Sports Concussion

Dr. Penny-Jane BaylisMBBS, CCFP, Dip Sport Med, BSc PTMcGill Sport Medicine Clinic

• I have no conflicts of interest to declare

International Consensus on Concussion In

SportVienna 2001• Epidemiology

• Basic and clinical science• Injury grading systems• Cognitive assessment• New research methods• Protective equipment• Management• Prevention • Long term outcome

• 1st Vienna 2001, 2nd Prague 2004, 3rd Zurich 2008• N Meeting in Zurich 2012

• NIH consensus development conference format

• Pre-defined group of questions

• Body of literature identified

• Presentation by experts in open session day 1 and day 2

• Discussion / debate closed session with consensus panel on day 3

• Document drafted by authors and circulated to panel

• Knowledge translationConsensus statement on concussion in sport:

the 4th International Conference on Concussion in Sport held in Zurich, November

2012

Is concussion a mild traumatic brain injury?

• External force injures the brain

• GCS 13/15

• Should not use terminology interchangeably

• Different injury constructs

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DEFINITION DEFINITION “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include…”

Natural history• Still not well described

• 80% of persons with mild TBI will recover completely, but this can take days, weeks or months

• Up to 18 months or longer before maximum recovery is reached

• Recovery is faster in the beginning and slows down over time

• Little is known about recovery in children

Copyright restrictions may apply.

McCrea, M. et al. JAMA 2003;290:2556-2563.

Symptom, Cognitive, and Postural Stability Recovery in Concussion and Control Participants

Common features• clinical, pathological & biomechanical injury constructs

• impulsive force transmitted to the head

Direct or indirect

Head or any part of the body

Common features• Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously

Common features• Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

Common features• No abnormality on standard structural neuroimaging studies is seen in concussion.

Take Home Messages

• graded set of clinical symptoms

• that may or may not involve loss of consciousness

• Resolution of the clinical & cognitive symptoms typically follows a sequential course

• 80% to 90% resolve in 7 to 10 days

• In a small percentage of cases post-concussive symptoms persist

• May be longer with children & adolescents

Old Concussion Guidelines

• 27+ different grading systems in

literature !!

• No universal agreement with regards to injury definition and return to play guidelines

Old Concussion Guidelines• Common elements: memory, loss of consciousness, and symptoms

• Used to assess severity of a concussion

• Poor prognostic value

• Varying return to play timelines

Grading systems• By 2001 at least 25 grading systems

• Allows determination of injury severity

• Limited evidence that injury severity correlates with S & S or degree of severity

• Only truly know retrospectively

• Individually guide return to play

Grading systems

• What are they?

• Why have them?

• Vienna 2002 abandon grading systems

• Prague 2004 simple vs complex concussion

• Zurich 2009 abandon simple vs complex

What is the Mechanism of Concussion?

•Exact mechanism unknown

•Rotational acceleration more important than linear acceleration–the “jiggle” of the brain within the skull causes concussion

•Axonal injury may occur

•Probably, the first concussion is a biochemical injury

•NOT DUE TO Bleeding

•NOT DUE TO Tearing or Bruising of the brain

Pathophysiology• Complex cascade of biochemical, metabolic and gene expression changes

(severe injury in animal models)

• What happens with mild TBI in humans?

Pathophysiology• Axonal shear is the primary pathologic feature of traumatic brain injury in all levels of severity

• Diffuse axonal injury

• Sudden chemical changes

• Stretching and tearing of brain cells

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PathophysiologyPathophysiology

• In a concussion, certain chemical levels are altered at the cellular levelIn a concussion, certain chemical levels are altered at the cellular level

• Blood supply to the brain decreasesBlood supply to the brain decreases

• The brainThe brain’’s demand for glucose increasess demand for glucose increases

• Mismatch in fuel supply and demandMismatch in fuel supply and demand

• Neuronal tissue vulnerabilityNeuronal tissue vulnerability

• Brain needs time to recoverBrain needs time to recover

Pathophysiology

http://eix.dyndns.org/~icier/html/concussion.html

Neurometabolic changes

http://schatz.sju.edu/neuro/cascade.html

Post Concussion Syndrome

• prolonged symptoms related to the initial head injury

• severity of the concussion does not necessarily predict who will experience prolonged symptoms

http://brainmind.com/images/NerveShearing33.jpg

• Use term concussion where other diagnoses are excluded

• Concussion includes all neurological dysfunction however minor

• Limitations exist with sideline assessments as it is an EVOLVING injury

Second Impact Syndrome

• Rare• Second brain injury occurs while the symptoms from the first impact have not resolved.

• Impact can be separated by minutes, days, and, perhaps weeks.

• Loss of autoregulation of the brain’s blood supply

• Vascular engorgement• Cerebral edema • In worst cases, death

Management

Canadian Academy of Sport & Exercise

Medicine1.1.RecognitionRecognition: : concussion

recognition

2.2.ResponseResponse: : removal from play

3.3.RehabilitationRehabilitation: : rest until asymptomatic SSTT, cervical spine, vestibular, balance

4.4.ReturnReturn: : graded return to play

• Athletes underreport

• Athletes do not associate symptoms with concussion

Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions Among University Football and Soccer Players. Clinical Journal of Sports Medicine. 12:331-338. 2002.

• Athletes don’t realize they have or have had a concussion

• 328 football, 201 soccer • 70.4% football, 62.7% soccer players had experienced symptoms of concussion in previous year

• 23.4% football and 19.8% soccer realized they had suffered a concussion

• Coaches don’t recognize injury either

• Players who recognized concussion were more likely to have had one in the past

Sideline Evaluation

• ABC’s

• LOC…suspect spine

• Unsure mech, neck pain…suspect spine

• SCAT3 or similar tool (McGill ACE) performed

• Symptoms may be delayed by several hours - obs

ON-FIELD OR SIDELINE ON-FIELD OR SIDELINE EVALUATION OF ACUTE EVALUATION OF ACUTE

CONCUSSION-WHEN A PLAYER CONCUSSION-WHEN A PLAYER SHOWS ANY FEATURES OF A SHOWS ANY FEATURES OF A

CONCUSSIONCONCUSSION The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management

principles and particular attention should be given to excluding a cervical spine injury.

The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available the player should be safely removed from practice or play and urgent referral to a physician arranged. Once the first aid issues are addressed an assessment of the

concussive injury should be made using the SCAT3 or other sideline assessment tools.

The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few

hours following injury. A player with diagnosed concussion should not be allowed to return to

play on the day of injury.

Signs & Symptoms

http://www.cdc.gov/concussion/signs_symptoms.html

SCAT3 – 4 PAGE SCAT3 – 4 PAGE LAYOUTLAYOUT2. Scoring

3. Instructions

4. Patient Information

1. Sideline Assessment

Red Flags•Young age

•Confusion lasting > 30 minutes

•Loss of consciousness > 5 minutes

•Focal neurologic deficit

•Deteriorating level of consciousness

EVALUATION IN EMERGENCY ROOM EVALUATION IN EMERGENCY ROOM OR OFFICE BY MEDICAL OR OFFICE BY MEDICAL

PERSONNELPERSONNEL • Individual clinical decision

• A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance.

• A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury.

• A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality

In large part, these points above are included in the SCAT3 assessment

Canadian CT Head Rules

• High risk of neurosurgical intervention

• Glasgow Coma Scale score <15 within 2 hr after injury

• Suspected open or depressed skull fracture

• Any sign of basal skull fracture§

• Two or more episodes of vomiting

• Age >65 yr

• Moderate risk of brain injury detected by CT

• Retrograde amnesia for ≥30 min

• Dangerous mechanism

Removal from play

Rehabilitation

Rehabilitation

MANAGEMENTMANAGEMENT• CORNERSTONE = initial period of rest until acute symptoms resolve

Physical Rest

No training, playing, exercise, weights

Beware of exertion with activities of daily living

Cognitive Rest

No television, extensive reading, video games?

Caution re: daytime sleep

MANAGEMENTMANAGEMENTExpect gradual resolution within 7-10 days

Gradual return to school and social activities that does not result in significant exacerbation of symptoms

Proceed through step-wise return to sport / play (RTP) strategy

RECOVERED?RECOVERED?

• Everyone “feels fine”

• Always ask:

1.“On a scale of 0 to 100%, how do you feel?”

2.“what makes you not 100%?”

3. Symptom Checklist – SCAT3

Return to play

Major deficits in balance, cognition, symptoms:Balance 3-5 days; cognition 5-7 days; symptoms 7 days10% of athletes had symptoms > 1 week(JAMA 2003 McCrea et al)

75% of same-season repeat concussion occurred <7 days from the first & 92% < 10 days (JAMA 2003 Guskiewicz et al)

1. No activity Physical & cognitive rest Recovery

2. Light aerobic exs

Walking, stat bike

<70% HR maxIncrease HR

3. sport specific exs

Skating, running Add movement

4. Non contact drills

Progress to complex drills

Exs, coordination, cognitive load

5. Full contact practice

Medical clearance

Restore confidence

6. Return to play

Normal game play

GRADUATED RTP GRADUATED RTP PROTOCOLPROTOCOL

• 24 hours per step (therefore about 1 week for full protocol)•If recurrence of symptoms at any stage, return to previous asymptomatic level and

resume after further 24 hr period of rest

Rehabilitation stage Functional exercise at each stage of rehabilitation

Objective of each stage

1. No activity Symptom limited physical and cognitive rest.

Recovery

2.Light aerobic exercise

Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training.

Increase HR

3.Sport-specific exercise

Skating drills in ice hockey, running drills in soccer. No head impact activities.

Add movement

4.Non-contact training drills

Progression to more complex training drills e.g. passing drills in football and ice hockey. May start progressive resistance training

Exercise, coordination, and cognitive load

5.Full contact practice

Following medical clearance participate in normal training activities

Restore confidence and assess functional skills by coaching staff

6.Return to play Normal game play

Recap...• The player should not be allowed to return to play in the current game or practice

• The player should not be left alone; and regular monitoring for deterioration is essential over the initial few hours following injury

• The player should be medically evaluated following the injury

• Return to play must follow a medically supervised stepwise process

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SAME DAY RETURN TO SAME DAY RETURN TO PLAY?PLAY?

•NO!• Unanimously agreed that no RTP should occur on the day of concussive injury

RETURN TO PLAY / RETURN TO PLAY / SPORTSPORT

• Must pass graded exertion first

=remain asymptomatic

• Is the athlete confident to go back?

• New helmet/head gear?

• Other “protective” equipment / behaviors / factors?

• Consider implications of multiple/recent injury

PCS rehabilitation

•Concept of regulated exercise

•Exercise to subthreshold of concussion symptoms

•Tested every two to three weeks

•Cerebral blood flow regualtion remains dysfunctional

http://www.medicalnewstoday.com/articles/53995.php

““DIFFICULTDIFFICULT”” OR OR PERSISTENTLY SYMPTOMATIC PERSISTENTLY SYMPTOMATIC

CONCUSSION PATIENTCONCUSSION PATIENT

•Persistent symptoms (>10 days) in about 10-15%

•Important to consider other issues

•Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion

•In order to consider sub-symptom threshold exercise and other forms of therapy /rehabilitation

PSYCHOLOGICAL & MENTAL PSYCHOLOGICAL & MENTAL HEALTH ISSUESHEALTH ISSUES

• Psychological approaches may have application especially in selected situations (modifiers)

• Evaluate for affective symptoms (depression, anxiety) as common in all forms of traumatic brain injury

• Depression-may be consequence of concussion, underlying pathophysiological abnormality, may be multifactorial but should be considered in management

MANAGEMENTMANAGEMENT

•Pharmacotherapy Prolonged symptoms (sleep disturbance,

anxiety)

Modify underlying pathophysiology

•Upon return to play should not be on medication that could mask symptoms Antidepressants?

FACTORS MODIFIERSymptoms Number

Duration (>10 days)Severity

Signs Prolonged LOC (>1min)Amnesia

Sequelae Concussive convulsionsTemporal Frequency –repeated concussion over time

Timing – injuries close together“Recency” – recent concussion or TBI

Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

Age Child and adolescent (< 18 years old) Co and Pre-morbidities Migraine, depression or other mental health

disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders

Medication Psychoactive drugsAnticoagulants

Behaviour Dangerous style of playSport High risk activity

Contact and collision sportHigh sporting level

MODIFIERSMODIFIERS• May influence investigation and management

• May predict potential for prolonged or persistent symptoms

• Multidisciplinary approach coordinated by a physician with specific expertise in management of concussion.

Canadian Academy of Sport & Exercise

Medicine1.1.RecognitionRecognition: : concussion recognition

2.2.ResponseResponse: : removal from play

3.3.RehabilitationRehabilitation: : rest until asymptomatic

4.4.ReturnReturn: : graded return to play

CHILD AND CHILD AND ADOLESCENT ATHLETEADOLESCENT ATHLETE

• Adult recommendations can apply down to age 13

• Below 13 require age appropriate symptom checklists and evaluation tool

• child SCAT3 developed for this purpose

• Include both patient and parent, teacher, school input.

• Possibly use neuropsychological testing before symptoms resolve to help plan school management

• must be developmentally sensitive, consider use of trained pediatric neuropsychologistNOTE: Pediatric subcommittee has developed age-specific Child SCAT3

(Davis,  McCrea, G. Gioia, Purcell, Ellenbogen, C. Vaughan, Guskiewicz, Kutcher, Meeuwisse, McCrory)

CHILD AND CHILD AND ADOLESCENT ATHLETEADOLESCENT ATHLETE

• Consider age specific physical and cognitive rest issues

• school attendance and activities need to be modified

• No return to sport or activity until returned to school successfully

• Symptom resolution may take longer, modifiers apply even more

• More conservative RTP approach recommended:

• Consider extending symptom-free period before starting return to play protocol

• Consider extending length of the graded exertion protocol

• Never return to play same day

Child & adolescent

• Adult recommendations can apply down to age 10

• Use symptom check list

• Include athlete & parent

• Neuropsych prior to symptom resolution

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ELITE VS NON-ELITE VS NON-ELITEELITE

• All athletes should be managed the same regardless of level of participation

• Available resources and expertise may determine management approaches

• Consider cognitive evaluation in all organized high-risk sports regardless of age or level of performance

CHRONIC TRAUMATIC CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)ENCEPHALOPATHY (CTE)

• Acknowledge potential for long-term problems in all athletes

• CTE unknown incidence in athletic populations, cause/effect not yet demonstrated between CTE and concussions or exposure to contact sport

Objective Balance Assessment

•Balance Error Scoring System

(BESS)

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Neuroimaging• Brain CT or brain MRI contribute little

• Functional MRI: activation patterns reflecting severity & recovery

• PET, MR spectroscopy, functional connectivity in research settings

Source: http://www.neurology.org/cgi/content/abstract/53/6/130

0

INVESTIGATIONSINVESTIGATIONS• Neuroimaging (CT, MRI)

• Contributes little to concussion evaluation

• Use when suspicion of intracerebral or structural lesion exists:

• focal neurologic deficit

• worsening symptoms

• Prolonged disturbance of conscious state

• Other modalities such as fMRI correlate with symptom severity and recovery and although not routinely used presently may provide additional insight.

• Alternative imaging technologies are still at early stage of development in concussion and not recommended other than research setting

INVESTIGATIONSINVESTIGATIONS•Postural stability testing-deficits 72hr post concussion

• Balance error scoring system (BESS), force plate technology

•Genetic testing/markers

• Significance unclear for Apolipoprotein (Apo) E4, ApoE promoter gene, Tau polymerase, other genetic and cytokine factors

• Insufficient evidence for routine clinical use

INVESTIGATIONSINVESTIGATIONSNeuropsychological (NP) assessment:•Important component in overall assessment and RTP•Should NOT be sole basis of management decisions, but an aid to clinical decision making•Included as part of clinical neurological assessment by treating physician often with computerized NP screening tools•Formal NP testing not required for all but, if so, interpretation should be performed by trained neuropsychologist. •Best done when asymptomatic but may be advantageous at other stages in particular situations•Baseline testing not mandatory. May be helpful in test interpretation and for education opportunity

Neuropsychological Testing

• Clinical value

• Cognitive recovery ~ physical recovery

• Should not be sole basis for management decisions

• Done when athlete is symptom free

Impact Testing

1.Word Memory : Verbal recognition memory (learning and retention)

2.Design Memory : Spatial recognition memory (learning and retention)

3.X’s and O’s : Visual working memory and cognitive speed

4.Symbol Match : Memory and visual-motor speed

5.Color Match : Impulse inhibition and visual-motor speed

6.Three Letter Memory : Verbal working memory and cognitive speed

7.Symptom Scale: Rating of individual self-reported symptoms

Genetic Testing

• Apolipoprotein Epsilon 4 & long term damage

• ApoE promotor gene & severity

• Tau polymerase & chronic traumatic brain injury (CTE)

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Chronic Traumatic Brain Encephalopathy

• Progressive degenerative disease

• Accumulation of tau protein

• Multiple concussions

• Football, hockey, wrestling, contact sports

• Clinically like dementia

• Dementia pugilistica in boxing

Owen Thomas•21 year old defensive lineman and captain for the University of Pennsylvania football team,

•Committed suicide

•autopsy showed evidence of incipient chronic traumatic encephalopathy (CTE)

•Fifth Estate: Head Games; what is killing our professional football players

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OTHER ISSUESOTHER ISSUES•Rule changes•Consider where clear cut mechanism is implicated

•To allow for effective off-field medical assessment (time and proper environment)

•Risk compensation•Use of protective equipment may change behavior-especially child and adolescent

•Aggression vs violence•Violent behavior that increases concussion risk should be eliminated

•Promote fair play and respect

Prevention?• Elimination, substitution, engineering• Baseball balls, ground surface/hardness

• Training• Strength, fitness, skills

• Administration: laws and rules• PPE, rugby scrum, tackle, checking

• Protective equipment• Helmets, mouthguards (not proven to definitely prevent concussio

Beware of Risk Compensation

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• Practical Approach:

• Better diagnosis of concussion.

• When can players return to play?

• When has full recovery occurred?

• Scientific Approach:

• What happens to brain function following concussion?

• How does that correlate with symptoms?

• What is the effect of multiple concussions

Future Directions• SCAT2 validation

• Gender effects (risk, severity, outcome)

• Paediatric concussion and management

• Virtual reality tools (assessment & treatment)

• Surveillance via standardized definitions

• Best practice neuropshych testing

• Long term sequelae

• On field severity predictors

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concussion.jpg

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THANK YOU!

IMPROVING OUTCOMEpost

CONCUSSION inSPORT

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Concensus Statements

2001 : Vienna (First international conference in concussion in sport)

2004 : Prague

2008 : Zurich

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What is a concussion?Complex

pathophysiological process affecting the brain

Induced by traumatic forces on the brain

ModifiersSymptoms: number, duration, severity

Signs: prolonged LOC, amnesia

Sequelae: convulsions

Temporal: repetitive, close together, recent

Sport: contact, collision, high competition

ModifiersThreshold: less impact to cause repeated concussions & slower recovery

Age: child & adolescent

Comorbidity: migraine, depression, ADHD

Medication: psychoactive, anticoags

Behaviour: dangerous style of play