Dr. Salvatore Trazzera, a Board Certified Cardiologist, Internal Medicine Specialist and Sports Medicine Physician has rapidly established himself as the athletes and fitness conscious individual’s physician. He has extensive experience in coronary angiography, non invasive vascular imaging and state of the art cardiac and vascular computed tomography. His life long experience as a competitive athlete combined with his extensive medical training, knowledge and clinical experience provide an uncommon combination of skills which allow him to relate to his athletes in a way unique to few physicians. He is owner and supervising team physician of professional, Jr. A and youth hockey programs for NYTEX Sports, Suffolk PAL and the Texas Brahmas of the Central Hockey League he has introduced a concussion prevention and management program utilizing state of the art clinical neurocognitive (ImPACT@) and neurophysical (Biodex Balance SD@) assessment. This program will help to guide athletes to safer timing of return to play minimizing recurrent and long term injury further decreasing post concussive cognitive impairment. To date he has over 250 competitive athletes baseline tested with ImPACT and Biodex Balance-SD and experience and expertise in returning athletes to competition safely post traumatic brain injury (concussion).
Below is an overview of concussion (Traumatic Brain Injury, TBI) prevention, recognition, assessment and treatment which will serve as a general outline for any school or club programs “Concussion Management Program”.
Recently much over due attention has been focused by the media on the epidemic of concussion or Traumatic Brain Injury in sports (we will use concussion, TBI or Traumatic Brain Injury interchangeably). A concussion is in fact just that. A functional brain injury sustained after direct or indirect head or brain trauma. Annual incidence of sports related concussion is estimated to be over 300,000 per year according to the Center for Disease Control. FACT: There need not be loss of consciousness to have sustained a concussion. FACT: The developing brain, in our younger athletes, is much more susceptible to functional brain injury. FACT: Recovery from TBI takes longer in the developing brain. FACT: The long term effect of repeated concussion in the younger athlete is incrementally worse than in older athletes. FACT: In a University of Pittsburgh Medical Center (UPMC) study of high school and college athletes with concussion, on-the-field amnesia, not loss of consciousness, as long thought, was predictive of post-injury symptom severity and neurocognitive (brain function) deficits.
Common signs of TBI include the athlete appearing to be dazed or stunned, confused about assignments, forgets plays, is unsure of game, score, or opponent, moves clumsily, answers questions slowly, loses consciousness (even temporarily), shows behavior or personality change, forgets events prior to hit (retrograde amnesia) or forgets events after hit (anterograde amnesia).
Signs frequently reported by the athlete include headache, nausea, balance problems or dizziness, double or fuzzy vision, sensitivity to light or noise, feeling sluggish, feeling “foggy”, change in sleep pattern and concentration or memory problems.
The overwhelming majority of athletes that sustain a concussion recover fully but unfortunately the number of athletes that go on to experience chronic cognitive and neurobehavioral difficulties is difficult to estimate, or for that fact accurately know especially if the athlete is reluctant to report symptoms to coaches, parents or trainers for fear of being removed from competition.
In the event of a witnessed blow to the head or the remotest of suspicion of a coach or trainer considering the possibility of TBI to one of his/her athletes, the athlete should be removed from competition until further evaluated by a clinician specializing in sports concussion management.
Upon ruling out more severe injury, acute evaluation continues with assessment of the concussion. First, the clinician should establish the presence of any loss or other alteration of consciousness (LOC). LOC is relatively rare and occurs in less than 10% of concussions.
The identification of LOC can be very tricky, as the athlete may lose consciousness very briefly and this event may not be directly observed by others. By definition, LOC represents a state of brief coma in which the eyes are typically closed and the athlete is unresponsive to external stimuli. LOC is most obvious when an athlete makes no attempt to brace his or her fall following a blow to the head. Any athlete with documented LOC should be managed conservatively, and return to play is contraindicated.
Although helpful in identifying more serious concerns (e.g. skull fracture, hematoma, contusion), traditional neurological and radiologic procedures, such as CT, MRI, and EEG, are not useful in identifying the effects of concussion. Such tests are typically unremarkable or normal, even in athletes sustaining a severe concussion. The reason for this issue is that concussion is a metabolic rather than structural injury. Thus, structural neuroimaging techniques are insensitive to the effects of concussion.
Concussion Management Guidelines
At the forefront of proper concussion management is the implementation of baseline and/or post-injury neurocognitive and neurophysical (balance, proprioception) testing. Such evaluation can help to objectively evaluate the concussed athlete’s post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the “cornerstone” of proper concussion management by an international panel of sports medicine experts.
Current management guidelines (i.e. Grade 1, 2, 3 of concussion) are not evidenced-based and little to no scientific data support the arbitrary systems that are in place to manage concussion. As a result, there are currently 19 different management criteria available for concussion management, which are often misused and misinterpreted.
According to the Vienna Concussion Conference Recommendations, athletes should complete the following step-wise process prior to return to play following concussion:
- Removal from contest following signs and symptoms of concussion
- No return to play in current game
- Medical evaluation following injury
- Rule out more serious intracranial pathology
- Step-wise return to play
1. No activity – rest until asymptomatic
2. Light aerobic exercise
3. Sport-specific training
4. Non-contact drills
5. Full-contact drills
6. Game Competition
The goal of concussion treatment is to allow the brain injury to heal. Treatment of concussions differs depending on the level of severity. Concussion treatment may include:
- Rest. Provide adequate time for recovery from a concussion. Do not rush back into daily activities for work or school.
- Preventing reinjury. Avoid activities that might jolt or jar your head. Never return to a sports activity until your doctor has given you clearance. Ask when it’s safe to drive a car, ride a bike, work or play at heights, or use heavy equipment.
- Observation by a responsible adult. Ask someone to awaken you every few hours as advised by your doctor. The doctor will explain how to watch for complications such as bleeding in the brain.
- Limiting exposure to drugs. Do not take medicines without your doctor’s permission. This is especially true with aspirin, blood thinners, and drugs that cause drowsiness. Avoid the use of alcohol or illicit drugs.
- Consult with a Credentialed ImPACT Consultant for a full recovery.
Athletes who are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussion.
Such difficulties are prevented if the athlete is allowed time to recover from a concussion and return to play decisions are carefully made. No athlete should return to sport or other at-risk participation when symptoms of concussion are present and recovery is ongoing.
In summary, the best way to prevent difficulties with concussion is to manage the injury properly when it does occur.
Overview of Adult Traumatic Brain injuries, Copyright 2011 Orlando Health Education & Development
Measurement of Symptoms Following Sports Related Concussions: Reliability and Normative Data for the Post Concussion Symptom Scale, Applied Neuropsychology, Lovell et al, May 2006
Neurocognitive and Symptom predictors of Recovery; Brian Lau, BS, Clin J Sports Med, Vol 0 Num 0, 2009
Concussions in the News Feb 12, 2012; http://www.stopconcussions.com/2012/02/dr-salvatore-trazzera/
Concussion Management recommendations; http://dev.impacttest.com/index.php/concussion/management
Salvatore Trazzera, MD, FACC, FACP, RPVI, RTV, RPhS, March 7, 2012
Center for Athletic Medicine & Phys