head injury in sport james r. borchers, md the ohio state university assistant clinical professor...

Head Injury in SportHead Injury in Sport

James R. Borchers, MDJames R. Borchers, MDThe Ohio State UniversityThe Ohio State University

Assistant Clinical ProfessorAssistant Clinical Professor

Team PhysicianTeam Physician

Dept of Family MedicineDept of Family Medicine

Division of Sports MedicineDivision of Sports Medicine

ObjectivesObjectives

• Define and discuss various types of head Define and discuss various types of head injuries in sportinjuries in sport

• Review initial evaluation of an athlete with a Review initial evaluation of an athlete with a head injuryhead injury

• Review concussion evaluation and treatmentReview concussion evaluation and treatment• Discuss return to play guidelines for an Discuss return to play guidelines for an

athlete with a head injuryathlete with a head injury

Head Injuries in SportHead Injuries in Sport

• Actual number of injuries unknown Actual number of injuries unknown because many are not reported by the because many are not reported by the athleteathlete

• Most head injuries in sport are minor:Most head injuries in sport are minor:– Sports are third behind MVA and Sports are third behind MVA and

falls as cause of minor head injuriesfalls as cause of minor head injuries– Most common head injury in sports Most common head injury in sports

is a concussionis a concussion


• NCAA Injury Surveillance System developed NCAA Injury Surveillance System developed in 1982 and has guided the NCAA regarding in 1982 and has guided the NCAA regarding head injury in sport:head injury in sport:– 1984-1991 the highest # of head injuries 1984-1991 the highest # of head injuries

were in ice hockey, followed by were in ice hockey, followed by football,field hockey, women’s lacrosse football,field hockey, women’s lacrosse and men’s soccer.and men’s soccer.

– Football had the highest concussion rateFootball had the highest concussion rate


• 1995-1996 data showed an 1995-1996 data showed an increase in the number of head increase in the number of head injuries injuries – More aggressive play and More aggressive play and

increased contactincreased contact– Better reporting and Better reporting and

diagnosis of head injuriesdiagnosis of head injuries

Types of Head InjuriesTypes of Head Injuries

• FocalFocal– Blunt traumaBlunt trauma– Usually associated with Usually associated with

LOC and focal neuro LOC and focal neuro deficitsdeficits

– Subdural hematoma, Subdural hematoma, epidural epidural hematoma,cerebral hematoma,cerebral contusions and intra contusions and intra cerebral hemorrhagecerebral hemorrhage

• DiffuseDiffuse– Not associated with Not associated with

focal intracranial focal intracranial injuriesinjuries

– Severity depends on Severity depends on the amount of the amount of anatomic disruption anatomic disruption that occursthat occurs

– Concussion is the Concussion is the most common typemost common type

Subdural HematomaSubdural Hematoma

• Often LOC, focal deficits and slow Often LOC, focal deficits and slow deterioration in mental statusdeterioration in mental status

• Low pressure disruption of venous blood Low pressure disruption of venous blood supplysupply

• Two types: simple and complexTwo types: simple and complex– Depends on the presence of underlying Depends on the presence of underlying

cerebral contusion or edemacerebral contusion or edema

Subdural HematomaSubdural Hematoma

Epidural HematomaEpidural Hematoma

• LOC at time of injury, lucid interval and LOC at time of injury, lucid interval and then CNS deteriorationthen CNS deterioration

• Associated with disruption of the middle Associated with disruption of the middle or other meningeal arteriesor other meningeal arteries

• Must have a high suspicion for injury Must have a high suspicion for injury based on mechanism and exambased on mechanism and exam

• Neurosurgical emergencyNeurosurgical emergency

Epidural HematomaEpidural Hematoma

ConcussionConcussion


• Most common head injury in sportsMost common head injury in sports

• Term has been used since the 10Term has been used since the 10 thth century AD, first described as an century AD, first described as an abnormal physiologic state without abnormal physiologic state without gross traumatic lesions of the braingross traumatic lesions of the brain

• Pathophysiology of concussion is Pathophysiology of concussion is still not well understoodstill not well understood


In 2004, the Concussion in Sport Group (CSIG) In 2004, the Concussion in Sport Group (CSIG) Prague statement defined concussion:Prague statement defined concussion:– Concussion is defined as a complex Concussion is defined as a complex

physiological process affecting the brain, physiological process affecting the brain, induced by traumatic biomechanical forces.induced by traumatic biomechanical forces.– Caused by a direct blow to the head, face, Caused by a direct blow to the head, face,

neck, or elsewhere on the body with an neck, or elsewhere on the body with an impulsive force transmitted to the headimpulsive force transmitted to the head


–Typically results in the rapid onset of short-lived Typically results in the rapid onset of short-lived impairment of neurological function that resolves impairment of neurological function that resolves spontaneouslyspontaneously

–May result in neuropathological changes reflecting May result in neuropathological changes reflecting a functional disturbance rather than a structural a functional disturbance rather than a structural injuryinjury

–Graded set of clinical syndromes that may or may Graded set of clinical syndromes that may or may not involve LOCnot involve LOC

–Associated with grossly normal neuroimaging Associated with grossly normal neuroimaging studiesstudies

Concussion SymptomsConcussion Symptoms

• EarlyEarly– HeadacheHeadache– DizzinessDizziness– ConfusionConfusion– TinnitusTinnitus– NauseaNausea– VomitingVomiting– Loss of balanceLoss of balance

• LateLate– Memory Memory

DisturbancesDisturbances– Poor ConcentrationPoor Concentration– IrritabilityIrritability– Sleep disturbancesSleep disturbances– FatigueFatigue– Personality changesPersonality changes

Concussion TypesConcussion Types

• SimpleSimple– Symptoms resolve over 7 – 10 daysSymptoms resolve over 7 – 10 days– Limit physical activityLimit physical activity– No neuropsychiatric testing requiredNo neuropsychiatric testing required– Rest until all symptoms resolve and Rest until all symptoms resolve and

then graded program of exertion then graded program of exertion before return to sportbefore return to sport

Concussion TypeConcussion Type

• ComplexComplex– Persistent symptoms even with Persistent symptoms even with

exertion, specific sequelae, exertion, specific sequelae, LOC> 1 min, prolonged LOC> 1 min, prolonged cognitive deficitcognitive deficit

– Neuropsychiatric testing Neuropsychiatric testing indicatedindicated

– Multidisciplinary approachMultidisciplinary approach

Concussion EvaluationConcussion Evaluation

• Begins with basic life support:Begins with basic life support:– AAirway, irway, BBreathing and reathing and CCirculationirculation

• Determine if there is any loss of Determine if there is any loss of consciousness:consciousness:– If LOC exists the athlete must be If LOC exists the athlete must be

suspected to have a cervical suspected to have a cervical spine injury and treated spine injury and treated appropriatelyappropriately


• If the athlete can be moved to the sideline a If the athlete can be moved to the sideline a neurologic exam should be performedneurologic exam should be performed

• Evaluate long and short term memoryEvaluate long and short term memory– Assess memory using sport specific Assess memory using sport specific

questions; orientation questions have poor questions; orientation questions have poor yield for assessing memoryyield for assessing memory

• Assess for retrograde and antegrade amnesiaAssess for retrograde and antegrade amnesia• Monitor frequentlyMonitor frequently


• Preparticipation ExamPreparticipation Exam– Baseline evaluation for cognitive Baseline evaluation for cognitive

screen and symptom scorescreen and symptom score– Sport Concussion Evaluation Tool Sport Concussion Evaluation Tool

(SCAT)(SCAT)– ImPactImPact

Concussion GradingConcussion Grading

• No consensus exists regarding the grading of No consensus exists regarding the grading of concussionsconcussions

• There is very little evidence to support any There is very little evidence to support any specific grading schemespecific grading scheme

• Most have been based on expert opinion and Most have been based on expert opinion and limited datalimited data

• Glasgow Coma Scale is the only validated Glasgow Coma Scale is the only validated scale for use in head injuryscale for use in head injury

Concussion Grading ScalesConcussion Grading Scales

Concussion GradingConcussion Grading

• In 2004, the CISG recommended that In 2004, the CISG recommended that no specific system be used to grade no specific system be used to grade concussions but that a clinical construct concussions but that a clinical construct evaluating individual signs and evaluating individual signs and symptoms be used to determine symptoms be used to determine concussion severity and guide concussion severity and guide management and return to playmanagement and return to play


• Neuropsychological testing has been shown to Neuropsychological testing has been shown to be of value when evaluating concussionbe of value when evaluating concussion– Baseline testing is needed for accurate Baseline testing is needed for accurate

results and periodic baseline updates are results and periodic baseline updates are recommendedrecommended

– Players may return to baseline testing while Players may return to baseline testing while still symptomaticstill symptomatic

– Aid to clinical decision makingAid to clinical decision making


• Neuroimaging is not usually necessary and is Neuroimaging is not usually necessary and is usually normal with a concussion injuryusually normal with a concussion injury– CT scan initial study of choice if concurrent focal CT scan initial study of choice if concurrent focal

injury is presentinjury is present– MRI better for anatomy and if imaging is needed MRI better for anatomy and if imaging is needed

48 hours or more post injury48 hours or more post injury• Newer modalities (PET scan, structural MR Newer modalities (PET scan, structural MR

modalities) promising but not established for use in modalities) promising but not established for use in concussionconcussion

Concussion ManagementConcussion Management

• Dependent on individual Dependent on individual guidelinesguidelines

• Consensus that any athlete Consensus that any athlete that has signs or symptoms of that has signs or symptoms of concussion should be concussion should be removed from the event removed from the event immediately and should not immediately and should not return if signs or symptoms return if signs or symptoms persist at rest or with exercisepersist at rest or with exercise


• CSIG 2004 states when any player shows CSIG 2004 states when any player shows any signs or symptoms of concussionany signs or symptoms of concussion– No RTP in game or practiceNo RTP in game or practice– Regular monitoringRegular monitoring– Player medically evaluatedPlayer medically evaluated– RTP must follow medically supervised RTP must follow medically supervised

stepwise processstepwise process


• Should follow a stepwise approachShould follow a stepwise approach• At each level the athlete should be At each level the athlete should be

asymptomatic before progressing to the next asymptomatic before progressing to the next stagestage

• 24 hours between stages24 hours between stages• If an athlete is symptomatic at any stage, the If an athlete is symptomatic at any stage, the

athlete should drop back to the previous level athlete should drop back to the previous level and try to progress again in 24 hoursand try to progress again in 24 hours


• Step wise progressionStep wise progression– No activity, complete restNo activity, complete rest– Light aerobic exerciseLight aerobic exercise– Sport specific exerciseSport specific exercise– Non-contact drillsNon-contact drills– Full contact trainingFull contact training– Game playGame play

• Should be followed for any concussion occurrenceShould be followed for any concussion occurrence

Concussion GuidelinesConcussion Guidelines

• NATANATA• Allows RTP same dayAllows RTP same day

– Symptoms < 20 minSymptoms < 20 min– No symptoms with exertionNo symptoms with exertion– No LOCNo LOC– No amnesiaNo amnesia

• Team Physician Consensus StatementTeam Physician Consensus Statement– No evidence based data for RTP same dayNo evidence based data for RTP same day

Post Concussion RisksPost Concussion Risks

Second Impact SyndromeSecond Impact Syndrome

• Most serious risk of premature return to play Most serious risk of premature return to play following a concussionfollowing a concussion

• Any insult to the head following premature Any insult to the head following premature return to play causes instantaneous collapse return to play causes instantaneous collapse and deathand death

• Thought to be due to loss of autoregulation of Thought to be due to loss of autoregulation of the brain’s blood supplythe brain’s blood supply

• Researchers have questioned its existenceResearchers have questioned its existence

Postconcussive SyndromePostconcussive Syndrome

• Constellation of symptoms that persist Constellation of symptoms that persist following minor head injuryfollowing minor head injury

• Criteria defined in DSM-IV are viewed as too Criteria defined in DSM-IV are viewed as too strict and often clinical judgment is needed to strict and often clinical judgment is needed to evaluate on an individual basisevaluate on an individual basis

• Multidisciplinary approach to treatmentMultidisciplinary approach to treatment• Beta-blockers , SSRIs and TCAs can be Beta-blockers , SSRIs and TCAs can be

usedused

Chronic Traumatic EncephalopathyChronic Traumatic Encephalopathy

• Premature loss of normal CNS function due to Premature loss of normal CNS function due to multiple blows to the headmultiple blows to the head

• May occur in athletes with no LOC and it is difficult May occur in athletes with no LOC and it is difficult to predict which athletes are at risk for developing to predict which athletes are at risk for developing this syndromethis syndrome

• ““Punch drunk syndrome”Punch drunk syndrome”• Syndrome occurs in 9-25% of professional boxers, Syndrome occurs in 9-25% of professional boxers,

depends on # of fights and length of their careerdepends on # of fights and length of their career

Pediatric ConcussionPediatric Concussion

• Physical and cognitive restPhysical and cognitive rest

• Neuropsychiatric testing Neuropsychiatric testing difficultdifficult

• Stepwise progression Stepwise progression suggestedsuggested

• Stay conservativeStay conservative

PreventionPrevention

• Multiple factors can help with head injury Multiple factors can help with head injury prevention in sport:prevention in sport:– Equipment modificationEquipment modification– Rule enforcement and changes as necessaryRule enforcement and changes as necessary– Education of proper sport specific techniquesEducation of proper sport specific techniques

• No clinical evidence that concussion in sport can No clinical evidence that concussion in sport can be preventedbe prevented

ConclusionConclusion

• Most head injuries in sport are mild but there Most head injuries in sport are mild but there is no such thing as a minor head injuryis no such thing as a minor head injury

• Appropriate evaluation will help to avoid Appropriate evaluation will help to avoid complications of an athletic head injurycomplications of an athletic head injury

• When in doubt, sit them outWhen in doubt, sit them out• Clinical judgment and experience are Clinical judgment and experience are

important when dealing with head injuries in important when dealing with head injuries in sportsport

Thank YouThank You

head injury in sport james r. borchers, md the ohio state university assistant clinical professor...

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