Concussion: The Basics Bill Meehan, MD Micheli Center for Sports Injury Prevention Sports Concussion Clinic, Boston Children s Hospital
Definition Working definition Characteristics Trauma Impulse Immediate Self-resolves Functional
Biomechanics Biomechanics Rotational acceleration Slaughterhouses free to move, accelerate Denny-Brown 1941 medicine, acceleration Holburn 1943 thought experiment, rotational Ommaya and Genarelli 1974 - definitive
Normal Physiology
Normal Physiology
Normal Physiology
Normal Physiology
Pathophysiology Biomechanical injury Ion flux, K+, Na+ Excitatory neurotransmitters NMDA Ca++ influx, further EAA release Exacerbates efflux of K+ Depolarization spreading depression Glyolysis -pump restoration Decreased flow
Assessment Acute assessment ABC Other or associated injuries History classic Physical (Imaging)
Signs and Symptoms Loss of Consciousness Amnesia, retrograde or antegrade Disorientation Appearing dazed Acting confused Forgetting game rules or play assignments Inability to recall score or opponent Inappropriate emotionality Physical incoordination Imbalance Seizure Slow verbal responses Personality changes Headache Dizziness Nausea or vomiting Difficulty balancing Vision changes Photophobia Phonophobia Feeling out of it Difficulty concentrating Tinnitus Drowsiness Sadness Hallucinations
Specific Assessment Tools Assessment Symptoms - PCSS Balance - BESS Neurocognitive: computerized vs. neuropsychological
Post Concussion Symptom Scale None Mild Moderate Severe Headache 0 1 2 3 4 5 6 Pressure in head 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6 Balance problems or dizzy 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Vision problems 0 1 2 3 4 5 6 Hearing problems / ringing 0 1 2 3 4 5 6 Don t feel right 0 1 2 3 4 5 6 Feeling dinged or dazed 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like "in a fog" 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 More emotional than usual 0 1 2 3 4 5 6 Irritability 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 Nervous or Anxious 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6 Sleeping more than usual 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Other: 0 1 2 3 4 5 6
Balance Error Scoring System 1. Double Leg Stance Feet together, hands on hips, eyes closed for 20 seconds. 2. Single Leg Stance Non-dominant foot, 30 degrees hip flexion, 45 degrees knee flexion, hands on hips, eyes closed for 20 seconds. 3. Tandem Stance Non-dominant foot in back, hands on hips, eyes closed for 20 seconds.
BESS Errors 1. Hands off iliac crest 2. Opening eyes 3. Step, stumble or fall 4. Moving hip into >30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of position > 5 seconds Errors counted.
Percentile Neurocognitive Testing 100 90 80 70 60 50 40 30 20 10 0 Verbal Memory Visual Memory Processing Speed Reaction Time Baseline Post Injury 1 Post Injury 2 Post Injury 3 6 Days Post 16 Days Post 23 Days Post
Management Management Physical rest Cognitive rest RTP stages Most athletes recover quickly
Step Level of activity 1. No activity, complete rest. Once asymptomatic, proceed to level 2. 2. Light aerobic exercise such as walking or stationary cycling, no resistance training. 3. Sport specific exercise - for example, skating in hockey, running in soccer; progressive addition of resistance training at steps 3 or 4. 4. Non-contact training drills. 5. Full contact training after medical clearance. 6. Game play.
Weeks to months: Prolonged recoveries Insomnia Post-traumatic headaches Cognitive dysfunction Balance problems / dizziness
Sports Concussion Clinic 10 physicians, a neuropsychologist, 2 sports psychologists Consultants in neurosurgery, neurology, otorhinolaryngology, vestibular therapy, optometry, ophthamology, >400 patient visits / month (peak season) Basic science research and clinical research
Recent Concern Risk Cumulative Second Impact Syndrome Chronic Traumatic Encephalopathy
Increased Risk Gerberich 1983 Schultz 2004 Guskiewicz 2003
Cumulative Effects Gronwall 1975 Collins 1999 Guskiewicz 2003
Second Impact Syndrome Saunders and Harbaugh 1984
Andre Waters Terry Long Mike Webster Chris Benoit
Non-Professional Athletes What about the rest of us? If you played football in high school, are you at risk for neurobehavioral problems? Rebekah Mannix, MD, MPH
Cross sectional study Methods New England Small College Athletic Conference (NESCAC) Alumni (40-70 years old) Sports played, number of seasons Collision: football, rugby, men s ice hockey, men s lacrosse Non-contact: swimming, cross country, golf, tennis, squash, Frisbee, volleyball
Methods Assessment Center, NIH, Neuro-QOL Never Rarely (Once) Sometimes (Two to three times) Often (About once a day) Very often (several times a day) (Applied cognition)
Methods Compared collision sport vs. non-contact sport Adjusted for potential confounders Removed those with a history of concussion
Effect of collision sports participation on patient reported outcomes (participants without history of concussion) β- coefficient* Standard Error 95% CI p-value Outcome Measure General Concerns -0.497 0.505-1.487, 0.494 0.326 Executive Function 0.204 0.563-0.900, 1.307 0.717 Anxiety -0.056 0.551-1.138, 1.025 0.919 Depression -0.440 0.449-1.321, 0.442 0.328 Alcohol Use 1.957 0.576 0.827, 3.086 0.001 Sleep Disturbance 0.378 0.542-0.685, 1.441 0.485 Emotion/Behavior 0.243 0.608-0.949, 1.435 0.689 Dyscontrol Fatigue 0.330 0.536-0.721, 1.380 0.538 Positive Affect 0.442 0.449-0.439, 1.323 0.325
Further Reading McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport. J Athl Train 2009;44(4):434-48 Meehan WP III, Bachur RG. Sport-related concussion. Pediatrics 2009;123:114-123 Collins MW, Grindel SH, Lovell MR, et al. Relationship between concussion and neuropsychological performance in college football players. JAMA 1999;282:964-70 Shaw NA. The neurophysiology of concussion. Prog Neurobiol 2002;67:281-344 Non-medical: Meehan WP III. Kids, Sports, and Concussion: A guide for coaches and parents. 2011 Praeger Publishers, ABC-CLIO, LLC.