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MANAGEMENT OF SPORTS RELATED CONCUSSION

MANAGEMENT OF SPORTS RELATED CONCUSSION

Brad Herskowitz MD

Neurologist

Baptist Hospital

Disclosures

� I have no relevant financial conflicts of interest. I will not discuss off label or unapproved usage.

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Objectives

� Understand the basic pathophysiology of concussions

� Recognize concussion signs and symptoms

� Be competent in primary care setting in evaluating and treating athletes with sports related concussions

� Be able to know when it is safe for an athlete to RTP or when to refer to a concussion specialist

Why do we care so much about

CONCUSSION?

� Major public health issue

� Frequent occurrence in sport

� Potential catastrophic or long term sequelae

� NFL

� We have the ability to change culture of sport

Lystedt Law

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Epidemiology

� 1.6- 3.8 million SRC occur annually (underestimate)

� McCrea et al 2004 studied 1,532 varsity HS football players in Wisconsin

� 29.9% reported previous concussion

� 15.3% suffered a concussion during current season but only 47.3% reported their injury

� Reasons: did not think injury serious or did not know it was a concussion, did not want to be held out of play

� Risk of repeat concussions greatest in first 7-10 days after RTP

Epidemiology

� Increased rates last decade

� 9% high school injuries, 6% college

� Males: football, rugby, ice hockey and wrestling

� Females: soccer and basketball

� In comparable sports with same rules, Females 2x more concussions

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Concussion Guidelines

� 1st International Conference on Concussion in Sport, Vienna 2001

� Consensus statement created

� 2nd Prague 2004

� Did away with concussion grading

� Simple vs complex

� 3rd Zurich 2008

� All classifications removed

� 4th Zurich 2012

� New tools, SCAT 3

� Timing of treatments

Sports Societies

� American Academy of Neurology (AAN)

� American Medical Society for Sports Medicine (AMSSM)

� National Athletic Trainers Association (NATA)

� Concussion in Sport Group (CISG)- 4th

International Consensus Conference of Concussion in Sport (Zurich, 2012)

Definition (Zurich 2012)

� “complex pathophysiologic process affecting the brain,

induced by traumatic biomechanical forces that may be

caused by a direct blow to the head, face, neck or

other part of body with an impulsive force transmitted to the head.” McCrory et al

� Rapid onset of short lived impairment of neuro fxn

resolving spontaneously

� May have neuropath changes, but acute clinical

symptoms reflect functional disturbance, not

structural

� Graded set of neurological syndromes, with or w/o

LOC

� Grossly normal neuroimaging studies

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Mechanism of Injury

• Rapid linear acceleration and deceleration

• Rotational or angular acceleration

• Midbrain/diencephal

• RAS

Pathophysiology

-Complex metabolic

cascade:

• impaired neurotransmitter function

• abnormal concentration

of ions

• depolarization

• decreased blood flow

-Brain has increased

vulnerability in post concussion state

ENERGY CRISIS-Increased need for energy coupled with decreased blood

flow- BRAIN HAS TO WORK HARDER TO MEET SAME

DEMANDS!

Acute Assessment

• On Field

• ABC’s

• Cervical spine injury- if concerned immobilize

• Assess for more serious brain injury-ED for brain imaging

• Suspicion- REMOVE FROM PLAY

• Sideline

• HISTORY/ PHYSICAL/COGNITIVE/BALANCE TESTING

• SCAT 3

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Signs and Symptoms

Signs and Symptoms

• HEADACHE- 70%

• DIZZINESS-

• LOC- 10%

• Amnesia- rga, pta

• Symptoms typically present immediately but can be delayed

• 80-90% of athletes will have symptom resolution by 7-10 days

• “miserable minority” last longer

Detailed Assessment- SCAT 3

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Sideline Assessment

� If no evidence for concussion

� RTP

� Serial evaluations

� If diagnosed with a concussion

� Should not return to play same day of concussion

� SCAT 3 or other sideline assessment

� Player should not be left alone following injury, requires serial monitoring for several hours

� Arrange for appointment with HCP

NEUROIMAGING

� Adds little benefit to concussion workup

� Use when suspicion of intracerebral or structural process exists:

� Focal abnormality

� Worsening symptoms

� Prolonged disturbance of conscious state

� Other imaging not recommended yet i.e. fMRI, PET

Patient Instructions

� No frequent awakenings, SLEEP is beneficial to athlete

� If level of consciousness is a concern, send to ER for imaging

� Avoid aspirin or NSAIDS

� Physical and mental rest

� No driving

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OFFICE EVALUATION

• History

Event Mechanism

Symptoms

History of concussion or risk factors

Speak to trainer or parents

• Concerning symptoms for Imaging

Worsening symptoms

Pronounced amnesia

Office Evaluation

� Physical Exam

� Neuro exam-look for focal deficits

� SCAT 3

� Balance testing- BESS

Office Evaluation- TOOLS

� SCAT 3

� Objective

� Serial monitoring

� Computerized Neuropsychological Testing

� Provides objective assessment of cognitive function

� Usually follows symptom resolution

� Performed when clinically asymptomatic

� Determine academic restrictions

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� 28 minutes

� Baseline before season

� Can be abnormal even with symptom resolution

� McGrath et al- Post exertion NP test failure

� 27%-normal IMPACT, abnormal Post exertion IMPACT

Neuroimaging

� Typically normal in concussion

� Head CT

� Skull fracture, hemorrhage

� MRI brain

� May obtain if prolonged symptoms

� Others

� fMRI, SPECT, DTI, PET- mainly research tools

Concussion

Management

� Physical Rest-not strict

� Cognitive Rest

� No TV, extensive reading, video games, etc.

� May need school accomodations

� Sleep- no naps

� Regular diet and hydration

� Gradual RTP

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Concussion

Management

� Medications

� Headaches- NSAIDS, acetominophen

� Insomnia- melatonin, trazodone, zolpidem, tricyclics

� Neurobehavioral- Amantidine, methylphenidate

� Depression- SSRI’s

� Vestibular Therapy

Management

� Gradual resolution within 7-10 days

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

� Step wise RTP strategy

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Graduated RTP Protocol24 hours per step

If symptoms return to previous asymptomatic level

Return To Play

� No symptoms

� Normal Physical exam

� Normal NP testing

� Off all medications

Modifying Factors effecting RTP

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Post Concussion Syndrome

� 15% with history of concussion

� >3 months

� Symptoms

� Headache- tension, migraine

� Irritability

� Dizziness

� Insomnia

� Depression/anxiety

� Cognitive/ memory� Psychological factors

When to Hang it Up?

� No clear criteria

� 3 concussions in a season- sit out season

� Retirement consideration

� Lower threshold for concussion

� Longer duration of symptoms and more severe

� Neurocognitive impairment

SECOND IMPACT SYNDROME

Does it exist?

� “an athlete who has sustained an initial head injury, most of a concussion, sustains a second head injury before symptoms from the first concussion have cleared. “

� This second injury is believed to result in catastrophic cerebral swelling which can be fatal

� Hypothesis- disordered cerebral autoregulation causing congestion and malignant cerebral edema with increased ICP and herniation

� LACK OF EVIDENCE THAT IT EXISTS

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Second Impact

Syndrome

� Single blow enough to cause cerebral swelling

� McCrory, 2001- 17 cases in world literature, only 5 with repeated injury

� 14 autopsy- 11 with structural brain injury (SDH)

� Only described in North America, not Europe or Australia (rugby)

� Boxers at risk- why not more in boxers with repetitive head injury?

� BOTTOM LINE: increased risk for more severe injury if brain not healed

PreventionDaneshvar et al 2011

� Mouthguards have benefit in prevention oral injury, but no evidence of concussion reduction

� Head gear and helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence

� Helmets reduce head and facial injury in skiing and snowboarding and other sports

Chronic Traumatic Encephalopathy

� First described 1928- dementia pugulistica, CTE

1996

� Progressive neurodegenerative disorder caused by multiple concussions or subconcussive blows

to the head

� Other causes?

� Steroid abuse, drug and alcohol abuse,

Genetic predispositions, Depression/Stress

� Over 30 NFL players diagnosed with CTE, hockey, wrestling…

� Signs and Symptoms

� Dementia/ memory loss, Aggression,

Depression/ suicide, behavioral change

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Chronic Traumatic

Encephalopathy

� First described 1928- dementia pugulistica, CTE 1996

� Progressive neurodegenerative disorder caused by multiple

concussions or subconcussive blows to the head

� Other causes?

� Steroid abuse, drug and alcohol abuse, Genetic predispositions, Depression/Stress

� Over 30 NFL players diagnosed with CTE, hockey, wrestling…

� Signs and Symptoms

� Dementia/ memory loss, Aggression, Depression/ suicide,

behavioral change

CTE� Pathology- tau

deposition in cerebral sulci distinct from AD, FTD

� APOE may be RF?

� Post mortem diagnosis

A bill to be entitled 2 An act relating to youth and student athletes; 3 amending s. 943.0438, F.S.; requiring independent 4 sanctioning authorities to adopt policies to inform 5 certain officials, coaches, and youth athletes and 6 their parents of the nature and risk of certain head 7 injuries; requiring that a signed consent form be 8 obtained before the youth participates in athletic 9 practices or competitions; requiring that a

youth 10 athlete be immediately removed from an athletic 11 activity following a suspected head injury; requiring 12 written clearance from a medical professional before 13 the youth resumes athletic activities; authorizing a 14 physician to delegate the performance of medical care 15 to a licensed or certified health care practitioner 16 and consult with or use testing and the evaluation of 17 cognitive functions performed by a licensed 18 neuropsychologist; amending s. 1006.20, F.S.; 19 requiring the

Florida High School Athletic Association 20 to adopt policies to inform certain officials, 21 coaches, and student athletes and their parents of the 22 nature and risk of certain head injuries; requiring 23 that a signed consent form be obtained before a 24 student athlete participates in athletic practices or 25 competitions; requiring that a student athlete be 26 immediately removed from an athletic activity 27 following a suspected head injury; requiring written 28 clearance from a medical professional before the 29

student resumes athletic activities; authorizing a 30 physician to delegate the performance of medical care 31 to a licensed or certified health care practitioner 32 and consult with or use testing and the evaluation of 33 cognitive functions performed by a licensed 34 neuropsychologist; providing an effective date. 35

Florida Concussion Bill

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Conclusion

� Heterogenous/complex disorder

� Institution of safety guidelines and laws to protect the athletes

� Algorithms in place to assist LHCP and get athletes back on the field safely and timely

� Tremendous research/ Neuroimaging

� Bottom line is to make it safer for athletes and prevent long term sequelae

THANK YOU!!THANK YOU!!

Baptist Children’s HospitalBaptist Hospital Doctors Hospital

Miami Cardiac &Vascular Institute

Homestead Hospital Mariners Hospital

West KendallBaptist Hospital

Baptist Outpatient Services

South Miami Hospital

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