Concussions in Basketball Marc Richard Silberman, M.D

Concussions in Basketball

Marc Richard Silberman, M.D.

Has the game changed?

Wilt “The Stilt” Chamberlain7-1, 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 63.4% of concussionsWrestling 10.5%Girls Soccer 6.2%Boys Soccer 5.7%Girls Basketball 5.2%Boys Basketball 4.2%Softball 2.1%Baseball 1.2%Field Hockey 1.1%Volleyball 0.5%

JAMA. 1999 Sep 8;282(10):989-91

Ligament sprains 44% Muscle/tendon strains 17.7% Contusions 8.6% Fractures 8.5% Concussions 7.0%

H.S. Basketball Injuries 2005-2007

Am J Sports Med December 2008 vol. 36 no. 12 2328-2335


Rebounding caused the majority of injuriesJumping/landing caused the majority of sprains




Girls

Boys

5 %

14 %5 %

3 %

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



Concussion Cause Collision with another player 65% Contact with the floor 13% Personal opinion this is not the truth

Concussion Activity Rebounding 30% Defending

20%

Illegal Activity Total number of injuries 13% Concussions 35%

H.S. Basketball Concussions 2005-2007


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 1.40 Lacrosse 1.46 Basketball 0.47

Females Soccer 2.10 Lacrosse 1.05 Basketball 0.73

Collegiate Concussions 1997-2000

J Athl Train. 2003 Jul–Sep; 38(3): 238–244

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

Collegiate Basketball Concussions 1997-2000

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

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

Recovery from Concussion

a ‘miserable minority’ experience persistent symptoms

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

Post-concussion syndrome

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 modifiersSymptoms Number, Duration (>10 days), Severity

Signs Prolong loss of consciousness (> 1 min), amnesia

Sequelae Concussive convulsions

Temporal Frequency – repeated concussions over time

Timing – injuries close together in time

“Recency” – recent concussion

Threshold Repeat concussions occurring with progressively less impact

Repeat concussions with slower recovery after each one

Age Child and adolescent

Comorbidity Migraine, depression, ADHD, LD, sleep disorder

Medication Psychoactive drugs

Behavior Dangerous style of play

Sport High risk activity, contact collision sport, high sporting level

Graduated return to play protocol

Day 1 Light aerobic exercise

Light jog/stroll, stationary bicycle

Goal: elevate HR

Day 2 Sport-specific exercise

Running drills in basketball

Goal: add movement

Day 3 Non-contact training drills

Passing and shooting, light resistance training

Goal: coordination, cognitive load, valsava

Day 4 Full contact practice only after physician clearance

Day 5 Return to competition

Any symptoms at any stage, return to complete rest

Consensus Statement on Concussions in Sport reference

2001 1st International Conference on Concussion in Sport, Vienna

2004 2nd International Conference on Concussion in Sport, Prague

2008 3rd International Conference on Concussion in Sport, Zurich http://www.sportconcussions.com/html/Zurich

%20Statement.pdf Sport Concussion Assessment Tool (SCAT2)

Concussions in Basketball

Thank you.

Marc Richard Silberman, M.D.

Gillette, NJ

[email protected]

(908) 647 6464

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Concussions in Basketball Marc Richard Silberman, M.D