Embed Size (px)
DESCRIPTION
Citation preview
Concussion in sportsFadi Hassan – Hull York Medical School
Definition
• “Complex pathophysiological process affecting the brain. It is the result of traumatic biomechanical forces to the head, face, neck or elsewhere on the body leading to short-lived impairment of neurological function (changes in alertness, concentration and memory)”
• It may or may not involve loss of consciousness (<10%)• Loss of consciousness does not mean the case is more severe!
Epidemiology
• 2-5 % of all athletic injuries• 300,000 sports-related concussions annually in the US
only!• 900 sports-related traumatic brain injury deaths• Risk of concussion is 6x higher in players with a history
of previous concussion
Risk factors
• Risk Factors:• Male• Younger athlete• High risk sport (boxing, wrestling, football, basketball) • History of multiple concussions• Dangerous style of play• Comorbid mental health disorder
Symptoms
• Headache and Irritability• Dizziness and Lightheadedness• Nausea• Lethargy• Sleep disturbance• Visual changes• Sensitivity to light or sound• Cognitive features:
• Amnesia• Disorientation• Confusion• Short attention span
Signs
• Impaired attention• Vomiting• Vacant stare• Delayed responses• Decreased alertness• Disorientation• Slurred incoherent speech• Gross incoordination• Pseudobulbar affect (Emotional lability)
• Uncontrollable burst of emotions like episodes of crying and/or laughing or any other emotional displays
• Inappropriate playing behavior
Pathophysiology
• Occurs when momentum of the head is changed by either • Blunt trauma• Accelerative, declarative or rotational force
• The above forces are then transmitted indirectly to the brain chemical changes in certain parts of the brain at cellular level affecting membrane stability (abnormal movements of ions) impaired function increased demand for glucose (for repair).
• Blood supply is decreased to the injured part less glucose delivery mismatch in supply vs demand brain tissue becomes vulnerable to another impact
• Explaining why RTT is something teams should NOT rush into
Types of brain injury
• Brain injuries can be• Focal (Coup)
• Blunt trauma to the stationary head brain contusions, lacerations and hemorrhage • Maximal brain injury is beneath the point of cranial impact• Example: Player A goes for an overhead kick, totally missing the ball and hitting
Player B’s head.• Diffuse (Contra-coup)
• When the moving head strikes a stationary object (Acceleration/deceleration force with angular rotation)
• Example: Corner kick position Player A is on the far post, tries to go for a header, misses the ball and collides with the post (stationary object).
Sideline assessment
• Airway, Breathing, Circulation (ABC)• Level of consciousness and mental status• Inspect for skull, neck or back injuries• Determine the mechanism of injury• Check for prior concussion injury history (previous symptoms,
number of concussions, post concussive convulsions)• Past medical history, medications, drug or alcohol use • Any player with concussion or suspected concussion is NOT
allowed to return to play on the same day as the injury.
Neurological Screening
• Assess speech for fluency and lack of slurring• Eye movements and pupils reflexes (visual examination)• Examine coordination, fine movements, gait and balance• Pronator drift:• Ask the patient to hold both arms in front of them with palms
up and eyes closed• Positive test is pronating the forearm, dropping the arm or
drifting away from the midline
Mental state testing
• Orientation (Maddocks questions)• Where are we now?• Which half is it now?• What was the score of last game?• What team did you face last week?• Who scored last in this game?
• Memory recall• Recite months of the year in reverse orders• Select 5 words or an address, then ask the patient later about them.
Exertional maneuvers
• Tests to elicit possible post-concussion symptoms• When considering RTT (return to play) for an athlete who is
oriented and asymptomatic (5reps)• Jumping jacks• Push-ups• Sit-ups• Up-downs• Single-leg balance with eyes closed, arms at 90 degrees abduction• Running (40 yard dash) or stationary bike
Sideline assessment - GCS
• Glasgow coma scale (GCS)• Tool used for initial and subsequent assessment to assess consciousness state after a head injury.
•
1 2 3 4 5 6
Eyes Does not open eyes
Opens eyes in response to painful stimuli
Opens eyes in response to voices
Opens eyes spontaneously
N/A N/A
Verbal Makes no sounds
Incomprehensible sounds
Slurred speech (muttering)
Confused, disoriented
Oriented, converses normally
N/A
Motor Makes no movements
Extension to painful stimuli
Abnormal flexion to painful stimuli
Flexion/withdrawal to painful stimuli
Localizes painful stimuli
Obeys commands
Sideline assessment -GCS
• Lowest score you can get is 3 (deep coma/death) while the highest is 15 (fully awake)
• Score interpretation• Severe injury: GCS <9• Moderate injury: GCS 9-12 • Minor: GCS >=13
• Tracheal inturbation and severe oedema or damage makes it hard to test for verbal and eye responses give score of 1 with a modifier (E1c, C= closed, V= tube)• GCS 6tc (1 eyes closed, 1 inturbation, leaving 4 for motor)
SCAT2
• Sport Concussion Assessment Tool 2• Standardized method for evaluating concussion• Crucial to have when assessing head injuries • it includes
• a symptom evaluation • a physical sign score• GCS • Maddocks score • standardized assessment of concussion (SAC) score
• Self explanatory once you get a copy• Can be downloaded from the CDC website:
• http://www.cces.ca/files/pdfs/SCAT2[1].pdf
Return To Play
• It is often tricky to recognize this injury, especially in asymptomatic athletes.
• Once this injury is identified:• The player shouldn’t be left alone monitor + evaluate• The player shouldn't’t RTT while symptomatic. It is against the
rules and regulations• Satisfactory rest period is crucial• Cognitive rest is crucial as most sports require concentration and
attention, which could worsen the symptoms
Return to play
• Zurich guidelines allow 7-10 days for symptoms and signs of most concussions to resolve.
• Exercise challenge is required (>60% of max predicted HR) and cognitive testing
• Symptoms lasting >=7days CT/MRI to exclude further brain damage
• Reference to sports concussion specialist is useful.
Return To Play - process
• Obs: • Recommended for at least 24-48 hours after a concussion• Awaken patient from sleep every 2 hours• Patient should avoid strenous activity for at least 24-48 hours• Warning signs:
• Inability to awaken the patient• Severe or progressive headache • Restlessness +/- confusion• Visual disturbances• Vomitting, fever or stiff neck• Urinary/bowel incontinence• Weakness or numbness
Return To Play - process
• RTT protocol (Steps)1. Complete rest (exertional and cognitive)
2. Light aerobic exercise (walking, stationary bike). No weight lifting
3. Sport-specific exercise with slow progressive addition of resistance training
4. Non-contact training drills
5. Full-contact training after medical clearance
6. Game play
• Players only progress to the next step once they’re asymptomatic AT the current step• Symptomatic drop back to the previous step for 24 hours
• Each step should take at least 1 day. • Not allowed to take medications that may modify the symptoms
Complications
• Immediate • Concussive convulsions (non-epileptic)• Due to loss of cortical inhibition and release of brainstem activity• CT/MRI normal
• Epidural hematoma• Laceration of the middle meningeal artery
• Subdural hematoma• Tearing of bridging veins
Complications
• Delayed• Post-concussive syndrome: Physical/cognitive concussive symptoms
lasting days-months after the injury and is often triggered by exercise.• Treated by rest or NSAIDs, beta-blockers, Tricylclic antidepressants or
calcium channel blockers
• Cumulative neurocognitive impairment• Dementia pugilistica: Parkinsonism, ataxia, dysarthia, behavioural changes
and Alzheimer’s disease.• Mohammed Ali? Due to repetitive concussions
Complications
• Delayed• Second impact syndrome• Associated with premature RTT• Rapid catastrophic brain swelling due to cerebral vasculature
autoregulatory dysfunction• Rapid deterioration and is often fatal• Long term memory and attention impairments• Younger athletes are at a greater risk
Prevention
• Mouthguards (orofacial safety)• Helmets and head protectors• Strict regulations and punishment on reckless tackles• Low threshold in suspecting a concussion is necessary
When in doubt, give the player sufficient rest• In athletes suffering from concussion, if they are not
getting better suspect more serious damage CT/MRI
Key message
• Identifying a concussion is crucial in sports medicine
1. Blow to the head or other part of the body that can transfer the impact to the head
2. Recognize a change in player’s function (you, the manager, the player those who know the player)
3. Refer to the SCAT2 card
4. Concussed? take them out
Evidence Based Medicine
• Very interesting paper that I recommend you reading is • “Current practices in determining return to play following
head injury in professional football in the UK”• Authors: Jo Price, Peter Malliaras, Zoe Hudson • Published on 28th/August/2012
