Concussions in Soccer: Assessment and Management. Ruben J. Echemendía, Ph.D.

Transcription

1 Concussions in Soccer: Assessment and Management Ruben J. Echemendía, Ph.D.

2 Legalese All opinions expressed in this presentation are my own and do not necessarily represent the views of US Soccer unless specifically noted. I have no conflicts of interest to declare.

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4 Cerebral Concussion Defined Mild traumatic brain injury Not necessarily produced by a blow to head Loss of consciousness is NOT necessary Usually transient changes in mental status Usually transient changes in somatic functioning May produce a wide range of symptoms

5 Symptoms of Concussion are Dynamic and evolve from the initial blow through the recovery period.

6 EARLY SIGNS OF CONCUSSION ν Confusion, Disorientation ν Retrograde amnesia ν Anterograde amnesia ν Headache ν Nausea/vomiting ν Motor problems, incoordination

7 LATER SIGNS OF CONCUSSION ν Decreased processing speed ν Short-term memory impairment ν Irritability, depression ν Fatigue ν Sleep disturbance ν General feeling of fogginess

8 BIOMECHANICS AND PATHOPHYSIOLOGY OF CONCUSSION

9 Mechanisms for Head Injury in Soccer Elbow to Head Head to Ground Head to Head Head to Post Foot to Head

10 LINEAR INJURY

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12 ROTATIONAL INJURY

13 So what happens in the brain?

14 Blow to Brain Cerebral Blood Pressure CBF Open K+ channels Excitatory Amino Acids (Glutamate) Hypermetabolic state (ATP O2 Consumed) Glucose Availability Metabolic Depression

15 Neurometabolic Cascade: Glucose Utilization in Animals Glutamate % of normal Glucose minutes hours days

16 Why all the fuss?

17 Second Impact Syndrome Second Injury Prior to the resolution of First Injury Typical time from second injury to brain stem failure is 2-5 minutes. Mortality Rate: 50% (Bailes & Cantu) 26 confirmed cases of SIS death between , primarily HS football Cause: Disruption in autoregulation of CBF vascular engorgement massive edema herniation.

18 Second Impact Syndrome Reconsidered SIS controversial Does it exist? Diffuse cerebral swelling Is it always fatal? Does a subclinical version exist? Clinical data suggest that continued play following an initial concussion may lead to more severe, intense and prolonged sxs. Do SIS and subclinical SIS arise from the same mechanism? Must be careful to not confuse SIS with possible effects o repetitive concussion

19 HOW OFTEN DOES THIS HAPPEN?

20 Epidemiology CDC estimates 1.6 to 3.8 million sports concussions occur annually 75% Mild but 9% require hospitalization Sports & recreation brain injuries cause 900 deaths per year Brain Injury in sports was the reason Theodore Roosevelt established the NCAA Death due to brain injury in American football have decreased from 50 per year in 1950 to 5 per year now. 32 deaths per year from skiing; 7% skateboarding.

21 Younger Players Younger athletes Are more vulnerable to concussive injury Symptoms are more severe Take longer to recover symptomatically Take to longer to recover cognitively - often exceeding symptom recovery.

22 US National Soccer Teams Concussion History Men: U23, U20, U18, U17, U15 Women: U21, U19, U17, U15 Age group % Prev Conc 1 2 or more % 27% 6% % 35% 7% % 25% 13% Combined 39% 31% 8%

23 Sport NCAA ISS JAT 2007 Percent of Game Injuries 1 Injury Rate per 1000 Athlete Exposures Ice Hockey - W Football - M Wrestling - M Ice Hockey M Soccer - W Wrestling - W Soccer - M Lacrosse - W Field Hockey W Basketball - W Basketball - M Gymnastics - W Softball - W Baseball M Volleyball W Injury Rank

24 Mechanism of Concussion Injury-NCAA Women s Soccer

25 NCAA Injury Surveillance System Men s Soccer Agel, Evans, Dick, et al., 2007, Journal of Athletic Training

26 Mechanism of Concussion Injury-NCAA Men s Soccer

27 Concussions in HS and College Students

28 Assessment

29 Assessment On Field Observed vs. Reported Sxs LOC Orientation Anterograde/Retrograde Amnesia Concentration (Digits, WORLD, Alph Back) Learning/Memory (Word Lists) SCAT 2

30 Assessment In Office Complete Concussion History Athlete description of Injury 3 rd Party description of Injury Anterograde/Retrograde Amnesia Player Symptom Report Observed Symptoms Cognitive Symptoms (DSpan Back, Word Lists)

31 Assessment Neuroimaging Effective in determining STRUCTURAL injuries Ineffective in detecting MTBI

32 Sports and Neuropsychology: A good fit?

33 The Role Neuropsychological Testing Neuropsychological testing examines neurocognitive functioning.. Learning, Memory, Information Processing Speed, Problem Solving Skills, Cognitive Flexibility Emphasis on functional rather than structural assessment Can be repeated serially during recovery In conjunction with thorough symptom evaluation can be used to establish the point at which RTP is safe.

34 Typical Neuropsychology Testing Program BASELINE INJURY 24/48 HRS 3/5/7 DAYS 14 DAYS Time

35 Baseline Testing Allows for evaluation and control of preinjury cognitive functioning. Not all athletes have the same cognitive functioning!

36 Return to Play

37 Return to Play: Vienna (2002) & Prague (2005) Guidelines Rest until asymptomatic (24 hours) Light aerobic exercise Sport-specific training Non-contact drills & light resistance training Full contact training RTP

38 3 rd International Conference in Sport Zurich October, 2008 Formal consensus meeting using the NIH consensus format Panel of 22 international, multidisciplinary, and multi-sport experts

39 CIS Zurich, 2008 Unanimous support for elimination of simple/complex distinction. Sideline eval of cognitive function is essential. SCAT-2 Player dx with concussion should not RTP on the day of injury. May be modified in the professional ranks if comprehensive eval is available.

40 CIS Zurich, 2008 Conventional imaging is NORMAL in concussion. Assessment of postural stability is useful in detecting post-concussion deficits. NP testing should be an important component in ANY return to play protocol. Neuropsychologists are in the best position to interpret NP test data. In the absence of NP and other formal testing A more conservative approach may be appropriate.

41 CIS Zurich, 2008 NP testing is appropriate while player is symptomatic to assist in determining management. The significance of genetic markers in concussion are unclear at this time. Reiterated Graded RTP Psychological factors should be assessed Detailed concussion HX should be obtained

42 CIS Zurich, 2008 Children should be managed differently than adults. SCAT-2 not appropriate for children under 10. RTP may take longer for children A more conservative RTP approach is suggested for children.

43 US SOCCER CONCUSSION MANAGEMENT All athletes who are diagnosed or suspected of having a concussion should be removed from play immediately and not returned to the same game or practice. individualized and graded approach to RTP should begin after the player is asymptomatic at rest and during exertion for at least hours.

44 US SOCCER CONCUSSION MANAGEMENT Graded Return to Play 1. Rest until asymptomatic at rest (24 hours); 2. If available, neurocognitive functioning should have returned to baseline; 3. Light aerobic exercise (e.g. stationary bicycle) for minutes (do not allow player to break a sweat). 4. Moderate intensity aerobic exercise (30 minutes, moderate intensity, breaking a sweat). 5. Sport-specific training (ball handling, passing, light running, NO HEADING).

45 US SOCCER CONCUSSION MANAGEMENT CONT. non-contact training drills, including full exertion interval training (may start light resistance training). Begin Heading Training Full contact training with heading Return to competition (game play).

46 US SOCCER CONCUSSION MANAGEMENT CONT. Heading Training (Modified from Johnston, et al., 2004) 1. Partner and player inside 6-yd box. Partner tosses ball softly to player; controlled, straight header, within box, perfect technique (ball off forehead, eyes open, mouth closed, neck rigid). Five tosses straight ahead, then five to the left, and five to the right. If no sxs occur then proceed to step 2 the NEXT DAY. 2. Repeat step 1 to start. After an active rest period (run, ball work with feet), partner and player within 18yd box. Partner tosses ball (longer distance, slightly harder), player does controlled header with perfect technique within box. Five each straight, left, right. If no sxs occur then proceed to step 3 the NEXT DAY. 3. Same as Step 2 with Partner and Player outside 18yd box (longer distance, harder throw). If player remains sx-free then move to step 4 the following day. 4. Full practice with more dynamic, unpredictable heading

47 Padded Headgear

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49 Padded Headgear There has been increased marketing and awareness of headgear in soccer. The use of headgear is a player s personal choice and right. There is no evidence for the beneficial effect with heading. Laboratory data suggest that forces may be decreased by 30% at peak acceleration (depending on headgear).

50 Padded Headgear There are no on-field clinical studies to support the contention that headgear reduces frequency or severity of concussion. Players may assume a feeling of invincibility that may lead them to play more recklessly.

51 "Now I don't even realize I have it on. It gives me added security. It feels like a headband. If anything, I feel more comfortable to be physical on the field.".alecko Eskadarian May be problematic for players who have already had one or more concussions.

52 Thank you!