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

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Presentation on theme: "Concussion in soccer Thomas Martinelli, MD Commonwealth Orthopaedics and Rehabilitation."— Presentation transcript:

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

2 Presented to Virginia Youth Soccer Association January 22, 2011

3 Historical Example of what not to do year old CYO football punter in first half – bad snap – runs for it 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 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 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 Dinged Bell rung Bell rung Knocked out Knocked out Fell out Fell out Saw stars Saw stars MTBI (Mild Traumatic Brain Injury) MTBI (Mild Traumatic Brain Injury)

7 How frequent are they ? 1.4 to 3.6 million sports and recreation related concussions per year 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 Sport Age Age Male vs Female Male vs Female Position on field Position on field How they happen How they happen Prior concussions Prior concussions

9 Sport Intentional brain injury sports – boxing, mixed martial arts, extreme fighting 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: Non-Intentional brain injury sports: High school level High school level –Ice hockey –Football –Soccer –Wrestling –Basketball –Field hockey (Wilson Pediatrics 2006)

11 Sport – Soccer/Age 50,000 high school concussions/year in 2006 data 50,000 high school concussions/year in 2006 data (J Athletic Training) Various studies 2 % to 62.7% 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 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 40% higher rate in women at high school level (J Athletic Training 2007) 2.6 times more likely for women in University level soccer 2.6 times more likely for women in University level soccer (McGill university 1999 study) Several reasons postulated for this: Several reasons postulated for this: 1. reporting differences 2. game differences 3. musculature differences

14 Position on field Of players with at least 1 concussion: 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 Head to head (ACC , US Olympic data 1993) Hand/Arm/elbow to head Hand/Arm/elbow to head (J Athletic Training) Ball to head Ball to head Head to ground Head to ground Other body part to head 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

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20 Does heading the Ball cause concussions?

21 Heading the ball ? Footballers Migraines Yes but only reports and not on ImPact testing Yes but only reports and not on ImPact testing (Kaminski Delaware, Putukian Princeton) Yes and measurable long term Yes and measurable long term (Tysvaer 1989 AJSM) No 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 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 So caution is needed in return to head impact sports with recent concussion

23 Best predictor of concussion ? Prior 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 Dizziness Double vision Double vision Drowsiness Drowsiness Foggy Foggy Headache Headache Nausea Nausea Nervousness Nervousness Ringing in ears Ringing in ears Vomiting Vomiting

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

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

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

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

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

30 Multiple tests exist Cognitive Cognitive –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 Physical –Smart Balance Master, Chattecx Balance System, Balance Error Scoring System

31 Cognitive – U of P sideline test Orientation Orientation –What stadium is this –What city is this –Who is the opposing team –Month, day, year Posttraumatic amnesia Posttraumatic amnesia –Repeat 3 words Retrograde amnesia 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 Concentration –Days of the week backwards –Repeat numbers backward – 2 digit, 3 digit,… Word list repeat Word list repeat –What were the 3 words given earlier

32 Sports Concussion Assessment Tool (SCAT2) 4 page cognitive and physical assessment 4 page cognitive and physical assessment Lots of sections with scores in each Lots of sections with scores in each No current normative data so no cutoff scores are established No current normative data so no cutoff scores are established Best in comparison to pre-injury score Best in comparison to pre-injury score Available for free download at Available for free download athttp://www.sportalliance.com/Images/Sport%20Safety/SCAT2.pdf

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

34 Physical tests Double leg stance with eyes closed, hands on hips Single leg stance, same Single leg stance, same Heel to toe walking in line Heel to toe walking in line Finger to nose - rapid alternating Finger to nose - rapid alternating 40 yard sprint 40 yard sprint Balance Error Scoring System Balance Error Scoring System –UNC Chapel Hill –Supposed to take 10 minutes ProtocolNATA09.pdf

35 MRI, CT Scan Consensus – no role in the management of concussion ! Consensus – no role in the management of concussion ! Concussion is a microscopic brain injury with no MRI or CT findings 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 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 Look at brain activity in the course of cognitive activity Can demonstrate abnormal patterns Can demonstrate abnormal patterns Have correlated with ImPact score improvement Have correlated with ImPact score improvement Not widely available and expensive Not widely available and expensive

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

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

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

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

41 Colorado Medical Society Classification First to add specific guidelines for return to sport Timing based on first or repeat concussions 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 Introduced 1997 – based on Colorado guidelines Grade 1no loss of consciousness Grade 1no loss of consciousness confusion lasts less than 15 minutes Grade 2same but more than 15 minutes Grade 2same but more than 15 minutes Grade 3abrief loss of consciousness (seconds) Grade 3abrief loss of consciousness (seconds) Grade 3bprolonged loss of consciousness (minutes) Grade 3bprolonged loss of consciousness (minutes)

43 AAN return to play guidelines Same as Colorado except grade 1 Same as Colorado except grade 1 Do neuro exam every 5 minutes Do neuro exam every 5 minutes Return to play if normal within 15 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 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 FirstVienna 2001 FirstVienna 2001 SecondPrague2004 SecondPrague2004 ThirdZurich 2008 ThirdZurich 2008 Consensus panels of international experts Consensus panels of international experts Each built on the prior panels work Each built on the prior panels work Latest guidelines for return to sport, work- up and follow-up Latest guidelines for return to sport, work- up and follow-up Wide range of recommendations, some controversial Wide range of recommendations, some controversial

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

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

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

48 Soccer helmets Allstar, Headblast Allstar, Headblast Full90 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 Not currently widely used –Relatively new –Not cool yet since not highly endorsed by professional players 2006 attempted law in Mass did not pass 2006 attempted law in Mass did not pass Worries exist that it will cause more head impact injuries due to American football spearing effect 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 So far however no changes in the game where it has been used are noted –Did shin guards change the game?

50 Old myths Dont go to sleep after a concussion Dont go to sleep after a concussion –Current recommendation is to periodically wake for assessment every 3 hours but sleep itself is ok Dont take medications for a headache after a concussion Dont 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 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 Dont eat or drink after a concussion Dont eat or drink after a concussion –Only if nausea/vomiting prevent it Stay at bedrest after a concussion 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 Loss of consciousness is an indicator of concussion severity –At least 3 studies and the 3 rd ICCS say this is not true Young people do not have as severe concussions as professionals 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 Single injury Rapid repeat injury Rapid repeat injury Multiple injuries over long term Multiple injuries over long term

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

55 Rapid repeat injury More likely to get another concussion until brain returns to baseline More likely to get another concussion until brain returns to baseline Second Impact Syndrome (SIS) 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 persons career Some studies recommend 3 concussions lifetime end a persons career –(NCAA Concussion study, Guskiewicz AJSM, Collins NS) Others not conclusive Others not conclusive –(Collie Br JSM, McCrory Br JSM)

57 Multiple injuries over time Retired NFL players with 3 or more concussions 2005 study 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 More recent studies link to –Alzheimers dementia –Post-traumatic Encephalopathy –Parkinsons disease –Depression –Emotional lability

58 Notable Soccer stars Taylor Twellman – MLS MVP 2005 Taylor Twellman – MLS MVP 2005 –Played just 2 games since Aug 30, 2008 –Still cant head the ball Lori Chalupny Lori Chalupny –Former captain of US womens team –MDs refuse to clear her return to national team but playing this year in the womens professional league Alecko Eskandarian – MVP of 2004 MLS Cup final Alecko Eskandarian – MVP of 2004 MLS Cup final –Out since 4 th concussion in 2009 Ross Paule Ross Paule –Retired age 29 with post concussion syndrome Josh Gros - Former all-star 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 Minimal interventions actually work Time seems to be the best treatment Time seems to be the best treatment Brain rest may include avoidance of video games Brain rest may include avoidance of video games (Cantu et al 1 st ICCS)

60 Future directions Army announces blood test for brain injury in concussion 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 SBDP145, SBDP120, UCH-L1, MAP-2 –Remains to be seen how accurate this turns out to be over time HITS Head Impact Telemetry System 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 Increased NFL vigilance against head impact –Trickle down effect to youth football Soccer mandates helmet use starting with goalies 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 ImPact baseline before season Serial cognitive/physical monitoring using U of P, BESS or similar guidelines Serial cognitive/physical monitoring using U of P, BESS or similar guidelines Serial ImPact testing until return to baseline Serial ImPact testing until return to baseline Grade 3 concussion (if you believe in grading) 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 !


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