Sports Concussion: Injury Signs & Symptoms Return to Play Samuel R. Browd, M.D., Ph.D. UW Assistant Professor Neurological Surgery Attending Neurosurgeon, Seattle Children's Hospital Richard G.
Download ReportTranscript Sports Concussion: Injury Signs & Symptoms Return to Play Samuel R. Browd, M.D., Ph.D. UW Assistant Professor Neurological Surgery Attending Neurosurgeon, Seattle Children's Hospital Richard G.
Sports Concussion: Injury Signs & Symptoms Return to Play Samuel R. Browd, M.D., Ph.D. UW Assistant Professor Neurological Surgery Attending Neurosurgeon, Seattle Children's Hospital Richard G. Ellenbogen, M.D. Chairman, UW Department of Neurological Surgery Co-Chairman NFL Head, Neck and Spine Committee OBJECTIVES 1. A REVIEW OF HEAD INJURY IN THE ATHLETE 2. A REVIEW OF THE SYMPTOMS AND SIGNS OF CONCUSSION 3. A REVIEW OF THE TOOLS AND GUIDES IN RETURN TO PLAY DECISIONS THE CONCUSSION CONTROVERSY IN SPORTS TODAY Any Given Sunday • 17+ ARTICLES IN 2009 ALONE • Forum for Football Brain Injuries Set for Houston – 01/07/10 • Lawmakers Grill Doctor for His Views on Concussions – 01/04/10 • Silence on Concussions Raises Risks of Injury – Alan Schwarz 09/15/07 Richard Ellenbogen, M.D. Zackery Lystedt Concussion International Conference on Concussion in Sport – Vienna 2001, Prague 2004, Zurich 2008 – “THIS IS A WORLDWIDE PROBLEM AFFECTING BOTH SEXES, STUDENT/ATHLETES, PROFESSIONALS AND THE MILITARY“ • (Ellenbogen, NFL Committee) – CONCUSSION: • “Complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.” Concussion Definition – COMPLEX • no “easy” concussions! – PATHOPHYSIOLOGY • RARELY structural! – TRAUMA INDUCED • an impact to the head or body that is transmitted to the head – LOSS OF CONSCIOUSNESS • < 10% of players Concussion Definition Common features include: • Rapid onset of usually short-lived neurological impairment which typically resolves spontaneously. • A range of clinical symptoms that may or may not involve loss of consciousness (LOC). Less than 10% of sports concussions involve loss of consciousness Epidemiology of Severe Injuries Among United States High School Athletes • National High School Sports-Related Injury Surveillance System 2005-2007 • Nationally representative sample of 100 US high schools • 9 sports (football, wrestling, baseball, softball, girls’ volleyball, and boys’ and girls’ soccer and basketball) • Loss of >21 days of sports participation Darrow, CJ et al. Am J Sports Medicine Vol 7, #9 2009 Sport Concussion (% >21 days) Boy’s football Boy’s soccer Girl’s soccer Girl’s volleyball Boy’s basketball Girl’s basketball Boy’s wrestling Boy’s baseball Girl’s softball 5.9% 11.8% 7.7% 8.9% 1.2% 6.6% 3.3% 1.4% 1.2% World-Wide: Australia Epidemiology of Concussions in High School and Collegiate Sports • Data from the High School Reporting Information Online System and the NCAA Injury Surveillance System – 5.9% of all collegiate athletic injuries – 8.9% of all high school athletic injuries – Concussion rates were higher in college, but concussions were a higher proportion of all high school athletic injuries Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503 High School Sports • Concussion rate per 1000 athlete-exposures • • • • • Football 0.47 Girl’s soccer 0.36 Boy’s soccer 0.22 Girl’s basketball 0.21 Boy’s basketball 0.07 Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503 High School Sports • 16.8 % of concussed athletes had suffered a previous concussion in that season or in a prior season – Greater than 20% of concussions in boys’ and girls’ basketball were recurrent concussions • Girls took longer than boys to recover Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503 Recurrent Injuries: High School Athletes • 11.6% of the recurrent injuries were concussions • Swenson, DM et al. Am J Sports Medicine 2009;37(4) Brain Injury-Related Fatalities American Football Players Different Levels of Play (1945-1999) 400 350 300 374 High school Sandlot College Professional 250 200 150 100 50 0 76 33 fatalities 14 Cantu and Mueller. Neurosurgery 2003;52:846-853 Brain Injury-Related Fatalities American Football Players Injury Type (1945-1999) 450 400 429 350 300 Subdural Unknown Fracture Aneurysm Edema 250 200 150 100 50 0 40 18 6 4 Fatalities Cantu and Mueller. Neurosurgery 2003;52:846-853 Catastrophic Head Injuries High School and College Football • National Center for Catastrophic Sports Injury Research data from 1989-2002 – 94 cases • 75 subdural hematomas • 10 subdural with diffuse brain swelling • 5 diffuse brain swelling • 4 AVM or aneurysm – 92 cases were in high school players » Boden et al. AJSM 2007; 35: 1075 - 1081 Catastrophic Head Injuries High School and College Football • 59% of athletes had a previous history of concussion(s) • 71% of those injuries occurred in the same season as the catastrophic injury • 39% of athletes at time of catastrophic injury were playing with residual symptoms from a previous concussion » Boden et al. AJSM 2007; 35: 1075 - 1081 Classification/Grading Guides Conflicting and do NOT guide therapy!!! Guideline Grade 1 Grade 2 Cantu 1. No LOC 2. Posttraumatic amnesia <30 min 1. LOC > 5 min 2. Posttraumatic amnesia > 30 min 2. Posttraumatic amnesia >24˚ Colorado 1. Confusion w/out amnesia 2. No LOC 1. Confusion w/ amnesia 2. No LOC 1. LOC (of any duration) AAN 1. Transient confusion 2. No LOC 3. Concussion syx, ms change resolve w/in 5 min 1. Transient confusion 2. No LOC 3. Concussion syx, ms change >15 min 1. LOC (brief or prolonged) Cantu (Revised) 1. No LOC 1. LOC < 1 min 1. LOC > 1min OR 2. Posttraumatic amnesia signs/syx < 30 min Grade 3 OR OR 2. Posttraumatic amnesia >30 min, <24˚ 1. LOC > 5 min OR OR 2. Posttraumatic amnesia >24˚ OR 3. Post concussion signs/syx > 7d A Ding Is Not Always Just A Ding 1.6 to 2.3 million sports concussions per year Center for Disease Control 2006 Acute Signs and Symptoms: Suggestive of Concussion COGNITIVE SOMATIC •Confusion •Post-traumatic amnesia •Retrograde amnesia Loss of consciousness •Disorientation •Feeling “in a fog,” “zoned out” •Vacant stare •Inability to focus •Delayed verbal and motor responses •Slurred/incoherent speech •Excessive drowsiness •Headache •Fatigue •Disequilibrium, dizziness •Nausea/vomiting •Visual disturbances (photophobia, blurry/double vision) •Phonophobia AFFECTIVE •Emotional lability •Irritability Pathophysiology • In a concussion, certain chemical levels are altered at the cellular level • Blood supply to the brain decreases • The brain’s demand for glucose increases • Mismatch in fuel supply and demand – Neuronal tissue vulnerability • Brain needs time to recover Game-Day: Evaluation & Treatment Pre-Game It is essential to: – Implement a game-day medical plan specific to concussion. – Understand the indications for cervical spine immobilization and emergency transport. Game-Day: Evaluation & Treatment On-Field It is essential to: • Evaluate the injured athlete on-the-field in a systematic fashion • Determine initial disposition – emergency transport vs. sideline evaluation Recognizing a Concussion Signs and Symptoms Signs observed by trainer preferably, coach, parent, teammates include: Symptoms reported by athlete include: • Headache Is confused about assignment Nausea Forgets plays Balance problems or dizziness Is unsure of game, score, or opponent Double or fuzzy vision Moves clumsily Sensitivity to light or noise Answers questions slowly Feeling sluggish Loses consciousness Feeling foggy or sluggish Shows behavior or personality changes Concentration or memory problems Confusion • Appears dazed or stunned Can’t recall events prior to hit Can’t recall events after hit. Game-Day: Evaluation & Treatment Sideline It is essential to: – Not leave the player unsupervised – Determine disposition • home with observation • transport to hospital – Provide post-event instructions to the athlete and others • e.g., regarding alcohol, medications, physical exertion and medical follow-up THE EVIDENCE FOR RETURN TO PLAY THERE IS NONE IT IS: JUDGEMENT EXPERIENCE Return to Play Same Day It is essential to understand: – A (youth) player with diagnosed (or suspected) concussion should not be allowed to return to play on the same day as the injury. • McCory P, et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport – Held in Zurich, November 2008. » Clin J Sport Med 2009;19:185-200 Post-Game Management by Healthcare Provider: Return to Play • Obtain a comprehensive history • current concussion • any previous concussion • Determine the need for further evaluation and consultation. • Determine return-to-play status – ***CONCUSSION FOLLOWED BY SYMPTOMS AFTER 20 MINUTES OF REST… • DISQUALIFIED FROM PLAYING ON THE DAY OF INJURY – COGNITIVE REST AS WELL (NO SCHOOL!) • HIGH SCHOOL IS EASY: “WHEN IN DOUBT, SIT THEM OUT” – COLLEGE/PROS IF AFTER 20 MINUTES OF REST AND THEY HAVE NO EXERTIONAL SYMPTOMS THEY MAY RETURN Post-Game Management by Healthcare Provider: Return to Play – LOC or Amnesia • Disqualified from immediate RTP – no tool is sufficient to determine RTP » SCATII, SAC or BESS • Athletes under 18 years old and Females – longer period of neurocognitive recovery after concussion Symptom, Cognitive, and Postural Stability Recovery in Concussion and Control Participants McCrea, M. et al. JAMA 2003;290:2556-2563. Copyright restrictions may apply. PRINCIPALS OF RTP • 3 or more CONCUSSIONS in a SEASON – 3 MONTH SYMPTOM FREE PERIOD BEFORE THEY RETURN TO A COLLISION SPORT • 3 or more CONCUSSIONS in a SEASON with SLOWED RECOVERY – THEY SIT OUT FOR THE SEASON OR MAYBE PERMANENTLY • DISQUALIFY: – NEURO EXAM IS NOT RETURNED TO NORMAL – NEUROPSYCH BATTERY IS ABNORMAL – SYMPTOMS • Take into account the SEVERITY OF THE BLOW AND PROLOGNATION OF THE AMNESIA • ABNORMAL MRI: 1 YEAR OF REST PRINCIPALS OF RTP • Understand: – Brief LOC (seconds, not minutes) – Amnesia, as well as the number and duration of additional signs and symptoms (and neuropsychological data) are more accurate in predicting severity and outcome. – The treatment of and the RTP decision for the athlete with concussion must be individualized – Manage by symptoms, not by grades • Many return to play guidelines are weighed to LOC – NOT A GOOD IDEA! PRINCIPALS OF RTP • Consider factors which may affect RTP, including: – – – – – – – – Severity of the current injury Previous concussions (number, severity, proximity) Significant injury in response to a minor blow Age (developing brain may react differently to trauma than mature brain) Sport Learning disabilities Depression, anxiety Migraine headaches PRINCIPALS OF RTP • Neuropsychological testing – Post-injury neuropsychological test data are more useful if compared to the athlete’s pre-injury baseline. – It is unclear what type and content of test data are most valuable. – It is only one component of the evaluation process. Graduated Return to Play in 1 Slide Rehab Stages (1-6) Functional Exercise Objective 1. No activity Complete physical & cognitive Recovery of cognitive rest (No school, if indicated!) function 2. Light aerobic exercise Walking, swimming or stationary bike; no resistance training HR 3. Sport-specific exercise Running drills; no head impact activity Add movement 4. Non-contact training drills Progression to more complex training drills; start progressive resistance training Exercise, coordination, cognitive load 5. Full contact practice After Medical Clearance Only; Restores confidence & Normal activity assess functional skills 6. Return to play Normal game/competition Prevent Next Injury PRINCIPALS OF RTP • Physical and cognitive rest may be necessary including cognitive rest from school • Determine the athlete is asymptomatic at rest before resuming any exertional activity. • Utilize progressive aerobic and resistance exercise challenge tests prior to full return to play. Sport Concussion Assessment Tool • SCAT 2 • Developed from International Conference on Concussion in Sport – Zurich 2009 • Used during and after game time for RTP Sport Concussion Assessment Tool • Update of the 2005 SCAT1 • Used by medical and health professionals • 4 pages • 20 minutes to administer • Athletes 10 years old and above • Preseason baseline • Evaluates for one or more of the following: – Symptoms – Signs – Impaired brain function – Abnormal behavior – Impaired Neuro Function 22 questions None Mild Moderate Severe Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck pain 0 1 2 3 4 5 6 Nausea/vo miting 0 1 2 3 4 5 6 Do the symptoms get worse with physical activity? ☐Yes☐No Do the symptoms get worse with mental activity? ☐Yes☐No At what venue are we today? 0 1 Which half is it now? 0 1 Who scored last? 0 1 What team did we play last week? 0 1 Did we win last week? 0 1 Scoring: 1 point for each correct answer (maximum of 5) Validated for sideline diagnosis 1. Orientation 2. Immediate Memory 3. Concentration • • • • • What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? (within 1 hour) 0 1 0 1 0 1 0 1 0 1 Scoring: 1 point for each correct answer (maximum of 5) List Trial 1 Trial 2 Trial 3 Alternative Word List elbow apple 0 1 0 1 0 1 0 1 0 1 0 1 candle paper baby monkey carpet saddle 0 1 0 1 0 1 0 1 0 1 0 1 sugar sandwich perfume sunset bubble 0 1 0 1 0 1 wagon iron Scoring: 1 point for each correct answer (maximum of 15) Digits Backward List 4-9-3 3-8-1-4 0 1 0 1 6-2-9-7-1 7-1-8-4-6-2 0 1 0 1 Alternative Digit List 6-2-9 5-2-6 3-2-7-9 1-7-9-5 1-5-2-8-6 5-3-9-1-4-8 3-8-5-2-7 8-3-1-9-6-4 Scoring: 1 point for each correct answer (maximum of 4) • Months in reverse order Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan Scoring: 1 point for entire sequence correct Instructions: • “Which foot do you kick with?” (i.e. dominant foot) • 20 seconds per stance • Shoes off • Remove ankle taping • Place hands on hips • Close eyes A. Double leg stance Feet shoulder-width apart B. Single leg stance Lift the dominant foot (30° hip flexion, 45° knee flexion) C. Tandem stance Dominant foot in the front Scoring: 1 point for each error (max. of 10 per stance) Final score is 30 minus total errors Finger-to-nose task: • Athlete is to touch their nose and then your finger • Athletes fail if they don’t touch their nose, don’t fully extend the elbow, or don’t perform 5 repetitions Scoring: 1 point for five repetitions in < 4 seconds (maximum of 1) • Delayed recall List elbow apple carpet saddle bubble Scoring: 1 point for each recalled word (maximum of 5) SCAT 2: Scoring • Symptom score (22) • Physical signs score (2) • GCS (15) • Maddocks’ score (5) • Orientation (5) • Immediate memory (5) • Concentration (5) • Balance examination (30) • Coordination exam (1) • Delayed recall (5) Max is 100/100 Lowest is 3/100 Goals • Recognition of a potential concussion • Initial screening (SCAT2, SAC, Maddocks) to obtain post-injury baseline • Avoid leaving the athlete unsupervised • Serial neurologic exams • Determine disposition • Post-game instructions and follow-up screening • SCAT2 is just a screening tool • It won’t catch every concussion – Use your judgment • Only gives you one moment in time – Things change and they change quickly –“When in doubt, sit them out" SECOND IMPACT SYNDROME • Rare • Limited to teenagers or under 18 in all cases • No cases in NFL/NHL/MLB • Medical review after witnessed 1st impact • Documented ongoing symptoms until 2nd impact • Witnessed 2nd impact followed by rapid deterioration • Evidence of cerebral swelling without other cause Recurrent Concussion: Who Cares? • 2- 4X increased risk for recurrent concussion – More symptoms – Last longer – Small but repetitive hits • Cumulative brain trauma: – CHRONIC TRAUMATIC ENCEPHALOPTHY Sports Concussions: Education, Awareness, Action Washington State Heads Up: Concussion in Youth Sports Campaign Washington State Road Show Stan Herring, M.D. Richard Adler, J.D. Educate or Legislate? wsata Engrossed House Bill 1824 Requiring the adoption of policies for the management of concussion and head injury in youth sports. • All student athletes and parents/guardians sign an information sheet regarding concussion prior to each season • School districts to work with the Washington Interscholastic Activities Association (WIAA) to develop information and policies on educating coaches, youth athletes, and parents about the nature and risk of concussion including the dangers of premature return to practice or play after a concussion • Any athlete suspected of suffering a concussion is removed from play until they receive written clearance for return to practice and play by a licensed health care provider trained in the evaluation and management of concussions Zackery Lystedt Law May 14th, 2009 Is This Practice/Game More Important Than: • The rest of the season? • The rest of the athlete’s career? • The rest of the athlete’s life? CONCLUSION Do not let a injured athlete back into practice or games until they have been evaluated and cleared in writing by a licensed healthcare provider trained in the evaluation and management of concussions. That is not only the LAW; It Is The Right Thing To Do!