Transcript Document

Concussions in Basketball
Marc Richard Silberman, M.D.
Has the game changed?
Wilt “The Stilt” Chamberlain
7-1, 250
Tiny Gallon 6-9, 290
The game has changed
“Now everyone looks like a sumo wrestler”
- North Carolina Coach Roy Williams
Your Brain
“This is your brain. This is your brain on drugs.”
This is your brain
The Brain



Freely floating within the cerebrospinal fluid
Moves at a different rate than the skull in collisions
Collision between the brain and skull may occur



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
Lies, headlines, and statistics









Headline: “Concussions in basketball are on the rise in teens”
Study: Retrospective review of ER visits from 1997-2007
Truth: “Emergency room visits diagnosed as concussions are
on the rise for teens playing basketball”
2.6% = overall concussion percentage of basketball injuries
Percentage doubled in boys, tripled in girls from 1997-2007
Does not tell us if more concussions are being suffered
The real story:
1/3 did not recognize or report symptoms to their ATC
28% continued to play with symptoms
Pediatrics, McKenzie, October 2010 issue
High School Concussions 1995-1997
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 Injuries 2005-2007





Ligament sprains
Muscle/tendon strains
Contusions
Fractures
Concussions
44%
17.7%
8.6%
8.5%
7.0%
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
H.S. Basketball Injuries 2005-2007
Rebounding caused the majority of injuries
Jumping/landing caused the majority of sprains
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
H.S. Basketball Injuries 2005-2007
Girls
5%
14 %
Boys
3%
5%
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
H.S. Basketball Injuries 2005-2007

Females




Greater proportion of concussions
Greater proportion of knee injuries
Knee was most common injury requiring surgery
Males



More frequently sustained fractures
More frequently sustained contusions
Contact sport
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
H.S. Basketball Concussions 2005-2007

Concussion Cause




Concussion Activity



Collision with another player
65%
Contact with the floor
13%
Personal opinion this is not the truth
Rebounding
Defending
30%
20%
Illegal Activity


Total number of injuries
Concussions
13%
35%
Am J Sports Med December 2008 vol. 36 no. 12 2328-2335
Collegiate Concussions 1997-2000




Soccer, lacrosse, basketball, softball, baseball, and gymnastics
14,591 injuries in male and female athletes
5.9% classified as concussions
Males Game Injury Rate / 1000 exposures




Soccer
Lacrosse
Basketball
1.40
1.46
0.47
Females



Soccer
Lacrosse
Basketball
2.10
1.05
0.73
J Athl Train. 2003 Jul–Sep; 38(3): 238–244
Collegiate Basketball Concussions
1997-2000






Females more likely than males to suffer concussions
Games 3.4X riskier than practices for females
A finesse sport has become a contact sport
Concussions in Women Basketball

4.7% total injuries sustained in practice

8.5% total injuries sustained in games
Concussions in Men Basketball

4.1% total injuries sustained in practice

5.0% total injuries sustained in games
NBA game injury rate 2X the NCAA
J Athl Train. 2003 Jul–Sep; 38(3): 238–244
This is your brain
What is a concussion?

Complex pathophysiological process affecting the brain
induced by traumatic biomechanical forces

Functional disturbance of the brain with no structural injury

Typically short lived impairment that resolves spontaneously

Direct blow to the head

Indirect blow with a force transmitted to the head
Classification of concussions

A concussion is a concussion

There is no such thing as a mild concussion

No grading system

Most symptoms resolve in a short period of 7-10 days

Post concussive symptoms may be prolonged in children
Concussion diagnosis


There is NO test to diagnose a concussion
Clinical diagnosis based on the following:





Symptoms
Physical Signs
Behavioral Changes (cry, irritable)
Cognitive Impairment (slow reaction time, memory)
Sleep Disturbances (drowsiness)
Symptoms







Headache is the most common
Feel dazed, cobwebs, or in a 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






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







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

Complete physical and cognitive rest until symptom free





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
 Most recovery in 7-10 days.
 About 95% recover in 3 months
 Post-concussion syndrome is the term used to
describe prolonged or incomplete recovery
 Non-injury factors often play a role in the persistence
of symptoms
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

Second Impact Syndrome
 A concussion within 2 weeks of one
 Athlete is still symptomatic
 Mostly males < 21 years old
 Rapid increase in intracranial pressure
 Rare but almost always fatal

Cumulative effects

Risk of concussion is 4-6 times greater after one concussion

Risk is 8 times greater after sustaining two concussions

Prolonged or incomplete recovery

Increased risk of later depression or dementia
How many is too many ?
Return to activity





No symptoms at rest
Neuropsychological test
returns to baseline
Balance testing
returns to baseline
Consideration of concussion modifiers
Graded return to play protocol
Neuropsychological Tests



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
You can be fooled!
Concussion modifiers
Symptoms
Signs
Sequelae
Temporal
Threshold
Age
Comorbidity
Medication
Behavior
Sport
Number, Duration (>10 days), Severity
Prolong loss of consciousness (> 1 min), amnesia
Concussive convulsions
Frequency – repeated concussions over time
Timing – injuries close together in time
“Recency” – recent concussion
Repeat concussions occurring with progressively less impact
Repeat concussions with slower recovery after each one
Child and adolescent
Migraine, depression, ADHD, LD, sleep disorder
Psychoactive drugs
Dangerous style of play
High risk activity, contact collision sport, high sporting level
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
Consensus Statement on
Concussions in Sport reference

2001


2004


1st International Conference on Concussion in Sport, Vienna
2nd International Conference on Concussion in Sport, Prague
2008

3rd International Conference on Concussion in Sport, Zurich

http://www.sportconcussions.com/html/Zurich%20Stat
ement.pdf
Sport Concussion Assessment Tool (SCAT2)

Concussions in Basketball
Thank you.
Marc Richard Silberman, M.D.
Gillette, NJ
[email protected]
(908) 647 6464