concussion update the state of play terry coyne brizbrain & spine sunshine coast brain &...
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Concussion UpdateThe State of Play
Terry CoyneBrizBrain & SpineSunshine Coast Brain & Spine
Aims
• Identify concussion• Appropriately advise players/other
stakeholders re management, return to play
• Access resources
NFL, RETIRED PLAYERS RESOLVE CONCUSSIONLITIGATION; COURT-APPOINTED MEDIATORHAILS “HISTORIC” AGREEMENT
Thousands of Retirees and Families to BenefitMedical Testing; Research; Compensation andPromotion of Safety All Part of Agreement
Former United States District Judge Layn Phillips, the court-appointed mediator in the consolidated concussion-related lawsuits brought by more than 4,500 retired football players against the National Football League and others, announced today that .
• NFL would pay $765 million plus legal costs, but admits no wrongdoing.
• Individual awards would be capped at $5 million for players suffering from Alzheimer’s disease.
• Individual awards would be capped at $4 million for deaths from chronic traumatic encephalopathy (CTE).
• Greg Williams has said that multiple concussions in his career resulted in permanent damage.
• The Age, September 2013
NRL legend Mark Geyer set to have a brain examination and wants to other players who suffered concussion to be tested for potential trauma
James Hooper The Sunday TelegraphMarch 15, 2014
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What is concussion?
• Subset of mechanical brain injury• Can be direct or transmitted force to head• Typically rapid onset of neurological
impairment which resolves spontaneously, but may evolve over minutes/hours
• Acute symptoms usually due to functional disturbance rather than structural
• May or may not involve LOC• Occasionally symptoms may be prolonged
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• AFL – 5-6/1000 player hours
• Equals 6-7/season per team on average
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Symptoms & Signs
• Symptoms - somatic (eg headache) - cognitive (eg “feeling foggy”) - emotional (eg lability)• Signs eg loss of consciousness, amnesia• Behavioural change (eg irritability)• Cognitive impairment (eg slowed reaction
times)• Sleep disturbance (eg insomnia)
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On field/Sideline evaluation
If ANY features of concussion:• Player requires evaluation; if none available,
remove from play and arrange assessment• Standard emergency evaluation (ABC’s), Cx
spine assessment• Assessment using appropriate tool (eg SCAT
3)• Player not left alone• If concussion – no return to play that day
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• Diagnosis is a medical decision based on clinical judgement
• Traditional questions to assess orientation (T,P, P) unreliable
• Can be delayed
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In Emergency Room/Surgery
• Good history, detailed neuro exam (including mental status, cognition, gait, balance)
• Improving or deteriorating?
• Assess need for neuroimaging if need to exclude structural injury (prolonged disturbed LOC, focal deficit, deteriorating)
(SCAT 3)
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Other Investigations
• Balance Error Scoring System (BESS) – postural stability correlates well with overall neurological motor function
• Biomarkers – genetic (eg Apo 4) - cytokines (eg IGF-1, S-100), in serum, CSF• Electrophysiological – EEG, evoked
responses) - interesting, but significance unknown
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Neuropsychological Assessment
• Useful, but not practical except in professional setting
• Symptoms usually resolve first, so when used usually after player asymptomatic
• No evidence to support baseline neuropsych testing
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Concussion
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Management
• Key Points – physical and cognitive rest until acute symptoms resolve - then graduated exertion to normal play
• No return to play on day of a concussion, esp school age, where cognitive deficits may not be present on the sideline, but may be delayed, more so than in adults
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Graduated RTP
• Usually 24 hrs for each level, so 1 week to progress to RTP from when asymptomatic at rest
• If symptoms recur, rest 24 hrs, and restart one level back, where was asymptomatic
• Elite v non-elite – elite may have more resources, but their brains are the same, so management no different
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Persisting symptoms (>10 days)
• 10-15 % of concussions• Consider other pathologies (imaging)• Maybe multi-disciplinary approach – physio,
psychologist, neuropsychologist, vestibular rehab etc
• Pharmacology – specific symptoms (eg sleep disturbance, anxiety)
- modify pathophysiology to shorten symptoms - methylphenidate (Ritalin), amantadine. But…….
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Children (<13 yrs)
• Ist step is successful return to school, prior to physical activity, even physical ADL’s
• Increased risk of cerebral swelling• Need to be entirely symptom free before
return to sport• May take longer to recover than adults• Child SCAT – neuropsych more difficult as
brain not mature, so hard to standardise tests• Generally be more cautious
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Risks of too soon RTP• Impaired performance, re-injury due to slower
reaction times, for example• 2nd impact – acute severe cerebral swelling - ? disturbed auto regulation - case report level• ?CTE – seems to be greater risk of cognitive
impairment, depression/other mental health issues amongst NFL players with multiple concussions; but we don’t know the type, number or severity of concussions required, and why a small # only get CTE. So, err on the side of caution
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Chronic traumatic encephalopathy (CTE)
• Distinct tau-opathy• Incidence in athletes unknown• Cause and effect unknown• ?Genetic disposition• Other factors – age, mental health,
alcohol/drug use, medical co-morbidities – largely not accounted for in studies to date
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Prevention
• Unfortunately, little evidence for protective gear. Mouthguards, football helmets good for dental, facial protection, but no evidence they decrease concussion. Also “risk compensation”, esp children, adolescents
• Skiing, snowboarding – evidence, so recommended
• Cycling, equestrian, motor sports - prob protect against falls against hard surfaces, less skull #’s
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Thank you
Visit BBS Website to download:
• Pocket Concussion Recognition Tool• SCAT 3• Child SCAT 3• Consensus statement on concussion in
sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012
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