9/22/13

1

Concussions in Sports

Ronnie I. Mimran, M.D. Pacific Brain and Spine Medical Group Neurosurgery Consultant, Oakland Raiders

What is a Concussion?

!   “Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. They may be caused by either a direct blow to the head, face, or neck, or by a blow elsewhere in the body that is impulsively transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. Acute clinical symptoms may or may not involve a loss of consciousness, and largely reflect a functional disturbance rather than a structural injury.”

--Zurich Consensus Statement, 2008

!   From Latin concutere, meaning “to shake violently”

What is a Concussion?

!   A concussion is a brain injury.

!   All concussions are serious.

!   Concussions can occur without loss of consciousness.

!   Concussions can occur in any sport.

!   Recognition and proper management of concussions when they first occur can help prevent further injury or even death.

9/22/13

2

How Common are Concussions? !   Depends on who you ask and how you ask it... !   Surveys of medical professionals and athletic trainers consistently

shows incidence 2-6% of players per season

!   Ask players about symptoms (without the word “concussion”) and the incidence jumps to 50-70%

!   This means that less than 10% of concussions are reported...

!   CDC: Approximately 300,000 sports and recreation related head injuries in US per year.

Culture of Football !   Silence is Deadly… !   “Would I come out? No chance. It’s not dangerous to

play with a concussion. You’ve got to sacrifice for the sake of the team. The only way I come out is on a stretcher.”

!   “Our coaches would take us out in a second. So why would we tell them?”

!   “Football... you have to suck it up. You’re going to feel pain... If you don’t put yourself through that, you don’t really love the game.”

Culture of Football…

Silence is Deadly... !   A 2004 survey of 1,532 Varsity high school players

!   47% of players that had sustained a concussion did not report it. Here’s why: !   66% Did not think a concussion was serious enough to

report

!   41% Did not want to leave the game

!   36% Did not realize that they had sustained a concussion

!   22% Did not want to let down their teammates

!   EDUCATION IS THE KEY TO THIS PROBLEM

9/22/13

3

Sideline Concussion Evaluation !   ANY player with features of a concussion: !   Onsite evaluation by coach, trainer, or physician, with

particular attention to cervical spine !   Assessment using SCAT2 or similar tool !   Player should not be left alone following the injury, serial

monitoring for deterioration over the initial few hours

!   Player should not, UNDER ANY CIRCUMSTANCES, be allowed to return to play on the day of injury

!   Medical Evaluation

Symptoms of Concussion Physical Cognitive Emotional Sleep Headache Fogginess Irritability Drowsiness

Double/Blurry Vision Slowness of thought Sadness/Depression Insomnia

Balance difficulty Concentration probs Emotional lability

Nausea Memory problems Nervousness

Dizziness/Vertigo Forgetfulness Mood swings

Vomiting Confusion Personality change

Fatigue Repetitiveness

Light sensitivity Vacant stare

Noise sensitivity Disorientation

Numbness/Tingling Amnesia

Dazed/stunned look

Clumsiness

Sideline Concussion Evaluation Sideline Concussion Evaluation

Concussion Evaluation

!  Medical Assessment !   Imaging !  Objective Balance Assessment !   Balance Error Scoring System (BESS)

!  Neuropsychological Assessment !   ImPACT

Why the Frequent Checks?

!   Subdural Hematoma

!   Epidural Hematoma

!   Cortical Contusion

!   Cerebral Edema

!   Skull Fracture

9/22/13

4

Second Impact Syndrome

!   Occurs with 2nd head injury while brain is still symptomatic/recovering from the first injury

!   2nd injury usually minor

!   Massive, uncontrollable cerebral swelling

!   100% permanent neurological deficits, 50% mortality

Consequences of Mismanagement

!   October 2006, Washington: Zackery Lystedt, 13 years old

!   Zack makes a goal line tackle, landing hard on his helmet.

!   He is helped off field by coaches, sat out 3 plays and halftime.

!   Zack returned to game in 3rd quarter.

!   During the 4th quarter, after seemingly typical play, he collapsed on the field, in a coma.

!   He required emergent brain surgery to save his life…

Zackery Lystedt"Case Example of SIS

!   2006: 13 year old Zack suffers Second Impact Syndrome !   Airlifted to hospital where he underwent emergency

brain surgery !   7 days on life support, 3 months in coma !   9 months until he spoke his first word !   13 months until he moved his left arm !   20 months on feeding tube !   3 years before he could stand, only with assistance

Long Term Effects of Concussion !   Chronic Traumatic Encephalopathy (CTE):

Neurodegenerative condition associated with repeated sublethal brain trauma

!   Marked by cognitive changes (memory loss, dementia) and personality/behavioral changes (aggressive or violent behavior, confusion, depression, paranoia)

Long Term Effects of Concussion

60 yo Control 45 yo NFL player 80 yo pro boxer

Long Term Effects of Concussion

18 yo male: Cognitively intact. High school football player. Focal evidence of tau protein buildup.

9/22/13

5

When a Concussion Occurs

!   Remove the athlete from play.

!   If there is any doubt, remove the athlete from play.

!   Have the athlete evaluated by a health care professional as soon as possible.

!   Return to play should only occur after clearance from a health care professional.

Concussion Management !   Best treatment for a concussion? REST !   Avoid loud noises, bright lights, computers, video games, television,

phones, texting, etc. !   Symptoms usually go away in a week or so, but may persist for

weeks or even months !   Especially in children, symptoms can interfere with school and social

interactions !   Headaches !   Memory difficulties !   Poor concentration !   Mood changes

Concussion Management

!   PRIMARY GOAL: Physical and cognitive rest until symptoms resolve

!   SECONDARY GOAL: Graduated return to play protocol !   Stepwise progression !   Each step should take at least 24 hours, longer in

children !   Proceed to next step if asymptomatic; if symptomatic,

rest for at least 24 hours and drop back to step before

Graduated Return to Play 1.  No Activity

!   Complete physical and cognitive rest

2.  Light Aerobic Exercise !   Walking, cycling (<70% MHR), no resistance training

3.  Sport-specific Exercise !   Running, skating, no contact or resistance training

4.  Non-contact training drills !   Complex training, passing, progressive resistance training

5.  Full contact practice !   Normal practice

6.  Return to Play

Red Flags !  Worsening headaches !  Seizures !  Neck pain !  Difficult to arouse/

awaken !  Repeated vomiting !  Slurred speech !  Difficulty recognizing

people or places

!   Increasing confusion !  Weakness/numbness

in arms or legs !  Unusual behavioral

changes !   Increasing irritability !  Loss of consciousness !  Any worrisome sign or

symptom

Concussion Prevention !   Equipment !   Mouthguards !   No evidence that mouthguards have any effect in preventing

concussions !   They are effective against dental and maxillofacial trauma, and

should be worn for that reason

!   Helmets !   Biomechanical studies have

shown a reduction in impact forces to the brain

!   This has not translated to a reduction in concussion incidence

9/22/13

6

Protection Paradox

!  Doctors and trainers yelled at for holding players out of game

!  Players berated for reporting symptoms !  Players instructed to change uniform/number after

concussion to go back into game unnoticed !  Parents destroying doctors notes, taking players “doctor shopping”

!  Players coached to rehearse answers to concussion questions

!  Players purposefully doing poorly on baseline neuropsychological testing

!  What we have witnessed:

Where do we go from here? !   Develop an Action Plan for teams in your area

!   Quality, well-fitting equipment

!   Train in, and practice with proper techniques

!   Education extremely important at the youth and high school levels

!   Athletes !   Parents !   Trainers !   Coaches

!   Consult with a Physician or other trained medical professional on all cases of concussion

Thank You... and be safe.