Talk Trauma 2011 Thursday April 29th, 2011 Concussion in Sport

Concussions in Sport Definitions, Mechanisms, and Current Issues Concussions are Everyone’s Responsibility! If you do not LOOK FOR IT you will not FIND IT! Paul Echlin MD CCFP, Dip. ABFM, Dip. SM, CAQSM

Review of Causes of Concussions The brain moves within the skull and has both translational and rotational movement applied to all of the lobes. Current theory is that trauma disrupt the brain function at cellular, molecular (e.g. neural cells, and ionic channel disruption), and anatomical (neuronal and vascular damage) levels. Symptoms are usually short-lasting and can not be diagnosed with a CT or MRI. Higher resolution and multi-modal MRI are now detecting objective evidence(metabolic/vascular/neurologic)of brain injury.

Causes of Concussions Most Common- Any direct blow to the head, face, or jaw. In hockey the head can also hit a stationary object such as the ice, boards, or goalpost. A sideways or glancing blow to the head can translate rotational forces to the brain. A blow to the body from any angle especially from behind can cause a whiplash effect that can translate traumatic force to the brain.

Current Knowledge of Concussion A recent study (Cusimano et. al. 2009) of concussion knowledge of hockey athletes, coaches, trainers, and parents demonstrated a significant lack of knowledge concerning concussion. This study, as well as others have found serious misconceptions existed concerning understanding the signs and symptoms of concussion and its’ treatment. Kaut et al. (2003) found that 30.4% of athletes admitted to continuing playing while experiencing symptoms after being hit in the head. Only 43% of the players surveyed stated they had some knowledge of concussion. Delaney et. al.(1997) found that only 20% of the professional athletes who were experiencing a concussion realized that they had suffered this injury. The reluctance to report a concussion most commonly occurs because the athlete is unaware of the seriousness of the injury, or fears that he or she will be restricted from play.

Incidence of Concussion HCEP : 7 times higher than previously reported in same age group/gender (NCAA Div 1). 21.52 concussions per 1000 athlete exposures; 21 concussions in 52 independent physician observed games 36.5% of the games contained a diagnosed concussion 29% (5/17) of the players who suffered a concussion, also suffered a repeat concussion in the same season The Education and Return to Play components of the HCEP were also significant Current NHL reports 1.04-1.81 concussions per 1000 athlete exposures; 75 concussions were reported in 1230 team physician observed games. 3% of games contained a concussion

Reported Incidence of Concussion in Major League Baseball MLB reported 1 concussion in 2006 MLB reported 10 concussions in 2010 MLB currently considering a specific 7 day concussion DL.

Incidence of Concussion 300,000 to 2.5 million sport related concussions were reported in the US last year. However it is estimated significant underreporting of concussions. In one study approximately 50% of sport related concussion were not reported (McCrea et. al. 2004). Concussion is the most common athletic injury (Cantu 1996). In Canada hockey is the main cause of sport related concussions. However, concussion in all sports (e.g. baseball, football, lacrosse) is currently under-diagnosed, under-reported, and subsequently under treated.

Concussion Definition The 3rd International Conference on Concussion in Sport held in Zurich, November 2008 Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.   2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

Concussion Definition The 3rd International Conference on Concussion in Sport held in Zurich, November 2008 3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.   4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however it is important to note that in a small percentage of cases however, postconcussive symptoms may be prolonged. 5. No abnormality on standard structural neuroimaging studies is seen in concussion.

Evaluation of a patient/athlete with a concussion A patient can have only one of the following symptoms and signs to initially be diagnosed with a concussion

Symptoms and Signs of a Concussion Headaches, dizziness, feeling dazed Feeling “dinged”, “stunned”, or “having bell rung” seeing stars, sensitivity to light, ringing in the ears, tiredness, nausea/vomiting, confusion, disorientation. Poor balance or coordination, slow/slurred speech, poor concentration and/or attention, delayed response to questions, vacant stare, decrease playing ability/performance, unusual changes in emotions, personality or behavior.

Diagnosis and management On-Field Diagnosis “If In Doubt - Sit Them Out” Then have the player assessed by a physician with expertise in concussions

Diagnosis and Management The gold standard of diagnosis still the clinical exam by a physician. An immediate evaluation on the playing surface should be performed to determine the emergent status of the player. Any obvious prolonged loss of consciousness, neurologic deficits, vomiting or central neck pain should, the EMS should be activated and the ABC’s of basic resuscitation and cervical stabilization should be followed.

Diagnosis and Management If the player is stable and not emergent, he/she can be removed from the playing surface. The injured athlete should not be left alone remain in the company of a responsible adult The player should not return to play and ideally should be evaluated by a physician, as this is a medical diagnosis. In many cases a physician is not immediately available. An individual qualified to evaluate the player for a suspected concussion should ideally have access to a physician. The injured player should be sent home with instructions to an adult to monitor but not disturb the individual for significant changes. If significant physical behavior changes occur before the player is able to access a physician the following day, he should taken immediately to an Emergency department for evaluation.

Diagnosis and Management A sideline screening evaluation test (e.g. SCAT 2) can be used to determine current status of symptoms, orientation, memory (immediate and delayed), concentration, coordination and balance. Other neurocognitive tests can be used (e.g. IMPACT, CogSport) for preseason baseline testing, and post concussion evaluation of fine cognitive changes secondary to a traumatic brain injury. While the individual is symptomatic he/she rest from all physical and mental stimulation (e.g. academics and videogames).

Diagnosis and Management Return to play may take days, weeks, or months depending on the individual. It should not occur until the individual is completely asymptomatic, and has passed a return to play protocol after being cleared by a physician.

Zurich Graduated Return to Play Protocol 1. No activity Complete physical and cognitive rest. Goal: Recovery 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity70% maximum predicted heart rate. Goal: Increase heart rate. No resistance training. 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities. Goal: Add movement

Zurich Graduated Return to Play Protocol 4. Non-contact training drills. Progression to more complex training drills, e.g. passing drills in football and ice hockey. Goal: Exercise, coordination, and cognitive load. May start progressive resistance training. 5. Full contact practice following medical clearance participate in normal training activities Goal: Restore confidence and assess functional skills by coaching staff 6. Return to play Normal game play Each stage should be at least 24 hours in duration. If the individual develops symptoms during a particular stage, he/she goes back to the rest stage and begins the protocol again.

Prevention and Future Directions Development of better data, and the use of uniform objective testing and documentation/registry of this injury. Utilization of this data to review the enforcement of current rules concerning intentional brain trauma (e.g. Fights, high hits, head hits). Utilization of this data to teach the value of RESPECT for yourself your opponent and the GAME.

Prevention and Future Directions Improve the quality and uniformity of concussion education available to all those individuals involved with contact and collision sports including the athlete, trainer, coach, parent, executives and physician. Consider the institution of mandated concussion education. Improve the specific concussion certification criteria for those that are charged with the responsibility of supervising and educating young athletes at PLAY. Improve the availability and quality of specific medical care for athletes that are diagnosed with concussion. Current HCEP Projects

Prevention and Future Directions Concussions are Everyone’s Responsibility! Thank You

Prevention and Future Directions Concussions are Everyone’s Responsibility! Thank You