concussions: evolution of the science and culture · concussions each year. • if a young athlete...
TRANSCRIPT
Concussions: Evolution of
the Science and Culture
Wellstar Neurosurgery
Franklin Lin, MD
January 23, 2016
Disclosures
• Stryker
• Globus Medical
• Julian Bailes, MD
• David Wright, MD
• Jeff Hopp, ATC
• Mickey Fitzgerald, NFL Alumni
• Moderator: Franklin Lin, MD
Culture Shift
In 2009, there was a significant shift in the
stance of NFL on handling concussions
• Protocols/Technology
• Acceptance of 3rd party evaluations (avoid
conflict of interests)
• Penalties
Culture Shift
• More recognition and media attention and at all
levels of play
• Changes in perception of a concussion
• “Bell Rung,” terms downplaying concussion
banned in many instances
• No longer a “Badge of courage” or a rite of
passage
• Zack Lystedt Law passed in 2009 in Washington
State
3 KEY POINTS
• Athletes, parents and coaches must be
educated about the dangers of
concussions each year.
• If a young athlete is suspected of
having a concussion, he/she must be
removed from a game or practice and
not be permitted to return to play.
When in doubt, sit them out.
• A licensed health care professional
must clear the young athlete to return
to play in the subsequent days or
weeks.
Zachery Lystedt Law
GA House Bill 284 (2013)
1. Prior to the beginning of each athletic season of a youth athletic activity,
provide information sheet to all youth athletes' parents or legal guardians
which informs them of the nature and risk of concussion and head injury;
2. If a youth athlete participating in a youth athletic activity exhibits symptoms
of having a concussion, that athlete shall be removed from the game,
competition, tryout, or practice and be evaluated by a health care provider;
and
3. If a youth athlete is deemed by a health care provider to have sustained a
concussion, the coach or other designated personnel shall not permit the
youth athlete to return to play until the youth athlete receives clearance from
a health care provider for a full or graduated return to play
'Health care provider' means a licensed physician or another licensed
individual under the supervision of a licensed physician, such as a nurse
practitioner, physician assistant, or certified athletic trainer who has received
training in concussion evaluation and management.
Definition
A clinical syndrome characterized by immediate
and transient alteration in brain function,
including alteration of mental status and level of
consciousness, resulting from mechanical force
or trauma. (AANS)
A concussion is a type of traumatic brain injury, or
TBI, caused by a bump, blow, or jolt to the head
that can change the way your brain normally
works. (CDC)
Mechanism
Sudden acceleration/deceleration over an extremely short
distance (inches).
Direct and indirect impacts.
A blow to the head is NOT required.
Second Impact Syndrome
• Subsequent concussion/TBI before symptoms of the initial concussion resolve
• Catastrophic – severe neurological injury or death
• Loss of cerebral autoregulation from initial concussion results in uncontrolled brain swelling/edema when a second injury occurs.
Statistics
• 65,000 diagnosed concussions in high
school football/yr
• There is at least one mild concussion in
nearly every football game
• Incidence is increasing – partly due to
better recognition, admission by players,
presence of trained personnel (ATCs)
Neuropsychological Testing
ImPACT ™ test • Reaction time
• Memory – verbal and visual
• Processing speed
Neuropsychological Testing
• Not an aptitude test.
• Very sensitive to “throwing” the test
• Used in NFL, NHL, NCAA, many
international leagues
• Essentially becoming a standard
Balance Testing
Changes in balance also a sensitive way of
monitoring problems and recovery
Helmets
• Extremely effective in minimizing external trauma – skull/facial fractures, lacerations
• Impact to the head NOT REQUIRED to sustain a concussion
• Sudden acceleration/deceleration
• Misperception that all that is required is a “Better helmet”
• Limits of what a helmet can do in terms of dissipating energy imparted over collision – One study said you need padding 15 inches thick
• Improving helmets may increase risk to other areas of the body - SPINE
Tackling Technique
• “See what you tackle” I.e. take your
head/neck out of the tackle
• Prevent use of a helmeted head as a
weapon, battering ram
• Penalties for intentionally striking
opponent’s head
• Proposals even as far is eliminating
helmets.
Athletic Trainers
• More schools employing Certified Athletic
Trainers (ATCs) – true health care professionals.
• Operating independent of the team/coaching
staff. Though coaches have better awareness
and training
• Protocols established
• Better, earlier detection and intervention.
• Liaisons with Teachers/professors, coaches,
parents
• Increased incidence of concussions at
schools with ATCs (DETECTION)
Evaluation
• Requires more than a single visit or evaluation. “Seeing
your pediatrician” is not enough anymore.
• Needs to expeditious as not to discourage compliance
• Utilization of team approach, i.e. other allied health care
providers (ATCs) to manage volume and “front line”
• Referral to Concussion, sports medicine centers
Standard Protocols
• Suspected concussion – removed from play immediately
• NO RETURN TO PLAY
• Monitor for symptom resolution
• Stepwise increase in activity with symptom monitoring
• +/- Neuropsychological testing (ImPACT), Balance
testing (Baseline and Post injury)
• RTP 1-2 weeks of all of above passed
• Any deviation – prolonged recovery, severe symptoms,
multiple recent concussions may prompt a more
comprehensive MD visit.
• In professional and collegiate sports – Comprehensive
protocols and teams managing concussions
Example of Monitoring and Reporting by ATC
College Student Athlete suffered a concussion yesterday, 7/23/15, at
approximately 6:30am. He had his legs taken out from under him during a
football drill and fell face first to the ground. He was initially treated for epistaxis
and a small lower lip laceration, reporting no concussive symptoms.
Nonetheless, Student was removed from activity, and while observing he rest
of the workout he asked several times what happened regarding the cut on his
lip. Upon further evaluation athlete exhibited mild anterograde amnesia
lessened over the course of the evaluation. Athlete also self reported fogginess
and blurred vision.
Initial Assessment:
(7/23/14) at 6:30am
S&S: Initial blurred vision, confusion/disorientation, poor memory, poor
concentration,
Example of Monitoring and Reporting by ATC
Clinical Evaluation:
· Antero-Grade Amnesia
Initially athlete was unable to remember moments directly following the incident
(initial eval, wound care)
Athlete kept asking what happened with the cut on his lip after repeatedly
having it explained to him.
o Athlete did begin to recall some aspects of the incident by the end of the
evaluation
o Inability to perform 3-word recall
· Poor Concentration
o Multiple errors with serial 7's
o One error with months in reverse error
o Unable to perform reverse digits without errors
Example of Monitoring and Reporting by ATC
TREATMENT PLAN
· Educated Athlete about Concussion
· Taylor will be closely monitored
· Tylenol was provided
· Instruction on Treatment plan
· Parents have been contacted
· Academic Support Staff was contacted to assist communication with Taylor’s
professors in making them aware of the circumstances.
· ImPACT test was repeated and is ready for review. ImPACT testing will
administered again when Taylor is asymptomatic for 24 hours.
· SWAY balance has been repeated and results are attached for your review.
· Upon your clearance, return to play protocol will be initiated.
Please advise if you feel any changes should be made to the treatment plan.
Academia:
Attached is a letter to be provided to the student-athlete's professors
Example of Monitoring and Reporting by ATC
SUBSEQUENT REPORT
Student Athlete has completed the following steps of the RTP progression outlined below
and has remained asymptomatic:
7/27/15: Non-impact CV training on stationary bike for 20 minutes
7/28/15: Impact CV training; jogging on treadmill for 20 minutes
7/28/15: High intensity CV training; 60 yard sprints x6, 40 yard sprints x4
7/29/15: Body weight exercises; pushups, sit-ups, squat thrusts
7/29/15: Resistive strength exercises; RDL's, Squats, Push Press
7/31/15: Sport Specific Drills
We are planning on having him complete non-contact practice (helmets only) on
Saturday (8/1/15) and Sunday (8/2/15) as you previously recommended.
As long as he remains asymptomatic, we are looking for clearance to return to contact
and full participation on Monday 8/3/15.
Please let us know if you feel any modifications should be made.
Example of Monitoring and Reporting by ATC
HS Student was blindsided last Tuesday at practice. He was out of school on
Wednesday due to a mild headache. I did do an impact test on him last Friday
and it didn’t look good. I will be testing him again this morning around 10.
The decision is whether or not to let him continue playing. This is his sixth
concussion in the since October 2011 (10/22/11, 6/9/12, 8/6/12, 10/18/13,
5/14/14, and 5/12/15). Recoveries usually take a couple weeks and sometimes
longer. I am leaning towards telling him and his mother he should hang up his
cleats. Thoughts?
MD Response
Completely agree. I saw him following his last concussion and told him
that he should stop playing if any more injuries.
Even if he makes it into a college program, the hits only get harder
there. Absolutely no reason to continue with his history
Example of Monitoring and Reporting by ATC
I would like to apologize to both of you for what is currently ongoing
with our cheer program. I am in complete agreement with both of you
on the concerns over the high rate of concussion injury dating back to
last year regarding this program. I begin compiling data from other
NCAA division I institutions regarding cheer/concussion episodes at
their institutions last spring, I also compiled our concussion numbers
from our collision/contact, and non contact sports over the past three
years for comparison…
In regards to our cheer program, we have currently stopped all
participation in competitions. In addition, we have decreased the
amount and difficulty of stunting that is being performed during
practices. Dr. Dysart is also planning a meeting with our Athletic
Director to discuss the cheer program.
Take-Home points
• Treatment protocols are evolving
especially at high school/youth level
• More comprehensive monitoring and care
is required (Concussion centers)
• Team-based approach to manage the
volume (ATC, Psych, Rehab)
• Use of tools (ImPACT, Sway) becoming
standard