Sports Related Concussion - Performance Orthopedics

Sports Related Concussion - Performance Orthopedics

Sports Related Concussion Dr. Pete Biglin, DO Consensus statement on concussion in sport: th the 4 International Conference in Sport held in Zurich,

November 2012 1 s t (Vienna 2001), 2 nd (Prague 2004), 3 rd (Zurich 2008) Dr. Pete Biglin, DO Board Certified: 1. Physical Medicine & Rehabilitation 2. Pain Management 3. Sports Medicine 4. Electrodiagnosis-EMG

Training: 5. Wayne State University- PM&R 6. Michigan State University Fellowship- Sports Medicine Definition of Concussion A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

*Considered to be among the most complex injuries in sports medicine to diagnose 5 Main Features of Concussion 1. Trauma including a direct blow to the head, neck or face, or a blow to another part of the body which transmits an impulsive force to the head 2. Rapid onset of short-lived neurological

impairment(s) which resolve over time 3. Acute clinical symptoms of concussion reflecting a functional injury rather than a structural abnormality 5 Main Features of Concussion 4. A graded set of clinical syndromes, which may or

may not involve loss of consciousness and which resolve in a sequential course. 5. Typically normal structural neuro-imaging in studies such as MRI or CT scan. Mechanisms of Brain Injury

Acceleration/ Deceleration (tensile) Rotational (shearing) Impact (compressive)- least likely to cause concussion Types of Brain Injury Diffuse injury: 1. Diffuse Axonal Injury (shearing) 2. Concussion/ mTBI (75% brain of injury)

Focal injury: 1. Hemorrhagic (subdural, epidural, subarachnoid, intracerebral) 2. Depressed or Linear skull Indirect Blow (acceleration/deceleration) Direct Blow (compressive)

Epidemiology 1. Many go undetected as part of the game 2. mTBI (% overall in life) 1.Sports- 18% 2.MVA - 46% 3.Falls - 23% 4.Assaults - 10% Team Physicians Handbook. 3rd edition Concussion Frequency

(% of all game injuries) HELMETS Ice hockey M. Lacrosse Football Spring FB Softball Baseball NO HELMETS

7.5% 5.2% 4.5% 3.9% 3.6% 2.7% F. Lacrosse F. Soccer M. Soccer Field Hockey

F. Basketball M Basketball NCAA Injury Surveillance Data 8.5% 6.5% 5.4% 5.2% 4.9% 3.1%

PATHOPHYSIOLOGY Glucose and Oxygen Acute metabolic dysfunction which is characterized by fuel need to fuel delivery mismatch ****** There is increased need for glucose (hyperglcolysis) and oxygen after injury to the brain . This has been demonstrated in humans following severe TBI using

PET scanning. Bergsneider M, J Neurosurgery. Feb. 1997. Pathophysiology of concussionBlood flow (DECREASED) Assessment of MCA blood flow (TCD) n=51 (all TBI), after mild TBI revealed increased BF on the day of injury followed by a decrease in the following days in young patients (<30yr). In older persons (>30yr) indices of

BF did not differ from those in the control group (n=61). Are younger athletes more Becelewski J. Poland.2002 Nov vulnerable? (YES) Pathophysiology of concussion molecular level Potassium (extracellular) may activate ATP dependent Na-K pumps which add to metabolic

stress Glutamate (excitatory AA) may increase extracellular K as above Calcium (intracellular) may reduce local blood flow Team Physicians Handbook. 3rd edition CLINICAL FEATURES OF CONCUSSION

5 CLINICAL DOMAINS* 1. Symptoms (eg. H/A, fogginess) 2. Physical Signs (eg. LOC, amnesia) 3. Behavior Changes (eg. irritability) 4. Cognitive Impairment (eg.slow reaction times) 5. Sleep disturbance (eg. insomnia) 1. Physical Symptoms

Headache Nausea or Vomiting Sensitivity to light

Sensitivity to noise Feeling out of it or not acting like self

Hearing problems or ringing in ears Balance difficulty Dizziness- w/ position changes Fatigue 2. Physical Signs

Loss of Consciousness Amnesia Unsteady, slow to get up Head shaking Grabbing their head Glazed look Rubbing their eyes Eye blinking Eye squinting 3. Cognitive Symptoms

Feeling mentally foggy Feeling slowed down or slower than usual Difficulty concentrating Difficulty remembering Confusion 4.Behavioral Symptoms Sadness More emotional than usual Irritability

Nervousness What is unusual for your child/player? Compare their behavior to what his/her NORMAL . 5. Sleep Related symptoms Excessive daytime drowsiness Sleeping more than usual Sleeping less than usual Trouble falling asleep

Recovery Timeline 80-90% resolve in 7-10 days Longer in children & adolescents 10-15% of cases last longer than 10 days- may need to rule out other DX RISK FACTORS- for prolonged recovery

Previous history of concussion Once an individual has sustained a concussion, he/she is FOUR TIMES as likely to sustain another injury. It will take less of a blow each time and symptoms will take longer to resolve Diagnosis of ADD/ADHD History of headaches or migraines treated by a physician

Other potential modifying factors for complicated recovery Females LOC > 1 min Amnesia Convulsive phenomenon Anxiety or Depression *Note: LOC < 1 minute & duration of post traumatic amnesia do NOT reliably predict outcomes

Younger athletes more vulnerable? ANSWER=YES Baseline NP testing in 371 college athletes and 183 high school athletes. 54 concussions occurred after baseline testing. HS athletes with concussion had prolonged memory dysfunction on NP testing compared with college athletes with concussion. Data may suggest more prolonged recovery

from concussion in the HS athlete. Field M, Collins M. J Pediatrics. 2003 May Younger athletes Younger athletes take longer to recover Emphasis on RETURN TO LEARN (SCHOOL) before RETURN TO PLAY Emphasis on a conservative approach to RTP for kids

Should the high school athlete RTP after bell ringer ? ANSWER = NO 64 high school athletes with grade 1 concussion as defined by the AAN 1997. No LOC. Symptoms cleared by 15 minutes. Ahtletes did not reach baseline memory or symptom scores on ImPACT neuropsychologic testing until appx day

7. Evaluations were at baseline, then 2,4,&7 days post injury. Lovell, Collins,Feild, Maroon,Cantu,Fu. J Neurosurg 98:295-301:2003 On Field ACUTE EVAUATION On Field Identification Variable presentations Difficulty making timely

diagnosis Poor sideline tools Reliance on player reported symptoms Symptoms can evolve serial exams needed On Field CONCEPTS to consider Cervical Spine injury (broken neck) with the concussion*

Disposition- removal from contest, ER, doctor visit if needed etc. Other First Aid/ other medical issues Sideline assessment tool (SCAT-3) Player should not be left alone No return to play (RTP) same day Home instructions should be given to parent etc. RED FLAGS for Emergent Referral (up to 24-48hr)

Loss of consciousness > 1 min Any suspected cervical spine injury Repeated vomiting Disorientation Slurred speech Cant recognize people or places Headache that gets progressively, severely worse Increased lethargy Facial swelling, significant bruising of the face/head Fluid from ears and/or nose

Weak arms or legs Emergency Action Plan Know your organizations requirements Have a plan Educate those involved in the plan Practice the plan annually SPORT CONCUSSION

ASSESMENT TOOL (3rd version2013) SCAT -3 SCAT-3 - Overview Tool used to evaluate Concussion Athletes 13 yr & older Child SCAT -3 for children 5-12 yr old (slightly different questions & parent portion) Preseason baseline testing with

SCAT-3 can be helpful for interpreting post injury test scores. SCAT-3 - Overall areas of evaluation 1.Sideline Assessment (GCS & Maddocks Score) 2.Background information ( demographics, prior concussions) 3.Symptom Evaluation (# symptoms

& symptom severity score) 4.Cognitive (SAC) & Physical Exam (Neck, Balance & Coordination) Medical Office CONCEPTS to consider Medical Assessment comprehensive history with comprehensive neurological assessment to include MS, cognition, gait and balance Clinical Status: any improvement

Possible need for imaging - to exclude structural abnormality Full SCAT-3 or equivalent evaluation RTP , School, advanced treatment options NP testing New State laws NEUROPSYCHOLOG IC TESTING Neuropsych Testing

Used as adjunct with clinical exam to determine RTP. Currently used in some High Schools, NFL,NHL, & NCAA Baseline pre-concussion followed by serial post-concussion testing (can also be helpful if no pre-injury test performed) Not a substitute for clinical assessment

Components of Neuropsych Testing 1.Concentration 2.Motor dexterity 3.Information processing 4.Visual memory 5.Verbal memory 6.Executive function 7.Brain stem function

ImPACT: computer based neuropsych test Immediate Post-Concussion Assessment and Cognitive Testing Computer based Includes athlete demographics, symptoms, injury description, & graphic display of data. Baseline & Post-injury testing Measures multiple Cognitive processes: Verbal and Visual Memory

Cognitive Speed Interaction of Memory & Speed Cognitive Efficiency Self-reported symptoms Impact ImPACT Concussion Management Model OVERVIEW STEP 1 Pre-season Baseline testing &

Education STEP 2 Concussion is suspected STEP 3- Post- Injury Testing & Treatment Plan STEP 4 Is Athlete ready for Non-Contact Activity STEP 5 Determining Safe RTP Impact ImPACT Concussion Management Model

STEP 1 Pre-season Baseline testing & Education Educate athletes, parents, coaches, & teachers Take baseline ImPACT Concussion protocols in place Impact ImPACT Concussion Management Model

STEP 2 Concussion is suspected Sideline assessment ImPACT mobile apps used if available Remove from play AT sets up referral to specialist Vestibular screening Imaging if needed (MD/DO) Impact ImPACT Concussion

Management Model STEP 3- Post- Injury Testing & Treatment Plan Post injury test 24-72 hr after injury AT coordinates ongoing care with specialist Team coordinates care btw athlete, parent, coach, & doctor Further NP evaluation if needed Vestibular or PT referral if

Impact ImPACT Concussion Management Model STEP 4 Is Athlete ready for NonContact Activity Symptom free at rest and with cognitive exertion Post- injury test with normal range Normal vestibular evaluation Implement RTP protocol if above criteria met & approval concussion

specialist (MD/DO/PHD) Impact ImPACT Concussion Management Model STEP 5 Determining Safe RTP RTP decisions should always be made by MD/DO/PHD No recurring symptoms at rest or exertion ImPACT scores back to baseline

Final Impact is their NEW baseline Impact ImPACT: Facts Baseline Testing (pre-season) Testing provides the basis for comparison to self ImPACT Facts:

Useful & reliable concussion management program Tool to help determine recovery from injury Tool to help manage concussion ( RTP, Return to learn) Tool to help communicate status to coaches, parents, clinicians NOT a SUBSTITUTE for medical evaluation & treatment Impact

ImPACT: without BASELINE testing Athlete must be compared to pre-injury estimates of functioning Need to consider SAT/ACT percentiles, GPA, LD Estimated percentiles on ImPACT A/B student- > 65th percentile B/C student - > 35th percentile D/F student - >20th percentile

Impact TREATMENT & RETURN TO PLAY (& SCHOOL) Return to play (RTP) When in doubt, sit them out* Removal from activity once suspected concussion is sustained is THE STANDARD OF CARE!

TREATMENT = Cognitive Rest* Possibly stay home from school 1-2 days Limit homework NO TV, computer usage, video games, texting TREATMENT = Physical Rest* No return to activity until no symptoms at Cognitive rest possibilities for a child at school Extra time to complete tasks

Quiet room to complete tasks Avoidance of Noise (cafeteria etc) Frequent breaks during class or tests No more than one exam per day Shorter assignments Use of a tutor Shorter school day No internet, TV etc. Graduated RTP protocol 1.No Activity

2.Light Aerobic 3.Sport Specific 4.Non-contact Drills 5.Full Contact Practice 6.Full Contact Game Note: 24 hr at each stage. Can progress if the player is asymptomatic Advanced Treatments 1.Medication 2.Vestibular therapy

3.Formal neuropsychological testing 4.Gradual, very closely monitored physical exertion that does not exacerbate symptoms 5.Counseling/psychological intervention *Prolonged symptoms can greatly affect quality of life Other Advanced treatment Options 1.Headache (analgesics)

2.Sleep disturbance (avoid caffeine, TCA, Trazadone) ) 3.Cognitive-memory, concentration (Ritalin, Sinemet) 4.Memory (ACh meds, training aids) Note: Medications should never be used to mask symptoms for early RTP. Potential areas for concussion prevention

1.Rule changes & enforcement of rules in sports is important 2.Risk compensation by players bad habits (causes paradoxical increase in injury rates) 3.Aggressive play (typically good thing) vs. Violence (bad thing) 4.Knowledge transfer (athletes, coaches, referees, parents, leagues) Rule Changes/Enforcement

RESEARCH Blood tests, CSF testing, Imaging, Helmets, CTE, Rule changes Lack of Knowledge &Research Recommendations for classification & management are based on literature review and expert consensus Return to play after concussion should

be considered practice options. These may be arbitrary and conservative. Science of concussion is evolving, RTP decisions are in the realm of clinical judgment on individualized basis. Some current research topics 1.Other imaging fMRI, PET scanning, MR spectroscopy. Not recommended. Early stages of research at this time.

2.Balance Testing- Force Plate or BESS testing can be useful tools 3.Serum (blood) Markers for concussion, nerve injury, or genetic testing not proven. 4.CSF Markers for brain injury not proven. Research study -Serum (blood) markers for concussion (sample study) Pilot study (S-100B, and NSE-neuron

specific enolase) 1.Swedish elite male Hockey (26) & Basketball (18) players had the above markers drawn pre & postgame. 2.The levels all increased with normal play. However, one hockey player sustained a concussion, whose S-100B level increased more than the other players. 3.Is Genetic marker ApoE4 associated with adverse outcomes? (Clin J Sports

Clin. J Sport Med. 2003 Sep;13:292-302 Med 2002) Helmets in sports (difficult task*) Helmets to prevent concussion would have to protect the brain from: 1.Change in head velocity up to 10 m/s 2.Head linear acceleration up to 50 G 3.Head angular acceleration below 1500 rad/s (This helmet does not exist- to my

knowledge) Helmets & Mouth guards- they help local trauma, but new technology has NOT shown them to decrease the incidence of concussion! Other areas of research Hockey: there is new evidence that eliminating body checking in Pee Wee hockey (11-12yr olds) were effective strategies

in decreasing incidence of concussions. Chronic Traumatic Encephalopathy CTE Media awareness increased Unknown Incidence Cause & effect relationship has not yet been demonstrated between CTE and Sports Concussion.

CTE is likely not related to concussion ALONE. Other contributing factors might be- age related degeneration, mental illness, ETOH use, drug use, other dementia like diseases. Must proceed cautiously with modern CTE cases SECOND IMPACT SYNDROME SECOND IMPACT

SYNDROME Malignant brain edema after a 2 nd head injury while still recovering from the first. Thought to be due to loss of autoregulation of blood vessels causing increased ICP, brain herniation through the tentorium and foramen magnum. Rapid demise Respiratory failure Death. All cases reported < 21 years old (17 total cases) per Cantu.

35 total cases reported - 2003 (up to 14 years later), Collins. Second Impact Syndrome.Clinics in Sports Medicine p37-45. January 1998- Cantu Second Impact Syndrome (SIS) Does it exist? McCrory found only 5 probable cases in the literature based on strict criteria. CRITERIA: (17 supposed cases)

A. Medical review after a witnessed first impact (5/17) B. Documentation of sx up to the 2 nd impact (7/17) C. Witnessed 2nd impact with rapid deterioration (6/17) D. Postmortem or Imaging indicating evidence of cerebral swelling without hematoma or any other case for edema (13/17) McCrory P, Berkovic S. Second Impact Syndrome. Neurology 1998;50: 677683.

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