Concussion in Sports Stephen V. Cantrill, MD, FACEPAssociate DirectorDepartment of Emergency MedicineDenver Health Medical CenterDenver, Colorado: Concussion in Sports Stephen V. Cantrill, MD, FACEP Associate Director Department of Emergency Medicine Denver Health Medical Center Denver, Colorado On the Sidelines of a Soccer Match: On 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 Questions: The 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? Background: Background 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 Reporting: Reasons 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 Version: And 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 Concussions per 1000 player hours: Sports at Risk: Incidence versus Concussions per 1000 player hours Football
Multiple others The Controversy over Heading: Does it contribute to brain injury?: The Controversy over Heading: 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 Factors: Other 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 Injury: Cerebral Forces Causing Injury Compresssive/Direct Pressure
Cause of most devastating injuries Cellular Effects: Cellular Effects Metabolic dysfunction resulting in increased cellular vulnerability
Large potassium ionic flux
Increased cellular glucose demand
Decreased cerebral blood flow
Intracellular acidosis Concussion Presentation: Concussion Presentation Confusion and amnesia are cardinal features
Multiple manifestations Concussion Presentation:Neurobehavioral Features: Concussion Presentation: Neurobehavioral Features Vacant stare
Delayed verbal and motor responses
Inability to focus attention
Slurred or incoherent speech
Gross observable incoordination
Any period of loss of consciousness
Commonly Reported Symptoms: Commonly Reported Symptoms Commonly Seen Early (min to hours)
Dizziness or vertigo
Lack of awareness of surroundings
Nausea and vomiting
Commonly Reported Symptoms: Seen Late (days to weeks): Commonly Reported Symptoms: Seen Late (days to weeks) Persistent low-grade headache
Poor attention and concentration
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
Concussion Grading andReturn-to-Play Guidelines: Why Worry?: Concussion Grading and 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 Concussion Grading and Return to Play Guidelines: Concussion Grading and Return to Play Guidelines As many as 25 different sets of criteria
Little evidence-based support
Three most often referenced:
Colorado Medical Society
American Academy of Neurology Classification of Severity of Concussion: Classification of Severity of Concussion Return to Play - Cantu, 1998: Return to Play - Cantu, 1998 Return to Play - CMS, 1991: Return to Play - CMS, 1991 Return to Play - AAN, 1997: Return to Play - AAN, 1997 Points of Commonality in Most RTP Guidelines:: Points of Commonality in 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 Neurological Function: Sideline Assessment of Neurological Function Glasgow Coma Scale
Standard orientation (X3)
Sideline Assessment of Neurological Function: Sideline Assessment of Neurological 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 Concussion” - SAC - McCrea 1997: 'Standardised Assessment of Concussion' - 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 Concussion”: 'Standardised Assessment of 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 Testing: Neuropsychological Testing Much development in past decades
Additional tool to evaluate recovery
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 Testing: Neuropsychological Testing May be helpful in situations of:
Prolonged post-concussive symptoms
Questions of athlete truthfulness
Concept endorsed by Concussion in Sport Group
Problems with Hospital Care: Problems 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 Summary: Concussion 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 Summary: Concussion in Sports Summary 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 Summary: Concussion in Sports Summary 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.