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“New Frontiers in Sports Concussion”
Sports Medicine and Performance Summit
22 October2016
William Haug, Jr., MD, CAQSM Advanced Orthopedics
Altru Health System
Disclosures
No Disclosures to report
Objectives
• Guidelines and classification
• Investigation and emerging research
• Return to Play
“ ‘It’s not dangerous to play with a concussion,’ said Kelby Jasmon, a senior two-way player for his high school in Springfield, Ill., who has had three concussions. ‘You’ve got to sacrifice for the sake of the team. The only way I come out is on a stretcher.’ ”
September 15, 2007, NY Times
August 2013
Ex-players agree to $765 million settlement
Frontline
http://www.pbs.org/wgbh/pages/frontline/league-of-denial/
National Football League
.
“Ivy League Moves to Eliminate Tackling at Football Practices”
“So Many Sports, So Little Time: Texas High School Athletes Opt Out Of Football”
“Pop Warner Youth Football League
Settles First Concussion-Related
Lawsuit” (Joseph Churnach)
Suicide Mortality Among Retired National
Football League Players Who Played 5 or More Seasons CDC May 2016
Suicide among this cohort of professional football players was significantly less than would be expected in comparison with the United States population (SMR = 0.47; 95% CI, 0.24-0.82). There were no significant differences in suicide mortality between speed and non speed position players.
Published online before print May 5, 2016, doi: 10.1177/0363546516645093
Am J Sports Med May 5, 2016 0363546516645093
General Principles
Head injuries may be…
undetected
underreported
untreated
Effects of Head Injury
• Cerebral Concussion
• Cerebral Contusion
• Epidural Hematoma
• Subdural Hematoma
Cerebral Concussion
• The most common consequence of head injury in sports
Vienna Group Definition (2001)
• “Sports concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”
How many Concussions occur each year?
A. 1.6 million to 3.8 million
B. 500,00 to 900,000
C. 2.4 Billion to 5 Billion
D. Less than 500,000
American Medical Society for Sports Medicine position statement:
concussion in sport
DIAGNOSIS OF CONCUSSION:
Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion
Use of graded symptom checklists and standardized assessment tools provide a helpful structure for the evaluation of concussion.
SIDELINE EVALUATION AND MANAGEMENT:
Any athlete suspected of having a concussion should be stopped from playing and assessed by a licensed healthcare provider trained in the evaluation and management of concussions
Imaging is reserved for athletes where intracerebral bleeding is suspected.
There is no same day RTP for an athlete diagnosed with a concussion.
American Medical Society for Sports Medicine position statement:
concussion in sport NEUROPSYCHOLOGICAL TESTING:
Neuropsychological (NP) tests are an objective measure of brain behavior relationships
RETURN TO CLASS:
Students will require cognitive rest and may require academic
RETURN TO PLAY:
Concussion symptoms should be resolved before returning to exercise. A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact
American Academy of Pediatrics Position Statement on Concussions
Coaches and Athletic Trainers should be trained in the identification of concussions, and refer any student athlete suspected of sustaining a concussion to a licensed physician, such as a pediatrician, neurologist, primary care sports medicine specialist, or neurosurgeon with expanded knowledge and experience in pediatric concussion management for evaluation.
Pediatricians and other physicians can be an important resource in educating coaches, athletic trainers, and other adults that work with young athletes in recognizing the signs of concussion injuries and when to seek medical attention for their athletes.
A team approach consisting of the child or adolescent athlete’s pediatrician and medical team, the school team, and the family team to assist the student in his or her return to learning is ideal.
AMERICAN ACADEMY OF NEUROLOGY
POSITION STATEMENT ON SPORTS CONCUSSION
Recommendations
Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions
No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion.
Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation.
A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion.
Concussion Video 1
Journal of Pediatrics Dec 2010
• 144,000 ED visits annually in pediatric population to age of 21
• 69% males
• 30% sports related
• 33% had no follow-up
• Most undergo CT
University of Ottowa JAMA March 2016
5-18 years of age
3,000 children
Persistent post concussive symptoms
Low, medium or high clinical risk score
2016 Mar 8;315(10):1014-25. doi:
10.1001/jama.2016.1203.
Concussion Rates by Sport in Twin Cities area 2013-2014
Minnesota Department of Health
2014
Brandi Chastain
1999 World Cup
Boston University Center for the study of Traumatic Encephalopathy
John Grimsley
• Former Linebacker for the Houston Oilers and Miami Dolphins, who died in February 2008 at the age of 43.
• Confirmed CTE
• Immunostained for tau protein
65 year old control study
Chronic Traumatic Encephalopathy
Early evidence of CTE in the youngest case to date, a deceased 18-year-old boy who suffered multiple concussions in high school football.
Complex Physiology
• Abnormal energy metabolism
• Low cerebral blood flow
• Mitochondrial function decreases
• Increased glucose use
• Magnesium decreases
• Increased lactate
• ATP decreases
Neurosurgery 75 S24-S33
2014
Consequences
• Athletes suffering 3
concussions are at a 3 fold greater risk of suffering a repeat concussion
• Repeat concussions impart a cumulative effect, producing symptoms of increasing severity and duration
Effects of Repeated Concussions
• Post Concussive Syndrome
• Dementia Pugilistica
• Second Impact Syndrome (SIS)
• Post-traumatic Seizures
• Traumatic Encephalopathy
Chris Nowinski
Case Study by Kevin Guskiewicz, PhD, ATC
2005 University of North Carolina:
• 20-year-old Division I football defensive end
• Concussion #1: August 14, 2004
• Concussion #2: October 16, 2004
Accelerometry Instrumentation
• Head Impact Telemetry System (HITS)
• Sensors embedded in the padding of helmet
• Measures and records blows to the head:
– Impact location
– Impact magnitude
– Impact duration
– Linear and angular acceleration components
– Exact times of impacts
Concussion #1: August 14, 2004
Clinical Findings
• At the time of injury player reported
experiencing 16 of 18 concussion symptoms on
the Graded Symptom Checklist (GSC).
• SAC and BESS performed on the sideline
revealed moderate deficits. Follow-up
computerized neuropsychological (NP) and
postural stability (PS) testing revealed moderate
deficits through post injury day 3.
• Symptoms resolved over the course of 5 days, and he was returned to restricted participation, followed by full participation at post injury days 6 and 7 respectively.
ImPACT Data: Concussion #1
• All 4 significant impacts
– 2 in morning session (79.18 & 97.97 g)
– 2 in evening session (64.51 & 63.95 g)
Concussion #2: October 16, 2004 Clinical Findings
• Reported 13 of 18 concussion symptoms at the
time of injury. Symptoms lingered for 10 days,
with drowsiness, fatigue, and dizziness being
the most persistent symptoms.
• Sideline SAC and BESS scores were again moderately depressed, however, serial assessments of NP tests were significantly depressed during the initial 4 days post injury.
An MRI was not conducted as part of the
Treatment. However, the player was evaluated by the team physician daily to detect signs of any neurological deterioration.
Player withheld for 15 days before being
permitted to return to full participation.
ImPACT Data: Concussion #2
• 6 total impacts
• Between 13.10 g to 102.39 g (mean = 40.78 g)
Concussion Video 2
Conclusions Raises several intriguing questions with respect to sport-
related concussion:
1) was there a cumulative effect on the initial injury day,
since there were two significant impacts during the
morning practice?
2) could the threshold for injury be lowered because of
these repetitive loads to the brain? “Acute cumulative
effect of sub-concussive impacts”
3) was the delayed symptom recovery and depressed NP
scores following the repeat concussion a result of
a more chronic cumulative effect, or simply a result of the
increased magnitude (102 g)?
Concussion Classification Schemes
• Cantu (1986)
• Colorado (1991)
• AAN (1996)
• Vienna (2001)
• Prague (2004)
• Zurich (2008)
• Zurich (2012)
Fourth International Conference on Concussion in Sport, Zurich 2012
Zurich Meeting 2008
• Recommended injury grading scales be abandoned
• Severity determined in retrospect
A “true” concussion involves loss of consciousness
A. True
B. False
Loss of Consciousness
• Limited in assessing the severity of a sports concussion
• Its presence does not necessarily classify the concussion as complex
• Only 10% sport related concussion have LOC longer than 1-2 seconds
Significance of Amnesia
• Presence or duration may be associated with slower recovery, but not all studies confirm this
Zurich Classification 2008
• Simple
• Complex
How long does it take for concussion symptoms to develop?
A. Symptoms develop immediately
B. It can take hours for symptoms to develop.
C. It can take days for symptoms to develop.
D. The onset of symptoms varies depending on the person and injury. Symptoms may appear immediately or within hours or days of the event.
Simple Concussion
• Progressively resolves without complication over 7–10 days
Complex Concussion
•Persistent symptoms or sequelae (concussive convulsions, prolonged loss of consciousness or cognitive impairment )
• May include multiple concussions over time (with progressively less force)
Typical Symptoms
• Balance
• Headaches
• Cognition
• Confusion
• Amnesia
• Loss of Consciousness
• Motor
Which tool is NOT used on the sideline for diagnosis of concussions?
A. SCAT3
B. King-Devick
C. MACE
D. CAPP
E. BESS
Sport Concussion Assessment Tool (SCAT)
• A standardized approach to
assessment and
management of
concussion
• Produced as a result
of Prague conference
in 2004
Sport Concussion Assessment Tool (SCAT3)
• Signs
• Memory
• Symptom Score
• Cognitive Assessment
• Neurologic Screening
• Return to play
M-BESS
Modified Balance Error Scoring System (M-BESS)
Cleats, equipment vs. control subjects in regular athletic shoes, etc..
BMJ Open Sport Exerc Med 2016;2:e000117 doi:10.1136/bmjsem-2016-000117
MACE
2010 Jul;175(7):477-81
Military Medicine
Treatment Plan
• Note for school, physical education, sport, work
• Modify activity, school work, etc.
• Physical Therapy
• FU in 1 week
• Visual treatment program
• +/- Neuropsych testing
• +/- Imaging • +/- Amitriptyline for sleep
• +/- NSAIDs, Tylenol
INVESTIGATIONAL ISSUES
• Neuropsychological Testing
• Blood test
• Neuroimaging
Neuropsychological Testing
• A variety of tests that measure reaction time, memory,
and concentration (e.g., King-Devick, ImPACT,
AxonSports, and Headminder Concussion Resolution
Index)
• Baseline tests are obtained preseason to provide a basis for comparison in the event an athlete suffers a
concussion
• Tests are of no value when the athlete is symptomatic because it will not affect the return to play decision
• Has not been proven to reduce morbidity or mortality
• Should not be used as the sole basis for management
decisions
King-Devick
Based on measurement of
the speed of rapid number
naming (reading aloud
single-digit numbers from 3
test cards)
Captures impairment of eye
movements, attention,
language, and other
correlates of suboptimal
brain function
Neurology; Prepublished online February 2, 2011;
K.M. Galetta, J. Barrett, M. Allen, et al.
Glial fibrillary acidic protein (GFAP)
Protein in cytoskeleton of astroglia brain cells
C terminal hydrolase L1 protein studied as well
Prospective cohort study
CTHL1 was higher initially
GFAP elevated up to a week following the head injury
Not a stand alone test
JAMA Neurol. 2016;73(5):551-560. doi:10.1001/jamaneurol.2016.0039.
When should an MRI or CT ordered?
A. On all concussions
B. Concussions that have symptoms > 7days
C. When ruling out more severe head and brain injuries, such as skull fractures, cervical spine injuries, intracranial hemorrhages, as well as cerebral swelling that would require surgical intervention
D. In patients with > 4 symptoms
MR Spectroscopy
DOI:http://dx.doi.org/10.1093/brain/awq2003232-3242 First published online: 23 August 2010
Resting State Functional MRI
Found that the corpus callosum may be primary site of injury after head injury
Exp Brain Res. 2010 Apr; 202(2):341-354
Diffusion Tensor Imaging
Diffusion Tensor MRI
White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study, Brain. 2007 Oct;130(Pt 10):2508-19. Epub 2007 Sep 14
PET Scan (Positron Emission Tomography)
Marvin Bergsneider, MD, University of California Medical Center, UCLA Brain Injury Research Center, Los Angeles. Brain Briefings, Society for Neuroscience. Feb 2001
UCLA April 2015 FDDNP 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-napthyl}ethylidene) malonitrile
When should an athlete return to play
A. After athlete has been cleared by a medical professional and completed the league's return-to-play protocol.
B. After his or her guardian gives him permission.
C. After athlete can tell the coach his or her name.
D. There's no need to hold a player out. Let’s go back to “how many fingers?”
Prague Return to Play Criteria
• Asymptomatic at rest
• Asymptomatic physical and cognitive exertion
• Intact neurocognitive function
National Athletic Trainers’ Association (NATA) Position Statement on management of concussions
ATC should spearhead the development of a detailed written plan outlining the concussion-management strategy and share it with administrators and coaches.
The plan should include a baseline evaluation of athletes, including a neurologic history with symptoms and physical examination and objective measures of neurocognitive performance and motor control.
Once the concussion diagnosis has been made, the patient should be immediately removed from further participation for at least 24 hours. Follow-up testing, using the same protocol as the baseline examination, can aid in determining when to start the return to physical activity after the patient is cleared by a physician or designate.
Lastly, although most concussions resolve in a relatively short time frame, patients who are young, who have had multiple concussions, or who have premorbid factors may require additional attention.
Return to Play Protocol
1. No activity, complete rest. NO return to play that day.
2. Light aerobic exercise
3. Sport specific exercise (skating in hockey, running in soccer), progressive addition of resistance training
4. Non-contact training drills.
5. Full contact training.
6. Game play.
Discontinuing the Season
• Number of lifetime concussions
• Duration and severity of symptoms
• Decreasing force
• Life goals
• Ongoing cognitive or emotional issues
• Time of year/season
Referrals
• Any referral is appropriate
• Symptoms longer than four to seven days
• Worsening symptoms
• Interference with ADL
• Difficulty returning to prior academic or athletic standards despite lack of symptoms
Prevention
• Education and coaching
• Enforcement of existing rules
• Eliminate dangerous activities
• Promotion of sportsmanship and mutual respect
Cantu RC: Is Helmet Design the Answer to Concussion in
Sports? Active Voice Bulletin ACSM, September 2010
“The only way I come out is on a stretcher.”
