Concussion in SportsConcussion in Sports

Stephen V. Cantrill, MD, FACEPStephen V. Cantrill, MD, FACEP

Associate DirectorAssociate DirectorDepartment of Emergency MedicineDepartment of Emergency Medicine

Denver Health Medical CenterDenver Health Medical CenterDenver, ColoradoDenver, Colorado

On the Sidelines of a Soccer MatchOn the Sidelines of a Soccer Match• Soccer forward collides with opposing player while trying to

head the ball. Both players tumble to the ground. • Opposing player immediately jumps to his feet• Other player arises slowly and starts walking towards the goal,

appearing dazed. Is brought to sidelines by teammates• Complains of a headache and dizziness but denies any tinnitus,

nausea or vision changes. • Is oriented to person, place and time, but is unable to recall what

period they are playing in or the current score. • Symptoms abate after 30 minutes. He denies any other

symptoms and desperately wants to continue in the game.

The QuestionsThe Questions

• What is the appropriate decision about return to play for this player?• Return to this game?• Able to practice tomorrow?

• What type of sideline evaluation is appropriate?

• Is any follow-up needed?

BackgroundBackground

• Estimated 200,000-300,000 concussions per year in sports in US alone

• 75% of concussions in sports DO NOT involve Loss of Consciousness (LOC)

• May be under-recognized• Concussion with LOC is obvious• 75% that do not have LOC may be much

less obvious

Reasons for Under ReportingReasons for Under Reporting

• Player lack of knowledge as to what compromises a concussion• Delaney, 2001: Only 16% of university

football players who suffered a concussion knew what it was

• Concern about being removed from play

Concussion - What is It?Concussion - What is It?

• Defined in 1966 by the Congress of Neurological Surgeons:• “A clinical syndrome characterized by

immediate and transient post traumatic impairment of neural function due to brainstem involvement”

• Broadened to include any posttraumatic alteration in mental status that may or may not involve loss of consciousness

And Now, the Updated VersionAnd Now, the Updated Version

• A complex patholophysiological process affecting the brain, induced by traumatic biomechanical forces….• Causes: direct or indirect force• Rapid onset of short lived impairment that

resolves spontaneously• Reflects functional disturbance, not structural• Usually grossly normal structural imaging studies

First International Conference on Concussion in Sport, Vienna 2001

Sports at Risk: Incidence versus Sports at Risk: Incidence versus Concussions per 1000 player hoursConcussions per 1000 player hours

• Football• Soccer• Wrestling• Basketball• Baseball

• Softball• Field Hockey• Ice Hockey• Lacrosse• Volleyball• Multiple others

The Controversy over Heading: The Controversy over Heading: Does it contribute to brain injury?Does it contribute to brain injury?

• Much sensation in the lay press

• Some poorly designed studies state emphatically: YES

• Other studies are much less clear

• May be a factor in players who sustain multiple concussions

Other Epidemiologic FactorsOther Epidemiologic Factors

• Concussed football players have a six fold increase in suffering yet another concussion

• Cumulative effect of multiple insults• Apolipoprotein E epsilon-4: May

imply increased brain susceptibility to damage (Rabadi, 2001)

Cerebral Forces Causing InjuryCerebral Forces Causing Injury

• Compresssive/Direct Pressure

• Tensile/Negative Pressure

• Rotational/Shearing Forces• Cause of most devastating injuries

Cellular EffectsCellular Effects

• Metabolic dysfunction resulting in increased cellular vulnerability

• Large potassium ionic flux

• Increased cellular glucose demand

• Decreased cerebral blood flow

• Lactate accumulation

• Intracellular acidosis

Concussion PresentationConcussion Presentation

• Confusion and amnesia are cardinal features

• Multiple manifestations

Concussion Presentation:Concussion Presentation:Neurobehavioral FeaturesNeurobehavioral Features

• Vacant stare• Delayed verbal and motor responses • Inability to focus attention• Disorientation• Slurred or incoherent speech • Gross observable incoordination • Excessive emotionality • Memory deficits• Any period of loss of consciousness

Commonly Reported SymptomsCommonly Reported Symptoms

Commonly Seen Early (min to hours)

• Headache

• Dizziness or vertigo

• Lack of awareness of surroundings

• Nausea and vomiting

Commonly Reported Symptoms:Commonly Reported Symptoms: Seen Late (days to weeks) Seen Late (days to weeks)

• Persistent low-grade headache

• Lightheadedness

• Poor attention and concentration

• Memory dysfunction

• Easy fatigability

• Irritability and low frustration tolerance

• Intolerance of bright lights or difficulty focusing vision

• Intolerance of loud noises, sometimes ringing in ears

• Anxiety and depressed mood

• Sleep disturbance

Concussion Grading andConcussion Grading andReturn-to-Play Guidelines: Why Return-to-Play Guidelines: Why

Worry?Worry?

• Return to play with altered cognition and physical capability• Risk of additional injury

• Risk of “Second Impact Syndrome”• Blow to head of individual still symptomatic

from previous mild brain injury• Rapid, diffuse brain swelling resulting most

often in death• Controversial entity

Concussion Grading and Concussion Grading and Return to Play GuidelinesReturn to Play Guidelines

• As many as 25 different sets of criteria• Little evidence-based support

• Expert opinion• Consensus

• Three most often referenced:• Cantu• Colorado Medical Society• American Academy of Neurology

Classification of Classification of Severity of ConcussionSeverity of Concussion

Concussion Grade

Cantu – 1998 CMS - 1991 AAN – 1997

Grade 1 – Mild No LOC and Post-traumatic amnesia < 30 min

No LOC Post-traumatic confusion No post-traumatic amnesia

No LOC Post-concussive sx last < 15 min

Grade 2 – Moderate

LOC < 5 min or Post-traumatic amnesia > 30 min, < 24 hrs

No LOC Post-traumatic amnesia

No LOC Post-concussive sx last > 15 min

Grade 3 - Se-vere

LOC > 5 min or Post-traumatic amnesia > 24 hrs

Any LOC Any LOC

Return to Play - Cantu, 1998Return to Play - Cantu, 1998 First Concussion Second Concus-

sion Third Concussion

Grade 1

May RTP if as-ymptomatic for 1 week

RTP in 2 weeks if asymptomatic for 1 week

Terminate season; may RTP next season if asymp-tomatic

Grade 2 May RTP if as-ymptomatic for 1 week

Minimum of 1 month; may then RTP if asympto-matic for 1 week; consider terminat-ing the season

Terminate season; may RTP next season if asymp-tomatic

Grade 3 Minimum of 1 month; may then RTP if asympto-matic for 1 week

Terminate season; may RTP next sea-son if asympto-matic

Return to play recommendations: Cantu, 1998

Return to Play - CMS, 1991Return to Play - CMS, 1991 First Concussion Second Concus-

sion Third Concussion

Grade 1

May RTP if as-ymptomatic for > 20 min

RTP if asympto-matic for 1 week

Terminate season; may RTP in 3 months if asymp-tomatic

Grade 2 May RTP if as-ymptomatic for 1 week

Consider terminat-ing season. May RTP after asymp-tomatic for 1 month

Terminate season; may RTP next season if asymp-tomatic

Grade 3 Minimum of 1 month; may then RTP if asympto-matic for 2 weeks

Terminate season; discourage any re-turn to contact sports

Return to play recommendations: CMS, 1991

Return to Play - AAN, 1997Return to Play - AAN, 1997

First Concussion Multiple Concussions Grade 1

May RTP if asymptomatic in < 15 min at rest and with exertion

RTP in 1 week if asymp-tomatic at rest and with exercise

Grade 2 May RTP if asymptomatic for 1 week at rest and with exercise

May RTP if asymptomatic for 2 weeks at rest and with exercise

Grade 3 Transport to ED if appropriate; Brief (seconds) LOC: RTP if as-ymptomatic for 1 week at rest and with exercise; Prolonged (minutes) LOC: RTP if asymptomatic for 2 weeks at rest and with exercise

Transport to ED if appro-priate; RTP for a mini-mum of 1 asymptomatic month or longer based on physician evaluation

Return to play recommendations: AAN, 1997

Points of Commonality inPoints of Commonality in Most RTP Guidelines: Most RTP Guidelines:

• Any concussed athlete should be removed from competition, examined and observed

Serial assessment of the athlete after the concussion Any evidence of deterioration, no matter how mild the

injury: transport to hospital for appropriate evaluation Athlete with LOC, even momentary, or post-event

amnesia should not be allowed to immediately return to play

Post-concussed athlete cannot return to play until completely asymptomatic, both at rest and after exertion

Multiple concussions may have a cumulative effect on the athlete

Sideline Assessment of Sideline Assessment of Neurological FunctionNeurological Function

• Glasgow Coma Scale• Lacks sensitivity

• Standard orientation (X3)• Lacks sensitivity

Sideline Assessment of Sideline Assessment of Neurological FunctionNeurological Function

• Maddocks Questions• Which field are we at?

• Which team are we playing today?

• Who is your opponent at present?

• Which quarter (period) is it?

• Which side scored the last goal?

• Which team did we play last week?

• Did we win last week?

• More sensitive: concussed vs nonconcussed

““Standardised Assessment of Standardised Assessment of Concussion” - SAC - McCrea 1997Concussion” - SAC - McCrea 1997

• Orientation (Month, Date, Day of Week, Year, Time) Immediate Memory (3 trials of 5 words) Concentration (3, 4, 5 and 6 digit strings backwards) Delayed Recall (1 trial of 5 words, used above) Maximum of 30 points Brief neurological screen

• LOC - Amnesia - Strength - Sensation - Coordination

• Exertional evocative component:• 5 jumping jacks - 5 sit-ups - 5 push-ups - 5 knee-bends

““Standardised Assessment of Standardised Assessment of Concussion”Concussion”

• Useable in the field

• Best if individual baseline established before season starts

• Decrease in 1 point or more from baseline: 96% sensitivity, 76% specificity in detecting symptomatic concussed players using AAN criteria (McCrea, 2001)

Neuropsychological TestingNeuropsychological Testing

• Much development in past decades• Additional tool to evaluate recovery• But:

• Best tests yet to be demonstrated• Baseline testing should be done• Time and dollar costs are high

• Computer and web-based testing may help

Neuropsychological TestingNeuropsychological Testing

• May be helpful in situations of:• Severe concussion• Prolonged post-concussive symptoms• Multiple concussions• Questions of athlete truthfulness

• Concept endorsed by Concussion in Sport Group

Problems with Hospital CareProblems with Hospital Care

• Lack of awareness of RTP guidelines by clinicians

• Discharge instructions don’t address adequate follow-up and return-to-play criteria nor limitations in activities of daily living

Concussion in Sports SummaryConcussion in Sports Summary• Most concussions in sports do not involve LOC,

but rather confusion/amnesia• Concussion grading criteria RTP criteria have

limited scientific grounding but serve as useful tools for guidance

• To avoid further injury and possibly the potentially lethal “second impact syndrome”, concussed athletes should not return to play until completely asymptomatic, sometimes requiring a prolonged period of time

Concussion in Sports Concussion in Sports SummarySummary

• The sideline use of detailed mental status screening tools allows for more sensitivity and standardization in the evaluation of the concussed athlete

• Neuropsychological testing may be helpful with ongoing post-concussive symptoms, multiple concussions or severe concussions

• Ongoing education of athletes is necessary to emphasize a concussion does not require loss of consciousness

Concussion in Sports Concussion in Sports SummarySummary

Ongoing education of providers about guidelines for concussion in sports to insure appropriate and thorough evaluation of concussed athletes on the field, in the office and in the emergency department.

These guidelines should be utilized as part of the decision-making process of when the athlete should be allowed to return to play and to insure the adequacy of patient post-injury education.

Back on the Soccer Field… Back on the Soccer Field…

• Due to duration of his symptoms, the athlete sat out the rest of the game

• He was administered Standardized Assessment of Concussion (SAC) instrument, scoring 23 out of 30. His preseason baseline score was 27.

• The athlete was instructed by the trainer about symptoms to be aware of that could represent a worsening of his traumatic brain injury or could indicate a post-concussive syndrome.

And Finally...And Finally...

• He did have recurrence of his headache that evening, but it had abated by the next morning and he remained symptom free.

• Re-administration of the SAC instrument 48 hours post-injury revealed return to his normal baseline of 27.

• The athlete was counseled to not engage in contact sports for an additional week.

• By the way, his team won the league title, 2-1.