Transcript Concussions on Campus - University of Pennsylvania

Concussions:
Should Richie play football?
Christina Smith Paul MD, FAQSM
Primary Care & Sports Medicine
Student Health Service
University of Pennsylvania
Concussions are not a new phenomenon, but they certainly have
been getting a lot of attention in the news in the past few
years. High profile professional athletes and former athletes have
started to come forward and speak about their experiences with
this injury and its (sometimes) prolonged and profound effect on
their respective futures. The heightened awareness about this
important injury has led to a boom in marketing efforts: both from
an injury prevention standpoint and a diagnosis standpoint, with
inconsistent evidence that these efforts are successful. Education
about the injury remains the most important tool in preventing
bad outcomes. Come learn a bit more about concussion, help
clarify some myths, and hear how we take care of our concussed
students here at Penn
Concussions in the News:
ESPN, NYTimes
• “SEC concerned about concussions”
• “New concussion law suit filed by 100 explayers”
• “Concussions affecting women more often
than men”
• “More retired players sue NFL over concussion
effects”
• “Trying to Reduce Head Injuries, Youth
Football Limits Practices”
Overview
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Definitions
Diagnosis
Cognitive tests
Treatment
Prevention
Return to school, return to athletics/clearance
Ongoing research
Systems at Penn
Headgames
• http://vimeo.com/headgames/trailer
Concussion
• Concussion = Traumatic Brain Injury
• Loss of consciousness = Rare (and not predictive)
• Causes: blow to head or body
http://www.youtube.com/watch?feature=player_
detailpage&v=fY7J7bccNoU
• Symptoms vary
• Grading systems obsolete
– Simple vs Complex (Prague, abandoned Zurich)
– Avoid slang terms as well (“bell rung” etc.)
• Consensus Statement on Concussion in Sport:
the 3rd International Conference on
Concussion in Sport held in Zurich, November
2008
What we know
• Numbers are increasing
– More so in females
• Each subsequent concussion seems to require
less force
• Balance testing is an objective measure (BESS:
Balance Error Scoring System)
• Is a functional, not structural issue
What we know
• Equipment does not PREVENT concussion
“Absence of Proof is not Proof of Absence” www.sportsdentristy.com
What we don’t know
(but are working on)
• How to predict duration of recovery
• Why some people are more susceptible
• http://www.youtube.com/watch?v=O8R1x6Co
6OY&feature=player_detailpage
• How many is “too many”
• How to speed recovery
– Supplements
– Medications
– Physical therapy
Concussion Symptoms
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Headache
Nausea
Dizziness
Blurry vision
Sensitivity to light or noise
Feeling sluggish, foggy, “out of it”
Confusion
Difficulty with concentration, memory
Concussion Facts
• High risk activities: Bicycling, Football,
Playground Activities, Basketball, Soccer
– Numbers and rates are highest in:
• football (55,007; 0.47 per 1000 athlete exposures)
• girl’s soccer (29,167; 0.36 per 1000 athlete exposures)
• ED visits:
– 1.37 million per year (790k male/575k female)
Concussion Diagnosis
• You can’t SEE it
• Sings/symptoms usually follow the injury but
there can be a delay
• Awareness/education of coaches, parents,
athletes is VITAL
• http://www.nfl.com/videos/nfl-network-aroundthe-league/09000d5d814d2543/Concussionsafety
Concussion Treatment
• Initial Treatment:
– Do I need to take Richie to the ED?
– Should Richie get a head CT?
• COGNITIVE AND PHYSICAL REST
Treatment, continued
• Ongoing:
– Do I need to wake Richie up at night?
– Can Richie go to school?
– Can Richie do homework, watch TV, email?
– Can Richie play in his game tomorrow?
– Can Richie take ibuprofen?
– Role of meds or physical therapy?
Concussion Investigations
• Neuroimaging
– CT scan
– MRI (structural and functional: studies emerging)
• Objective balance assessment (BESS)
• Neuropsychological assessment
Neurocognitive Testing
• Computer-based
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ImPACT, CogSport, HeadMinder
Added tool for use in return-to-play decisions
Avoidance of returning an athlete too soon
Baseline testing
Timing of testing
Pros/cons of testing
• Formal “paper and pencil” testing
• Several hours
• Comprehensive
• Reserved for chronic/difficult cases
Return To School Guidelines (CHOP)
• Step 1
– Complete cognitive rest: No TV, computer, text, etc.
• Step 2
– Light cognitive activity, 5-15 min increments, frequent
breaks, stop if symptomatic
• Step 3
– Schoolwork at home, 30 min increments
• Step 4
– if tolerating 1-2 hrs at home, can go half day
*advance to next step if symptom-free x 24 hrs
Graded Return to Play
Rehab Stage
Functional Exercises
Objective at each stage
1. No activity
Physical and Cognitive Rest
Recovery
2. Light aerobic exercises
Walking, swimming,
stationary bike; intensity
<70% maximum HR
Increase HR
3. Sport-specific exercises
Skating drills, running drills
etc. No head impact.
Add movement
4. Non-contact training
drills
Progression to more
complex training (passing,
etc.); May start resistance
training
Exercise, coordination, and
cognitive load
5. Full contact practice
Following medical
clearance participate in
normal training/practice
Restore confidence and
assess functional skills
6. Return to play
Normal game play
Recurrent Concussions
• Second impact syndrome:
– Brain swells rapidly, death near certain
– repeat injury w/o proper healing time
– Young people more vulnerable
– Few cases
• Post concussive syndrome
• Chronic Traumatic Encephalopathy
Sports Legacy Institute
• Chris Nowinski
Concussions and mental health:
In the news
Chronic Traumatic Encephalopathy (Tau Protein)
Prevention?
• Gear
– Head gear
• Helmet
• Other head gear
– Mouth guards
– Softer balls (soccer)
• Exercises:
– Strengthen neck
– Learn proper techniques
• Tackle techniques
• Heading techniques
Prevention
• Rule Changes:
– NFL and College Football
• Kickoffs moved up to 35 yd line (from 30 yd line)
– Pop Warner Football
• No hitting in 2/3 of practice
• Additional precautions (3 yards or less, etc)
– USA Hockey
• Raise checking age (11 to 13)
– Education (coaches, trainers, athletes, parents)
What we are doing at Penn
• Concussion policy (NCAA requires)
• All varsity and club athletes must be evaluated
and cleared by SHS physician
• Baseline ImPACT testing done on all Varsity
athletes involved in contact sport
• Referral resources:
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Neurology and Neuropsychiatry
Weingarten
CAPS
Physical Therapy (Vestibular Rehabilitation)
SHS visits for concussions
Mechanisms of Injury,
All Concussions 2010
n=87
60
50
52
40
30
20
10
12
9
9
4
1
assault
work
0
sports
fall
MVC
hit object
2010 SHS Data
By Gender
Concussions by Degree
n=87
n=87
female
46%
Graduate
Students
22%
male
54%
Undergrad
s
78%
2010 SHS Data
Competition or practice?
n=52
Pct of sports concussions
in NCAA athletes
n=52
missing or
n/a
15%
non-NCAA
35%
competition
50%
practice
35%
NCAA
65%
2010 SHS Data
Pct of concussions
related to alcohol
Injury mechanism in alcoholrelated concussions
n=87
n=14
alcohol
16%
assault
14%
hit object
29%
no alcohol
or not
documented
84%
fall
57%
summary
• http://www.youtube.com/watch?v=yyRBlSAfb
_k&feature=player_detailpage
Should Richie play football?
Should Finley play Soccer??
References
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www.cdc.gov/concussion/sports
McCrory P, Meeuwisse W, Johnston K, et al.Consensus Statement on Concussion in
Sport: the 3rd International Conference on Concussion in Sport, Zurich 2008. Br J
Sports Med 2009;43:i76-i84.
New York Times, June 13 2012
Internet resources (ESPN, Youtube, Vimeo, google,etc.)
More video, if time…
• Sudden Impact Syndrome
http://www.youtube.com/watch?v=dqlDOH45xWM
&feature=relmfu