Sports Concussions Melissa Schiff, MD, MPH Objectives 1. Recognize signs and symptoms of concussion 2. Understand WA Lystedt concussion law 3. Understand return to play (RTP) requirements 4. Understand gaps in compliance with RTP requirements Concussion Definition 4 th International Conference on Concussion in Sport 2012 (Zurich) Complex pathophysiological process affecting the brain that is induced by biomechanical forces Blow to head, neck, or impulsive force Neurological impairment, resolves spontaneously 1
Signs and Symptoms Loss of consciousness Confusion Drowsiness Fatigue Memory problems Concentration problems Feeling in a fog Headache Pressure in head Nausea/vomiting Blurred vision Sensitivity to light Sensitivity to noise Emotionality Irritability Epidemiology of Concussions 1.6 3.2 million sports related concussions annually 13.2% of all high school athletic injuries Among concussions in high school athletes reported to athletic trainer (20 sports) 47.1% football 8.2% girls soccer 5.3% boys soccer Langlois JA et al. 2006 RIO data (Marar et al.) 2012 Serious sequelae Recurrent concussions subsequent impact causes concussion at lower force, delayed recovery time Second Impact Syndrome second concussion after incomplete recovery time resulting in brain injury, death 2
When to return to play (RTP)? 2012 Concussion Consensus Statement Resolution of all concussion symptoms Graduated return to physical activity if no symptoms Minimum time to full participation 7 days Cannot return to play same day Based on expert opinion Zachary Lystedt Law Washington State passed law July 1, 2009 Applies to school districts and athletic clubs who utilize school property Requirements: Sign a concussion information sheet all parents and athletes Remove youth athlete from practice or game if suspected of having concussion coach Athlete cannot return to play until evaluated by a qualified health care provider MD, NP, PA, ATC Written medical authorization to return to play WA State Concussion Research 3
Methods 2 prospective studies Female middle school (MS) soccer players (2008 2012) High school (HS) football and female soccer players (2012) Player enrollment 4 youth soccer associations and 20 high schools in WA At start of season enrolled players and parents at team meetings Parent consent, player assent UW IRB approved studies Concussion Surveillance System Weekly email or text to parents/athletes Athletic exposures = number practices, games in past week Concussion reporting Concussion definition Did you hit your head while playing soccer and have any symptoms? Telephone interview of all injured players within 1 week Weekly follow up interviews until symptom resolution Sports medicine physicians reviewed all concussion reports Outcome Measures Concussion rates Types, severity of symptoms (1 6 scale) Playing with symptoms Evaluation by health care provider (HCP) Coach aware of concussion 4
RESULTS Epidemiology Middle School Girls Soccer High School Girls Soccer High School Football Number athletes 353 288 490 Participation (%) 83.1 38.0 30.9 Number concussions 51 32 51 Concussion rate / 1000AE 1.5 3.6 3.6 Cumulative incidence rate (%) 13.0 11.1 10.4 Concussion Symptoms (HS) Symptom % Reporting symptom Mean severity of symptom Headache 94 3.8 Pressure in head 75 3.1 Not feeling right 75 2.9 Dizziness 71 3.0 Feeling slowed 58 2.9 Neck pain 56 3.5 Concentration problems 55 1.8 In a fog 47 2.9 Fatigue 46 3.2 Confusion 41 2.7 Loss of consciousness 7 2.1 5
Concussion Length (MS) Concussion length (days) % <1 12 1 7 53 8 14 12 15 21 15 >21 8 Length of Concussion by Symptom (MS) 18 16 14 12 10 8 6 4 2 0 With symptom Without symptom Concussion Evaluation (MS) % Person who evaluated player before 1 st interview Coach 8 Qualified HCP 34 Ever evaluated by qualified HCP No 56 Yes 44 Concussion diagnosed by qualified HCP No 23 Yes 77 Qualified health care provider MD, PA, NP, ATC 6
Middle School Girls Soccer % High School Girls Soccer % High School Football % Returned to play with symptoms 59 79 56 Coach not aware of symptoms 57 63 CONCLUSIONS Middle and high school athletes at significant risk of concussion 10 to 13% Concussion rates similar for high school football and girls soccer Headache, pressure, not feeling right common symptoms Loss of consciousness rare symptom, not required to diagnose concussion 7
60% of the time coach unaware of concussion Less than 50% concussed athletes evaluated by health care professional Majority (60 80%) of athletes RTP with symptoms Recommendations for future studies: Evaluation of concussion laws needed Additional educational strategies to improve concussion reporting Youth athletes focus on long term vs short term, consider use of social media for information dissemination Parents increase their awareness of concussions in their teens Health care providers diagnosis and treatment of concussions in youth athletes Limitations Under reporting of concussions Motivation to keep playing Concussion length based on symptoms rather than neuropsychological testing Not all concussions confirmed by HCP evaluation 8
John O Kane Fred Rivara Sara Chrisman Marni Levy Nayak Polissar Moni Neradilek Special Thanks Shana Chung All athletes, parents, coaches, team managers NIAMS grant # R01 AR051059 RWJ Public Health Law grant Concussion Symptoms (HS) Symptom % Reporting symptom Mean severity of symptom Balance problems 39 3.1 Light sensitivity 37 3.1 Noise sensitivity 37 2.8 Blurred vision 36 2.8 Memory loss 34 3.4 Irritable 31 3.1 Sleep problems 29 2.9 More emotional 27 3.1 Nausea 27 3.0 Nervous 25 2.4 Sad 18 3.7 Loss of consciousness 7 2.1 Dissemination of Concussion Laws in US 41 states have passed legislation 4 states have legislation pending 9