1. Thomas Martinelli, MD Commonwealth Orthopaedics and Rehabilitation
Concussion in soccer
Thomas Martinelli, MD
Commonwealth Orthopaedics and Rehabilitation

2. Virginia Youth Soccer Association
Presented to
Virginia Youth Soccer Association
January 22, 2011

3. Historical Example of what not to do
1973
13 year old CYO football punter in first half – bad snap – runs for it
Knocked unconscious on field – ambulance called – woke up before they arrived
Went back in second half, played entire half, tackles QB for safety, team wins

4. Definition of Concussion
“A trauma induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are the hallmarks of concussion.”
(American Academy of Neurology Summary Statement – The Management of Concussion in Sports)

5. Simply put – It is a Brain injury !

6. Synonyms Dinged Bell rung Knocked out Fell out Saw stars
MTBI (Mild Traumatic Brain Injury)

7. How frequent are they ?
1.4 to 3.6 million sports and recreation related concussions per year
The majority occur at high school level !
(2006 CDC estimate)

8. Who gets them? Sport Age Male vs Female Position on field
How they happen
Prior concussions

9. Sport
Intentional brain injury sports – boxing, mixed martial arts, extreme fighting
100 % even with protective headgear
Persistent brain/neuro damage
Some with serious long term effects (Muhammad Ali)
(AAN)

10. Sport Non-Intentional brain injury sports: High school level
Ice hockey
Football
Soccer
Wrestling
Basketball
Field hockey
(Wilson Pediatrics 2006)

11. (Delaney, McGill University)
Sport – Soccer/Age
50,000 high school concussions/year in 2006 data
(J Athletic Training)
Various studies 2 % to 62.7%
(Delaney, McGill University)

12. Sports - Soccer
Almost all of the studies done since 2004 show minimal difference in incidence of concussion in football and soccer players at the high school level or at the university level

13. Male vs Female in Soccer
40% higher rate in women at high school level
(J Athletic Training 2007)
2.6 times more likely for women in University level soccer
(McGill university 1999 study)
■ Several reasons postulated for this:
1. reporting differences
2. game differences
3. musculature differences

14. (Delaney, McGill University)
Position on field
Of players with at least 1 concussion:
Goalie 79% incidence
Defense 70.2%
Mid/Forward both 57%
(Delaney, McGill University)
Other studies not as clear a difference

15. How Do These Occur?

16. How do these occur ? Head to head Hand/Arm/elbow to head Ball to head
(ACC , US Olympic data 1993)
Hand/Arm/elbow to head
(J Athletic Training)
Ball to head
Head to ground
Other body part to head

17. It is possible to get a concussion without head impact!
Rapid acceleration/deceleration from impact to shoulders/torso transmitted to the brain

20. Does heading the Ball cause concussions?

21. Heading the ball ? “Footballers Migraines”
Yes but only reports and not on ImPact testing
(Kaminski Delaware, Putukian Princeton)
Yes and measurable long term
(Tysvaer 1989 AJSM) No
(Fuller, Dick, Anderson)
Overall felt to be inconclusive but AYSO recommends against heading until age 10.

22. Heading the ball – however…
Several studies have demonstrated worse performance on physical (balance) and/or cognitive tests in recent concussion patients who repeatedly head the ball
(ACSM meeting 2009)
■ So caution is needed in return to head impact sports with recent concussion

23. Best predictor of concussion ?
Prior concussion !!!
3 to 10 times more likely to get another concussion if you have had one before
92% occur within 10 days of first one
Thoughts range from style of play to genetic or anatomic factors
No current recommendations for prevention, other than teaching proper technique and using proper equipment

24. Initial Complaints Dizziness Double vision Drowsiness Foggy Headache
Nausea
Nervousness
Ringing in ears
Vomiting

25. Later complaints Depression/Sadness Excessive sleep/fatigue
Irritability
Sensitivity to light
Sensitivity to noise
Vomiting
Poor concentration/memory issues

26. Worrisome physical findings
Worsening neurologic exam
Worsening headache
Seizure
Stiff neck
Fluid leaking from nose
Bleeding from ears
Unequal pupil size
Weakness/tingling in arms or legs
All of these mean an immediate trip to the emergency room

27. Physical exam Standard field management if unconscious
Airway
Breathing
Circulation
Ambulance if needed
Sideline management
Overall exam
Cognitive testing
Motor testing
Serial repeats

28. Overall exam Rule out other pathology Rule out bad things
Neck, Back, extremities
Rule out bad things
Eye tracking, pupil reaction and size
Fluid leaking from places it should not leak from
Swelling/deformity
specifically around the head and face

29. Tests Sideline exam ImPact MRI,CT Scan Functional MRI Blood tests
Mental
Physical
ImPact
MRI,CT Scan
Functional MRI
Blood tests

30. Multiple tests exist Cognitive Physical
SAC, U of Pitt for sideline/initial evaluation
ImPact, CogSport, Headminder Concussion Resolution Index, ANAM-SMB for later eval
Graded Symptom Checklist for both
Physical
Smart Balance Master, Chattecx Balance System, Balance Error Scoring System

31. Cognitive – U of P sideline test
Orientation
What stadium is this
What city is this
Who is the opposing team
Month, day, year
Posttraumatic amnesia
Repeat 3 words
Retrograde amnesia
What happened last quarter
What do you remember before the hit
What was the score of the game before the hit
Do you remember the hit
Concentration
Days of the week backwards
Repeat numbers backward – 2 digit, 3 digit,…
Word list repeat
What were the 3 words given earlier

32. Sports Concussion Assessment Tool (SCAT2)
4 page cognitive and physical assessment
Lots of sections with scores in each
No current normative data so no cutoff scores are established
Best in comparison to pre-injury score
Available for free download at

33. ImPact test Immediate Post-concussion Assessment and Cognitive Testing
Developed in 1990’s by Mark Lovell, PhD and Joseph Maroun, MD, who run the U of P concussion program
20 minute online test - 5 sections with 6 modules in the actual test section
Given before season begins then after concussion
Return to baseline indicates return to contact time
Purely neurocognitive
Used in Fairfax County Schools, MLS, US Olympic Soccer, NFL, NHL, MBL, NBA (8 teams), Rugby, auto racing
Validated

34. Physical tests Double leg stance with eyes closed, hands on hips
Single leg stance, same
Heel to toe walking in line
Finger to nose - rapid alternating
40 yard sprint
Balance Error Scoring System
UNC Chapel Hill
Supposed to take 10 minutes

35. MRI, CT Scan Consensus – no role in the management of concussion !
Concussion is a microscopic brain injury with no MRI or CT findings
However, can rule out other worse pathologies and is useful if symptoms deteriorate over time

36. Functional MRI, PET scans
Look at brain activity in the course of cognitive activity
Can demonstrate abnormal patterns
Have correlated with ImPact score improvement
Not widely available and expensive

37. Blood Tests/Genetic Markers
Myelin Basic Protein
Tau
GFAP
S100
Neuron specific enolase
SOD1
Genetic markers
APO E4
APO E promotor
Tau polymerase

38. Classification schemes
Over 40 known classifications
Most do not agree with each other
3 are widely used:
Cantu
Colorado Medical Society
American Academy of Neurology

39. Classification - Cantu
First published in 1986
based on amnesia and loss of consciousness
Updated in 2001 to include secondary symptoms
Grade 1 no loss of consciousness
less than 30 minutes post traumatic amnesia
Grade 2 LT 1 minute loc
amnesia 30 minutes to 24 hrs
Grade 3 GT 1 minute loc
any symptoms lasting over 1 week

40. Classification – Colorado Medical Society
Published 1991
in response to high school athletes death
Grade 1 confusion only
Grade 2 confusion and post traumatic amnesia
Grade 3a unconscious for seconds
Grade 3b unconscious for minutes

41. Colorado Medical Society Classification
First to add specific guidelines for return to sport Timing based on first or repeat concussions
Grade
First concussion
Second concussion 1
15 minutes
1 week 2
2 weeks with MD approval 3a
1 month
6 months with MD approval 3b
6 months
1 year with MD approval

42. Classification- American Academy of Neurologists
Introduced 1997 – based on Colorado guidelines
Grade 1 no loss of consciousness
confusion lasts less than 15 minutes
Grade 2 same but more than 15 minutes
Grade 3a brief loss of consciousness (seconds)
Grade 3b prolonged loss of consciousness (minutes)

43. AAN return to play guidelines
Same as Colorado except grade 1
Do neuro exam every 5 minutes
Return to play if normal within 15 minutes
However, policy was stated in 1997 and is slated for a late 2011 update. Expect much more stringent guidelines

44. International Conference on Concussion in Sport
First Vienna 2001
Second Prague 2004
Third Zurich 2008
Consensus panels of international experts
Each built on the prior panels’ work
Latest guidelines for return to sport, work- up and follow-up
Wide range of recommendations, some controversial

45. ICCS recommendations
Pre-participation concussion history is very important
Sideline evaluation medically then cognitive using SCAT2
Attention to cervical spine as additional concern
No return to sport day of concussion except in rare adult instances
Should not be left alone for several hours post injury
Imaging, genetic studies not helpful in most cases
Graduated return to sports

46. ICCS Controversies Guidelines can apply to as young as 10 year olds
Treat elite/non-elite athletes the same
Helmet/mouthguard use does not lessen concussions
Do not agree that loss of consciousness under 1 minute is a measure of severity
No consensus about chronic effects
No defined guidelines based on grading – in fact no grading system
Modifying factors may lengthen recovery
ADD/ADHD LD
Depression
Sleep disorders

47. Do Mouthguards/Helmets help?
Mouthguards – a resounding no!
But important for oral/dental injury prevention
Helmets
In American Football, yes for skull fractures, facial injuries, eye injuries
Uncertain for concussions
Different game now vs pre-helmet days
Different reporting of injuries
Different awareness of concussion risks

48. Soccer helmets Allstar, Headblast Full90 25 to 45 dollars online
Complies with FIFA and US Soccer regulations
2008 study: use cut risk in half and 19% decrease in recurrent concussions
(Delaney BJSM)
May not be as beneficial for women as men in lab study
(Tierney J Ath Train 2008)

49. Soccer Helmets Not currently widely used
Relatively new
Not cool yet since not highly endorsed by professional players
2006 attempted law in Mass did not pass
Worries exist that it will cause more head impact injuries due to American football spearing effect
So far however no changes in the game where it has been used are noted
Did shin guards change the game?

50. Old myths Don’t go to sleep after a concussion
Current recommendation is to periodically wake for assessment every 3 hours but sleep itself is ok
Don’t take medications for a headache after a concussion
No indications against any medication except alcohol
Weak recommendations against aspirin/Motrin for bleeding
Better helmets will lessen the risk in football players
Risk has gone up with bigger and faster players who use their helmets to lead in tackles

51. Old myths Don’t eat or drink after a concussion
Only if nausea/vomiting prevent it
Stay at bedrest after a concussion
Physical and mental rest are good, but no study indicated better outcomes with bedrest

52. Old myths Loss of consciousness is an indicator of concussion severity
At least 3 studies and the 3rd ICCS say this is not true
Young people do not have as severe concussions as professionals
At least 4 studies say younger athletes have more severe symptoms that last longer

53. Long term effects Single injury Rapid repeat injury
Multiple injuries over long term

54. Single injury Measurable learning deficits
“Testing effect” absent in post concussion states until back to baseline
Frequently worsening scores over 48 hours
Measurable cognitive and physical deficits can persist for weeks or months
Seldom result in long-term effects

55. Rapid repeat injury
More likely to get another concussion until brain returns to “baseline”
Second Impact Syndrome (SIS)
Nearly all in under 20 age group
High incidence in American football
All die or are severely disabled afterward
Massive brain swelling is the reason
CDC estimates 1.5 deaths per year due to concussions so the incidence is low

56. Multiple injuries over time
Some studies recommend 3 concussions lifetime end a person’s career
(NCAA Concussion study, Guskiewicz AJSM, Collins NS)
Others not conclusive
(Collie Br JSM, McCrory Br JSM)

57. Multiple injuries over time
Retired NFL players with 3 or more concussions 2005 study
5x likelihood of cognitive impairment
3x likelihood of significant memory issues
(vs other retired NFL players without concussions)
More recent studies link to
Alzheimer’s dementia
Post-traumatic Encephalopathy
Parkinson’s disease
Depression
Emotional lability

58. Notable Soccer stars Taylor Twellman – MLS MVP 2005 Lori Chalupny
Played just 2 games since Aug 30, 2008
Still can’t head the ball
Lori Chalupny
Former captain of US women’s team
MD’s refuse to clear her return to national team but playing this year in the women’s professional league
Alecko Eskandarian – MVP of 2004 MLS Cup final
Out since 4th concussion in 2009
Ross Paule
Retired age 29 with post concussion syndrome
Josh Gros - Former all-star
Retired at 25 in 2007 with 7 concussions that year alone
USMC will not readmit him

59. Treatment Minimal interventions actually work
Time seems to be the best treatment
“Brain rest” may include avoidance of video games
(Cantu et al 1st ICCS)

60. Future directions
Army announces blood test for brain injury in concussion
Details are very scarce at this time but 4 markers
SBDP145, SBDP120, UCH-L1, MAP-2
Remains to be seen how accurate this turns out to be over time
HITS Head Impact Telemetry System
Instrumented helmets in football and other sports gives instant feedback about likelihood of concussion in a given hit
Problem is not all brains react the same to the same energy impact

61. Future directions Increased NFL vigilance against head impact
Trickle down effect to youth football
Soccer mandates helmet use starting with goalies
MY GUESS - IT IS JUST A MATTER OF TIME !

62. So back to the 13 year old football player What should have been done?
ImPact baseline before season
Serial cognitive/physical monitoring using U of P, BESS or similar guidelines
Serial ImPact testing until return to baseline
Grade 3 concussion (if you believe in grading)
Minimum 1 month before return to sports per Colorado and AAN guidelines
Minimum 1 week after symptoms resolve per ICCS

63. Thank You !