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Sports Concussion Update: 2012
Michael C. Koester, MD, ATC
May 14th, 2012 Director, Slocum Sports Concussion Program
Slocum Center for Orthopedics and Sports Medicine Eugene, OR
Disclosures
I am a paid consultant for the Oregon Center for Applied Science, Inc. (ORCAS). They have developed two on-line concussion education programs- ACTive and Brain 101: The Concussion Playbook.
I am the Chair of the NFHS Sports Medicine Advisory Committee and the OSAA Medical Aspects of Sports Committee. Both are unpaid positions.
Concussions and Politics
The flying wedge, football's major offense in 1905, spurred the formation of the NCAA
Large numbers of players injured and killed
President Roosevelt summoned college athletic leaders to the White House Reform game or have it
banned
Concussions in Popular Entertainment
1939
Concussions in Popular Entertainment
2012
What is a Concussion?
A concussion is a mild traumatic brain injury that interferes with normal function of the brain
Evolving knowledge- “dings” and “bell ringers” are serious brain injuries
LOC not required- Far less than 5%
What happens to the brain?
A complex physiological process induced by traumatic biomechanical forces: sudden chemical changes- neurotransmitters
and glucose utilization disrupted stretching and tearing of brain cells
Structural brain imaging (CT or MRI) is almost always normal
Concussions are physiologic, not anatomic injuries
Still many unanswered questions . . .
Pediatric and Adolescent Brain
Increased risk for injury Water content Cerebral blood volume Level of myelination Skull geometry More vulnerable to
diffuse injury More difficult to
assess and monitor recovery the younger the patient!!!
Concussion Effects
Impacts 4 areas of function Cognitive
Concentration, memory Somatic
HA, fatigue Emotions
Irritability Sleep
Insomnia
Extent of the Problem
Professional athletes get a great deal of attention
Much more common in high school than any other level- due to large number of participants Oregon HS Sports
Participants Football- 15,000 Boys Soccer- 6,000 Girls Soccer- 5,000 Boys Hoops- 7,000 Girls Hoops- 7,000
Extent of the Problem Estimated 250,000
sports-related concussions in high school athletes yearly
20% of all HS sports injuries
47.1% of all injuries occurred in FB
Likely more than 2000 concussions in Oregon HS athletes every year Planned 3 year injury
data collection in HS FB to begin Fall 2012
Not Just a Football Problem Injury rate per 100,000 player exposures
Football 69 Ice Hockey 61 Boys’ Lacrosse 42 Girls’ soccer 38 Girls’ Lacrosse 34 Wrestling 28 Girls basketball 28 Boys’ soccer 23 Boys basketball 18 Softball 15 Cheerleading 14
High School RIO 08-11
Chronic Traumatic Encephalopathy
CTE- progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma Tau protein
Examples- Normal brain 45 year old former
NFL player 73 year old boxer
“Max’s Law” 2009
Mandatory coach education Player must be removed
from play if “exhibits signs, symptoms, or behaviors consistent with a concussion”
Cannot return to play that day
Cannot return to play until asymptomatic and cleared to return by a “health care professional”
Concussion management made easy!
When in doubt, sit ‘em out!!
No return to activity on the same day of a concussion
No return to activity if having symptoms of a concussion
Concussion Management: Zurich Guidelines, 2008 Notion of grading systems
has been abandoned Over 20 classifications Can only be applied
retrospectively No same day return to play Modifying Factors
Persistent symptoms, age, prolonged LOC, multiple concussions
Graded Return to Activity Management continues to
evolve!!!
Return to Activity Protocol
7 Steps to a Safe Return Step 1. Complete
cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.
Step 2. Return to school full-time.
Return to Activity Protocol
7 Steps to a Safe Return (cont) Step 3. Light exercise. This
step cannot begin until you are cleared by your physician for further activity.
Step 4. Running in the gym or on the field. No helmet or other equipment.
Step 5. Non-contact training drills in full equipment. Weight-training can begin.
Return to Activity Protocol
7 Steps to a Safe Return (cont)
Step 6. Full contact practice or training.
Step 7. Game play. Must be cleared by your physician before returning to play.
Cannot advance to next level if symptomatic
Progression usually takes about 1 week
The Biggest Problem
How do you know who has recovered from a concussion?
Return to Play Determination
No symptoms Rest and Exertion
Normal Exam “Normal” academic
performance “Pass”
Neuropsychologic testing
Computerized Neuropsychological Testing
Computerized testing has role in RTP Never stands alone
ImPACT most widely used and known 40+ Oregon high schools
Current data shows similar efficacy among all 3 tests
Coach Education
On-line training for coaches:
CDC Heads Up USA Football NATA/NHL Collaboration NFHS/CDC Heads Up
collaboration www.nfhslearn.com
Additional resources 400,000+ courses delivered
Brain 101: The Concussion Playbook
School-wide Concussion Management Targets everyone- coaches, athletes, teachers,
and parents!! Research projects ongoing
http://brain101.orcasinc.com/#
OCAMP Oregon Concussion Awareness and Management Program Max’s Law: Concussion Management
Implementation Guide for School Administrators Can be used as a companion document to Brain 101 Sample Policies and Procedures Sample school forms
http://www.ode.state.or.us/teachlearn/subjects/pe/ocampguide.pdf
CBIRT Contact: Melissa Nowatzke [email protected]
REAP Concussion Management Program
R = Reduce – physical and cognitive demands E = Educate – everyone on symptoms: Physical (How one “feels physically”) Cognitive (How one “thinks”) Emotional (How one “feels”) Maintenance (Energy and Sleep) A = Accommodate academics – teach the teachers P = Pace – Graduated Return-to-Play http://www.rockymountainhospitalforchildren.com/sports-
medicine/concussion-management/reap-guidelines.htm
Principles of Concussion Management No cure for concussion, but treatment can
help the athlete feel better and function better while symptomatic Medication?
Early diagnosis and education is critical, especially to avoid re-injury
Rest early (7-10 days?) and then gradually increase activity Cognitive rest
Concussion in the Classroom
Fatigue - tire easily in class and over the course of the day
Headache and other symptoms worsen with reading or concentration
Trouble doing more than one thing at a time (e.g., looking at PowerPoint and taking notes)
Frequent visits to the nurse’s office
Biggest Issue- NO ONE TAKES THEM SERIOUSLY!!!
Management- Academic Accommodations
School Stay home!!!
Transition to half-days Naps/rest time Extended time to
complete assignments Limit homework
Skip assignments, modify, or reduce
Extended time to take tests Open note/book
Allow time to visit school
nurse for treatment of headaches, if needed
Written instructions for homework
Repeat and present new information slowly
No standardized testing Share progress and
difficulties Someone to talk to
Need “point person” Don’t leave them adrift!!
Management- Cognitive Rest
Home Sleep!!! Limit “stimulation”: Phone Computer Music TV Texting Gaming
Management Challenges
Very little EBM Variation in initial
management by providers
School setting RTP when
“Asymptomatic” Role of neuropscyh
testing Academic performance
Prolonged symptoms
Athletes with Prolonged Symptoms Variation in services
Where do you live? Typical problems
Headache Insomnia Irritability
Medications OTC Analgesics Headache
Exercise Protocols Aerobic protocol
Stationary bike
Concussion Prevention
“Concussion prevention” has become the “holy grail” for sports equipment marketers Soccer head gear Football helmets with “new
technology” Helmets were designed to
prevent skull fractures- NOT concussions!!
NO PROVEN PROTECTION FROM CONCUSSION!!
Concussion Prevention
Everyone has something to sell to “prevent concussion” or monitor for “possible” concussion Shockstrips Chin straps Mouthpieces Various helmet paddings
Concussion Prevention Many interventions
sound good, but have little or no evidence to support efficacy
Concept of unintentional consequences
What are best steps forward? Girls’ Lacrosse
Prevention- National, State and Local
Football Rules POE No helmet to helmet contact Almost 70% of concussions
Limit contact in off-season Regulate camps and “spring
football” 7 on 7 football
Lengthen preseason Looking to add a week in
2013 Tackling progression- USA
Football Kidsports
Local Efforts
Kidsports, Eugene Metro FC, and Pop Warner have all mandated coach education and return to play policies.
Athletic Trainers @ South Eugene, North Eugene, Sheldon, Willamette, Churchill and Marist have been leaders in community and state.
Continued research efforts at UO Motion Analysis Lab and ORCAS, Inc.
Conclusions Everyone dealing with
young athletes must be aware of the signs and symptoms of concussions
Early recognition and management are essential to good outcome
Schools and organizations must have a concussion management plan in place
THANK YOU!!!!!! Thad Stanford, MD, JD- Salem Bill Bowers- Executive Director, OADA Tom Welter- Executive Director, OSAA Mickey Collins, PhD- Pittsburgh Ron Savage, EdD- New Jersey Brian Rieger, PhD- New York Ann Glang, PhD- Eugene Stan Herring, MD- Seattle
