Overview Definitions Incidence data Mechanisms of Injury Symptoms Diagnostic tools Outcome Prevention
Definitions TBI = traumatic brain injury – Any injury to the brain which produces structural or functional alterations – May be “mild” – concussion – Severe cases cause coma and death Concussion = transient trauma-induced alteration in brain function – Does NOT require loss of consciousness CTE = chronic traumatic encephalopathy – Slowly progressive loss of global neurologic function in athletes with history of multiple concussions
Scope of the problem Between 2 and 3.8 million cases of TBI reported annually in the US – 500,000 – 760,000 are sports-related 50,000 deaths/year 70,000 – 90,000 permanently disabled/year Highest incidence: ages 15-24
Scope of the problem Concussion in athletes: – Duration of symptoms is highly variable – 15% of these patients will continue to have symptoms one year after the injury – An athlete who sustains a concussion is 4-6 times more likely to sustain a second concussion
Scope of the problem Horseback riding causes 11.7% of all TBIs among recreational sports – Highest percentage of any recreational sport In 2009 there were over 14000 ER visits for brain injuries among riders
Major traumatic brain injury REMEMBER: in the unconscious patient ALWAYS assume an associated spine injury ABC’s – Emergency airway – Hyperventilation
Types of TBI Skull fractures Intracranial hematomas Concussions
Skull fractures – diagnosis and management CANNOT reliably diagnose these lesions by palpation – Significant individual variability in baseline contours of skull Does not always have an associated scalp laceration May occur even with mild brain injury If suspected – refer for CT – X-ray useless
Basilar skull fracture Can present in delayed fashion Symptoms: – Hearing loss, severe dysequilibrium – CSF rhinorrhea or otorrhea – Loss of smell or taste Signs: – “racoon eyes” – Battle sign (bruising over mastoid)
Intracranial hematomas in sports Suspected from symptoms and course – Severe headache with vomiting – Lethargy – Pupil asymmetry (with above) – Lateralizing neuro signs – Beware the “lucid interval” Initial mild symptoms, then rapid deterioration Usually occurs within 6 hours Valadka AB (2004). "Injury to the cranium". in Moore EJ, Feliciano DV, Mattox KL. Trauma. New York: McGraw-Hill, Medical Pub. Division. pp. 385–406."Injury to the cranium"
Basic Science Studies Current knowledge limited due to available models – There is no existing animal or experimental model that accurately reflects a sporting concussive injury
How do we diagnose a concussion? Mostly a clinical diagnosis based on reported symptoms, observation of the athlete’s behavior and function and examination of specific brain function Inherent problem of truthful symptom reporting Requires on site assessment by personnel trained to identify brain injury
Signs and Symptoms of Concussion Signs Appears dazed or stunned Confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness Shows behavior or personality change Forgets events prior to play (retrograde amnesia) Forgets events after hit (anterograde amnesia) Symptoms Headache Nausea Balance problems or dizziness Double vision Sensitivity to light or noise Feeling sluggish Feeling “foggy” Concentration or memory problems Change in sleep pattern (appears later) Feeling fatigued
From Powell et al. Neurosurg 54(1) 2004 Three most common symptoms: 1.Headaches (55%) 2.Dizziness (42%) 3.Blurred vision (16.3) 45.9% experienced either cognitive or memory problems 9.3% had loss of consciousness
Maddocks’ Questions Which field are we at? Which team are we playing? Who is your opponent at present? Which quarter (period) is it? Which side scored the last point? Which team did we play last week? Did we win last week? Clinical Journal of Sports Medicine, 1995
Concussion grading scales Several grading scales have been used as an attempt to classify severity of concussions based on presenting symptoms (grade1, 2, and 3) – No standardized definitions – No correlation with outcome – Arbitrary return to play guidelines – Becoming obsolete
Concussion classification – modern thoughts Each concussion is assessed independently based upon: – Nature and duration of symptoms and signs – Patient’s age – Patient’s previous concussion history
Note: in the overwhelming majority of cases both CT and MRI imaging modalities will be normal. This does NOT rule out a very serious brain injury, since CT and MRI are tests of structure and not brain function
Treatment BY FAR THE MOST EFFECTIVE STRATEGY FOR PREVENTING SEVERE BRAIN INJURY IS TO AVOID RETURNING TO EXPOSURE BEFORE A PREVIOUS INJURY HAS FULLY HEALED
Time course of recovery Guskiewicz et al. JAMA 2003 Average duration of symptoms is 3.5 days 88% of athletes have full recovery at 1 week
Second Impact Syndrome Initially described by Schneider 1973 – 3 cases moderate impact caused almost immediate death Coined by Saunders and Harbaugh 1984 – Described college FB player who was in a fight week before then sustained minor trauma and died “….an athlete who has sustained an initial head injury, most often a concussion, sustains a second head injury before symptoms associated with the first have fully cleared.”
Second Impact Syndrome Pathophysiology – Loss of autoregulation of brain’s blood supply – Leads to vascular engorgement with resultant cerebral edema – Increasing ICP and herniation 50% mortality 100% morbidity Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998.
Delayed worsening of symptoms Delayed Symptoms: – Division 1 College Football: 33% of players who returned to play prior to resolution of symptoms experienced delayed onset of additional symptoms vs 12.6% that did not return – Guskiewicz. JAMA. 2003
Why are individual neurocognitive baselines useful in assessment of sports-related concussions?
What is computerized cognitive testing ? Concussion will produce transient alterations in objective measures of visual attention, concentration, visual, verbal and spatial memory, and reaction time Measurement of these functions has historically required a paper and pencil battery of tests administered by a neuropsychologist – Expensive, time-consuming, and subject to the limited availability of qualified practitioners who understand the unique time sensitivity of athletic team schedules A computerized test can provide a quick, reproducible assessment of these parameters – Eliminates reliance on honesty of athlete’s reporting of symptoms
WHAT DOES ImPACT MEASURE? Demographic/Concussion History Questionnaire Concussion Symptom Scale - 21 Item Likert scale (e.g. headache, dizziness, nausea, etc) Eight Neurocognitive Measures - Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores Detailed Clinical Report - Automatically computer scored - Outlines demographic, symptom, neurocognitive data
N=410. p.<. 00001 N.S. p.<.0001p.<.03 Significant difference between groups out to at least 8 days post-injury Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002 ImPACT MEMORY COMPOSITE Control vs. Concussed Athletes *Lower score indicates poorer performance
Current ImPACT test users All NFL teams All NHL teams 31 Major League baseball teams 7 NBA teams All MLS teams Formula One and IRL auto racing USA Olympic teams – soccer, hockey, skiing, boxing Over 100 major US universities
The Bottom Line: Policies in place within the NCAA, NFL, NHL and all published practice parameters for medical professionals support neurocognitive testing as the standard of care for athletes with sports-related concussion.
RTP same game – 2010 NCAA guidelines “Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan.”
Step-wise return to play No activity until asymptomatic Light aerobic exercise Sport specific training Non-contact drills Full-contact drills Game action
Strategies for concussion prevention HELMETS! – Reduce risk of severe brain injury in all sports where used (including non-contact) – Multiple examples worldwide where mandatory helmet laws have reduced severe brain injuries and neurologic deaths from sports and leisure activities
2010 NFL/NFLPA study The results of an independent study commissioned by the NFL and the players’ union show modern helmets meet all national safety standards, though it stressed that no helmet can prevent concussions and more studies are necessary.
Rule changes NFL – No helmet–to–helmet hits – “defenseless quarterback” MLB – Automatic ejection for pitch aimed at head NHL – More frequent penalties for high sticks or checks above shoulders
Recent Equestrian Developments US Eventing Assoc. required that paticipants wear ASTM-approved helmets at all times when mounted US Dressage Assoc. adopts similar rule for non-FEI levels US Polo Assoc. to require that participants in sanctioned events wear NOCSAE-approved helmets (Jan 2012?)
Summary Management of sports concussions is under ever increasing scrutiny from regulatory bodies, media, and others RTP decisions should be based on standard assessment tools which include self-reported symptoms, standardized scales, balance testing, and neurocognitive testing of some form – Data from each of these components must not be considered in isolation
Summary Long term effects of multiple sports concussions remain to be elucidated Lifetime number of “safe” concussions remains unknown, though repeated traumatic brain injuries can clearly produce delayed cognitive deficits Proper equipment, technique, and avoidance of exposure to another head impact while recuperating from previous concussion are all important prevention strategies
Opportunities for Improvement Get professionals behind the use of proper helmets whenever mounted Institute a formal system of sideline evaluation of injured players Create formal return-to-play guidelines Use a Comprehensive Concussion Center to evaluate high-risk athletes EDUCATION
Thank You! US Polo Association Allen Sills, MD Craig Ferrell, MD