Concussions in Sport Mitigating Risks in the Student Athlete

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Concussions in SportMitigating Risks in the
Student Athlete

• Marc Richard Silberman, M.D.

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Tip of the iceberg
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Consensus Statement on Concussions in Sport

• 2001
• 1st International Conference on Concussion in
  Sport, Vienna
• 2004
• 2nd International Conference on Concussion in
  Sport, Prague
• 2008
• 3rd International Conference on Concussion in
  Sport, Zurich
• Sport Concussion Assessment Tool (SCAT2)

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High School Concussions

• Over 50 of concussed high school football
  athletes do NOT report their injury to medical
  personnel
• McCrea, M., Hammeke, T., Olsen, G., Leo,
  P., and Guskiewicz, K.M. (2004). Unreported
  concussion in high school football players
  implications for prevention. Clin. J. Sport Med.
  14, 1317.

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High School Concussions

• Concussion 5.5 of total injuries
• Football 63.4 of concussionsWrestling
  10.5Girls Soccer 6.2Boys Soccer
  5.7Girls Basketball 5.2Boys Basketball
  4.2Softball 2.1Baseball 1.2Field
  Hockey 1.1Volleyball 0.5

JAMA. 1999 Sep 8282(10)989-91
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H.S. Basketball Concussions

• Concussion Cause
• Collision with another player 65
• Contact with the floor 13
• Personal opinion this is not the truth
• Concussion Activity
• Rebounding 30
• Defending 20
• Illegal Activity
• Total number of injuries 13
• Concussions 35

Am J Sports Med December 2008 vol. 36 no. 12
2328-2335
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Collegiate Concussions

• Soccer, lacrosse, basketball, softball, baseball,
  and gymnastics
• 14,591 injuries in male and female athletes
• 5.9 of all injuries were classified as
  concussions
• Males Game Injury Rate / 1000 exposures
• Soccer 1.40
• Lacrosse 1.46
• Basketball 0.47
• Females
• Soccer 2.10
• Lacrosse 1.05
• Basketball 0.73

J Athl Train. 2003 JulSep 38(3) 238244
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Perceptions

• Survey 300 players, 100 coaches, 100 parents, 100
  ATCs
• If a player complains of a headache , should
  return to play?
• Players 55, Coaches 33, ATC 30, Parents 24
• Percentage who would play a concussed star in a
  title game?
• Players 54, ATC 9, Parents 6.1, Coaches 2.1
• Level of concern for concussions (1 most
  concerned 4 least)
• Players 3.5, Coaches 2.4, Parents 2.1, ATC 1.6
• Is a good chance of playing in the NFL worth a
  decent chance of permanent brain damage?
• Players 44.7, Coaches 19.4, Parents 15, ATC
  10

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Your Brain
This is your brain. This is your brain on
drugs.
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Your Brain
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The Brain

• Freely floating within the cerebrospinal fluid
• Moves at a different rate than the skull in
  collisions
• Collision between the brain and skull may occur
• On the side of the impact (coup)
• On the opposite side of the impact (contracoup
  injury)
• Acceleration-deceleration may result in
  stretching of the long axons and in diffuse
  axonal injury

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What is a concussion?

• Complex pathophysiological process affecting the
  brain induced by traumatic biomechanical forces
• Functional disturbance of the brain
• No visible structural injury
• Typically short lived impairment that resolves
  spontaneously
• Direct blow to the head
• Indirect blow with a force transmitted to the head

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Classification of concussions

• A concussion is a concussion
• There is no such thing as a mild concussion
• No grading system
• Most symptoms resolve in a short period of 7-10
  days
• Post concussive symptoms may be prolonged in
  children

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Concussion diagnosis

• There is NO test to diagnose a concussion
• Clinical diagnosis based on the following
• Symptoms
• Physical Signs (impaired balance)
• Behavioral Changes (cry, irritable)
• Cognitive Impairment (slow reaction time, memory)
• Sleep Disturbances (drowsiness)

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Symptoms

• Headache (83)
• Dizzy (65), dazed, fog
• Light and sound sensitivity
• Visual disturbances
• Everything seems slow
• My colors changed
• Teammate, Erics not right, coach
• Appearance can be delayed several hours

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Purdue Study

• Goal to study brains of concussed versus normal
  football players
• New group of injured players
• 298G force blow to the head produced no symptoms
• Concussion free brain scans in season versus
  pre-season were different
• 150 head impacts per week of about 40g
• Routine blocks and tackles around line of
  scrimmage
• Systemic changes in brain functioning

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Physical Signs

• You do not have to lose consciousness
• Amnesia (Doc, I dont remember the first half)
• Emotional labile (crying, talkative)
• Poor balance
• Difficulty concentrating
• Difficulty remembering

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On-Field Evaluation

• Standard emergency management
• Exclude cervical spine injury
• Return to play determined by a physician
• When in doubt, sit them out
• No player shall return to play the same day
• Sideline assessment of concussion (SCAT2)
• Monitor for any deterioration over time

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Syracuse Post-Standard Jan 16, 2005
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Concussion Management

• Complete physical and cognitive rest until
  symptom free
• No sports
• No horseplay
• No school, if necessary
• No texting, video games, internet, TV, driving
• Graded program of exertion prior to full return
  to play

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Exertion effects

• Symptoms are worsened by
• physical activity
• mental effort
• environmental stimulation
• emotional stress

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Academic Accommodations

• Excuse from school if necessary
• Excuse from homework
• Excuse from quizzes and tests
• Rest breaks during school in a quiet location
• Avoid re-injury in crowded hallways or stairwells
• Avoid over-stimulation (cafeteria or watching
  games)

Provide reassurance and support
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Recovery from Concussion

• Most recover in 1 2 weeks, 95 recover in 3
  months
• Longer in younger athletes and in female
  compared to male
• Post-concussion syndrome is the presence of
  symptoms for at least 3 months post injury
• Deficits in balance resolve in 5 days
• Cognitive tests return to baseline in 5 10
  days
• Abnormalities in metabolic balance, oxygen
  consumption, and electrical responses persist for
  several months

a miserable minority experience persistent
symptoms
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Post-concussion syndrome

• Risk factors for complicated recovery
• Re-injury before complete recovery
• Over-exertion early after injury
• Significant stress
• Unable to participate in sports
• Medical uncertainty
• Academic difficulties
• Prior or comorbid condition
• Migraine
• Anxiety
• ADHD, LD

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Multiple Concussions

• Second Impact Syndrome
• A concussion prior to recovery from a prior
  concussion
• Athlete is still symptomatic
• Mostly males lt 21 years old
• Rapid increase in intracranial pressure
• Rare but almost always fatal
• Cumulative effects
• Risk of concussion is 4-6 times greater after one
  concussion
• Risk is 8 times greater after sustaining two
  concussions
• Prolonged or incomplete recovery
• Increased risk of later depression or dementia

• How many is too many ?

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Chronic Traumatic Encephalopathy

• Progressive degenerative disease
• from multiple concussions
• Build up of Tau protein in brain
• 35 brains of deceased athletes
• Center for the Study of Traumatic Encephalopathy
  
• (13 belonged to former NFL players).
• 12 out of 13 brains manifested
• Chronic Traumatic Encephalopathy (CTE)
• 3 out of 12 exhibited motor neuron disease
• (Chronic Traumatic Encephalomyelopathy)

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Return to activity

• 1. No symptoms at rest
• 2. Balance testing
• returns to baseline
• 3. Neuropsychological test
• returns to baseline
• 4. Consideration of modifiers
• 5. Graded return to play protocol

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Neuropsychological Tests

• Neuropsychological testing is an additional tool
• May assist in return to play decisions
• Need a baseline
• Perform the follow-up test when symptom free
• Cognitive recover
• most overlap symptom recovery
• may precede symptom recovery
• may follow symptom recovery
• Motivation and practice effects affect results
• Do not reflect metabolic recovery of the brain

You can be fooled!
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Concussion modifiers

• Symptoms Number, Duration (gt10 days), Severity
• Signs Prolong loss of consciousness (gt 1 min),
  amnesia
• Sequelae Concussive convulsions
• Temporal Frequency repeated concussions over
  time
• Timing injuries close together in time
• Recency recent concussion
• Threshold Repeat concussions occurring with
  progressively less impact
• Repeat concussions with slower recovery after
  each one
• Age Child and adolescent
• Comorbidity Migraine, depression, ADHD, LD, sleep
  disorder
• Medication Psychoactive drugs
• Behavior Dangerous style of play
• Sport High risk activity, contact collision
  sport, high sporting level

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Graduated return to play protocol

• Day 1 Light aerobic exercise
• Light jog/stroll, stationary bicycle
• Goal elevate HR
• Day 2 Sport-specific exercise
• Running drills in basketball
• Goal add movement
• Day 3 Non-contact training drills
• Passing and shooting, light resistance
  training
• Goal coordination, cognitive load, valsava
• Day 4 Full contact practice only after physician
  clearance
• Day 5 Return to competition

Any symptoms at any stage, return to complete rest
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Prevention

• An once of prevention is worth a pound of
  cure
• - Benjamin Franklin

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Mechanism of Injury

• All sports head to head collision 50
• Soccer study of 20 FIFA tournaments from 98
  04
• Aerial challenges 55
• Use of the upper extremity 33
• Use of the head 30
• Only one injury (neck strain) as a result of ball
  heading
• Lacrosse study of 560 games, 50 schools, 5000
  athletes
• Men (32/34) almost all were a result of body
  checks
• Female (8/14) were a result of stick to head
  contact

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Mechanism of Injury Hockey

• Body checking 86 of all injuries in 9 15 year
  old
• Contact leagues 4x injury rate, 12x fracture rate
• 45 legal body checks, 8 illegal body checks
• Direct fatality and injury rates for football are
  half of hockey
• Spinal cord injury and brain injury rate
• 2.6 per 100,000 high school hockey players
• .7 per 100,000 high school football players

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Head Down Contact and Spearing

• Improved helmet technology has led to the
  increased use of the head at contact, intentional
  and unintentional
• Each time a player initiates contact with his
  head down he risks quadriplegia
• Each time a player initiates contact head
  firsthe risks concussion

Heck et al. Journal of Athletic Training
200439(1)101111
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Spearing

• The use of the helmet (including the face mask)
  to punish an opponent
• No player shall use his helmet (including the
  face mask) to butt or ram an opponent or to
  punish him
• No player shall strike a runner with the crown or
  the top of his helmet in an attempt to punish him
• Always make contact with your shoulder while
  keeping your head up

Head down contact and Spearing Slide Show
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Head Down Contact and Spearing

• Educate players, coaches, and officials
• Teach fundamentals and correct contact technique
• Survey of 600 Louisiana High School players
• 29 using top of helmet to tackle was legal
• 32 head butting was legal
• 35 permissible to barrel over an opponent
  headfirst
• Only 2 coaches showed a blocking and tackling
  safety video distributed free by the state
  federation

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Helmets and Mouth Guards

• Helmets prevent skull fractures
• Helmets do not prevent concussions, they cause
  concussions
• Mouth guards prevent dental injuries
• Mouth guards do not prevent concussions

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Mitigate Risk

• Fundamentals
• Respect

Hall of Fame Coach Bob Hurley Sr.
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Concussions in Sport

• Thank you.
• Marc Richard Silberman, M.D.
• Gillette, NJ
• drbicycle_at_njsportsmed.com
• [phone]

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This is your brain
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Has the game changed?

• Texas High School Super Team
• 1970 Offensive line 227 lbs
• 1990 Offensive line 252 lbs
• 2000 Offensive line 307 lbs
• Big and Fat
• Obesity levels at more than 40

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Custom Mouth Guards

• Prevent dental injuries
• Do NOT prevent concussions
• Prospectively recorded dental injuries and
  concussions among 50 men's Division I college
  basketball teams during one competitive season
• Custom-fitted mouth guards do NOT significantly
  affect rates of concussions or oral soft tissue
  injuries, but can significantly reduce the
  morbidity and expense resulting from dental
  injuries in men's Division I college basketball
• Labella, C. R., B. W. Smith, and A. Sigurdsson.
  Effect of mouthguards on dental injuries and
  concussions in college basketball. Med. Sci.
  Sports Exerc., Vol. 34, No. 1, 2002, pp. 41-44