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Talking Concussions

by Staff Writer / Florida Panthers

Hits are a big part of the game of hockey. They're jaw-dropping, they're game-changing and they’re violent.

With the game becoming more fast paced, more severe injuries are coming with the change.

One injury that hockey players, and other athletes have to deal with are concussions. They're more commonplace than ever, and can have both career- and life-altering affects. That's why sat down with the Panthers neurologist Dr. Frank Conidi to find out more about concussions, what causes them, the proper process for diagnosing and treating them, and more.

The Florida Center for Headache and Sports Neurology is a tertiary center specializing in the treatment of Headache and Sports Related Concussion, as well as most neurological disorders. Trained in Boston at Tufts, Boston University and Harvard affiliated hospitals, Dr Frank Conidi brings with him world class knowledge and a multidisciplinary approach normally found only at large academic institutions.

Neurological Care trusted by Professional Athletes and their fans.

Official Neurologist of the Florida Panthers.

Three Convenient Locations                1-877-648-4762
Broward, Treasure Coast, Palm Beach   www.fxneuro .org - How prevalent are sports related concussions?

Conidi - There are an estimated 1.8 to 3.6 million sports related concussions annually in the US and this number is likely higher as many go unrecognized or unreported. In fact after motor vehicle accidents, sports related concussions are the second most common cause of head trauma in adults and the most common cause in children. - What sport has the highest concussion rate?

Conidi - Most people are surprised to find that woman’s ice hockey has the highest rate of concussion at nearly 22% despite the fact that checking is not allowed. I suspect this is due to a high incidence or reporting and recognition of symptoms. Men’s ice hockey is second followed by football. - What exactly is a concussion?

Conidi - A concussion is a transient alteration of brain function. It is a traumatic event whereby biomechanical forces cause rotation of the brain’s cerebral hemispheres around the upper part of the brainstem, which is the part of the brain that is involved in attention, concentration and arousal. This results in complex and somewhat poorly understood short and long term electrical and chemical changes and the patient may experience a very brief alteration of awareness which is usually described as being “dazed” or “seeing stars”, or in rare occasions loss of consciousness.  Concussions portrayed in cartoons and movies, in which the front or back of the head is struck by a blunt object and no rotational or lateral force is induced are not possible. In fact many suggest that if the neck is restrained, concussion is difficult to produce.  Most concussions are short lived and resolve within seven to ten days, however children and adolescents usually take longer to recover. - What are the symptoms of a concussion?

Conidi - Immediately the athlete may present with a vacant stare (befuddled facial expression), delayed verbal and motor responses (slow to answer questions or follow instructions), confusion and inability to focus attention (easily distracted and unable to follow through with normal activities), disorientation (walking in the wrong direction, unaware of time, date. and place), slurred or incoherent speech (making disjointed or incomprehensible statements), gross observable decrease in coordination (stumbling, inability to walk tandem/straight line), emotions out of proportion to circumstances (distraught, crying for no apparent reason), memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes). Less then 10% will actually experience loss of consciousness. Within the first few hours the player may develop headache, dizziness, loss of equilibrium or vertigo lack of awareness of surroundings and nausea or vomiting. In the upcoming days they may go on to experience: Persistent low grade and sometimes even severe headache, or both. Light-headedness. Poor attention and concentration. Memory dysfunction. Easy fatigability. Irritability and low frustration tolerance. Intolerance of bright lights or difficulty focusing vision. Intolerance of loud noises, sometimes ringing in the ears. Intolerance to heat. Anxiety and/or depressed mood. Sleep disturbance. Decreased reaction time and balance (usually the last symptom to resolve). As a rule the longer the symptoms last the more severe the concussion. - How are concussions diagnosed and treated?

Conidi - The first individual to see an injured player is often a coach, parent and as the player progresses, an athletic trainer. Therefore it is extremely important that these individuals be properly trained and certified. The best tool for sideline assessment is SCAT 2 which tests orientation, symptoms and balance. Certain high schools, colleges and many professional sports organizations use computerized testing which is given before the season and again if the athlete suffers a concussion. The most popular test is IMPACT which is the standardized computer testing of the NHL. Computerized testing has many limitations including athletes actually performing better as a result of poor initial effort. There is also the possibility of a learning curve as the test is often given on consecutive days and most tests have little in the way of reaction time testing which is the last symptom of concussion to resolve and obviously the most important. Formal neuropsychological testing in conjunction with a good neurological exam and reaction time/balance testing are the best method of assessment. Once the athlete is completely asymptomatic they can begin to consider return to play (RTP).  The player starts out with a graded stepwise program where they need to remain asymptomatic for at least 24 hours before progressing to the next step. I actually prefer 48 to 72 hours as studies on the physiology of sports related concussion indicate that the brain does not return to normal function for 2 to 4 weeks. The program begins with light exercise, then more vigorous exercise. If they remain asymptomatic then they can begin non contact practice and then progress to contact at which time if they continue to remain asymptomatic are cleared to return to play. I also recommend that children who sustain a concussion refrain from all activity including school work, video games etc until asymptomatic and then undertake are more extended return to play program as their brains recover much slower then adult athletes. Finally, in some cases the player may suffer prolonged symptoms, i.e. post concussion syndrome which is usually require treatment by a neurologist who specializes in sports concussion management. They include headache, trouble with sleep, attention and concentration difficulties and loss of equilibrium and are usually treated with medications and physical and cognitive rehabilitation. The player must be off of all medications and asymptomatic before they can consider a graded return to play protocol. - What are the risks of a player returning to play before the symptoms of concussion have completely resolved?

Conidi - The most common and biggest risk of a player returning to play too early is a second concussion. In fact there are studies demonstrating an exponential risk of a second concussion in players who have suffered a concussion and have returned to play in a graded appropriate manner (and an even greater risk of a third after a second and so on). Second Impact Syndrome is a rare condition in which the brain swells rapidly and catastrophically after a person suffers a second concussion before symptoms from an earlier one have subsided. This deadly second blow may occur days or weeks after an initial concussion. The condition is often fatal, and if not usually leads to severe disability. The cause of SIS is unknown however may be secondary to a sudden loss of regulation of cerebral blood flow and uncontrolled brain swelling. Most cases of Second Impact Syndrome have occurred in young people, who are thought to be particularly vulnerable.  Finally, researchers at Boston University School of Medicine where I completed my education and neurology training are studying the brains of deceased retired professional athletes and have found premature neuro-pathological changes similar to those seen in older individuals who carry a diagnosis of Alzheimer’s Disease.  Furthermore, many retired NHL and NFL athletes are now beginning to report memory difficulties in their 40’s and 50’s. - You Recently formed a charity to address the problem of sports related concussion, and were voted by your neurology peers to be on the American Academy of Neurology Sports Concussion Executive Committee and Concussion Committee, can you tell us more about this.

Conidi - The American Academy of Neurology recently formed the Sports Neurology Section and I was elected by fellow neurologists throughout the world to serve on the executive committee. Our immediate goal is to update the outdated practice parameter on the diagnosis and management of sports related concussion. We expect these guidelines to be the world wide standard for concussion management and be adopted by all professional sports organizations including the NHL and NFL. We are also currently working on programs to certify neurologists in concussion evaluation, management and return to play.  Despite all the recent publicity in the media and subsequent congressional hearings there is little to no funding for sports related concussion education and research. With that in mind I along with members of the sports neurology section and concussion founded a charitable organization, The Seeing Stars Foundation ( Our mission is to support research and education on sports related concussion and sports related neurological injuries from the pee wee to the professional level. With its affiliation with the sports neurology section the Foundation is currently working on a national outreach program to train physicians, athletic trainers and other healthcare professionals in the diagnosis and management of sports related concussion, as well as a national television and print media campaign for sports related concussion awareness. I am also currently working with the US Congress on H.R. 1347 which provides for the establishment and implementation of concussion management guideline with respect to school age children. In the future we plan on developing and funding clinical research programs geared towards understanding the mechanism and physiology of sports related concussion, as well as evidenced based research studies on Neuroimaging techniques Neuropsychological testing, and the management of concussion related symptoms. We are currently planning our first major fundraising event in Palm Beach in March of 2011 where we hope to have a number of professional athletes and celebrities in attendance.
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