Title: Concussion in Sports Stephen V. Cantrill, MD, FACEP Associate Director Department of Emergency Medicine Denver Health Medical Center Denver, Colorado
1Concussion in Sports Stephen V. Cantrill, MD,
FACEPAssociate DirectorDepartment of Emergency
MedicineDenver Health Medical CenterDenver,
Colorado
2On 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.
3The 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?
4Background
- 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
5Reasons 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
6Concussion - 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
7And 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
8Sports at Risk Incidence versus Concussions per
1000 player hours
- Football
- Soccer
- Wrestling
- Basketball
- Baseball
- Softball
- Field Hockey
- Ice Hockey
- Lacrosse
- Volleyball
- Multiple others
9The 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
10Other 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)
11Cerebral Forces Causing Injury
- Compresssive/Direct Pressure
- Tensile/Negative Pressure
- Rotational/Shearing Forces
- Cause of most devastating injuries
12Cellular Effects
- Metabolic dysfunction resulting in increased
cellular vulnerability - Large potassium ionic flux
- Increased cellular glucose demand
- Decreased cerebral blood flow
- Lactate accumulation
- Intracellular acidosis
13Concussion Presentation
- Confusion and amnesia are cardinal features
- Multiple manifestations
14Concussion 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
15Commonly Reported Symptoms
- Commonly Seen Early (min to hours)
- Headache
- Dizziness or vertigo
- Lack of awareness of surroundings
- Nausea and vomiting
16Commonly 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
17Concussion 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
18Concussion 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
19Classification of Severity of Concussion
20Return to Play - Cantu, 1998
Return to play recommendations Cantu, 1998
21Return to Play - CMS, 1991
Return to play recommendations CMS, 1991
22Return to Play - AAN, 1997
Return to play recommendations AAN, 1997
23Points 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
24Sideline Assessment of Neurological Function
- Glasgow Coma Scale
- Lacks sensitivity
- Standard orientation (X3)
- Lacks sensitivity
25Sideline 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
26Standardized 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
27Standardized 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)
28Neuropsychological 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
29Neuropsychological 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
30Problems 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
31Concussion 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
32Concussion 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
33Concussion 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.
34Back 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.
35And 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.