Transcript Document

Concussions in Sport
Mitigating Risks in the Student Athlete
Marc Richard Silberman, M.D.
Tip of the iceberg
Consensus Statement on
Concussions in Sport
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2001
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2004
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1st International Conference on Concussion in Sport, Vienna
2nd International Conference on Concussion in Sport, Prague
2008
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3rd International Conference on Concussion in Sport, Zurich
Sport Concussion Assessment Tool (SCAT2)
High School Concussions
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Over 50% of concussed high school football
athletes do NOT report their injury to medical
personnel
McCrea, M., Hammeke, T., Olsen, G., Leo, P., and Guskiewicz, K.M.
(2004). Unreported concussion in high school football players:
implications for prevention. Clin. J. Sport Med. 14, 13–17.
High School Concussions
Concussion
5.5% of total injuries
Football
Wrestling
Girls Soccer
Boys Soccer
Girls Basketball
Boys Basketball
Softball
Baseball
Field Hockey
Volleyball
63.4% of concussions
10.5%
6.2%
5.7%
5.2%
4.2%
2.1%
1.2%
1.1%
0.5%
JAMA. 1999 Sep 8;282(10):989-91
H.S. Basketball Concussions
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Concussion Cause
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Concussion Activity
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Collision with another player
65%
Contact with the floor
13%
Personal opinion this is not the truth
Rebounding
Defending
30%
20%
Illegal Activity
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Total number of injuries
Concussions
13%
35%
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
Collegiate Concussions
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Soccer, lacrosse, basketball, softball, baseball, and gymnastics
14,591 injuries in male and female athletes
5.9% of all injuries were classified as concussions
Males Game Injury Rate / 1000 exposures
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Soccer
Lacrosse
Basketball
1.40
1.46
0.47
Females
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Soccer
Lacrosse
Basketball
2.10
1.05
0.73
J Athl Train. 2003 Jul–Sep; 38(3): 238–244
Perceptions
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Survey 300 players, 100 coaches, 100 parents, 100 ATCs
If a player complains of a headache , should return to play?
 Players 55%, Coaches 33%, ATC 30%, Parents 24%
Percentage who would play a concussed star in a title game?
 Players 54%, ATC 9%, Parents 6.1%, Coaches 2.1%
Level of concern for concussions (1 = most concerned; 4 = least)
 Players 3.5, Coaches 2.4, Parents 2.1, ATC 1.6
Is a good chance of playing in the NFL worth a decent chance of
permanent brain damage?
 Players 44.7%, Coaches 19.4%, Parents 15%, ATC 10%
Your Brain
“This is your brain. This is your brain on drugs.”
Your Brain
The Brain
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Freely floating within the cerebrospinal fluid
Moves at a different rate than the skull in collisions
Collision between the brain and skull may occur
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On the side of the impact (coup)
On the opposite side of the impact (contracoup injury)
Acceleration-deceleration may result in stretching
of the long axons and in diffuse axonal injury
What is a concussion?
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Complex pathophysiological process affecting the brain
induced by traumatic biomechanical forces
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Functional disturbance of the brain
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No ‘visible’ structural injury
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Typically short lived impairment that resolves spontaneously
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Direct blow to the head
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Indirect blow with a force transmitted to the head
Classification of concussions
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A concussion is a concussion
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There is no such thing as a mild concussion
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No grading system
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Most symptoms resolve in a short period of 7-10 days
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Post concussive symptoms may be prolonged in children
Concussion diagnosis
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There is NO test to diagnose a concussion
Clinical diagnosis based on the following:
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Symptoms
Physical Signs (impaired balance)
Behavioral Changes (cry, irritable)
Cognitive Impairment (slow reaction time, memory)
Sleep Disturbances (drowsiness)
Symptoms
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Headache (83%)
Dizzy (65%), dazed, fog
Light and sound sensitivity
Visual disturbances
“Everything seems slow”
“My colors changed”
Teammate, “Eric’s not right, coach”
Appearance can be delayed several hours
Physical Signs
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You do not have to lose consciousness
Amnesia (“Doc, I don’t remember the first half”)
Emotional labile (crying, talkative)
Poor balance
Difficulty concentrating
Difficulty remembering
On-Field Evaluation
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Standard emergency management
Exclude cervical spine injury
Return to play determined by a physician
“When in doubt, sit them out”
No player shall return to play the same day
Sideline assessment of concussion (SCAT2)
Monitor for any deterioration over time
Syracuse
Post-Standard
Jan 16, 2005
Concussion Management
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Complete physical and cognitive rest until symptom free
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No sports
No horseplay
No school, if necessary
No texting, video games, internet, TV, driving
Graded program of exertion prior to full return to play
Exertion effects
 Symptoms are worsened by
 physical activity
 mental effort
 environmental stimulation
 emotional stress
Academic Accommodations
 Excuse from school if necessary
 Excuse from homework
 Excuse from quizzes and tests
 Rest breaks during school in a quiet location
 Avoid re-injury in crowded hallways or stairwells
 Avoid over-stimulation (cafeteria or watching games)
Provide reassurance and support
Recovery from Concussion
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Most ‘recover’ in 1 – 2 weeks, 95% recover in 3 months
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Longer in younger athletes and in female compared to male
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Post-concussion syndrome is the presence of symptoms for at
least 3 months post injury
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Deficits in balance resolve in 5 days
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Cognitive tests return to baseline in 5 – 10 days
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Abnormalities in metabolic balance, oxygen consumption, and
electrical responses persist for several months
a ‘miserable minority’ experience persistent symptoms
Post-concussion syndrome
Risk factors for complicated recovery
 Re-injury before complete recovery
 Over-exertion early after injury
 Significant stress
 Unable to participate in sports
 Medical uncertainty
 Academic difficulties
 Prior or comorbid condition
 Migraine
 Anxiety
 ADHD, LD
Multiple Concussions
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Second Impact Syndrome
 A concussion prior to recovery from a prior concussion
 Athlete is still symptomatic
 Mostly males < 21 years old
 Rapid increase in intracranial pressure
 Rare but almost always fatal
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Cumulative effects
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Risk of concussion is 4-6 times greater after one concussion
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Risk is 8 times greater after sustaining two concussions
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Prolonged or incomplete recovery
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Increased risk of later depression or dementia
How many is too many ?
Chronic Traumatic Encephalopathy
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Progressive degenerative disease
from multiple concussions
Build up of Tau protein in brain
35 brains of deceased athletes
Center for the Study of Traumatic Encephalopathy
(13 belonged to former NFL players).
12 out of 13 brains manifested
Chronic Traumatic Encephalopathy (CTE)
3 out of 12 exhibited motor neuron disease
(Chronic Traumatic Encephalomyelopathy)
Return to activity
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1. No symptoms at rest
2. Balance testing
returns to baseline
3. Neuropsychological test
returns to baseline
4. Consideration of modifiers
5. Graded return to play protocol
Neuropsychological Tests
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Neuropsychological testing is an additional tool
May assist in return to play decisions
 Need a baseline
 Perform the follow-up test when symptom free
Cognitive recover
 most overlap symptom recovery
 may precede symptom recovery
 may follow symptom recovery
Motivation and practice effects affect results
Do not reflect metabolic recovery of the brain
You can be fooled!
Graduated return to play protocol
Day 1
Day 2
Day 3
Day 4
Day 5
Light aerobic exercise
Light jog/stroll, stationary bicycle
Goal: elevate HR
Sport-specific exercise
Running drills in basketball
Goal: add movement
Non-contact training drills
Passing and shooting, light resistance training
Goal: coordination, cognitive load, valsava
Full contact practice only after physician clearance
Return to competition
Any symptoms at any stage, return to complete rest
Prevention
“An once of prevention
is worth a pound of
cure”
- Benjamin Franklin
Mechanism of Injury
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All sports head to head collision 50%
Soccer study of 20 FIFA tournaments from ‘98 – ‘04
 Aerial challenges 55%
 Use of the upper extremity 33%
 Use of the head 30%
 Only one injury (neck strain) as a result of ball heading
Lacrosse study of 560 games, 50 schools, 5000 athletes
 Men (32/34) almost all were a result of body checks
 Female (8/14) were a result of stick to head contact
Mechanism of Injury Hockey
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Body checking
86% of all injuries in 9 – 15 year old
Contact leagues
4x injury rate, 12x fracture rate
45% legal body checks, 8% illegal body checks
Direct fatality and injury rates for football are half of hockey
Spinal cord injury and brain injury rate
 2.6 per 100,000 high school hockey players
 .7 per 100,000 high school football players
Head Down Contact and Spearing
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Improved helmet technology has led to the increased use
of the head at contact, intentional and unintentional
Each time a player initiates contact with his head down
he risks quadriplegia
Each time a player initiates contact head first
he risks concussion
Heck et al. Journal of Athletic Training 2004;39(1):101–111
Spearing
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The use of the helmet (including the face mask) to
punish an opponent
No player shall use his helmet (including the face
mask) to butt or ram an opponent or to punish him
No player shall strike a runner with the crown or
the top of his helmet in an attempt to punish him
Always make contact with your shoulder while
keeping your head up
Head down contact and Spearing Slide Show
Head Down Contact and Spearing
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Educate players, coaches, and officials
Teach fundamentals and correct contact technique
Survey of 600 Louisiana High School players
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29% using top of helmet to tackle was legal
32% head butting was legal
35% permissible to barrel over an opponent headfirst
Only 2 coaches showed a blocking and tackling safety
video distributed free by the state federation
Helmets and Mouth Guards
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Helmets prevent skull fractures
Helmets do not prevent concussions, they cause
concussions
Mouth guards prevent dental injuries
Mouth guards do not prevent concussions
Mitigate Risk
Fundamentals
 Respect
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Hall of Fame Coach Bob Hurley Sr.
Concussions in Sport
Thank you.
Marc Richard Silberman, M.D.
Gillette, NJ
[email protected]
(908) 647 6464