Concussion Concussions in Sports Medicine Britt Marcussen, MD Primary Care Sports Medicine Department of Family Medicine University of Iowa Hospitals and Clinics
Disclosures I have no financial or personal interests to report.
Objectives Be able to define a concussion. Discuss Epidemiology-What factors matter? Recognize common symptoms, features, and physical findings of concussions. Learn how to evaluate for a concussion. Understand immediate management and RTP issues. Be aware of the current trends in concussion research. Recognize the serious potential outcome(s) of a concussion.
Judge approved the final terms are north of $1 billion settlement the NFL concussion lawsuit.
Boston Study-33/34 2016-90/94 2017-110/111 NFL s live longer but have 3X the rate of Neurodegenerative disorders (Lehman et al, Neurology 2012)
Chronic Traumatic Encephalopathy Tau stain: NL 65yo John Grimsley 46yo 79yo former WC boxer w/ dementia
Iowa Concussion Law BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: Section 1. NEW SECTION. 280.13C Brain injury policies. 1. a. The Iowa high school athletic association and the Iowa girls high school athletic union shall work together to distribute the guidelines of the centers for disease control and prevention of the United States department of health and human services and other pertinent information to inform and educate coaches, students, and the parents and guardians of students of the risks, signs, symptoms, and behaviors consistent with a concussion or brain injury, including the danger of continuing to participate in extracurricular interscholastic activities after suffering a concussion or brain injury and their responsibility to report such signs, symptoms, and behaviors if they occur.
Iowa Concussion Law b. Annually, each school district and nonpublic school shall provide to the parent or guardian of each student a concussion and brain injury information sheet, as provided by the Iowa high school athletic association and the Iowa girls high school athletic union. The student and the student s parent or guardian shall sign and return the concussion and brain injury information sheet to the student s school prior to the student s participation in any extracurricular interscholastic activity for grades seven through twelve.
Iowa Concussion Law 2. If a student s coach or contest official observes signs, symptoms, or behaviors consistent with a concussion or brain injury in an extracurricular interscholastic activity, the student shall be immediately removed from participation. Not allowed back until evaluated by a health care provider knowledgeable in the evaluation and management of concussion.
Case NV is a 20 year old College BB player. During a game, accidentally runs into the official (head to head). He plays the rest of the game but later complains of headache and dizziness. He had a concussion 2 weeks prior and had just been returned to play Since he was able to play is he concussed? He is told by the trainer to go home and rest what does that mean? This is his 3 rd concussion in a year should you care? Does his dizziness matter? If it is still present in 2 weeks? What about the offical... nevermind
More After These Messages We will return to the cases after the educational (hopefully) component of today s session.
Epidemiology There are between 1.6 and 3.8 million sportrelated concussions per year. 207,830 sport-related concussions are seen Emergency Departments annually. Most commonly seen in football, boxing, hockey, wrestling, rugby, and soccer.
A Few Facts The average concussion lasts for 7 10 days. Adolescents and children tend to have a longer duration of symptoms...especially girls Migraines, depression are associated with prolong concussions. The strongest and most consistent predictor of slower recovery is the severity of a person s initial symptoms in Having had a concussion increases your risk of further concussion.
More Facts Some studies have estimated that 47% of high school football players suffer a concussion during the season. 35% of those players will incur a second concussion. > 60% of sports-related concussions occur in football. The State of Iowa requires a healthcare provider to sign-off on a players return to full contact.
A Little Perspective Maximum g force while turning in a fighter jet
A Little Perspective 9 12 g
The Hard Reality Football players regularly experiences >10 g.
Life of a Footballer The median number of impacts per practice ranged from 4.8 to 7.5. The median number of impacts per game ranged from 12.1 to 16.3.
Are Helmet sensors ready for Prime Time? At the college level: linear acceleration for a concussive event ranges from 55.8g to 168.8g The rotational acceleration for was between 163.4 and 15397.1 rad/s. At the high school level: linear acceleration values range from 74g to 146g (mean of 105) The rotational acceleration ranged from 5582.6 to 9515.6 rad/s Although current helmet-based measurement devices may provide useful information for collision sports, these systems do not yet provide data for other (non-collision) sports, limiting the value of this approach. Furthermore, accelerations detected by a sensor or video-based systems do not necessarily reflect the impact to the brain itself, and values identified vary considerably between studies. The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time. Berlin Guideline
Concussion Recognition (47.3% of concussions in HS football players unreported) McCrea et al. CJSM. 2004.
Lincoln AJSM 2011
Help Me Out Can someone please define concussion for me?
Concussion definitions: 1966 Congress of Neurological Surgeons Concussion is a clinical syndrome characterized by immediate and transient impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, due to mechanical forces
Concussion definitions: American Academy of Neurology: Trauma-induced alteration in mental status that may or may not involve loss of consciousness.
Concussion Defined Berlin Guideline: A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
Practically Speaking Caused by either a direct blow to the head, face, neck, or elsewhere with an impulsive force transmitted to the head. Typically results in the rapid onset of shortlived impairment of neurologic function that resolves spontaneously.
Additional Practicality The acute disturbance is a functional one rather than a structural one. No abnormalities on standard neuroimaging studies will be seen. May or may not involve loss of consciousness. Can have cognitive and balance abnormalities.
Diagnosing Concussions What common features should I be looking for?
Common Symptoms Somatic (eg, headache), Physical signs (eg, loss of consciousness, amnesia, neurological deficit) Balance impairment (eg, gait unsteadiness) Behavioral changes (eg, irritability) Cognitive (eg, slowed reaction times/foggy) Sleep/wake disturbance (eg, somnolence, drowsiness)
Diagnosis and Management
Neuro Exam
Summary of basic management -Preseason preparation and -Recognition -Initial evaluation (most use SCAT5) -Initial Rest-Best evidence-strict rest no more than 24-48 hours. Then low level sub-symptom activity is ok. -Monitored recovery +/- Neurocognitive testing-a tool in the tool box -Graduated RTP-24 hours between steps. If symptoms develop rest and return to last asymptomatic stage
Follow up
Symptoms Time
ImPACT Immediate Post concussion Assessment and Cognitive Testing
ImPACT Testing Symptom Score (similar to SCAT5) Word memory = learning and retention Design memory = learning and retention X&O s = visual working memory and cognitive speed Symbol match = memory and visual motor speed Color match = impulse inhibition and visual motor speed Three letter memory = verbal working memory and cognitive speed
ImPACT
ImPACT
Graduated RTP
When to Consider Transport Diplopia Severe or increasing emesis Seizure Focal neurologic findings Pupillary changes Rapidly progressive headache Personality change/any deteriorating neurologic changes. Hold helmet/frequent re checks!
On the Horizon
Biomarkers of Brain Injury Biochemical Marker Physiologic Role Location Comment Neuron Specific Enolase (NSE) S100B Myelin Basic Protein (MBP) Cleaved Tau (c-tau) Glial Fibrillary Acidic Protein (GFAP) Involved in increasing neuronal chloride levels Calcium binding protein, may inhibit synaptic plasticity Abundant protein in myelin Microtubule associated protein in axons Intermediate protein of astroglial skeleton Cytoplasm of neurons, platelets, RBC s Astroglia, bone marrow, fat, skeletal muscle Myelin Axons in the CNS Detectable within 6 hours, serum half life of 24 hours Detectable almost immediately after injury, ½ life 60 min Increased only after severe TBI, peaks 48-72 hours Poor marker in pediatric population Astroglial skeleton Peaks in 24-48 hours found only in CNS
Others (NCAA study group) Acute UCH-L1 GFAP SBDP150 S100B Micro RNA Chronic MAP-2 CNPase Micro RNA
Alzheimer s and More ApoE4 is a biomarker of particular interest. ApoE4 homozygous = increased risk of Alzheimer s and CAD (1% 2% of the population). ApoE4 hom/heterozygous = increased concussion risk and severity (25% of the population).
Imaging in the Future CT and MRI have a minimal role in evaluating concussions.
Imaging in the Future But other possibilities loom on the horizon
Imaging in the Future Diffusion Tensor Imaging and Tractography
The Ultimate Concern Second Impact Syndrome is one of the most detrimental potential outcomes.
Upon Further Review From studies evaluating sudden death in young athletes Found 17 deaths due to second impact syndrome from 1980 to 2009 but documentation is not rigorous and it is likely that as few as 5 were true incidence of second impact syndrome (Thomas et al, Pediatrics 2011) While rare, the entity exists and emphasizes the importance of a thorough evaluation and no same day return to play.
When to disqualify At some point the number of concussions matters more is worse! More severe and lasting symptoms Progressively prolonged recoveries Easy concussability
BB Player Revisited He had had 3 concussion but all were earned and prior recovery was uneventful. NV has no history of migraines, ADHD, or depression. He complained only of a fair amount of dizziness especially when looking up. His physical examination (cranial nerves, gait, cerebellar function, extremity strength, and sensation were unremarkable. SCAT 5 cognitive assessment was normal BESS testing was normal.
BB Player Revisited He was diagnosed with a concussion. Cognitive rest was advised, along with adequate rest and hydration. He continued to have issues with dizziness but was otherwise asymptomatic and passed his NC test. We allowed moderate intensity biking and enrolled him in vestibular rehab. Over the next week his dizziness resolved and he was progress back to play completed the season uneventfully.
What Else to Consider Return to Learn (Pediatrics, Nov 2013)-to help with school issues Consider vestibular and cervical rehab early on. Light sub symptom exercise is probably ok (Leddy et al, 2016 )
Things we all agree on when it comes to concussion Concussion are bad and more are worse. No one should return same day A graded return to play is necessary to safely get athletes back to competition We do not understand the natural history or the neurobiology of concussion. We know even less about the outcomes of repetitive sub-concussive hits.
Prevention Helmets-Limited Data for sure decreases severe injuries (skiing and snowboarding) Mouth Guards-Mixed data nothing definative Rule Changes-Body Checking in Ice Hockey ( in youth ice hockey leads to a 67% reduced risk of concussion in 11-year-old and 12-year-old hockey players.)and Kickoffs-moving the kickoff up 5 yards Limiting Contact Practices-May schools are j no data but clearly fewer impacts
Take Home Points Concussion are common so be prepared Education of staff/parents and player is important and now the law. Concussion is a clinical diagnosis. Don t image acutely unless neurologic deterioration is noted Use the SCAT5 form and RTP protocol. Neuropsych testing is very sensitive but not specific best used as a double check prior to RTP. Second impact is very rare. Disqualifacation from sport is tricky! Get help from experts We do not understand the natural history or the neurobilology of concussion and recovery/long term sequella (NCAA study ongoing looking at neurocog/biomarkers/imaging/sensors)
Questions?
References Crisco JJ, et al. Frequency and location of head impact exposures in individual collegiate football players. Journal of Athletic Training. December 2010; 45 (6): 549-559. Farkas O, Lifshitz J, and Povlishock JT. Mechanoproration induced by diffuse traumatic brain injury: an irreversible response to injury? Journal of Neuroscience. March 22 nd, 2006; 26 (12): 3130-3140. McCrory P, et al. Consensus statement on concussion in sport the 3 rd International conference on concussion in sport held in Zurich, November 2008. South African Journal of Sports Medicine. 2009; 21 (2): 36-46.
References Sports Concussion Assessment Tool 5. October 2011. Available at: http://dx.doi.org/10.1136/bjsports-2017-097506scat5 Terrell TR, et al. APOE, APOE promoter, and Tau genotypes and risk for concussion in college athletes. Clinical Journal of Sports Medicine. January 2008; 18 (1): 10 17. Thomas M, et al. Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics. July 1 st, 2011; 128 (1): e1 e8. Wilde EA, et al. Diffusion tensor imaging to aid early diagnosis in mild traumatic brain injury. Neurology. March 18 th, 2008; 70: 948-955.
References Harmon et al Clin J Sport Med Volume 23, Number 1, January 2013 McCrory P, et al. Br J Sports Med 2017 Williams et al May Jun 2016vol. 8 no. 3 SPORTS HEALTH Blienick, et al, Acata Neuropathol 2015
Thank You!