Concussion in Adventure Athletes Epidemiology and Current Guidelines Aaron Provance, MD Medical Director
No financial disclosures 2
Outline Epidemiology Good, Bad and Ugly Rest Injury prevention Long Term Complications 3
Sport Related Concussion (SRC) Concussions are common 13.2% of all sportsrelated injuries 11.5% of athletes report >1 SRC Girls > boys Competition ~6x increased risk vs practice Exception cheerleading 4
Concussion Background Highest Risk Sports: Boys: Football, wrestling Girls: Soccer, basketball Club sports: Rugby, ice hockey, lacrosse 90% of concussions in sports DO NOT involve loss of consciousness; many will be underreported or unrecognized 5
Emergency department reported head injuries from skiing and snowboarding among children and adolescents, 1996-2010 Graves JM, Whitehill JM, Stream JO, Vavilala MS, Rivara FP Injury Prevention 2013 RESULTS: An estimated number of 78,538 snow sports-related head injuries among children and adolescents were treated in EDs during the 14- year study period. Among these, 77.2% were TBIs (intracranial injury, concussion or fracture). The annual average incidence rate of TBI was 2.24 per 10,000 resort visits for children compared with 3.13 per 10,000 visits for adolescents. The incidence of TBI increased from 1996 to 2010 among adolescents (p<0.003). 6
Reasons for Under Reporting Lack of knowledge Misperceptions - getting your bell rung Concern about being removed from play Survey of youth sports coaches 42% stated concussion occurs only with LOC 26% would allow a symptomatic child to return to play Valovich McLeod et al. CJSM 2007 7
Concussions: the good Majority (80-90%) of concussions resolve in 7-10 days Recovery time may be longer in children and adolescents but ~90% recover within 4 weeks 8
Concussions: the bad 6-8x increased risk of suffering another concussion Cumulative effect of multiple concussions? Genetic component leading to increased susceptibility? CTE or long term complications? 9
Concussions: the ugly Continued participation risks increased symptoms, prolonged recovery, and potential for long term complications Second Impact Syndrome Catastrophic event which may occur in setting of a second head injury while athlete is still symptomatic from a previous concussion. Rapid swelling around the brain severe neurological damage or death 10
Initial Management Rest Exertion 11
12
Role of Helmets in Mitigation of Head Injuries Dr. Jasper Shealy, Dr. Robert Johnson, Carl Ettlinger, Dr. Irving Scher Skiing Trauma and Safety 2015 As the study concluded, while helmet usage increased in the last ten years, there was a dramatic improvement in the decline of PSHI, particularly in concussions 75% of all PSHI from skiing or snowboarding are mild concussions The study concluded that ski and snowboard helmets are extremely effective at preventing skull factures, and have virtually eliminated scalp lacerations 13
Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury Carroll et al. 2004 There was consistent and methodologically sound evidence that children's prognosis after mild traumatic brain injury is good, with quick resolution of symptoms and little evidence of residual cognitive, behavioral or academic deficits. 14
Systematic review of the risk of dementia and chronic cognitive impairment after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis Godbolt et al. 2014 DATA SYNTHESIS: Children with MTBI and intracranial pathology ("complicated" MTBI) performed worse than did children without intracranial pathology. Children showed higher rates of cognitive symptoms a year after MTBI than did a control group. CONCLUSIONS: There is a lack of evidence of an increased risk of dementia after MTBI. 15
Histomorphologic Variability Neurofibrillary tangles are a common finding among older persons without cognitive impairment (Bennett et al., 2006) Furthermore, 20% of the mtbi sample studied by McKee et al. (2013) did not show any changes of CTE Hence, the sensitivity and specificity of the most core histopathological feature are far from established! 16
Clinical Approach to mild TBI and CTE Much alarm surrounding CTE and consequences stemming from a single or modest number of concussive injuries Clinicians are better served by research on outcomes from mild TBI rather than on CTE literature derived from small (nonrandom) sample of persons unlike most of our patients in terms of either TBI exposure or psychiatric comorbidity 17
CDC study: Former NFL players not at increased risk of suicide AJSM May 2016 Examined the suicide death rate for 3,439 retired NFL players who played at least five seasons between 1959 and 1988 and compared it with the suicide death rate for gender-, race-, and age-matched people from the general U.S. population. They found that from 1979 to 2013, the rate of suicide among these former professional football players was less than half of what would be expected compared with the general U.S. population. There were also significantly fewer overall deaths from cancer, heart disease, and assaults/homicides among the former NFL players than in the general population. 18
Clinical Approach to mild TBI and CTE Misapplication of CTE data creates potential for negative expectations Misunderstanding of CTE research may foster maladaptive anxiety among patients, families, and health care providers Preexisting and current psychiatric problems, anxiety in particular, may influence post-injury symptoms more than mild TBI 19
References: 1. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Reprinted in Multiple Publications. 2. Pediatric Sport-Related Concussion: A Review of the Clinical Management of an Oft-Neglected Population. Kirkwood MW, Yeates KO, Wilson PE. Pediatrics. April 2006; 1359-1371. 20