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Heather Sloan, RN, BSN Washburn University Graduate Nursing Student Concussion in Sport
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Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Dec 24, 2015

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Page 1: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Heather Sloan, RN, BSN

Washburn University Graduate Nursing Student

Concussion in Sport

Page 2: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

• Washburn University Graduate

Nursing Student (Family Nurse

Practitioner focus)

• Thesis project on Concussion New topic surfacing in 1999

• 2004 OHS Graduate

• 2008 Emporia State University

Graduate

• Registered Nurse at St. Luke’s,

Stormont-Vail, and Mercy Regional

Who am I?

Page 3: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

3.8 million sport related concussions occur annually

Adolescents are of particular riskThree times more likely to experience a

catastrophic head injurySecond Impact Syndrome: (occurring only in

individuals <20 years old)90% of fatal sports related head injuries occur

in high school age or younger athletes.Life long debilitating injuriesFew safety measures to protect adolescents

(AAP, 2010; Theye & Mueller, 2004; Langlois, Rutland-Grown, & Wald, 2006; Boden, Tacchetti, Cantu, Knowles, & Mueller, 2007; Mueller, 2001; McCrory, 2001)

Topic Significance

Page 4: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Topic History

Concussion in sport became a hot topic in the 1990s

2001 the First International conference on concussion in Sport and Concussion in Sport Group (CISG) emerged .

CISG sets the standard for concussion management

Every 3 years a new conference is held and a resulting statement is issued to update evidence-based concussion management approaches.

2012 will be the next conference

Page 5: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Concussive Injury

Page 6: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Defining Concussion• “A complex pathophysiological process

affecting the brain, induced by traumatic

biomechanical forces.” (McCroy et al.,

2009, p. 37)

Direct blow to the head, face, neck or

body

Rapid onset of short-lived neurologic

impairment that may occasionally be

prolonged

Symptoms largely affect function rather

than a structural injury

Once an athlete has sustained a

concussion, he or she is 6 times more

likely to sustain a second.

Page 7: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Signs and SymptomsPhysical Cognitive Emotiona

lSleep

• Headache• Nausea/

vomiting• Balance

problems• Visual

problems• Fatigue• Light sensitivity• Noise

sensitivity• Stunned• Dazed• Amnesia• Loss of

consciousness• Seizure• Numbness/

tingling• dizzyness

• Feeling “foggy”

• Feeling slowed down

• Concentration difficulty

• Difficulty remembering

• Forgetful• Confusion

about recent events

• Slow question response

• Repeats questions

• Irritability• Sadness• Emotional

Liability• Nervousnes

s• frustration

• Drowsiness• Increased

sleeping• Decreased

sleeping• Difficulty

falling asleep

• restlessness

(APA, 2010; McCroy et al., 2001; McCroy et al. 2004; McCroy et al. 2009; Theye & Mueller, 2004)

Page 8: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

• Risk with any concussion

• Highest risk sports include football and women’s soccer.

• Females experience a higher rate of concussion than males in similar sports

( APA, 2010; Guskiewicz et al. 2004; Cobb & Battin, 2004; Theye & Mueller, 2004, McCroy, 2001)

• Special injury reported only in individuals less than 20 years

• Catastrophic fatal injury following two or more concussions within a short period of time (hours, days, weeks) when the athlete has not had a chance for complete recovery between injuries

• Causes rapid brain swelling from disrupted autoregulation and cerebrovascular congestion. Results in brain herniation and death in 2 to 5 minutes.

Second Impact Syndrome

Page 9: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

• It is well established in research that cumulative effects occur if repeat concussions take place.

• Diffuse Axonal Injury:

results from shearing forces impacting neuronal axons and small vessels.

Long term consequences

Page 10: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

• Chronic Traumatic Encephalopathy:

• Result of repeat head trauma

• Symptoms similar to Alzheimer’s and progressing into symptoms similar to Parkinson’s disease.

Long term consequences

Page 11: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Additional injuriesInjurySpinal injury

Epidural hematoma

Subdural hematoma

Subarachnoid hemorrhage

Cerebral contusion

Page 12: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Concussion Management

Page 13: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

1. Legislative changes

HB 2095 passed in 2011

2. Front line management

ImPACT

3. Medical Management

Return to play guidelines

Management Principles

Page 14: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

HB 2095 Education per state board of education and

Kansas state high school activities association for school districts, coaches, athletes, and guardians.

Immediate removal from competition or practice should occur if concussion is suspected.

Athletes will not return to competition or practice until evaluated by a licensed health care provider trained in the evaluation and management of concussion. Athletes must also receive final clearance by a MD or DO to return to play.

Legislative changes

Page 15: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Baseline Assessments

comparison of functioning if injured during play

ImPACT

Top of the line neuropsychological testing

Return to Play guideline adherence

Allows for complete recovery of injury

Front Line Management

Page 16: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Preseason baseline testing

every 1-2 years with

IMPACT

Appropriate

identification of injury

and sideline

emergency manageme

nt

Evaluation by health

care provider. IMPACT testing every 3 days.

Once returned to

baseline begin

Return to Play

protocol.

Medical Management

Page 17: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Return to Play guidelines (McCroy et al., 2009)

Medical Management

Rehabilitation Stage

Function allowed Objective

No Activity Complete physical and cognitive rest

Recovery

Light aerobic exercise

Walking, swimming, or stationary cycling keeping intensity <70%MPHRNo resistance training

Increase HR

Sport-specific exercise

Running drills in Soccer, no head impact activities

Add Movement

Non-contact training drills

Progression to more complex training drills

Exercise, coordination, and cognitive

Full Contact Practice

Following medical clearance participate in normal training activities

Confidence and assess functional skills by coaching staff

Return to play Normal game play

Page 18: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

1. To begin return to play process the athlete must be asymptomatic at rest and with cognitive stress.

2. If asymptomatic at the current level of activity the athlete may precede to the next level of activity every 24 hours.

3. If any symptoms occur the athlete returns to the last stage without symptoms and resumes

progression following 24 hours rest.

4. The average time required for complete recovery is 7-10 days but may be prolonged in adolescents

and children due to their developing brains.

Medical Management

Page 19: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Home Management

• Monitor for new or worsening concussion symptoms.• Encourage your teen to report any and all symptoms.• Remind your teen the priority is their health which is

more valuable than sitting out a game or practice. • Avoid taking medications except for

Acetaminophen/Tylenol.• Avoid alcohol or drug ingestion• Avoid activities that increase symptoms • Strive for physical and cognitive rest (including

texting, school work, and video games)• Awakening at night is only necessary for athletes who

had a loss of consciousness, prolonged amnesia, or is still experiencing significant symptoms at bedtime.

• Follow the step wise return to play approach as prescribed by the trainer/health care provider.

Page 20: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

What is ImPACT?

• Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)

• Neurocognitive testing has been identified as the “cornerstone” in proper concussion management by the international consensus statement on concussion management.

• Has emerged as the leader in computerized neurocognitive testing tools for athletes and was designed for detection and management of concussion in sport.

• ImPACT is a scientifically validated tool that is intended to be used as a baseline tool to appraise an athlete’s neurocognitive functioning that can later be compared back to if the athlete sustains a concussive injury.

• Assesses 5 key areas: verbal memory, visual memory, reaction time, processing speed, and a symptom scale.

Page 21: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

ImPACT Application• Baseline assessment tool

• Currently administered every two years.

• Post injury, the tool is readministered and compared to baseline findings to detect injury and track recovery progress.

• The test is readministered approximately every 24-72 hours post injury by the athletic trainer to track recovery progress and determine return to play guideline application.

• In practice this information is important when considering beginning the return to play process and final release to game play.

Additional Resources for ImPACT:www.impacttest.com - Pay close attention to the “Concussion Management “ tab and be sure to review the “management” link under this tab. http://impacttest.com/pdf/improtocol.pdf (ImPACT algorithm of best practices)

Page 22: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Evidence base for ImPACT

• ImPACT baseline testing has been found to be a stable measure of neurocognitive performance in high school athletes (Elbin, Schatz, Covassin, 2011)

• Schatz’s study in 2010 supported ImPACT’s test-retest reliability .

• 64% of concussed athletes reported an increase in symptoms with a symptom only based approach (Van Kampen et al., 2006, p. 1633).

• With ImPACT only, 83% of concussed athletes were detected or a net increase in sensitivity of 19% occurred (Van Kampen et al., 2006, p. 1633).

• When ImPACT is combined with postconcussion symptom (PCS) presentation, 93% of concussed athletes are appropriately identified (Van Kampen et al., 2006, p. 1634).

• 0% of the control group presented with both complaints of symptoms

and a change in their ImPACT score compared to their preseason baseline.

Page 23: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Prevention

Page 24: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

When in doubt, sit them out!

REMEMBER…

Page 25: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Fair play

Respect/Sportsmanship

Standardized management

Page 26: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Miscellaneous InformationAdditonal References

www.kansasconcussion.orgwww.impacttest.com

See attachments for the American Academy of Pediatricians 2010 statement on pediatric concussion management and the latest CSIG statement on concussion management.

- Please e-mail the attached consent form electronically signed, brief survey, and any

additional questions to [email protected]

Thank you for your time and dedication to concussion management!

Page 27: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

American Academy of Pediatrics (2010). Clinical report- Sport-related concussion in children and adolescents. Pediatrics, 126 (3), 596-616.

Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Johnston, K., Kelly, J. … Schamasch, P. ( 2002). Summary and agreement statement of the fi rst International Conference on Concussion in Sport, Vienna 2001. Br J Sports Med, 36, 6-10.

Borowski, L.A., Yard, E.E. Fields, S.K., Comstock, R.D. (2008). The epidemiology of high school basketball injuries. American Journal of Sports Medicine, 36(12),2328-2325.

Calvin A.C., Mullen, J., Lovell, M.R., West, R.V., Collins, M.W., Groh, M. (2009). The role of concussion history and gender in recovery from soccer-related concussion. American Journal of Sports Medicine, 37(9), 1699-1704.

Dick, R.W. (2009). Is there a gender diff erence in concussion incidence and outcomes? British Journal of Sports Medicine, 37(1), i46-i50.

Elbin, R.J., Schatz, P., Covassin, T. (2011). One-year test-retest reliability of the online version of ImPACT in high school athletes. The American Hournal of Sports Medicine, 39 (11), 2319-2324.

References

Page 28: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., Comstock, R.D. (2007). Concussions among United States high school and collegiate athletes. Journal of Athletic Training, 42 (4), 495-503.

Guskiewicz, K. M., Bruce, S. L., Cantu, R. C., Ferrara, M. S., Kelly, J. P., McCrea, M. … McLeod, T. C. (2004). National athletic trainers’ association position statement: management of sport-related concussion. Journal of Athletic Training, 39 (3), 280-297.

Langlois, J.A., Rutland-Brown, W., & Wald, M.M. (2006). The epidemiology and impact of traumatic brain injury: a brief review. Journal of Head Trauma Rehabilitation, 21(5), 375-378.

Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. PlexusPress: Bordentown, New Jersey.

McCroy, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J. … Schamasch, P. (2005). Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med, 39, 196-204.

References

Page 29: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Malloy, M., & Cantu, R. (2009). Consensus statement on concussion in sport – The 3 rd International Conference on Concussion in Sport held in Zurich, November 2008. SAJSM, 21 (2), 36-46.

House Bill NO. 2095 (2011). Retrieved from http://www.kslegislature.org/li/b2011_12/measures/documents/hb2095_00_0000.pdf

Schatz, P. (2010). Long-term test-retest reliability of baseline cognitive assessments using ImPACT. The American Journal of Sports Medicine, 38 (1), 47-53.

Sitzman, K. & Eichelberger, L.W. (2004). Understanding the work of nurse theorists: A creative beginning. Jones and Bartlett Publishers: Sudbury, Massachusetts.

References

Page 30: Heather Sloan, RN, BSN Washburn University Graduate Nursing Student.

Theye, F. & Mueller, K. A. (2004). “Heads up”: Concussions in high school sports. Clinical Medicine & Research, 2 (3), 165-171.

Tucker, A.L. & Edmondson, A.C. (2002). Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. Harvard Business School. Retrieved from http://www.hbs.edu/research/facpubs/workingpapers/papers2/0203/03-059.pdf

Van Kampen, D.A., Lovell, M.R., Pardini, J.E., Collins, M.W., & Creddie, H.F. (2006). The “Value Added” of neurocognitive testing after sports-related concussion. The American Journal of Sports Medicine, 34 (10), 1630-1635.

References