Transcript title

Concussions: New Guidelines and
What It Means In Today’s Athletic
Environment
Aaron Bott, MD
Dave Schultz, MEd, ATC
Sports Medicine Outreach Program
Nebraska Sports Concussion Network
The Concussion Problem
• Concussion injury reporting increasing
•
•
•
•
dramatically.
Substantial changes in concussion management
guidelines in past 3-5 yrs.
General void in education and awareness.
Disregard for seriousness of “minor” injuries.
Lack of consensus on management protocol by
healthcare professionals.
The Concussion Problem
• Athletes, knowingly & unknowingly, playing with
symptoms, leave the brain vulnerable to longterm neurological impairment, serious and
catastrophic injury, even death.
Nebraska Schools,
Serious & Catastrophic Head Injuries

Brent Cerny, Cedar Bluffs HS, FB 1995


Adrian Regier, Wheatland-Madrid HS, FB 1997


Subdural hematoma, decompression
Eric Lofton, Om. Northwest, FB, 2007


Subdural hematoma, decompression
Brady Beran, Lincoln East, FB 2004


Subdural hematoma, hospitalized only
David Huebner, North Platte, FB 2004


Subdural hematoma, decompression
Matt Hetrick, Coleridge HS, FB 2004


Second-Impact Syndrome
Nick Vorhees, Harvard HS, FB 1998


Second-Impact Syndrome
Subdural hematoma, decompression
Derek Ruth (12yo) Malcolm MS, FB 2008

Subdural hematoma, decompression
 Shelton Dvorak, Pierce HS,
 FB Sept. 30, 2011
Concussion Scenarios
• On-field Injuries (acute)
•
•
“Bell-Rung, Dinged”
“Dazed, Shaken Up, Rocked, Lit-Up”
• Injuries that are unknown and unreported
• Injuries occurring outside team play
•
MVA, playing on other teams, other mishaps
• Accumulative, sub-concussive injuries
• Post-Concussion Syndrome (chronic)
Post-Concussion Syndrome
• Chronic Headache (migraine)
• Sensitivity to Light & Noise
• Chronic Fatigue
• Balance (vestibular) Problems
• Behavioral Changes
• Sleep Problems
• Cognitive Deficits
• Academic Difficulties
The Concussion Problem
• Growing evidence of causation for memory
impairment, emotional instability, erratic
behavior, depression, problems with impulse
control, and early onset neuro-degenerative
diseases.
•
•
Dementia
Chronic Traumatic Encephalopathy (CTE)
•
Boxers, NFL football players
CTE

CTE, first reported in 1928 and originally referred to as “dementia pugilistica”
because it was believed to only affect boxers, is a progressive
neurodegenerative disease caused by repetitive trauma to the brain. The use of
the terms Traumatic Encephalopathy and CTE were first used in the 1960s.

The disease is characterized by the build-up of a toxic protein called tau in the
form of neurofibrillary tangles (NFTs) and neuropil threads (NTs) throughout the
brain. The abnormal protein initially impairs the normal functioning of the brain
and eventually kills brain cells.

Early on, CTE sufferers may display clinical symptoms such as memory
impairment, emotional instability, erratic behavior, depression and problems with
impulse control. However, CTE eventually progresses to full-blown dementia.
Although similar to Alzheimer’s disease, CTE is an entirely distinct disease.
CTE
TAKE HOME
Many head related catastrophes do not arise
from the blow on the day of the catastrophe –
but from an exacerbation of an earlier blow
that did not heal.
Concussions not only result from a substantial
blow or impact to the head, but also result
from the accumulative affect of minor blows
over time (hours/days/weeks), where such
circumstances are much less apparent to the
untrained and uniformed.
LB260 - Concussion Awareness Act
• Interscholastic sports teams, and any youth
sports organizations, 19yo and younger.
• 3 Primary Components:
•
Education, annual basis
•
•
•
•
Coaches concussion training (online)
Athletes/Parents provided concussion information
Removal of athlete if “reasonably suspected”
of having concussion.
Written Clearance for RTP by appropriate
licensed healthcare professional, and parent.
Appropriate Licensed Healthcare Provider
•
Physician: MD/DO, PA-C, APRN
Neuropsychologist
Athletic Trainer
Or, qualified individual able to provide healthcare
services where doing so falls within one’s scope of
practice and state licensure, AND trained in the
evaluation and management of traumatic brain
injuries among a pediatric population.
LB260, July 2012
CONCUSSIONS
Definition
A complex pathophysiological process affecting the brain, induced by
traumatic biomechanical forces.
1. Direct blow to the head region; impulsive force transmitted to
the head.
2. Rapid onset of short-lived neurological impairment that
resolve spontaneously.
3. Acutely, symptoms largely reflect a functional disturbance,
rather than structural injury.
4. Symptoms may or may not involve LOC, where resolution
follows a sequential course, where some of which may be
prolonged.
5. No abnormality in standard structural neuro-imaging studies.
Consensus Statement on Concussions in Sport: The 3rd International
Conference on Concussion in Sport held in Zurich,
P McCrory, W Meeuwisse, K Johnston, J Dvorak, M Aubry, M Molloy & R Cantu, Br. J. Sports Med. 2009;
43;i76-i84, doi: 10.1136/bjsm.2009.058248
“Metabolically
for the brain, a
concussion is
like running a
marathon.”
Bleiberg, J. MD 2002
CONCUSSIONS
Neurometabolic Cascade
 Indiscriminate release of
neurotransmitters
 Unchecked ionic fluxes


K+ efflux
huge Ca+ influx


 mitochondrial oxidation
activates cell death
mechanisms
 Neuronal depolarization
  Glucose metabolism

cellular energy crisis
  cerebral blood
flow
State of
PostConcussive
Vulnerability
Second Impact
Syndrome
• Condition is catastrophic;
carries a 50% chance of
death (mortality), and a
100% likelihood of
permanent neurological
impairment (morbidity).
Concussion Injury Rates
Powell & Barber-Foss, 1999
• 3-6% of all athletic
injuries occurring in
contact and collision
sports.
• 10% of athletes, on
avg. (FB: 15-20%), in
a contact or collision
sport will sustain a
concussion/season.
Concussion Case Rate
Football:
63.4%
Wrestling:
10.5%
Soccer (G):
6.2%
Soccer (B):
5.7%
Basketball (G):
5.2%
Basketball (B):
4.2%
Softball:
2.1%
Baseball:
1.2%
F. Hockey (B):
1.1%
Volleyball:
0.5%
Boden, BP, & Cantu, R. et al. Catastrophic Head Injuries in
High School and College Football. Am. J Sports Medicine,
2007, 35(7), 1075-1081.
• Nat’l Ctr. for Catastrophic Sports Injury Research
• 13 academic yrs., 1989-2002
• 94 catastrophic head injuries
•
•
•
•
75 subdural hematomas
10 subdural hematomas & diffuse brain edema
5 diffuse brain edema
4 aneurysms or congenital A-V malformations
• 7.2 catastrophic head injuries per year
CONCUSSIONS
Symptoms
• Subtleties of “Symptoms” are not easily
identifiable, but are at the core of proper
concussion management.
• Greater concern for length of time symptoms
are present, more so than which ones, or how
many – but all 3 remain important to proper
assessment & diagnosis of concussion.
CONCUSSIONS
Hallmark Signs
• Loss of
consciousness
• Confusion
• Disoriented
• Unsteady
Severity Grading Scales
C olorado M edic al
S oc iety G uidelines
C antu G rading S y s tem
A m eric an A c adem y of
N eurology G uidelines
G ra d e I
G ra d e II
G ra d e III
m ild
m oderate
s evere
N o LOC
N o LOC
LOC
C o n fu s io n w /o P TA
C o n fu s io n w /P TA
N o LOC
L O C < 1 m in .
L O C > 1 m in .
P TA < 3 0 m in .
P TA > 3 0 m in . - < 2 4 h rs .
P TA > 2 4 h rs .
S /S < 3 0 m in .
S /S > 3 0 m in . - < 2 4 h rs .
S /S > 1 w k.
N o LOC
N o LOC
An y L O C
s /s a b a te < 1 5 m in .
s /s > 1 5 m in .
Tra n s ie n t co n fu s io n
Tra n s ie n t co n fu s io n
Loss of Consciousness &
Post-Traumatic Amnesia
• Grading Scales have not been data driven.
• Only 9% of concussions involve LOC
• Only 24% of concussions involve PTA
•
•
•
Retrograde v. Anterograde
Short-term memory, Memory recall
More persistent symptoms than those with
brief LOC.
Concussion Symptom Clusters
Neuropsychiatric
More Emotional
Sadness
Nervousness
Irritability
Physical
Cognitive
Headaches
Attention Problems
Visual Problems
Memory Dysfunction
Dizziness
"Fogginess"
Light/Noise Sensitivity
Fatigue
Nausea
Cognitive slowing
Sleep Disburbances
Drowsiness
Difficulty falling asleep
Sleeping less than normal
CONCUSSIONS
Symptoms – Reported by Athlete
[50%]
• Prior History (risk factor) • Feeling like in a “fog”
• Headache
• Difficulty
• Nausea
• Balance Problem/
Dizziness
• Fatigue
• Drowsiness
• Blurred vision
•
•
•
•
concentrating
Difficulty
remembering
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Concussion Symptom Inventory (CSI)
Player Name: ________________________________________________________
Date of Injury: ________________
Date of Exam: ______________________
absent
0
Mild
1
2
moderate
3
4
severe
5
6
Score
Headache
Nausea
Balance problems/Dizziness
Fatigue
Symptom Checklist
Drowsiness
Feel like "in a fog"
(Graded Symptom Scale)
Difficulty concentrating
Difficulty remembering
Sensitivity to light
Sensitivity to noise
Blurred vision
Feeling slowed down
Total:
Other symptoms evident since injury?:
Randolph, C, Millis, S., Barr, WB, McCrea, M, Guskiewicz, KM, Hammeke, TA & Kelly, JP. Concussion Symptom Inventory: An Empirically Derived
Scale for Monitoring Resolution of Symptoms Following Sports-Related Concussion. Arch. Clin. Neuropsych, 24 (2009) 219-229.
Sideline Assessment Procedure
• Sideline Assessment Protocol
•
•
•
•
•
Assess for Signs & Symptoms
Check Orientation
Check Memory; Memory Recall
Check Concentration
Check Balance
• Athlete is disqualified with any abnormality or
deficiency (positive finding)
• Direct to appropriate licensed healthcare
provider
Balance Error Scoring System (BESS)
• Errors:
Opened eyes
• Stepped, fell, stumbled
• Removed hands off hip
• Moved hip 30º, flex/abd.
• Lifted toes/heels
• Remained out of
position >5 sec.
• Errors tabulated for all 6
tests.
•
CONCUSSIONS
No universal agreement on Grading Scales or
Management Protocol.
Unanimous agreement that an athlete with
post-concussion symptoms does not return to
play contact/collision sports.
Know who you’re dealing with
Type A - Warrior
 “…they’ll have to drag me off the field
before I stop playing – I’M FINE!!!”
Type B – Drama Queen
 “My mom and dad made me go out. I hate
playing… I’m looking for a way out… make
it look like I have a concussion”.
Symptom Resolution
Symptomatic
7 days
10 days
Concussed Athlete #1
Concussed Athlete #2
Concussed Athlete #3
Concussed Athlete #4
Concussed Athlete #5
Concussed Athlete #6
Concussed Athlete #7
Concussed Athlete #8
75% asymptomatic
within 7 days
Concussed Athlete #9
Concussed Athlete #10
92% asymptomatic
within 10 days
Symptoms vs. Neurocognitive Function
• Management & Return to Play (RTP)
decisions placing greater emphasis on brain
function and the value of Neurocognitive
Testing.
• Generally, Symptoms tend to resolve before
Neurocognitive Brain Function.
(Neuro)Cognitive Function
• Concentration
• Memory
•
•
Short-term
Delayed Recall
• Reaction Time
• Attention Span
• Processing Speed
Neurocognitive Testing
• Computerized application (on-line)
• Evaluation of multiple aspects of brain function:
•
Memory, Attention, Processing Speed, Reaction
Time, Concentration
• “Snapshot” of brain function.
• Pre-Injury v. Post-Injury Test Comparison
• Valid, objective, more consistent, safer
concussion management and RTP decisions.
Neurocognitive Testing
Baseline Testing
• Preseason testing under normal conditions
prior to injury.
• Testing conducted online in computer labs at
schools by school staff.
• Testing completed in ~25 minutes; multiple
users to be tested at same time.
• Baseline data saved on secure server and
accessed if an athlete sustains a head injury
requiring post-injury testing.
Neurocognitive Testing
Post-Injury Testing
• If an athlete sustains a concussion, they are
tested again, 24-72 hrs. s/p injury, or upon
being asymptomatic.
• Post-injury testing is conducted by a trained
physician, Neuropsych., or school’s ATC.
• Post-injury test data are compared to preinjury baseline data.
• Once post-injury test scores return to
baseline (normal), athlete may RTP*.
ImPACT
™
Test
ImPACT Test Modules
 Demographic section
 Symptom Inventory
1)
2)
3)
4)
5)
6)
Word Discrimination
Design Memory
X’s & O’s with distractor task
Symbol Matching
Color Match
Three-Letters with distractor task
 Symptom Inventory, 2nd trial optional
 Non-verbal Problem







Solving
Reaction Time
Visual & Verbal Memory
Response Variability
Attention Span
Working Memory
Sustained Attention
Selective Attention
ImPACT Test™
Return to Play Criteria
•
•
•
•
Symptom-Free at Rest
Symptom-free with Cognitive/Physical Exertion
Stepwise RTP Progression
Normal Neurocognitive Data
Stepwise Return to Play Progression
1. Complete Rest while symptomatic
•
Physical & Cognitive Rest
2. Begin light, aerobic activity (15-20 min.)
•
Bike, Walk, Swim; no wt. lifting
3. Sport/Position conditioning drills (30-45 min.)
4. Non-Contact practice (physician authorization)
5. Full, unrestricted practice
6. Competition
Timeline for Return to Play
[Days, Weeks, Months]
Timeline:
Asymptomatic
Baseline
Test
Injury
Post-Injury Test
(24-72 hrs.)
Symptomatic
Rest: physical & cognitive
RTP Progression
M onitor for return of
S/S during & after
exertion
Post-Injury Test
Return to full participation
Take Home
• FAR/coach’s role is to “RECOGNIZE”
potential for head injury.
• If any S/S are noted, FAR/coach removes
athlete. “The End – period.” Out of coach’s or
player’s hands.
• Coaches should never render their own
decision for RTP involving a concussed
athlete or one suspected of having a
concussion, without written authorization from
appropriate licensed healthcare professional.
Return to Play
• Schools/Athletic Training Staff retain the
responsibility to disqualify any athlete’s RTP in
the presence of note from anyone that clears an
athlete that remains symptomatic.
1. Symptom-Free, during exertion.
2. Neurocognitive Test scores return to normal.
3. Athlete completes RTP Progression before
resuming play.
Nebraska Sports Concussion Network
• Nebraska Orthopaedic & Sports Medicine, PC
• Saint Elizabeth Regional Medical Center
• Medical Director, Daniel Tomes, MD
• 100+ Credentialed ImPACT Consultants
• Regional Sponsors & Medical Communities
• 80+ High School Athletic Programs
• 9,000+ tests since July 2010
ImPACT Demo Test
www.impacttestonline.com/impactdemo
Customer ID: KJZB2X8FHG (case sensitive)
Resources
• Nebraska Sports Concussion Network
•
http://www.NebSportsConcussion.org/
• ImPACT Testing Services
•
http://www.impacttest.com/
In Review
•
•
•
•
•
•
Recognize that a concussion has occurred.
If concussion occurred, stop participation,
refer to appropriate healthcare provider
Symptom resolution varies widely.
While symptomatic, remain at rest, both
physically and cognitively.
RTP timeframe can not be established in
earliest stages of recovery.
RTP occurs after all criteria have been met.
Questions
Patrick E. Clare, MD
Ronald O. Schwab, MD
Donald J. Walla, MD
Thomas. M. Heiser, MD
Daniel R. Ripa, MD
David J. Clare, MD
James W. Gallentine, MD
Steven J. Volin, MD
Justin D. Harris, MD
Scott A. Swanson, MD
Daniel B. Cullan II, MD
Aaron M. Bott, MD
Joseph Mulka, MD
THANK YOU