Concussions in Sports

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Concussions in Sports

• Kevin deWeber, MD, FAAFP
• Primary Care Sports Medicine Fellowship Director
• USUHS/Dewitt Army Hospital
• August 2009

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Zurich Guidelines

• Consensus Statement on Concussion in Sport. 3rd
  International Conference on Concussion in Sport
  Held in Zurich, November 2008.
• Clin J Sports Med May 2009 19(3)185.

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Concussion - Definition

• Complex pathophysiological process affecting the
  brain
• Induced by traumatic forces
• Direct or Indirect
• Functional Disturbance rather than Structural
  Injury
• No abnormality on standard structural neuroimaging

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Pathophysiology

• Neuronal dysfunction
• Ionic shifts
• Altered metabolism
• Impaired connectivity
• Changes in neurotransmission
• Neuropathological Changes
• No evident structural changes

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Classification

• Simple vs Complex

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Signs and SymptomsOne or more of the following

• Symptoms
• Somatic Headache
• Cognitive Feeling In a Fog
• Emotional Lability
• Physical Signs
• Loss of Consciousness, Amnesia
• Behavioral Changes
• Irritability
• Cognitive Impairment
• Slowed reaction times
• Sleep Disturbance
• Drowsiness

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What proportion of athletes recognize symptoms as
being due to a concussion?

• 1 of 10
• 1 of 5
• 1 of 3
• 1 of 2
• Practically all

• 1 of 3
• Implication YOU as the physician need to be
  LOOKING for athletes w/ concussion

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On the Field Management

• If unconscious, assume concomitant cervical spine
  injury until proven otherwise
• Dont rush to get the athlete off the field, but
  also dont do your entire neuro/mental status
  exam on the field either

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After Initial Questioning

• Give the athlete a few minutes to cool off and
  regain composure
• Observe the athlete from afar- 10-30 feet away
• Look for the blank stare, shaking of the head,
  abnormal body language such as a slumped and less
  aggressive posture

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Sideline Management

• Place the athlete in a area where he/she can sit,
  not be bothered by other athletes and coaches,
  and can hear questions

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Sideline Management

• If a concussion is suspected, notify the coaches
  that the athlete is out until further notice
• Consider giving the athlete a few minutes to
  regain his composure before beginning the barrage
  of questions
• Assess with brief concussion tool
• Maddocks questions
• SAC
• Etc.

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• Brief neuro exam
• Symptom score
• Glascow Coma scale
• Maddocks game questions
• Short Assmt of Concussion (SAC)
• Balance
• Coordination

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Concussion or not?

• YES if ANY of the following
• Symptoms
• OR
• Signs (LOC, neuro deficits, cognitive deficits)
  

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Pearl

• Once a concussion has been diagnosed, take and
  hide the athletes helmet/headgear to prevent him
  from returning to the game

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Q For a concussion with no loss of consciousness
and resolution of symptoms in less than an hour,
when is return to play safe?

• Immediately
• Second game of double-header
• In 24 hours
• In 10 days
• Determined on case-by-case basis

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Return to Play Rules

• Individualized RTP decisions
• no cookie-cutter RTP guides
• NO ONE returns while still symptomatic
• Athletes must be asymptomatic both at rest, w/
  cognition, and w/ exertion
• Must have normal cognitive function

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• There is data...that, at the collegiate and HS
  level, athletes allowed to RTP on the same day
  may demonstrate NP deficits post-injury that may
  not be evident on the sidelines and are more
  likely to have delayed onset of symptoms.
• Zurich guidelines 2009

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Pearls

• Be wary of the delayed and recurrent symptoms
• Many athletes may seemingly normalize within
  minutes of an injury, but then have a recurrence
  and potential worsening minutes to hours later
• This concept suggests that very rarely should an
  athlete with a suspected concussion return to the
  game on the same day of an injury

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Explaining the Risks of Premature RTP

• 2nd impact syndrome
• Death
• Higher risk in young athletes
• Risk of prolonged symptoms with a premature
  return and/or a 2nd concussion before full
  recovery

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Staged Return To Play 24 hours for each stage

• Cognitive and Physical Rest until asymptomatic
• Light aerobic exercise
• Sport-specific aerobic exercise
• Noncontact training drills light resistance
  training
• Full-contact training if medically cleared
• Game play

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Staged Return to Play

• 24 hours for each stage
• Progress to next stage ONLY if asymptomatic
• If sxs recur w/ exertion
• Return to the previous stage OR
• Rest for an additional 1-3 days OR
• Return to stage 1

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f/u Management Issues

• Comprehensive evaluation
• Imaging?
• Serial assessments until normalized
• Neuropsych testing
• Symptom treatment
• Activity progression
• Return to play determination

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In-Office (or ED) Comprehensive Evaluation

• Comprehensive HP and detailed neuro exam by HCP
• Mental status
• Cognitive function
• Gait and balance
• Clinical status determination
• Improvement vs deterioration
• Determine if emergent neuroimaging is needed

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Immediate Imaging?

• Computed tomography and MRI rarely have a role in
  the diagnosis of uncomplicated concussions
• Consider an immediate CT scan under the following
  conditions
• Prolonged loss of consciousness (gt60 seconds)
• Post-concussive prolonged seizures
• Major neurological deficits, especially motor
  deficits
• Significant lethargy or rapid/progressive
  worsening of symptoms

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Concussion ModifiersThings that may influence
eval, mgmt, and may predict prolonged recovery

• Severe symptoms, or duration gt10d
• LOC gt 1 minute, or amnesia
• Concussive convulsions (other than immediate)
• Repeated concussions, esp close together or
  progressively requiring less force
• lt 18 years age
• Co-morbidities migraine, depression, ADHD, LD,
  sleep disorders
• Psychoactive drugs, anticoagulants
• Dangerous style of play
• Contact/colllision sport, high sporting level
• ?? Female gender

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Implications for Modifyers

• Neuropsych testing more important
• Balance assessment more important
• Neuroimaging more important
• Multi-disciplinary management

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Post-Game Management

• Find out the plans of the athlete for the evening
• Who can monitor him?
• Suggest strict rest
• Supply the athlete and/or roommate/parents with
  phone numbers for the physician or ATC
• Give copy of SCAT card
• Schedule follow-up with ATC or MD
• Next day for moderate-severe concussions
• 1-3 days for mild concussions

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Monitor for cognitive recovery with Neuropsych
Testing

• One of the cornerstones of concussion evaluation
• Tools available
• Sport Concussion Assessment Tool (SCAT2)
• Poor-mans method
• Computerized testing-- but GOOD
• ImPACT (Immediate Postconcussion Assessment and
  Cognitive Testing)
• Headminder
• CogSport
• ANAM (Automated Neuropsych Assmt Metrics)

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Neuropsychological Testing

• OBJECTIVE evaluation of function
• Baseline testing is VERY helpful
• Allows comparison of baseline to post-injury
  tests
• If baseline testing not available, compare to
  age-matched controls and a percentile generated

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Neuropsychological Testing

• When to test and how often?
• most useful when the athlete is asymptomatic
• may be useful for the symptomatic STUDENT athlete
  to help plan school home mgmt

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• Neuropsychological tests should neither be the
  primary determinant regarding return-to-play, nor
  should they take the place of good clinical
  judgment

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Concussion Management
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Symptom Treatment

• REST!... the only known effective treatment for
  a concussion
• Encourage frequent breaks from studying
• Encourage good hydration and regular meals to
  avoid dehydration and hypoglycemic-related
  headaches

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Medications

• Tylenol may be used to treat headache symptoms if
  there is no immediate intent to return-to-play
• NSAIDs safety?
• No sedating meds

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Managing Exercise

• 1. Rest completely until asymptomatic and NP test
  suggests resolution
• 2. light aerobic exercise
• Preferably indoors
• 3. sport-specific exercise
• E.g. running, skating, swimming

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Managing Exercise(continued)

• 4. individual sport-specific drills
• 5. non-contact team practice
• (jersey signifying non-contact status)
• 6. full practice/game

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Managing Exercise Principles

• To advance to the next stage, the athlete has to
  remain asymptomatic
• If symptoms develop, then consider
• Rest for an additional 1-3 days
• Return to the previous stage
• Return to stage 1
• Consider making each stage 2-3 days if returning
  from a more severe concussion or if multiple
  concussions during that season

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Special Populations
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Q Compared to adults, childrens and
adolescents recovery from concussion can be
described as

• Slower recovery
• Same rate of recovery
• Faster recovery

• Slower recovery

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High school athletes recovery from concussion
Collins M, et al. Neurosurg 2006
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Pediatric Athletes (lt18)

• AAP recommends conservative management
• NO return to play on same day
• Seriously, NO return to play on same day

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Student Athlete Management

• COGNITIVE REST
• If sxs recur with cognitive activity, time off
  school may be needed
• Involve teacher, school nurse, principal, coact

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Student Athlete Management

• Trial and error no students alike
• Tailor activities to minimize sxs
• Drive to school
• Reduce length of school day
• Rest periods as needed
• Reduce homework
• Longer time for tests delayed tests
• Minimize background noise excessive light

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Elite vs. Non-Elite Athletes

• Manage using SAME tx and RTP paradigm
• Recommend formal baseline NP screening in
  high-risk sports

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In-Game Return-to-Playis CONTROVERSIAL

• Only clear an ADULT, PROFESSIONAL athlete for
  return to same game under the following
  conditions
• Initial presentation was mild (no LOC)
• Symptoms completely resolve within only a few
  minutes (less than 5-10)
• All neurological testing is normal
• Sport-specific drills (running, cutting, kicking,
  catching) reveal normal speed and coordination
  and do not cause any symptoms
• You truly believe the athlete is being honest
  with regards to the reporting of his symptoms

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Return to Play DecisionsThe tough cases

• Three or more concussions end the season
• At least 3 months before resuming any contact
  sports
• Decreasing levels of trauma producing concussion
• End the career

Robert Cantu, expert opinion, Curr Sports Med Rep
2009
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Persistent Cases(gt2-3 weeks)

• Multidisciplinary approach needed
• Physician
• Control HAs with meds
• Referrals
• Full neuropsych testing
• Refer for specific treatment of identified
  problems

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The Role of Imaging

• PET scans, SPECT scans and functional MRI may be
  on the horizon to assist with concussion
  diagnosis, severity grading and return-to-play

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Conclusion

• Individualize your approach with each athlete
• Concussion management is not cookie-cutter
  medicine
• Disqualifying an athlete from competing for the
  remainder of the season is difficult, and must be
  individualized and based on multiple factors
• Determine who your concussion experts are
• Who manages the most?
• Many neurologists and neurosurgeons rarely see or
  manage athletes with concussions

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Questions?