Concussions on Campus

1
Concussions on Campus

• Christina Smith Paul MD, CAQSM
• Primary Care Sports Medicine
• Student Health Service
• University of Pennsylvania

2
Overview

• Definitions
• Diagnosis Clinical Course
• Cognitive tests
• Treatment
• Prevention (EDUCATION, gear)
• Clearance Academics, Sports
• Referrals?
• Ongoing research

3
(No Transcript)
4
Concussions in the News ESPN, NYTimes

• SEC concerned about concussions
• New concussion law suit filed by 100 ex-players
• Concussions affecting women more often than men
• More retired players sue NFL over concussion
  effects
• Trying to Reduce Head Injuries, Youth Football
  Limits Practices

5
NFL, players reach concussion dealAugust 2013

• Landmark decision
• 4500 plaintiffs (former players)
• 765 million dollars
• 75 million - health exams
• 675 million compensation
• 10 million - research

6
DP

• 19 yo M, plays ultimate Frisbee, collided w
  another player 2 d ago.
• No LOC
• Tried to get back in the game but didnt feel
  right
• HA, photophobia, difficulty concentrating
  ever since.
• Has a test tomorrow
• Wants to play in tournament this weekend
• Wants to know what he can take/do to get better

7
Concussion

• Concussion Traumatic Brain Injury
• Loss of consciousness Rare (and not predictive)
• Causes blow to head or body
• Symptoms vary
• Grading systems obsolete

8
Giza CC, Hovda DA. Ionic and metabolic
consequences of concussion. In Cantu RC, Cantu
RI. Neurologic Athletic and Spine Injuries. St
Louis, MO WB Saunders Co 200080100
9
Giza CC, Hovda DA. Ionic and metabolic
consequences of concussion. In Cantu RC, Cantu
RI. Neurologic Athletic and Spine Injuries. St
Louis, MO WB Saunders Co 200080100
10
Evidence-Based Medicine?
11
Consensus Statement on Concussion in Sport
International Conference(s)

• 1st (Prague) 2001
• 2nd (Vienna) 2004
• Produced SCAT
• 3rd (Zurich) November 2008
• Produced SCAT 2
• Designed to follow US NIH consensus criteria
• And..

12
British Journal of Sports Medicine April 2013
47 250-258
Panel included Stanley Herring and Margot
Putukian from AMSSM
13
The Fourth Conference Zurich 2012

• Used the same format as previously
• 32 international experts
• 2 full days of new research presentations
• Extensive structured discussion
• Drafted a consensus paper, edited until all were
  in agreement
• Updated version of SCAT (SCAT 3)-with 3 distinct
  tools
• Final drafting of 12 critical review papers,
  co-published in multiple journals

14
AMSSM Position Statement Concussion in
sport--Purpose--

• To provide an evidence-based, best practices
  summary to assist physicians with the evaluation
  and management of sports concussion
• To establish the level of evidence, knowledge
  gaps and areas requiring additional research

15
What we know

• Numbers are increasing. 3.8 million in US/yr
• More so in females
• Theories on why Anatomy
• heads are smaller
• necks are smaller/less muscle mass
• Theories on why Culture
• Girls more likely to self-report?
• Girls get more attention?

16
(No Transcript)
17
(No Transcript)
18
What we know

• Equipment does not PREVENT concussion

Absence of Proof is not Proof of Absence
www.sportsdentristy.com
19
What we know

• Each subsequent concussion - requires less force
• Post Concussion Vulnerability
• A second blow sustained before recovery results
  in worsening metabolic changes within the neuron
• This concept is distinct from second impact
  syndrome
• The concussed brain is less responsive to usual
  neuron activation
• Prolonged dysfunction may result from premature
  cognitive activity or vigorous physical activity
• Is a functional, not structural issue

20
What we dont know (but are working on)

• How to predict duration of recovery
• Why some people are more susceptible
• Genetic component (APOE e4 genotype)
• How many is too many
• How to speed recovery
• Supplements
• Medications
• Physical therapy

21
DP

• 19 yo M, plays ultimate Frisbee, collided w
  another player 2 d ago.
• No LOC
• Tried to get back in the game but didnt feel
  right
• HA, photophobia, difficulty concentrating
  ever since.
• Has a test tomorrow
• Wants to play in tournament this weekend
• Wants to know what he can take/do to get better

22
Concussion Symptoms

• Headache
• Nausea
• Dizziness
• Blurry vision
• Sensitivity to light or noise
• Feeling sluggish, foggy, out of it
• Confusion
• Difficulty with concentration, memory

23
(No Transcript)
24
Emotional

• Irritability, sadness, more emotional,
  nervousness
• If positive, screen further (PHQ-9)
• Compounding factors
• Loss of time from sport
• Falling behind in school
• Lack of physical activity/release as coping skill

25
Concussion Diagnosis

• You cant SEE it
• Sings/symptoms usually follow the injury but
  there can be a delay
• Awareness/education of coaches, parents, athletes
  is VITAL

26
Concussion Evaluation

• HEENT
• Pupils
• Ocular movement
• Nystagmus
• hemotympanum
• Neck
• C-spine tenderness
• Neuro
• Cranial Nerves
• Short term memory
• Concentration
• Balance (BESS testing if baselined)

27
Balance Error Scoring System (BESS)
28
Concussion Treatment

• Initial Treatment
• Need for immediate/ED evaluation?
• Imaging (ie Head CT?)
• Education (student family professors, etc.)
• HIPPA
• COGNITIVE AND PHYSICAL REST

29
Treatment, continued

• Ongoing
• Wake up at night?
• Attendance in class?
• homework, watch TV, email?
• Return to athletics?
• ibuprofen?
• Role of other meds or physical therapy?
• Melatonin
• Amantadine
• Amitriptyline
• Vestibular therapy

30
Concussion Investigations

• Neuroimaging
• CT scan
• MRI (structural and functional studies emerging)
• Neuropsychological assessment

31
Neurocognitive Testing

• Computer-based
• ImPACT, CogSport, HeadMinder
• Added tool for use in return-to-play decisions
• Avoidance of returning an athlete too soon
• Baseline testing
• Timing of testing
• Pros/cons of testing
• Formal paper and pencil testing
• Several hours
• Comprehensive
• Reserved for chronic/difficult cases

32
Management in College

• Student/Family education
• Health Center
• Deans Office
• Disability Services
• Professors
• Athletics
• Coaches
• ATCs

33
Accommodations

• Rest from class
• Frequent breaks
• Extra time for assignments
• Postpone tests/exams
• Note taking service
• Quiet environment

34
DP

• Returns 48 hours later after complete cognitive
  and physical rest
• Symptom score goes from 35 to 10
• Can he go to school?
• Can he go for a run?
• When would you expect all symptoms to clear?

35
Return To School Guidelines (CHOP)

• Step 1
• Complete cognitive rest No TV, computer, text,
  etc.
• Step 2
• Light cognitive activity, 5-15 min increments,
  frequent breaks, stop if symptomatic
• Step 3
• Schoolwork at home, 30 min increments
• Step 4
• if tolerating 1-2 hrs at home, can go half day
• advance to next step if symptom-free x 24 hrs

36
Graded Return to Play
Rehab Stage Functional Exercises Objective at each stage
1. No activity Physical and Cognitive Rest Recovery
2. Light aerobic exercises Walking, swimming, stationary bike intensity lt70 maximum HR Increase HR
3. Sport-specific exercises Skating drills, running drills etc. No head impact. Add movement
4. Non-contact training drills Progression to more complex training (passing, etc.) May start resistance training Exercise, coordination, and cognitive load
5. Full contact practice Following medical clearance participate in normal training/practice Restore confidence and assess functional skills
6. Return to play Normal game play
37
Recurrent Concussions

• Second impact syndrome
• Brain swells rapidly, death near certain
• repeat injury w/o proper healing time
• Young people more vulnerable
• Few cases
• Post concussive syndrome
• Chronic Traumatic Encephalopathy

38
Sports Legacy Institute

• Chris Nowinski

39
Concussions and mental healthIn the news

• Chronic Traumatic Encephalopathy (Tau Protein)

40
Prevention?

• EDUCATION (Coaches, parents, administrators)
• Gear limitations (Head gear, Mouth guards)
• Gear Changes (Softer balls - Soccer)
• Exercises
• Strengthen neck
• Learn proper techniques
• Tackle techniques
• Heading techniques

41
Prevention

• Rule Changes
• NFL and NCAA Football
• Kickoffs moved up to 35 yd line (from 30 yd line)
• NCAA Football
• Post-game video review targeted hits
• Impose suspension if intentional or reckless
• Pop Warner Football
• No hitting in 2/3 of practice
• Additional precautions (3 yards or less, etc)
• USA Hockey
• Raise checking age (11 to 13)
• Education (coaches, trainers, athletes, parents)

42
What we are doing at Penn

• Concussion policy (NCAA requires)
• Baseline ImPACT testing
• All Varsity contact sports
• All varsity and club athletes must be evaluated
  and cleared by SHS physician
• Referral resources
• Neurology Neuropsychiatry
• Weingarten Learning Resource Center
• CAPS (Counseling)
• Physical Therapy (Vestibular Rehabilitation)

43
SHS visits for concussions2012-2013
44
2012-13 SHS Data
45
(No Transcript)
46
2012-13 SHS Data
47
2012-13 SHS Data
48
2012-13 SHS Data
49
DP

• Symptom score 0
• ImPact back to baseline
• Tolerating full academics
• 5 day graded return to sport completed
• Cleared for ultimate frisbee tournament play

50
Summary

• Suspect concussion?
• NO return to play same day, regardless of
  resolution of symptoms
• Education most important tool in preventing bad
  outcomes
• Return to academics before athletics
• Stepwise approach for both

51
References

• www.cdc.gov/concussion/sports
• McCrory P, Meeuwisse W, Johnston K, et
  al.Consensus Statement on Concussion in Sport
  the 3rd International Conference on Concussion in
  Sport, Zurich 2008. Br J Sports Med
  200943i76-i84.
• New York Times, June 13 2012
• Internet resources (ESPN, Youtube, Vimeo,
  google,etc.)
• Giza CC, Hovda DA. Ionic and metabolic
  consequences of concussion. In Cantu RC, Cantu
  RI. Neurologic Athletic and Spine Injuries. St
  Louis, MO WB Saunders Co 200080100

52
Questions?