concussion in sports stephen v. cantrill, md, facep associate director department of emergency...
TRANSCRIPT
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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.
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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?
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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)
Stephen V. Cantrill, MDStephen V. Cantrill, MD
Cerebral Forces Causing InjuryCerebral Forces Causing Injury
• Compresssive/Direct Pressure
• Tensile/Negative Pressure
• Rotational/Shearing Forces• Cause of most devastating injuries
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
Concussion PresentationConcussion Presentation
• Confusion and amnesia are cardinal features
• Multiple manifestations
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
Commonly Reported SymptomsCommonly Reported Symptoms
Commonly Seen Early (min to hours)
• Headache
• Dizziness or vertigo
• Lack of awareness of surroundings
• Nausea and vomiting
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
Concussion Grading andConcussion Grading andReturn-to-Play Guidelines: Why Worry?Return-to-Play Guidelines: Why 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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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 andPost-traumatic amnesia < 30 min
No LOCPost-traumatic confusionNo post-traumatic amnesia
No LOC Post-concussive sx last < 15 min
Grade 2 – Moderate
LOC < 5 min orPost-traumatic amnesia > 30 min, < 24 hrs
No LOCPost-traumatic amnesia
No LOCPost-concussive sx last > 15 min
Grade 3 - Severe
LOC > 5 min orPost-traumatic amnesia > 24 hrs
Any LOC Any LOC
Return to Play - Cantu, 1998Return to Play - Cantu, 1998 First Concussion Second Concussion Third Concussion
Grade 1
May RTP if asymptomatic for 1 week
RTP in 2 weeks if asymptomatic for 1 week
Terminate season; may RTP next season if asymptomatic
Grade 2 May RTP if asymptomatic for 1 week
Minimum of 1 month; may then RTP if asymptomatic for 1 week; consider terminating the season
Terminate season; may RTP next season if asymptomatic
Grade 3 Minimum of 1 month; may then RTP if asymptomatic for 1 week
Terminate season; may RTP next season if asymptomatic
Return to Play - CMS, 1991Return to Play - CMS, 1991 First Concussion Second Concussion Third Concussion
Grade 1
May RTP if asymptomatic for > 20 min
RTP if asymptomatic for 1 week
Terminate season; may RTP in 3 months if asymptomatic
Grade 2 May RTP if asymptomatic for 1 week
Consider terminating season. May RTP after asymptomatic for 1 month
Terminate season; may RTP next season if asymptomatic
Grade 3 Minimum of 1 month; may then RTP if asymptomatic for 2 weeks
Terminate season; discourage any return to contact sports
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 asymptomatic 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 asymptomatic 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 appropriate; RTP for a minimum of 1 asymptomatic month or longer based on physician evaluation
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
Sideline Assessment of Sideline Assessment of Neurological FunctionNeurological Function
• Glasgow Coma Scale• Lacks sensitivity
• Standard orientation (X3)• Lacks sensitivity
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
““Standardized Assessment of Standardized 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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
““Standardized Assessment of Standardized 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)
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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.
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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.
Stephen V. Cantrill, MDStephen V. Cantrill, MD
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.