-to-Nose Test

Finger-to-Finger TestFinger-to-Finger Test

Heel-to-Toe WalkingHeel-to-Toe Walking

Supine Heel-to-Knee Supine Heel-to-Knee TestTest

Nerurocom Smart Balance Master System

SOT (Sensory SOT (Sensory Organization Test)Organization Test)

Forceplate system Forceplate system measures postural measures postural sway by quantifying sway by quantifying balance deficits and balance deficits and sensory organization sensory organization problems resulting problems resulting from a concussion from a concussion

Expensive and Expensive and immobileimmobile

(Guskiewicz, K. M. et al., 2001)

NeuroCom Smart Balance Master vs BESS

(Guskiewicz, K. M. et al., 2001)Strong Correlation between the two tests!

Balance Error Scoring System (BESS)

Quantifiable modified Quantifiable modified RhombergRhomberg

3 tests lasting 20s each3 tests lasting 20s each Double-legDouble-leg Single-legSingle-leg Heel-toeHeel-toe

Eyes ClosedEyes Closed Perform once on ground and Perform once on ground and

once on foamonce on foam Tally number of errorsTally number of errors

(Guskiewicz, K. M. et al., 2001)

6 Types of Errors in BESS

(Guskiewicz, K. M. et al., 2001)

Test Equilibrium and Balance

(Oliaro, S., et al. 2001).

(Shultz et al., 2000)

How long do symptoms linger?

(Guskiewicz, K. M. et al., 2001)

Post Concussion Syndrome

Functional Testing

Must be asymptomatic Must be asymptomatic Designed to see if Designed to see if

activity will cause activity will cause symptoms symptoms Sit-upsSit-ups Push-upsPush-ups JoggingJogging RunningRunning Sports Specific TasksSports Specific Tasks

Return to Play

Protocol

(Oliaro, S., et al. 2001).

95% of baseline on cognitive and

balance tests

Return to Play

Assuming the athlete Assuming the athlete passes the complete passes the complete exam he/she may exam he/she may return to playreturn to play

Take Home Message

While experts argue While experts argue over specifics of the over specifics of the guidelines all agree –guidelines all agree –

NO ATHLETE NO ATHLETE EXPERIENCING EXPERIENCING SYMPTOMS SYMPTOMS SHOULD SHOULD PARTICIPATEPARTICIPATE!!

ReferencesGuskiewicz, K.M., Weaver, N.L., Padua, D.A., Garrett, W.E. (2000). Epidemiology of concussion in

collegiate and high school football players. American Journal of Sports Medicine, 28, 643-650.

Guskiewicz, K.M., Ross S.E., Marshall, S. W. (2001). Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training. 36 (3), 263-273.

McCrea, M, Kelly, J.P., Kluge, J., Ackley, B., and Randolph, C. (1997). Standardized assessment of concussion in football players. Neurology, 48, (3), 586-588.

Mueller, F.O. (2001). Catastrophic head injuries in high school and collegiate sports. Journal of Athletic Training 36, (3), 312-315.

Oliaro, S., Anderson S., and Hooker, D. (2001). Management of cerebral concussion in sports: the athletic trainer’s perspective. Journal of Athletic Training, 36, (3), 257-262.

Shultz, S.J., Houghlum, P.A., Perrin, D.H. (2000). Assessment of Athletic Injuries. (1st Ed., pp.345-371). Human Kinetics. Champaign IL.

Thurman, J.D., Branche C.M., Sniezek, J.E. (1998). The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. Journal of Head Trauma Rehabilitation, 13, 1-8.

Winters, J.E. (2001). Commentary: Role of properly fitted mouthguards in prevention of sport-related concussion. Journal of Athletic Training, 36 (3), 339-341.