Player Safety: Concussion

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Player Safety Concussion Baseline Impact
Testing

• David Bernhardt, M.D.
• University of Wisconsin Sports Medicine

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Concussion
Mild traumatic brain injury
Vienna Consensus Statement 2001

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Symptoms

• Dazed appearance
• Confusion
• Memory Loss
• Headache
• Dizziness
• Balance problems

• Irritable
• Personality change
• Slowed response
• Poor focus/attention
• /- LOC

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Memory
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What if the athlete suffers brief LOC?

• Should this athlete be DQd for the remainder of
  the game?
• Does LOC predict long term prognosis?

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What if the athlete suffers brief LOC?

• 383 MTBI patients (GCS 14-15)
• Confusion, agitation, retrograde amnesia, LOC
• Poorer performance for all groups on
  neuropsychological tests sensitive to MTBI
• No differences between groups based on LOC,
  uncertain LOC and no LOC
• Lovell MR, et al. Clin J Sports Med 1999

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Simple Concussion

• Resolves without complication in 7-10 days
• Rest until all symptoms have resolved
• Graded return to play

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Complex Concussion

• Persistent symptoms
• Specific sequelae (seizures)
• Prolonged LOC (gt 1 minute)
• Prolonged cognitive impairment
• Repeated concussions with less force
• Consider neuropsychological testing
• Multidisciplinary approach

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Sideline evaluation

• Orientation Concentration
• Month ___________________ 0 1 Digits
  backward (If correct, go to
• Date _____________________ 0 1 next string
  length. If incorrect, read
• Day of week ______________ 0 1 trial 2.
  Stop if both incorrect.
• Year ____________________ 0 1 4-9-3 6-2-9
  ______0 1
• Time (within 1 hour) _______ 0 1 3-8-1-4
  3-2-7-9 _____0 1
• 6-2-9-7-1 1-5-2-8-6 ______0 1
• Orientation Total Score _________ / 5
  7-1-8-4-6-2 5-9-1-4-8 _____0 1
• Months in reverse order (entire
  sequence correct for 1 pt)
  
• Dec?Jan 0 1
• Concentration Total Score ____ / 5

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Sideline evaluation

• Immediate Memory (all 3 trials are complete
  regardless of score on trial 1 2 total score
  equals sum across all 3 trials)
• List Trial 1 Trial 2 Trial 3
• Word 1 0 1 0 1 0 1 Exertional maneuvers
• Word 2 0 1 0 1 0 1 Coordination
• Word 3 0 1 0 1 0 1 Strength
• Word 4 0 1 0 1 0 1 Sensation
• Word 5 0 1 0 1 0 1 Recall of injury
• Total
• Immediate Memory Total Score _____ / 15
• Delayed recall
• Word 1 0 1
• Word 2 0 1
• Word 3 0 1
• Word 4 0 1
• Word 5 0 1
• Delayed Recall Total Score _____/5 McCrea M et
  al.
• Summary of Total Scores _____ / 30 Neurology
  1997

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Serial 7s

• 522 high school athletes, PPPE
• Serial 7, serial 3, months in reverse
• Seven consecutive or 11 with one mistake
• 51 serial 7s, 79 serial 3s
• 89 months in reverse
• Young CC, Jacobs BA et al.
• Clinical Journal of Sports Medicine 1997

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DO NOT ALLOW RETURN TO PLAY UNTIL COMPLETELY
ASYMPTOMATIC
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If You Do Not Know Athletes Baseline
Neuropsychological Status, It Is Difficult To
Judge Normal
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• High school athletes often require a
  significantly longer period of time to become
  asymptomatic and for their cognitive function to
  return to normal than both collegiate and
  professional athletes

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Catastrophic complications

• Epidural
• Subdural
• Second impact syndrome

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Second impact syndrome

• Not fully recovered from previous head injury
  when sustain a second head injury
• Loss of vascular autoregulation
• Cerebral vascular congestion
• Malignant brain edema, brainstem herniation, death

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POST CONCUSSIVE SYNDROME

• Recurrent headaches Dizziness
• Memory impairment Depression
• Loss of libido Tinnitus
• Ataxia Anxiety
• Alcohol intolerance Photophobia
• Hyperacousis Concentration

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Post concussive syndrome

• Not necessarily related to severity of concussion
• Attention and learning difficulty may be subtle
• Cumulative effects of multiple concussions

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Neuropsychological testing

• Nature and degree of deficit acutely
• Relationship to standard sideline evaluation
• Recovery curves

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Computerized Neurocognitive Testing

• IMPACT
• Headminders
• Cogsport
• http//www.wiyouthsoccer.com/impact.html