Concussion in soccerConcussion in soccer

Thomas Martinelli, MDThomas Martinelli, MDCommonwealth Orthopaedics and RehabilitationCommonwealth Orthopaedics and Rehabilitation

Presented toPresented to

Virginia Youth Soccer AssociationVirginia Youth Soccer Association

January 22, 2011January 22, 2011

Historical Example of what not to doHistorical Example of what not to do

19731973 13 year old CYO football punter in first half – 13 year old CYO football punter in first half –

bad snap – runs for itbad snap – runs for it Knocked unconscious on field – ambulance Knocked unconscious on field – ambulance

called – woke up before they arrivedcalled – woke up before they arrived

Went back in second half, played entire half, Went back in second half, played entire half, tackles QB for safety, team winstackles QB for safety, team wins

Definition of ConcussionDefinition of Concussion

““A trauma induced alteration in mental status A trauma induced alteration in mental status that may or may not involve loss of that may or may not involve loss of consciousness. Confusion and amnesia are consciousness. Confusion and amnesia are the hallmarks of concussion.”the hallmarks of concussion.”

(American Academy of Neurology Summary Statement – The (American Academy of Neurology Summary Statement – The Management of Concussion in Sports)Management of Concussion in Sports)

Simply put – It is a Brain injury !Simply put – It is a Brain injury !

SynonymsSynonyms

DingedDinged Bell rungBell rung Knocked outKnocked out Fell outFell out Saw starsSaw stars MTBI (Mild Traumatic Brain Injury)MTBI (Mild Traumatic Brain Injury)

How frequent are they ?How frequent are they ?

1.4 to 3.6 million sports and recreation 1.4 to 3.6 million sports and recreation related concussions per yearrelated concussions per year– The majority occur at high school level !The majority occur at high school level !

(2006 CDC estimate)(2006 CDC estimate)

Who gets them?Who gets them?

SportSport AgeAge Male vs FemaleMale vs Female Position on fieldPosition on field How they happenHow they happen Prior concussionsPrior concussions

SportSport

Intentional brain injury sports – boxing, Intentional brain injury sports – boxing, mixed martial arts, extreme fightingmixed martial arts, extreme fighting

– 100 % even with protective headgear100 % even with protective headgear– Persistent brain/neuro damagePersistent brain/neuro damage– Some with serious long term effects Some with serious long term effects

(Muhammad Ali)(Muhammad Ali)

(AAN)(AAN)

SportSport

Non-Intentional brain injury sports:Non-Intentional brain injury sports:

High school levelHigh school level– Ice hockeyIce hockey– FootballFootball– SoccerSoccer– WrestlingWrestling– BasketballBasketball– Field hockeyField hockey

(Wilson (Wilson PediatricsPediatrics 2006) 2006)

Sport – Soccer/AgeSport – Soccer/Age

50,000 high school concussions/year in 50,000 high school concussions/year in 2006 data2006 data

(J Athletic Training)(J Athletic Training)

Various studies 2 % to 62.7%Various studies 2 % to 62.7%

(Delaney, McGill University)(Delaney, McGill University)

Sports - SoccerSports - Soccer

Almost all of the studies done since 2004 Almost all of the studies done since 2004 show minimal difference in incidence of show minimal difference in incidence of concussion in football and soccer players at concussion in football and soccer players at the high school level or at the university the high school level or at the university levellevel

Male vs Female in SoccerMale vs Female in Soccer

40% higher rate in women at high school level40% higher rate in women at high school level(J Athletic Training 2007)(J Athletic Training 2007)

2.6 times more likely for women in University level 2.6 times more likely for women in University level soccersoccer

(McGill university 1999 study)(McGill university 1999 study)

■■ Several reasons postulated for this:Several reasons postulated for this:1. reporting differences1. reporting differences2. game differences2. game differences3. musculature differences3. musculature differences

Position on fieldPosition on field

Of players with at least 1 concussion:Of players with at least 1 concussion:

– Goalie 79% incidenceGoalie 79% incidence– Defense 70.2%Defense 70.2%– Mid/Forward both 57%Mid/Forward both 57%

(Delaney, McGill University)(Delaney, McGill University)

– Other studies not as clear a differenceOther studies not as clear a difference

How Do These Occur?How Do These Occur?

How do these occur ?How do these occur ?

Head to headHead to head(ACC 1996-1998, US Olympic data 1993)(ACC 1996-1998, US Olympic data 1993)

Hand/Arm/elbow to headHand/Arm/elbow to head(J Athletic Training)(J Athletic Training)

Ball to headBall to head Head to groundHead to ground Other body part to headOther body part to head

It is possible to get a concussion It is possible to get a concussion without head impact!without head impact!

Rapid acceleration/deceleration from impact Rapid acceleration/deceleration from impact to shoulders/torso transmitted to the brainto shoulders/torso transmitted to the brain

Does heading the Ball cause Does heading the Ball cause concussions?concussions?

Heading the ball ?Heading the ball ?“Footballers Migraines”“Footballers Migraines”

Yes but only reports and not on ImPact testingYes but only reports and not on ImPact testing(Kaminski Delaware, Putukian Princeton)(Kaminski Delaware, Putukian Princeton)

Yes and measurable long termYes and measurable long term(Tysvaer 1989 AJSM)(Tysvaer 1989 AJSM)

NoNo(Fuller, Dick, Anderson)(Fuller, Dick, Anderson)

Overall felt to be inconclusive but AYSO recommends Overall felt to be inconclusive but AYSO recommends against heading until age 10.against heading until age 10.

Heading the ball – however…Heading the ball – however…

Several studies have demonstrated worse Several studies have demonstrated worse performance on physical (balance) and/or performance on physical (balance) and/or cognitive tests in recent concussion patients cognitive tests in recent concussion patients who repeatedly head the ballwho repeatedly head the ball

(ACSM meeting 2009)(ACSM meeting 2009)

■■ So caution is needed in return to head impact So caution is needed in return to head impact sports with recent concussionsports with recent concussion

Best predictor of concussion ?Best predictor of concussion ?

Prior concussion !!!Prior concussion !!!– 3 to 10 times more likely to get another concussion if 3 to 10 times more likely to get another concussion if

you have had one beforeyou have had one before– 92% occur within 10 days of first one92% occur within 10 days of first one

– Thoughts range from style of play to genetic or anatomic Thoughts range from style of play to genetic or anatomic factorsfactors

– No current recommendations for prevention, other than No current recommendations for prevention, other than teaching proper technique and using proper equipmentteaching proper technique and using proper equipment

Initial ComplaintsInitial Complaints

DizzinessDizziness Double visionDouble vision DrowsinessDrowsiness FoggyFoggy HeadacheHeadache NauseaNausea NervousnessNervousness Ringing in earsRinging in ears VomitingVomiting

Later complaintsLater complaints

Depression/SadnessDepression/Sadness Excessive sleep/fatigueExcessive sleep/fatigue IrritabilityIrritability Sensitivity to lightSensitivity to light Sensitivity to noiseSensitivity to noise VomitingVomiting Poor concentration/memory issuesPoor concentration/memory issues

Worrisome physical findingsWorrisome physical findings

Worsening neurologic examWorsening neurologic exam Worsening headacheWorsening headache SeizureSeizure Stiff neckStiff neck Fluid leaking from noseFluid leaking from nose Bleeding from earsBleeding from ears Unequal pupil sizeUnequal pupil size Weakness/tingling in arms or legsWeakness/tingling in arms or legs

All of these mean an immediate trip to the emergency roomAll of these mean an immediate trip to the emergency room

Physical examPhysical exam

Standard field management if unconsciousStandard field management if unconscious– AirwayAirway– BreathingBreathing– CirculationCirculation– Ambulance if neededAmbulance if needed

Sideline managementSideline management– Overall examOverall exam– Cognitive testing Cognitive testing – Motor testingMotor testing

Serial repeats Serial repeats

Overall examOverall exam

Rule out other pathologyRule out other pathology– Neck, Back, extremitiesNeck, Back, extremities

Rule out bad thingsRule out bad things– Eye tracking, pupil reaction and sizeEye tracking, pupil reaction and size– Fluid leaking from places it should not leak fromFluid leaking from places it should not leak from

Swelling/deformity Swelling/deformity – specifically around the head and facespecifically around the head and face

TestsTests

Sideline examSideline exam– MentalMental– PhysicalPhysical

ImPactImPact MRI,CT ScanMRI,CT Scan Functional MRIFunctional MRI Blood testsBlood tests

Multiple tests existMultiple tests exist

CognitiveCognitive– SAC, U of Pitt for sideline/initial evaluationSAC, U of Pitt for sideline/initial evaluation– ImPact, CogSport, Headminder Concussion ImPact, CogSport, Headminder Concussion

Resolution Index, ANAM-SMB for later evalResolution Index, ANAM-SMB for later eval– Graded Symptom Checklist for bothGraded Symptom Checklist for both

PhysicalPhysical– Smart Balance Master, Chattecx Balance Smart Balance Master, Chattecx Balance

System, Balance Error Scoring SystemSystem, Balance Error Scoring System

Cognitive – U of P sideline testCognitive – U of P sideline test OrientationOrientation

– What stadium is thisWhat stadium is this– What city is thisWhat city is this– Who is the opposing teamWho is the opposing team– Month, day, yearMonth, day, year

Posttraumatic amnesiaPosttraumatic amnesia– Repeat 3 wordsRepeat 3 words

Retrograde amnesiaRetrograde amnesia– What happened last quarterWhat happened last quarter– What do you remember before the hitWhat do you remember before the hit– What was the score of the game before the hitWhat was the score of the game before the hit– Do you remember the hitDo you remember the hit

ConcentrationConcentration– Days of the week backwardsDays of the week backwards– Repeat numbers backward – 2 digit, 3 digit,…Repeat numbers backward – 2 digit, 3 digit,…

Word list repeatWord list repeat– What were the 3 words given earlierWhat were the 3 words given earlier

Sports Concussion Assessment Sports Concussion Assessment Tool (SCAT2)Tool (SCAT2)

4 page cognitive and physical assessment4 page cognitive and physical assessment Lots of sections with scores in eachLots of sections with scores in each

No current normative data so no cutoff scores are No current normative data so no cutoff scores are establishedestablished

Best in comparison to pre-injury scoreBest in comparison to pre-injury score Available for free download at Available for free download at

http://www.sportalliance.com/Images/Sport%20Safety/SCAT2.pdfhttp://www.sportalliance.com/Images/Sport%20Safety/SCAT2.pdf

ImPact testImPact test

Immediate Post-concussion Assessment and Cognitive Immediate Post-concussion Assessment and Cognitive TestingTesting

Developed in 1990’s by Mark Lovell, PhD and Joseph Developed in 1990’s by Mark Lovell, PhD and Joseph Maroun, MD, who run the U of P concussion programMaroun, MD, who run the U of P concussion program

20 minute online test - 5 sections with 6 modules in the 20 minute online test - 5 sections with 6 modules in the actual test sectionactual test section

Given before season begins then after concussionGiven before season begins then after concussion Return to baseline indicates return to contact timeReturn to baseline indicates return to contact time Purely neurocognitivePurely neurocognitive Used in Fairfax County Schools, MLS, US Olympic Soccer, Used in Fairfax County Schools, MLS, US Olympic Soccer,

NFL, NHL, MBL, NBA (8 teams), Rugby, auto racingNFL, NHL, MBL, NBA (8 teams), Rugby, auto racing Validated Validated

Physical testsPhysical tests

Double leg stance with eyes closed, hands on hipsDouble leg stance with eyes closed, hands on hips Single leg stance, sameSingle leg stance, same Heel to toe walking in lineHeel to toe walking in line Finger to nose - rapid alternatingFinger to nose - rapid alternating 40 yard sprint40 yard sprint Balance Error Scoring SystemBalance Error Scoring System

– UNC Chapel HillUNC Chapel Hill– Supposed to take 10 minutesSupposed to take 10 minuteshttp://www.sportsconcussion.com/pdf/management/http://www.sportsconcussion.com/pdf/management/

BESSProtocolNATA09.pdfBESSProtocolNATA09.pdf

MRI, CT ScanMRI, CT Scan

Consensus – no role in the management of Consensus – no role in the management of concussion !concussion !

Concussion is a microscopic brain injury Concussion is a microscopic brain injury with no MRI or CT findingswith no MRI or CT findings

However, can rule out other worse However, can rule out other worse pathologies and is useful if symptoms pathologies and is useful if symptoms deteriorate over timedeteriorate over time

Functional MRI, PET scansFunctional MRI, PET scans

Look at brain activity in the course of Look at brain activity in the course of cognitive activitycognitive activity

Can demonstrate abnormal patternsCan demonstrate abnormal patterns Have correlated with ImPact score Have correlated with ImPact score

improvementimprovement Not widely available and expensiveNot widely available and expensive

Blood Tests/Genetic MarkersBlood Tests/Genetic Markers

Blood testsBlood tests– Myelin Basic ProteinMyelin Basic Protein– TauTau– GFAPGFAP– S100S100– Neuron specific enolaseNeuron specific enolase– SOD1SOD1

Genetic markersGenetic markers– APO E4APO E4– APO E promotorAPO E promotor– Tau polymeraseTau polymerase

Classification schemesClassification schemes

Over 40 known classificationsOver 40 known classifications Most do not agree with each otherMost do not agree with each other 3 are widely used:3 are widely used:

– CantuCantu– Colorado Medical SocietyColorado Medical Society– American Academy of NeurologyAmerican Academy of Neurology

Classification - CantuClassification - Cantu

First published in 1986 First published in 1986 – based on amnesia and loss of consciousnessbased on amnesia and loss of consciousness

Updated in 2001 to include secondary symptomsUpdated in 2001 to include secondary symptoms

Grade 1Grade 1 no loss of consciousness no loss of consciousness less than 30 minutes post traumatic less than 30 minutes post traumatic

amnesiaamnesia Grade 2Grade 2 LT 1 minute loc LT 1 minute loc

amnesia 30 minutes to 24 hrsamnesia 30 minutes to 24 hrs Grade 3Grade 3 GT 1 minute loc GT 1 minute loc

any symptoms lasting over 1 weekany symptoms lasting over 1 week

Classification – Colorado Medical Classification – Colorado Medical SocietySociety

Published 1991 Published 1991 – in response to high school athletes deathin response to high school athletes death

Grade 1Grade 1 confusion onlyconfusion only Grade 2Grade 2 confusion and post traumatic confusion and post traumatic

amnesiaamnesia Grade 3aGrade 3a unconscious for secondsunconscious for seconds Grade 3bGrade 3b unconscious for minutesunconscious for minutes

Colorado Medical Society Colorado Medical Society ClassificationClassification

First to add specific guidelines for return to sport First to add specific guidelines for return to sport Timing based on first or repeat concussionsTiming based on first or repeat concussions

GradeGrade First concussionFirst concussion Second Second concussionconcussion

11 15 minutes15 minutes 1 week1 week

22 1 week1 week 2 weeks with MD 2 weeks with MD approvalapproval

3a3a 1 month1 month 6 months with MD 6 months with MD approvalapproval

3b3b 6 months6 months 1 year with MD 1 year with MD approvalapproval

Classification- American Academy Classification- American Academy of Neurologistsof Neurologists

Introduced 1997 – based on Colorado Introduced 1997 – based on Colorado guidelinesguidelines

Grade 1Grade 1 no loss of consciousness no loss of consciousness

confusion lasts less than 15 minutesconfusion lasts less than 15 minutes Grade 2Grade 2 same but more than 15 minutessame but more than 15 minutes Grade 3aGrade 3a brief loss of consciousnessbrief loss of consciousness (seconds) (seconds) Grade 3bGrade 3b prolonged loss of consciousness prolonged loss of consciousness

(minutes)(minutes)

AAN return to play guidelinesAAN return to play guidelines

Same as Colorado except grade 1Same as Colorado except grade 1

Do neuro exam every 5 minutesDo neuro exam every 5 minutes Return to play if normal within 15 minutesReturn to play if normal within 15 minutes

However, policy was stated in 1997 and is However, policy was stated in 1997 and is slated for a late 2011 update. Expect much slated for a late 2011 update. Expect much more stringent guidelinesmore stringent guidelines

International Conference on International Conference on Concussion in SportConcussion in Sport

FirstFirst Vienna Vienna 20012001 SecondSecond PraguePrague 20042004 ThirdThird Zurich Zurich 20082008

Consensus panels of international expertsConsensus panels of international experts Each built on the prior panels’ workEach built on the prior panels’ work Latest guidelines for return to sport, work- up and Latest guidelines for return to sport, work- up and

follow-upfollow-up Wide range of recommendations, some Wide range of recommendations, some

controversialcontroversial

ICCS recommendationsICCS recommendations

Pre-participation concussion history is very Pre-participation concussion history is very importantimportant

Sideline evaluation medically then cognitive using Sideline evaluation medically then cognitive using SCAT2SCAT2

Attention to cervical spine as additional concernAttention to cervical spine as additional concern No return to sport day of concussion except in rare No return to sport day of concussion except in rare

adult instancesadult instances Should not be left alone for several hours post Should not be left alone for several hours post

injuryinjury Imaging, genetic studies not helpful in most casesImaging, genetic studies not helpful in most cases Graduated return to sportsGraduated return to sports

ICCS ControversiesICCS Controversies Guidelines can apply to as young as 10 year oldsGuidelines can apply to as young as 10 year olds Treat elite/non-elite athletes the sameTreat elite/non-elite athletes the same Helmet/mouthguard use does not lessen concussionsHelmet/mouthguard use does not lessen concussions Do not agree that loss of consciousness under 1 minute is a Do not agree that loss of consciousness under 1 minute is a

measure of severitymeasure of severity No consensus about chronic effectsNo consensus about chronic effects No defined guidelines based on grading – in fact no grading No defined guidelines based on grading – in fact no grading

systemsystem

Modifying factors may lengthen recovery Modifying factors may lengthen recovery – ADD/ADHDADD/ADHD– LDLD– DepressionDepression– Sleep disordersSleep disorders

Do Mouthguards/Helmets help?Do Mouthguards/Helmets help?

Mouthguards – a resounding Mouthguards – a resounding no!no!– But important for oral/dental injury preventionBut important for oral/dental injury prevention

HelmetsHelmets– In American Football, yes for skull fractures, In American Football, yes for skull fractures,

facial injuries, eye injuriesfacial injuries, eye injuries– Uncertain for concussionsUncertain for concussions

Different game now vs pre-helmet daysDifferent game now vs pre-helmet days Different reporting of injuriesDifferent reporting of injuries Different awareness of concussion risksDifferent awareness of concussion risks

Soccer helmetsSoccer helmets

Allstar, HeadblastAllstar, Headblast Full90Full90

– 25 to 45 dollars online25 to 45 dollars online– Complies with FIFA and US Soccer regulationsComplies with FIFA and US Soccer regulations– 2008 study: use cut risk in half and 19% decrease in 2008 study: use cut risk in half and 19% decrease in

recurrent concussionsrecurrent concussions

(Delaney BJSM)(Delaney BJSM)– May not be as beneficial for women as men in lab studyMay not be as beneficial for women as men in lab study

(Tierney J Ath Train 2008)(Tierney J Ath Train 2008)

Soccer HelmetsSoccer Helmets

Not currently widely usedNot currently widely used– Relatively newRelatively new– Not cool yet since not highly endorsed by professional Not cool yet since not highly endorsed by professional

playersplayers 2006 attempted law in Mass did not pass2006 attempted law in Mass did not pass Worries exist that it will cause more head impact Worries exist that it will cause more head impact

injuries due to American football spearing effectinjuries due to American football spearing effect So far however no changes in the game where it So far however no changes in the game where it

has been used are notedhas been used are noted– Did shin guards change the game?Did shin guards change the game?

Old mythsOld myths

Don’t go to sleep after a concussionDon’t go to sleep after a concussion– Current recommendation is to periodically wake for assessment Current recommendation is to periodically wake for assessment

every 3 hours but sleep itself is okevery 3 hours but sleep itself is ok

Don’t take medications for a headache after a concussionDon’t take medications for a headache after a concussion– No indications against any medication except alcoholNo indications against any medication except alcohol– Weak recommendations against aspirin/Motrin for bleedingWeak recommendations against aspirin/Motrin for bleeding

Better helmets will lessen the risk in football playersBetter helmets will lessen the risk in football players– Risk has gone up with bigger and faster players who use their Risk has gone up with bigger and faster players who use their

helmets to lead in tackleshelmets to lead in tackles

Old mythsOld myths

Don’t eat or drink after a concussionDon’t eat or drink after a concussion– Only if nausea/vomiting prevent itOnly if nausea/vomiting prevent it

Stay at bedrest after a concussionStay at bedrest after a concussion– Physical and mental rest are good, but no study Physical and mental rest are good, but no study

indicated better outcomes with bedrestindicated better outcomes with bedrest

Old mythsOld myths

Loss of consciousness is an indicator of Loss of consciousness is an indicator of concussion severityconcussion severity– At least 3 studies and the 3At least 3 studies and the 3rdrd ICCS say this is ICCS say this is

not truenot true

Young people do not have as severe Young people do not have as severe concussions as professionalsconcussions as professionals– At least 4 studies say younger athletes have At least 4 studies say younger athletes have

more severe symptoms that last longermore severe symptoms that last longer

Long term effectsLong term effects

Single injurySingle injury Rapid repeat injuryRapid repeat injury Multiple injuries over long termMultiple injuries over long term

Single injurySingle injury

Measurable learning deficitsMeasurable learning deficits– ““Testing effect” absent in post concussion Testing effect” absent in post concussion

states until back to baselinestates until back to baseline

Frequently worsening scores over 48 hoursFrequently worsening scores over 48 hours Measurable cognitive and physical deficits Measurable cognitive and physical deficits

can persist for weeks or monthscan persist for weeks or months Seldom result in long-term effectsSeldom result in long-term effects

Rapid repeat injuryRapid repeat injury

More likely to get another concussion until More likely to get another concussion until brain returns to “baseline”brain returns to “baseline”

Second Impact Syndrome (SIS)Second Impact Syndrome (SIS)– Nearly all in under 20 age groupNearly all in under 20 age group– High incidence in American footballHigh incidence in American football– All die or are severely disabled afterwardAll die or are severely disabled afterward– Massive brain swelling is the reasonMassive brain swelling is the reason– CDC estimates 1.5 deaths per year due to CDC estimates 1.5 deaths per year due to

concussions so the incidence is lowconcussions so the incidence is low

Multiple injuries over timeMultiple injuries over time

Some studies recommend 3 concussions Some studies recommend 3 concussions lifetime end a person’s careerlifetime end a person’s career– (NCAA Concussion study, Guskiewicz AJSM, Collins NS)(NCAA Concussion study, Guskiewicz AJSM, Collins NS)

Others not conclusiveOthers not conclusive– (Collie Br JSM, McCrory Br JSM)(Collie Br JSM, McCrory Br JSM)

Multiple injuries over timeMultiple injuries over time

Retired NFL players with 3 or more concussions 2005 Retired NFL players with 3 or more concussions 2005 studystudy– 5x likelihood of cognitive impairment5x likelihood of cognitive impairment

– 3x likelihood of significant memory issues3x likelihood of significant memory issues

(vs other retired NFL players without concussions)(vs other retired NFL players without concussions)

More recent studies link toMore recent studies link to– Alzheimer’s dementiaAlzheimer’s dementia– Post-traumatic EncephalopathyPost-traumatic Encephalopathy– Parkinson’s diseaseParkinson’s disease– DepressionDepression– Emotional labilityEmotional lability

Notable Soccer starsNotable Soccer stars

Taylor Twellman – MLS MVP 2005Taylor Twellman – MLS MVP 2005– Played just 2 games since Aug 30, 2008Played just 2 games since Aug 30, 2008– Still can’t head the ballStill can’t head the ball

Lori ChalupnyLori Chalupny– Former captain of US women’s teamFormer captain of US women’s team– MD’s refuse to clear her return to national team but playing this year MD’s refuse to clear her return to national team but playing this year

in the women’s professional leaguein the women’s professional league Alecko Eskandarian – MVP of 2004 MLS Cup finalAlecko Eskandarian – MVP of 2004 MLS Cup final

– Out since 4Out since 4thth concussion in 2009 concussion in 2009 Ross PauleRoss Paule

– Retired age 29 with post concussion syndromeRetired age 29 with post concussion syndrome Josh Gros - Former all-starJosh Gros - Former all-star

– Retired at 25 in 2007 with 7 concussions that year aloneRetired at 25 in 2007 with 7 concussions that year alone– USMC will not readmit himUSMC will not readmit him

TreatmentTreatment

Minimal interventions actually workMinimal interventions actually work Time seems to be the best treatmentTime seems to be the best treatment

““Brain rest” may include avoidance of video Brain rest” may include avoidance of video games games

(Cantu et al 1(Cantu et al 1stst ICCS) ICCS)

Future directionsFuture directions

Army announces blood test for brain injury in Army announces blood test for brain injury in concussionconcussion– Details are very scarce at this time but 4 markersDetails are very scarce at this time but 4 markers

SBDP145, SBDP120, UCH-L1, MAP-2SBDP145, SBDP120, UCH-L1, MAP-2– Remains to be seen how accurate this turns out to be over timeRemains to be seen how accurate this turns out to be over time

HITS Head Impact Telemetry SystemHITS Head Impact Telemetry System– Instrumented helmets in football and other sports gives instant Instrumented helmets in football and other sports gives instant

feedback about likelihood of concussion in a given hitfeedback about likelihood of concussion in a given hit– Problem is not all brains react the same to the same energy impactProblem is not all brains react the same to the same energy impact

Future directionsFuture directions

Increased NFL vigilance against head Increased NFL vigilance against head impactimpact– Trickle down effect to youth footballTrickle down effect to youth football

Soccer mandates helmet use starting with Soccer mandates helmet use starting with goaliesgoalies– MY GUESS - IT IS JUST A MATTER OF TIME !MY GUESS - IT IS JUST A MATTER OF TIME !

So back to the 13 year old football So back to the 13 year old football player player

What should have been done?What should have been done?

ImPact baseline before seasonImPact baseline before season Serial cognitive/physical monitoring using U of P, Serial cognitive/physical monitoring using U of P,

BESS or similar guidelinesBESS or similar guidelines Serial ImPact testing until return to baselineSerial ImPact testing until return to baseline

Grade 3 concussion Grade 3 concussion (if you believe in grading)(if you believe in grading)– Minimum 1 month before return to sports per Colorado Minimum 1 month before return to sports per Colorado

and AAN guidelinesand AAN guidelines– Minimum 1 week after symptoms resolve per ICCSMinimum 1 week after symptoms resolve per ICCS

Thank You !Thank You !