 Concussion Awareness and Safety: 2015 J. Peter Zopfi, DO, FACOS Trauma Medical Director Cal North Chairman USSF “A” License USSF “Goalkeeping” License

Definitions  Traumatic Brain Injury (TBI) : General term that includes concussions, contusions, subdural hematomas, cerebral hemorrhages and penetrating injuries.  Concussion : A disturbance in brain function caused by a direct or indirect force to the head.

What is a Concussion?  Usually from a direct blow to the head  Variable loss of consciousness (usually not!)  Rapid onset of “Neurologic Impairment”  “Injury” not seen on CT or MRI scans

“Neurologic Impairment”  Variable consciousness (“in a fog”)  Amnesia  Headache  Irritability / Emotional  Slowed Reaction Times  Insomnia

Sports with Highest Frequency of Concussions (<19 years) Source: Centers for Disease Control and Prevention

Concussions: By the Numbers  Fewer than 10% of sport related concussions involve a loss of consciousness  78% of concussions occur during games (as opposed to practices)  Headache (85%) and Dizziness (70-80%) are the most commonly immediate symptoms following concussions for injured athletes  47% of athletes do not report feeling any symptoms after a concussive blow  Soccer is the most common sport with concussion risk for females (50% chance for concussion)

Soccer Head Trauma

“What should I do?”

 4 th Consensus conference on concussion management, Zurich. September 2012  American Academy of Pediatrics  CDC – Center for Disease Control. July April 2013

“Zurich”Recommendations  Recommended:  Screen with SCAT3 evaluation tool  Clinical Neurologic exam for all with a positive screen  Formal Neuropsychological testing or MRI for some April 2013

SCAT3 (Sport Concussion Assessment Tool)  Designed for use by medical professionals  SCAT3 (13-19 years old) & Child-SCAT3 (5-12 years old)  8 Parts: Glasgow Coma Scale (GCS), Maddocks Score, Symptom Evaluation, Cognitive Assessment, Neck Examination, Balance Examination, Coordination Examination and SAC Delayed Recall

Pediatric version: SCAT3 (Age 5-12)

Pediatric version: SCAT3 (Page 2)

Glasgow Coma Scale

“Okay, but what should I do?”

The New York Times November 5, 2013  “Time to Remove Coaches From Concussion Decisions”

Initial Sideline Assessment  Indications for Emergency Management - Glasgow Coma Score less than 15 - Deteriorating mental status - Potential spinal injury - Worsening symptoms or new neurologic signs

Concussion Recognition Tool 1. Visible clues of suspected concussion 2. Signs and symptoms of suspected concussion 3. Memory function

Visible clues of suspected concussion  Lying motionless on the ground / Slow to get up  Unsteady on feet / Balance problems  Grabbing / Clutching of the head  Dazed, blank or vacant look

Signs and symptoms of suspected concussion  Nausea or vomiting  Drowsiness or fatigue  “In a fog” / “Don’t feel right”  Blurred vision / sensitivity to light

Memory function  “What field are we playing at today?”  “What is the score of the game?”  “What team did we play last game?”  “Did we win our last game?”

Concussion Recognition Tool “Practice” 1. Visible clues of suspected concussion 2. Signs and symptoms of suspected concussion 3. Memory function

“When in doubt, take them out”  Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be returned to activity until they are assessed medically.  Athletes with a suspected concussion should NOT BE LEFT ALONE and should not drive a motor vehicle.

Treatment

It’s a Concussion: Now what? SCAT3 or Child-SCAT3: Screen  Medical evaluation and Neurologic exam  if +LOC, then same day urgent evaluation  No school or sports until medically cleared.  Rest for at least 24 hours.  Avoid any computer, internet or electronic gaming activity.  No medications unless prescribed by a doctor

“Zurich” Recommendations  Treat with physical and cognitive rest until asymptomatic without meds  Initial hour period of strict rest.  Recommend gradual return to school and social activities prior to sports. April 2013

“Zurich”Recommendations  When to Return to sports  Graduated return program  Begins after asymptomatic off meds  Usually at least 7 days  Program“modifiers”  Number and frequency  LOC >1min  Symptoms >10 days  Seizures  Female April 2013

Multiple Concussions “Time Interval Between Concussions and Symptom Duration”- Journal of Pediatrics, June  Duration of symptoms longer for more than one concussion (28 days) vs. a single concussion (12 days)  2 concussions in a year: symptom duration is even longer (35 days)

“U.S. Soccer and MLS to hold First- of-Its-Kind Medical Symposium at NSCAA Convention” Philadelphia, PA January 16, 2015 Coach Education

Incidence & Mechanisms associated with concussion injuries in soccer “Coaches awareness of the injury” Dr. Ruben Echemendia, U.S. Soccer and MLS Neuropsychologist “Best Practice” for recognizing, evaluating and management of concussion injuries “From the sideline to return to participation” Dr. Margot Putukian, U.S. Soccer and MLS Primary Care Sports Medicine Return to participation process post-concussion injury John Gallucci Jr., MLS Medical Coordinator Panel Discussion – Coaches, players and experts share their experiences and looking to the future TOPICS Coach Education

Player Education

Tips for Counseling Parents  Do NOT give a specific time for a return  Must be symptom free first.  Graduated program that includes cognitive activity.  Repetitive concussions within a short time span  Potential lasting deficits.  Potential for longer restrictions.  Need for further testing is variable  Follow up MRI  Neuropsychology testing

Imaging in Concussions  CT Scan (primary modality)  MRI (magnetic resonance imaging)  DTI (diffusion tensor imaging)  MRI with DTI  MFC (magnetic field correlation)  fMRI (functional MRI)

Diffusion Tensor Imaging

Heading and Brain Injury  Albert Einstein College of Medicine (Gruss Magnetic Resonance Research Center) in New York (reported November 2013) - Diffusion Tensor Imaging (DTI) used - 37 soccer players (29 men); median age 31; played 22 years - > 1,000 headers in a year: injury in regions of the brain responsible for cognitive functions such as attention, memory, planning, organizing, physical mobility and high-level visual functions

Heading and Brain Injury  Evidence linking brain injury and heading has been inconsistent  American Academy of Pediatrics - “There is not sufficient data to recommend that young players abstain from heading, but suggest that players minimize contact between head and ball.”

Protective Headgear  Studies have shown peak force of impact and peak acceleration at impact are diminished wearing headgear which theoretically translates into concussion prevention or reduction.  This applies more to player-to-player and player-to-hard object contact (high force and speed) rather than to purposeful heading of a ball (lower force and speed)

Protective Headgear  No studies have sufficiently supported the protective effect of wearing headgear  The rules of the National Federation of State High School Associations, the United States Soccer Federation (USSF), and the Federation Internationale de Football Association (FIFA) do not require players to wear headgear during games but do permit players to wear headgear if they so choose

Impact Testing  Pre and post concussive Neuropsychologic function testing  Need an initial baseline exam  May be really useful for:  High risk kids  History of prior concussions (fit to play??)  Prolonged symptoms  Vague or poorly defined symptoms  Does not alter recommendations: rest until asymptomatic and then gradual return.

Summary  Concussions are serious injuries that result in significant “Neurologic Impairment”  Concussions are common in youth soccer and require initial sideline assessment followed by evaluation and treatment by a medical professional if a concussion is suspected  Education of players, parents, coaches and referees is essential for the successful treatment of this epidemic  Specific diagnostic tests are not available at this time and clinical suspicion and evaluation are the keystones to the management of traumatic brain injuries

Questions?