1. Concussions in Basketball Marc Richard Silberman, M.D.

2. Has the game changed? Wilt “The Stilt” Chamberlain 7-1, 250 Tiny Gallon 6-9, 290

3. The game has changed “Now everyone looks like a sumo wrestler” - North Carolina Coach Roy Williams

5. Your Brain “This is your brain. This is your brain on drugs.”

6. This is your brain

7. The Brain Freely floating within the cerebrospinal fluid Moves at a different rate than the skull in collisions Collision between the brain and skull may occur On the side of the impact (coup) On the opposite side of the impact (contracoup injury) Acceleration-deceleration may result in stretching of the long axons and in diffuse axonal injury

8. Neurometabolic Cascade (Giza and Hovda 2001) Abrupt neuronal depolarization Release of excitatory neurotransmitters Changes in glucose metabolism Altered cerebral blood flow The brain goes into an ENERGY CRISIS that usually last up to 7 – 10 days symptoms often get worse before they get better

9. History of Concussions 1945 Quigley developed the 3 strike rule: 3 concussions in a season, out for the season 1975 Gronwall and Wrightson studied 20 athletes who suffered 2 concussions the rate at which information was processed was reduced more in those who suffered 2 concussion those who had two concussions took longer to recover than those with only one concussion

10. History of Concussions 2003 Bailes surveyed 2,500 retired NFL players 3 or 4 concussions = 2x as likely to develop depression 2008 The Center for the Study of Traumatic Encephalopathy A collaboration between Boston University School of Medicine and the Sports Legacy Institute (founded by Christopher Nowinski and Robert Cantu, M.D.) to better understand the long-term effects of repeated concussions

11. Chronic Traumatic Encephalopathy Progressive degenerative disease from multiple concussions Build up of Tau protein in brain 35 brains of deceased athletes Center for the Study of Traumatic Encephalopathy (13 belonged to former NFL players). 12 out of 13 brains manifested Chronic Traumatic Encephalopathy (CTE) 3 out of 12 exhibited motor neuron disease (Chronic Traumatic Encephalomyelopathy)

12. Lies, headlines, and statistics Headline: “Concussions in basketball are on the rise in teens” Study: Retrospective review of ER visits from 1997-2007 Truth: “Emergency room visits diagnosed as concussions are on the rise for teens playing basketball” 2.6% = overall concussion percentage of basketball injuries Percentage doubled in boys, tripled in girls from 1997-2007 Does not tell us if more concussions are being suffered The real story: 1/3 did not recognize or report symptoms to their ATC 28% continued to play with symptoms Pediatrics, McKenzie, October 2010 issue

13. High School Concussions 1995-1997 Concussion 5.5% of total injuries Football63.4% of concussions Wrestling 10.5% Girls Soccer 6.2% Boys Soccer 5.7% Girls Basketball 5.2% Boys Basketball 4.2% Softball 2.1% Baseball 1.2% Field Hockey 1.1% Volleyball 0.5% JAMA. 1999 Sep 8;282(10):989-91

14. Ligament sprains 44% Muscle/tendon strains17.7% Contusions8.6% Fractures 8.5% Concussions7.0% H.S. Basketball Injuries 2005-2007 Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

15. H.S. Basketball Injuries 2005-2007 Rebounding caused the majority of injuries Jumping/landing caused the majority of sprains Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

16. H.S. Basketball Injuries 2005-2007 Am J Sports Med December 2008 vol. 36 no. 12 2328-2335 Girls Boys 5 % 14 % 5 % 3 %

17. Females Greater proportion of concussions Greater proportion of knee injuries Knee was most common injury requiring surgery Males More frequently sustained fractures More frequently sustained contusions Contact sport H.S. Basketball Injuries 2005-2007 Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

18. Injuries by position Guard50% girls, 45% boys Forward35% girls, 40% boys Center14% girls, 13% boys Injuries by activity Rebounding25% Defending15% General play17% Ball handling9% Shooting9% H.S. Basketball Injuries 2005-2007 Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

19. Concussion Cause Collision with another player65% Contact with the floor13% Personal opinion this is not the truth Concussion Activity Rebounding 30% Defending20% Illegal Activity Total number of injuries13% Concussions35% H.S. Basketball Concussions 2005-2007 Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

20. Soccer, lacrosse, basketball, softball, baseball, and gymnastics 14,591 injuries in male and female athletes 5.9% classified as concussions Males Game Injury Rate / 1000 exposures Soccer1.40 Lacrosse1.46 Basketball 0.47 Females Soccer 2.10 Lacrosse 1.05 Basketball 0.73 Collegiate Concussions 1997-2000 J Athl Train. 2003 Jul–Sep; 38(3): 238–244

21. Collegiate Male Concussions 1997-2000

22. Collegiate Female Concussions 1997-2000

23. Females more likely than males to suffer concussions Games 3.4X riskier than practices for females A finesse sport has become a contact sport Concussions in Women Basketball 4.7% total injuries sustained in practice 8.5% total injuries sustained in games Concussions in Men Basketball 4.1% total injuries sustained in practice 5.0% total injuries sustained in games NBA game injury rate 2X the NCAA Collegiate Basketball Concussions 1997-2000 J Athl Train. 2003 Jul–Sep; 38(3): 238–244

24. This is your brain

25. What is a concussion? Complex pathophysiological process affecting the brain induced by traumatic biomechanical forces Functional disturbance of the brain with no structural injury Typically short lived impairment that resolves spontaneously Direct blow to the head Indirect blow with a force transmitted to the head

26. Classification of concussions A concussion is a concussion There is no such thing as a mild concussion No grading system Most symptoms resolve in a short period of 7-10 days Post concussive symptoms may be prolonged in children

27. Concussion diagnosis There is NO test to diagnose a concussion Clinical diagnosis based on the following: Symptoms Physical Signs Behavioral Changes (cry, irritable) Cognitive Impairment (slow reaction time, memory) Sleep Disturbances (drowsiness)

28. Symptoms Headache is the most common Feel dazed, cobwebs, or in a fog Light and sound sensitivity, visual disturbances “Everything seems slow” “My colors changed” Teammate, “Eric’s not right, coach” Appearance can be delayed several hours

29. Physical Signs You do not have to lose consciousness Amnesia (“Doc, I don’t remember the first half”) Emotional labile (crying, talkative) Poor balance Difficulty concentrating Difficulty remembering

31. On-Field Evaluation Standard emergency management Exclude cervical spine injury Return to play determined by a physician “When in doubt, sit them out” No player shall return to play the same day Sideline assessment of concussion (SCAT2) Monitor for any deterioration over time

32. Syracuse Post-Standard Jan 16, 2005

33. Concussion Management Complete physical and cognitive rest until symptom free No sports No horseplay No school, if necessary No texting, video games, internet, TV, driving Graded program of exertion prior to full return to play

34. Exertion effects  Symptoms are worsened by physical activity mental effort environmental stimulation emotional stress

35. Academic Accommodations  Excuse from school if necessary  Excuse from homework  Excuse from quizzes and tests  Rest breaks during school in a quiet location  Avoid re-injury in crowded hallways or stairwells  Avoid over-stimulation (cafeteria or watching games) Provide reassurance and support

36.  Most recovery in 7-10 days.  About 95% recover in 3 months  Post-concussion syndrome is the term used to describe prolonged or incomplete recovery  Non-injury factors often play a role in the persistence of symptoms Recovery from Concussion a ‘miserable minority’ experience persistent symptoms

37. Risk factors for complicated recovery  Re-injury before complete recovery  Over-exertion early after injury  Significant stress  Unable to participate in sports  Medical uncertainty  Academic difficulties  Prior or comorbid condition  Migraine  Anxiety  ADHD, LD Post-concussion syndrome

38. Multiple Concussions  Second Impact Syndrome  A concussion within 2 weeks of one  Athlete is still symptomatic  Mostly males < 21 years old  Rapid increase in intracranial pressure  Rare but almost always fatal  Cumulative effects  Risk of concussion is 4-6 times greater after one concussion  Risk is 8 times greater after sustaining two concussions  Prolonged or incomplete recovery  Increased risk of later depression or dementia How many is too many ?

39. Return to activity No symptoms at rest Neuropsychological test returns to baseline Balance testing returns to baseline Consideration of concussion modifiers Graded return to play protocol

40. Neuropsychological Tests Neuropsychological testing is an additional tool May assist in return to play decisions Need a baseline Perform the follow-up test when symptom free Cognitive recover most overlap symptom recovery may precede symptom recovery may follow symptom recovery You can be fooled!

41. Not all doom and gloom Neurosurgery, January 2009, Volume 64, Issue 1, 100-106 858 collegiate male athletes computer neuropsych test, 298 reported a history of concussion 479 collegiate male athletes traditional neuropsych test, 187 reported a history of concussion 175 collegiate male athletes both tests, 57 reported concussion No significant association was found between self-reported concussion history and performance on either computerized or traditional neuropsychological tests Conclusion: Athletes who report a distant history of concussion have minimal enduring cognitive deficits. Prospective studies to identify moderating factors are necessary to help determine who is at risk for long-term cognitive difficulties after concussion.

42. Concussion modifiers SymptomsNumber, Duration (>10 days), Severity SignsProlong loss of consciousness (> 1 min), amnesia SequelaeConcussive convulsions TemporalFrequency – repeated concussions over time Timing – injuries close together in time “Recency” – recent concussion ThresholdRepeat concussions occurring with progressively less impact Repeat concussions with slower recovery after each one AgeChild and adolescent ComorbidityMigraine, depression, ADHD, LD, sleep disorder MedicationPsychoactive drugs Behavior Dangerous style of play SportHigh risk activity, contact collision sport, high sporting level

43. Graduated return to play protocol Day 1Light aerobic exercise Light jog/stroll, stationary bicycle Goal: elevate HR Day 2Sport-specific exercise Running drills in basketball Goal: add movement Day 3Non-contact training drills Passing and shooting, light resistance training Goal: coordination, cognitive load, valsava Day 4 Full contact practice only after physician clearance Day 5Return to competition Any symptoms at any stage, return to complete rest

44. Custom Mouth Guards Prevent dental injuries Do NOT prevent concussions Prospectively recorded dental injuries and concussions among 50 men's Division I college basketball teams during one competitive season Custom-fitted mouth guards do NOT significantly affect rates of concussions or oral soft tissue injuries, but can significantly reduce the morbidity and expense resulting from dental injuries in men's Division I college basketball Labella, C. R., B. W. Smith, and A. Sigurdsson. Effect of mouthguards on dental injuries and concussions in college basketball. Med. Sci. Sports Exerc., Vol. 34, No. 1, 2002, pp. 41-44

45. Consensus Statement on Concussions in Sport reference 2001 1 st International Conference on Concussion in Sport, Vienna 2004 2 nd International Conference on Concussion in Sport, Prague 2008 3 rd International Conference on Concussion in Sport, Zurich http://www.sportconcussions.com/html/Zurich%20Stat ement.pdf http://www.sportconcussions.com/html/Zurich%20Stat ement.pdf Sport Concussion Assessment Tool (SCAT2)

46. Concussions in Basketball Thank you. Marc Richard Silberman, M.D. Gillette, NJ drbicycle@njsportsmed.com (908) 647 6464