Concussion in Sports Stephen V. Cantrill, MD, FACEP Associate Director Department of Emergency Medic

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Concussion in Sports Stephen V. Cantrill, MD,
FACEPAssociate DirectorDepartment of Emergency
MedicineDenver Health Medical CenterDenver,
Colorado
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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.

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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?

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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

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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

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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

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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
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Sports at Risk Incidence versus Concussions per
1000 player hours

• Football
• Soccer
• Wrestling
• Basketball
• Baseball

• Softball
• Field Hockey
• Ice Hockey
• Lacrosse
• Volleyball
• Multiple others

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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

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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)

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Cerebral Forces Causing Injury

• Compresssive/Direct Pressure
• Tensile/Negative Pressure
• Rotational/Shearing Forces
• Cause of most devastating injuries

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Cellular Effects

• Metabolic dysfunction resulting in increased
  cellular vulnerability
• Large potassium ionic flux
• Increased cellular glucose demand
• Decreased cerebral blood flow
• Lactate accumulation
• Intracellular acidosis

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Concussion Presentation

• Confusion and amnesia are cardinal features
• Multiple manifestations

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Concussion PresentationNeurobehavioral 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

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Commonly Reported Symptoms

• Commonly Seen Early (min to hours)
• Headache
• Dizziness or vertigo
• Lack of awareness of surroundings
• Nausea and vomiting

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Commonly Reported Symptoms 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

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Concussion Grading andReturn-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

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Concussion Grading and Return 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

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Classification of Severity of Concussion
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Return to Play - Cantu, 1998
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Return to Play - CMS, 1991
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Return to Play - AAN, 1997
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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

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Sideline Assessment of Neurological Function

• Glasgow Coma Scale
• Lacks sensitivity
• Standard orientation (X3)
• Lacks sensitivity

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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

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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

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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)

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Neuropsychological 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

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Neuropsychological 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

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Problems with Hospital Care

• Lack of awareness of RTP guidelines by clinicians
• Discharge instructions dont address adequate
  follow-up and return-to-play criteria nor
  limitations in activities of daily living

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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

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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

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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.

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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.

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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.