Concussions in Youth Sports Shaun T. O Leary, M.D., Ph.D. Neurosurgeon & Medical Director of Neurosciences at Northwest Community Healthcare
Disclosure I am not a consultant for any products or methods discussed today. Non-FDA approved treatments may be discussed Assistant Professor of Neurosurgery, RUSH Medical center Coach, Allshore Lacrosse; Coach, AYSO Soccer
Introduction Since 776 BC, athletes have participated in organized sports exposing them to concussions, such as wrestling and fistfighting
Introduction Concussive symptoms have been observed since time of Hippocrates No head injury is too trivial to ignore Management of sports-related concussion (SRC) is one of the most controversial topics in sports medicine SRCs differs from concussions outside athletics Non-SRCs result from low-velocity impact Disorientation and confusion more than LOC Children/ Adolescents are the majority of at-risk athletes
How Common??
Mild Traumatic Brain Injury-How Common? Direct/Indirect Costs = $12 Billion 5% of patients have sx s 1/yr after injury Leading Causes: Falls MVC Struck by/against Assault
Definitions Concussion- Rotational acceleration or deceleration injury to the head that causes an alteration of mental status or various other symptoms such as headache or dizziness According to the American Academy of Neurology: trauma-induced alteration in mental status that may or may not involve a loss of consciousness Common features include:
Biomechanics Rotational or angular acceleration/ deceleration forces resulting in shear strain of the brain 1 Linear acceleration-deceleration produces focal effects, but not concussion Commonly associated with force, but direct impact in not required In lab, concussion can be more effectively achieved by nonimpact rotation 2
Pathophysiology Hovda, 1991 6 Studied concussion at neuronal level Stretching, twisting, compression, shearing Increased vulnerability to injury during acute recovery period (7-14 days) Postulated a metabolic mismatch between brain glucose utilization and cerebral blood flow
Pathophysiology
Epidemiology ~60% of high-school students in US participate in organized sports Concussion has been studied most widely in football, a sport in which 1.5 million Americans participate Incidence of SRC in high school football is 8-11% 13 Concussions are more likely to occur during games than practices 14 Concussions are more likely in high school athletes than college players 15
Epidemiology In most studies, injuries documented by athletic trainers For trainer to be aware, athlete must report Athletes do NOT regularly report concussions 16 Studies in which players have directly reported symptoms after blow to head report concussion rates of 15-45% 11
Under-reporting Although SRC appears common, its not fully appreciated by athletes >1/3 of athletes do NOT recognize their symptoms as result of concussion 17 Only 19% of concussed players (Canadian football) realized they sustained a concussion Even those with +LOC, >70% failed to recognize concussion or even as serious injury
Assessment Recognition, assessment, and classification of SRC is challenging SRC resulting in dramatic findings such as prolonged LOC are readily detected Majority of SRC are more subtle LOC is NOT a reliable predictor of cerebral dysfunction of length of recovery 19
Assessment On-field assessment of acute SRC begins with ABC s Cervical spine injury should be considered Suspected in the unconscious athlete The conscious athlete suspected of SRC should undergo complete neurologic exam The ability to perform simple tasks (including orientation), postural stability, and memory should be assessed Keep athlete in sitting position until symptoms are improving and can follow instructions When in standing position, support athlete from both sides If unsteady, place on cart
Return-to-play One- to two-week guidelines Involves 6 levels, with increasing levels of activity The child receives increasing challenges and moves up each level if asymptomatic Once achieves level 6, may return to play Involves no symptoms at play OR rest
Neuropsychological Testing Examples of computer-based tests: 1. CogSport 2. ConcussionSentinel 3. Concussion Resolution Index 4. Immediate Post Concussion Assessment and Cognitive Testing (ImPACT 2.0)
Neuropsychological Testing A dropped score from baseline indicates incomplete recovery Until recovery is complete, risk subsequent injury: Longer reaction time Diminished ability to concentrate Increased thought processing time Return to play an basis of neuropsych testing has NOT been explicitly studied 27 However, there is association between incomplete recovery and catastrophic outcomes
Back to School A few informal accommodations and modifications in first days to weeks will suffice for many symptomatic athletes
Prognosis Collins, 2003 28 Indicated that presence of retrograde amnesia indicated poor outcomes (higher symptoms and worse neurocog function) Those who experience post-traumatic amnesia with mental status change also had poor outcomes acutely post-injury Amnesia can indicate more severe injury in adolescents and a overall worse acute presentation following injury
Prognosis Complete recovery will vary Symptoms, neuropsych test scores, and postural stability usually recover within 7-10 days 7 There is no reliable predictable order in which recovery occurs During recovery, academic performance may suffer and intellectual activity may increase their symptoms. Cognitive-rest has been recommended for school-aged athletes
Prognosis- Age Matters Although several studies suggest collegiate athletes usually recover within 1-2 wks, young athletes may take considerably longer Collins, 2005 29 25% of high school players took up to 4wks to reach recovery criteria Field, 2003 30 Found by neuropsych testing, high-school athletes recovered significantly more slowly than college Indicates need for age-specific guidelines
Repeat Concussions After a first concussion, a player is at increased risk for additional concussions 11 Those who experience LOC are 6x more likely to sustain another concussion than those never losing consciousness 18 Risk of recurrent SRC greatest within first 7-10 days 14
Repeat Concussions Explanations for increased risk: Certain athletes styles of play predispose to SRC Certain athletes themselves are more susceptible Age and level of play may expose certain athletes to greater forces than those who don t experience concussion Players with multiple SRC receive more play time Once athlete s brain sustained a single concussion, it becomes more susceptible to injury
Repeat Concussions SRC reduces ability to process information rapidly, and overall neurocognitive ability Reduction is greater and longer after second concussion than after first No specific number of concussions is predictive of prognosis Tend to have cumulative effect Guskiewicz, 2003 14 Showed athletes with previous history of SRC require longer recovery times after acute SRC than those without history
Concussion and Soccer Concussions occur commonly in soccer, accounting for ~2-4% of all acute injuries 39 Rates are higher during game play In National Collegiate Athletic Association, concussions in soccer account for 8.6% of all game-time injuries
Concussion and Soccer Although SRC is a common injury in soccer, it does NOT seem to occur as a result of purposeful heading of the ball 40 Fuller, 2005 41 6yr prospective study of 120 soccer tournaments None of the recorded concussions resulted from purposeful heading of the ball Concussion most commonly caused by collision with another player, the goal post, or ground
Concussion and Soccer Studies have shown no neurocognitive deficits, symptoms, neurochemical changes, or MRI changes, either acute or chronic, from purposeful heading 42 However, SRC during soccer may lead to neurologic sequelae Any potential effects from frequent heading would be difficult to separate from those resulting from previous concussions Those heading the ball more frequently are at increased risk for SRC
Concussion and Soccer Helmets have been proposed as a possible way to negate any potential effects of purposeful heading or other injury However, no helmet has ever been shown to decrease the risk of concussion Headgear has been developed specifically for use in soccer, but has not been shown to affect decreasing head acceleration resulting from purposeful heading of the ball 43
Concussion and Soccer In soccer, headgear would clearly have negative impact on ball control along with the unclear benefit Perhaps most effective way to decrease the risk of SRC in soccer is to: Decrease the mass and air pressure used by smaller, young players 44 Pad goal posts 44
Concussion and Soccer Some have recommended that players not be allowed to head the ball until a certain age and their brain has reached a certain stage of development and is protected 40 Others argued players should Learn skill of heading properly 45 Develop neck musculature before allowed to head the ball 46 At this point, definitive recommendations cannot be made
Concussion in Female Athletes
Concussion in Female Athletes Most publications regarding SRC involve male athletes SRC occurs commonly in females Dick, 2007 47 Reported in female soccer players, concussion accounts to 3-5% of all injuries and as much as 11% of all game-time injuries Some studies suggest SRC occurs more commonly in female athletes 48 Women have more significant changes in neurpsych testing than men
Subconcussion in repetitive mild traumatic brain injury Research now suggests that head impacts commonly occur during contact sports, in which visible signs or symptoms of neurological dysfunction may not develop Recent biophysics studies utilizing helmet accelerometers have indicated that athletes at the collegiate, high school, and youth levels sustain a surprisingly high number of head impacts ranging from several hundred to well over 1000 during the course of a season.
Subconcussion Clinical studies have also identified athletes with no readily observable symptoms but who exhibit functional impairment as measured by neuropsychological testing and functional MRI. Such findings have been corroborated by diffusion tensor imaging studies demonstrating axonal injury in asymptomatic athletes at the end of a season.
DTI
Functional MRI
fmri
PET Scan
Subconcussion Recent autopsy data have shown that there are subsets of athletes in contact sports who do not have a history of known or identified concussions but nonetheless have neurodegenerative pathology consistent with chronic traumatic encephalopathy.
Genetics Several studies in adult literature suggested genetic predisposition to prognosis after brain injury Specifically, possessing apolipoprotein E-Ɛ4 allele has been associated with worse outcome 31 However, most studies are preliminary and most involve severe traumatic brain injury Studies of minor concussion have NOT found such an association 32 Absence of allele does NOT confer absolute protection and presence does NOT confer absolute predisposition
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Subconcussion Emerging laboratory data have demonstrated significant axonal injury, blood-brain barrier permeability, and evidence of neuroinflammation, all in the absence of behavioral changes.
Subconcussion Immunoexcitotoxicity may be playing a central role in many neurodegenerative diseases including chronic traumatic encephalopathy (CTE) The interaction between immune receptors within the central nervous system (CNS) and excitatory glutamate receptors trigger a series of events.
Neuroinflammation
Neuroinflammation Goal of suppressing microglial activation & excitotoxic cascade/inflammatory mediators Curcumin, quercetin, green tea catechins, balcalein, luteolin: cell signaling & antioxidants Omega 3 fatty acids Resveratrol Magnesium
Concussion Cocktail Omega -3 EPA/DHA: 2g/day Magnesium: 500 mg/day Vitamin C: 1g/day Vitamin D: 1000 IU/day Curcumin: 500 mg/day
UPMC Concussion Program Treatment/Rehabilitation Protocol Somatic Symptoms Headaches Prophylaxis Propranolol* Verapamil* Amitriptyline* Escitalopram (Lexapro) Sertraline (Zoloft) Vestibular Therapy Emotionality SSRIs Escitalopram (Lexapro) Sertraline (Zoloft) Therapy Sleep Disturbance Melatonin Trazodone Cognitive Symptoms Neurostimulants Amantadine* Methylphenidate* Atomoxetine (Strattera)* NOTE: *Off-label use
Take Home Points Most concussions will resolve 2 weeks is the minimum RTP time and Absolutely no play same day of concussion (with or without LOC) If symptoms persist, referral (early) to specialist recommended CT/MRI usually ordered early; persistent symptoms require MRI
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Make an appointment If symptoms persist, call Dr. O Leary 880 W. Central Road, Arlington Heights Office: 847-618-3800 Cell: Cell: 847-651-9897 soleary@nchmedicalgroup.com November 5, 2015 Northwest Community Healthcare 60
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Thank you! and special thanks to Dr. Adam Smith. November 5, 2015 Northwest Community Healthcare 62