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Thomas Martinelli, MD Commonwealth Orthopaedics and Rehabilitation

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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 !

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