sports concussion in the 21 century - cloud object … · sports concussion in the 21st century ......

Sports Concussion in the 21st Century

Anthony J. Saglimbeni, MD

S.O.A.R.

South Bay Sports and Preventive Medicine Associates, Inc.

Northern California Junior Lacrosse Association

September 25, 2010


• Definition

• Disturbance in brain function

• Following blow to head

• Following violent shake


• Epidemiology

• US Incidence TBI is 1.4

million

• US incidence of

concussion/MTBI is

300,000

• Some contact sports

risk up to 19% per

season

• 15% of concussions

have symptoms over 1

year

• Most athletes recover

• Most prevalent among

younger ages

• Perhaps activity

related

Incidence by sport in high schoolIncidence by sport in high school

FootballFootball

SoccerSoccer

WrestlingWrestling

BasketballBasketball

Field hockeyField hockey

BaseballBaseball

SoftballSoftball

VolleyballVolleyball

Facts and Statistics

• At least 10% of all contact sport athletes

have a concussion in a season

• 3.8 million injuries per year in US (CDC)

• An athlete who has a concussion is 4-6 times more likely to have a second concussion

• The best way to prevent problems after concussion is to manage them effectively when they occur and prevent premature return to play

6


• NCAA incidence 2007 Study

• 182,000 injuries over 16 years

• 1988-89 thru 2003-4

• All injuries required medical attention and missed at least 1 day

• Concussion Injury Rates per 1000 exposures

• Women’s ice hockey .91(only 4 of the 16 seasons)

• Men’s Spring Football .54

• Women’s soccer .41

• Men’s ice hockey .41

• Men’s Football .37

• Men’s Lacrosse .26(.25 women)

• Total Concussions .28(ankle sprains .87 and ACL’s .15)

8

Why Worry about Concussion in

Children?

• Most concussions occur in children, not adults

• Children’s brains are more vulnerable to injury

• Injury can seriously interfere with school

• Children often lie about symptoms

• Children are more likely to be seriously injured

• Post Concussion Syndrome

• Second Impact Syndrome (SIS) 8

The Problem

• Athletes of all ages often hide their symptoms • An athlete may not recognize that they have a concussion • It is difficult to determine when the athlete is back to normal 9

Neurometabolic Cascade

Following Cerebral Concussion

2 6 12 20 30 6 24 3 6 10

minutes hours days

500

400

300

200

0

50

100

% o

f norm

al K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

15

Concussion Symptoms

• Headache

• Nausea

• Balance problems

• Double vision

• Sensitivity to light

• Sensitivity to noise

• Feeling sluggish

• Feeling foggy/sleepy

• Change in sleep pattern

• Cognitive changes

Concussion Signs

• Appears dazed

• Confused about play

• Answers question slowly

• Personality/behavior change

• Irritability or aggression

• Forgets plays prior to hit

• Forgets plays after hit

• Loss of consciousness

Common Sign and Symptoms of

Concussion

16

“Fogginess” Athlete Descriptions

“It is like going from a high definition TV world to standard TV world”

“Feeling one step removed from my surroundings”

“It is like my vision is impaired, but it isn’t”

“Feeling like I am underwater”

Iverson, Lovell, Collins. JINS (2004),10, 94-906.

17

Decreased Brain Processing Speed

Short-Term Memory Impairment

Concentration Problems

Irritability/Depression

Fatigue/Sleep Disturbance

General Feeling of “Fogginess”

Academic Difficulties

Lasting Signs of Concussion:

Post-Concussion Syndrome

21


• Loss of Consciousness

• LOC is defined as unresponsiveness to external stimuli usually accompanied by closure of eyes

• Studies demonstrate that on field amnesia is more predictive of post injury course than loss of consciousness

• Any athlete with LOC should be treated conservatively


• Imaging

• CT and MRI of brain usually normal

• Only indicated if symptoms are increasing or bleeding suspected

• If symptoms persist consider imaging to rule out concomitant lesion

• Functional MRI and PET scans may be useful to assess physiologic status as these tools become accessible and less costly

Immediate Post-Concussion

Assessment and Cognitive Testing

ImPACT

A 20 minute battery of computer-based cognitive test

Evaluates memory, attention, speed, symptoms

Required in all professional sports in US

Available from age 11 to 60

Young children’s version available soon

Available in 13 languages 24

• Demographic / Concussion History Questionnaire

• Concussion Symptom Scale • 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc)

• 8 Neurocognitive Measures • Verbal Memory, Visual Memory, Reaction Time, Processing

Speed Summary Scores

• Detailed Clinical Report • Outlines Demographic, Symptom, Neurocognitive Data

• Automatically Computer Scored

• On-Line Versions Available • Extensive normative data available from ages 11-60

• Pediatric Version Developed-Ages 5-11

• Over 100 peer-reviewed research articles, books/chapters, abstracts published since 2000

• Reliability, validity, sensitivity/specificity of test established •

ImPACT: Test Summary

25

Concussion Management Programs ImPACT Computerized Neurocognitive Testing

NFL (Mandated)

NHL (Mandated)

MLB (Mandated)

Major League Soccer (all teams)

US Ski/Snowboarding Teams

NASCAR, IRL, CHAMP Racing Leagues

USA Rugby/US Lacrosse

USA Soccer

Cirque de Soleil

New Zealand, South Africa Rugby

World Wrestling Federation

US Military (All four branches/National Guard)

Approx 500 Colleges and Universities

Approx 3,500 High Schools (State programs underway in NJ, NC, NY, Nevada) 26

1-3 Days

Post-Injury

1st Follow up

Concussion

Suspected (Athlete is removed

from play)

Additional

Follow-ups

As needed

Preseason

Baseline

Testing (Done at the

school or in a

doctor’s office)

ImPACT

Rest

Gradual Exertion

Concussion Evaluation Timeline

27

28

• Initial treatment through rest/removal

• Approximately 85% return to normal

• 15% of patient’s do not recover on their

own within 3 to 4 weeks

- Interface with schools

- Medical Management in clinic

Our Treatment Philosophy

28

Second Impact Syndrome Occurs in athletes with prior concussion following relatively minor second impact - A number of recent cases (New Jersey, Pennsylvania, Washington) - Second impact has been shown to occur up to 14 days post-injury - Athlete returns to competition before resolution of symptoms

Catastrophic increase in intracranial pressure - Vasomotor paralysis, edema, massive swelling, herniation, death

Most often occurs in athletes <19 years old -Neuro-chemical processes appear to differ in developing brain

30

31

LYSTEDT’S LAW State of Washington

Zach Lystedt returned to play by coach after

two injuries in one game.

Second injury produced malignant brain

swelling and permanent brain damage.

State of Washington passed law requiring

evaluation prior to return to play.

14 other states have similar bill’s pending,

including NJ, Conn, Mass, RI, Oregon 31

California Impact Clients

• High Schools

• 69

• Universities and Colleges

• 40

• Does not include CIC clients

• Concussion is common in both girls and boys

• Proper management decreases the danger

• Do not rely on what the athlete tells you

• “When in doubt, sit them out”

• Utilize a properly trained expert

CONCUSSION SUMMARY

5 Things That You Must Know

36


• Recovery

• Vulnerability

• Recurrence

• Cumulative Effects

• Catastrophe

• Proper Management

• No contact or at

risk activity while

recovery is ongoing


• Zurich

• Return to play unchanged from Prague


• Conclusions on Concussions

• Management Should be individualized rather than based on various grading scales available

• Remove Symptomatic Athlete From Play

• Restrict Play while symptomatic

• Gradual Return to Activity after medical clearance

• Neuropsychological Testing is Cornerstone

• Recognize Differences in Children

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