Presentation on theme: "Concussion in Sports Stephen V"— Presentation transcript:
1 Concussion in Sports Stephen V Concussion in Sports Stephen V. Cantrill, MD, FACEP Associate Director Department of Emergency Medicine Denver Health Medical Center Denver, Colorado1111
2 On the Sidelines of a Soccer Match Soccer forward collides with opposing player while trying to head the ball. Both players tumble to the ground.Opposing player immediately jumps to his feetOther player arises slowly and starts walking towards the goal, appearing dazed. Is brought to sidelines by teammatesComplains of a headache and dizziness but denies any tinnitus, nausea or vision changes.Is oriented to person, place and time, but is unable to recall what period they are playing in or the current score.Symptoms abate after 30 minutes. He denies any other symptoms and desperately wants to continue in the game.
3 The QuestionsWhat is the appropriate decision about return to play for this player?Return to this game?Able to practice tomorrow?What type of sideline evaluation is appropriate?Is any follow-up needed?
4 BackgroundEstimated 200, ,000 concussions per year in sports in US alone75% of concussions in sports DO NOT involve Loss of Consciousness (LOC)May be under-recognizedConcussion with LOC is obvious75% that do not have LOC may be much less obvious
5 Reasons for Under Reporting Player lack of knowledge as to what compromises a concussionDelaney, 2001: Only 16% of university football players who suffered a concussion knew what it wasConcern about being removed from play
6 Concussion - What is It?Defined in 1966 by the Congress of Neurological Surgeons:“A clinical syndrome characterized by immediate and transient post traumatic impairment of neural function due to brainstem involvement”Broadened to include any posttraumatic alteration in mental status that may or may not involve loss of consciousness
7 And Now, the Updated Version A complex patholophysiological process affecting the brain, induced by traumatic biomechanical forces….Causes: direct or indirect forceRapid onset of short lived impairment that resolves spontaneouslyReflects functional disturbance, not structuralUsually grossly normal structural imaging studiesFirst International Conference on Concussion in Sport, Vienna 2001
8 Sports at Risk: Incidence versus Concussions per 1000 player hours FootballSoccerWrestlingBasketballBaseballSoftballField HockeyIce HockeyLacrosseVolleyballMultiple others
9 The Controversy over Heading: Does it contribute to brain injury? Much sensation in the lay pressSome poorly designed studies state emphatically: YESOther studies are much less clearMay be a factor in players who sustain multiple concussions
10 Other Epidemiologic Factors Concussed football players have a six fold increase in suffering yet another concussionCumulative effect of multiple insultsApolipoprotein E epsilon-4: May imply increased brain susceptibility to damage (Rabadi, 2001)
11 Cerebral Forces Causing Injury Compresssive/Direct PressureTensile/Negative PressureRotational/Shearing ForcesCause of most devastating injuries
13 Concussion Presentation Confusion and amnesia are cardinal featuresMultiple manifestations
14 Concussion Presentation: Neurobehavioral Features Vacant stareDelayed verbal and motor responsesInability to focus attentionDisorientationSlurred or incoherent speechGross observable incoordinationExcessive emotionalityMemory deficitsAny period of loss of consciousness
15 Commonly Reported Symptoms Commonly Seen Early (min to hours)HeadacheDizziness or vertigoLack of awareness of surroundingsNausea and vomiting
16 Commonly Reported Symptoms: Seen Late (days to weeks) Persistent low-grade headacheLightheadednessPoor attention and concentrationMemory dysfunctionEasy fatigabilityIrritability and low frustration toleranceIntolerance of bright lights or difficulty focusing visionIntolerance of loud noises, sometimes ringing in earsAnxiety and depressed moodSleep disturbance
17 Concussion Grading and Return-to-Play Guidelines: Why Worry? Return to play with altered cognition and physical capabilityRisk of additional injuryRisk of “Second Impact Syndrome”Blow to head of individual still symptomatic from previous mild brain injuryRapid, diffuse brain swelling resulting most often in deathControversial entity
18 Concussion Grading and Return to Play Guidelines As many as 25 different sets of criteriaLittle evidence-based supportExpert opinionConsensusThree most often referenced:CantuColorado Medical SocietyAmerican Academy of Neurology
23 Points of Commonality in Most RTP Guidelines: Any concussed athlete should be removed from competition, examined and observedSerial assessment of the athlete after the concussionAny evidence of deterioration, no matter how mild the injury: transport to hospital for appropriate evaluationAthlete with LOC, even momentary, or post-event amnesia should not be allowed to immediately return to playPost-concussed athlete cannot return to play until completely asymptomatic, both at rest and after exertionMultiple concussions may have a cumulative effect on the athlete
24 Sideline Assessment of Neurological Function Glasgow Coma ScaleLacks sensitivityStandard orientation (X3)
25 Sideline Assessment of Neurological Function Maddocks QuestionsWhich field are we at?Which team are we playing today?Who is your opponent at present?Which quarter (period) is it?Which side scored the last goal?Which team did we play last week?Did we win last week?More sensitive: concussed vs nonconcussed
26 “Standardised Assessment of Concussion” - SAC - McCrea 1997 Orientation (Month, Date, Day of Week, Year, Time)Immediate Memory (3 trials of 5 words)Concentration (3, 4, 5 and 6 digit strings backwards)Delayed Recall (1 trial of 5 words, used above)Maximum of 30 pointsBrief neurological screenLOC - Amnesia - Strength - Sensation - CoordinationExertional evocative component:5 jumping jacks - 5 sit-ups - 5 push-ups - 5 knee-bends
27 “Standardised Assessment of Concussion” Useable in the fieldBest if individual baseline established before season startsDecrease in 1 point or more from baseline: 96% sensitivity, 76% specificity in detecting symptomatic concussed players using AAN criteria (McCrea, 2001)
28 Neuropsychological Testing Much development in past decadesAdditional tool to evaluate recoveryBut:Best tests yet to be demonstratedBaseline testing should be doneTime and dollar costs are highComputer and web-based testing may help
29 Neuropsychological Testing May be helpful in situations of:Severe concussionProlonged post-concussive symptomsMultiple concussionsQuestions of athlete truthfulnessConcept endorsed by Concussion in Sport Group
30 Problems with Hospital Care Lack of awareness of RTP guidelines by cliniciansDischarge instructions don’t address adequate follow-up and return-to-play criteria nor limitations in activities of daily living
31 Concussion in Sports Summary Most concussions in sports do not involve LOC, but rather confusion/amnesiaConcussion grading criteria RTP criteria have limited scientific grounding but serve as useful tools for guidanceTo avoid further injury and possibly the potentially lethal “second impact syndrome”, concussed athletes should not return to play until completely asymptomatic, sometimes requiring a prolonged period of time
32 Concussion in Sports Summary The sideline use of detailed mental status screening tools allows for more sensitivity and standardization in the evaluation of the concussed athleteNeuropsychological testing may be helpful with ongoing post-concussive symptoms, multiple concussions or severe concussionsOngoing education of athletes is necessary to emphasize a concussion does not require loss of consciousness
33 Concussion in Sports Summary Ongoing education of providers about guidelines for concussion in sports to insure appropriate and thorough evaluation of concussed athletes on the field, in the office and in the emergency department.These guidelines should be utilized as part of the decision-making process of when the athlete should be allowed to return to play and to insure the adequacy of patient post-injury education.
34 Back on the Soccer Field… Due to duration of his symptoms, the athlete sat out the rest of the gameHe was administered Standardized Assessment of Concussion (SAC) instrument, scoring 23 out of 30. His preseason baseline score was 27.The athlete was instructed by the trainer about symptoms to be aware of that could represent a worsening of his traumatic brain injury or could indicate a post-concussive syndrome.
35 And Finally...He did have recurrence of his headache that evening, but it had abated by the next morning and he remained symptom free.Re-administration of the SAC instrument 48 hours post-injury revealed return to his normal baseline of 27.The athlete was counseled to not engage in contact sports for an additional week.By the way, his team won the league title, 2-1.