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Concussion Update The State of Play

Concussion Update The State of Play. Terry Coyne BrizBrain & Spine Sunshine Coast Brain & Spine. Aims. Identify concussion Appropriately advise players/other stakeholders re management, return to play Access resources. NFL, RETIRED PLAYERS RESOLVE CONCUSSION

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Concussion Update The State of Play

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  1. Concussion UpdateThe State of Play Terry Coyne BrizBrain & Spine Sunshine Coast Brain & Spine

  2. Aims • Identify concussion • Appropriately advise players/other stakeholders re management, return to play • Access resources

  3. NFL, RETIRED PLAYERS RESOLVE CONCUSSION LITIGATION; COURT-APPOINTED MEDIATOR HAILS “HISTORIC” AGREEMENT Thousands of Retirees and Families to Benefit Medical Testing; Research; Compensation and Promotion of Safety All Part of Agreement Former United States District Judge Layn Phillips, the court-appointed mediator in the consolidated concussion-related lawsuits brought by more than 4,500 retired football players against the National Football League and others, announced today that .

  4. NFL would pay $765 million plus legal costs, but admits no wrongdoing. • Individual awards would be capped at $5 million for players suffering from Alzheimer’s disease. • Individual awards would be capped at $4 million for deaths from chronic traumatic encephalopathy (CTE).

  5. Greg Williams has said that multiple concussions in his career resulted in permanent damage. • The Age, September 2013

  6. NRL legend Mark Geyer set to have a brain examination and wants to other players who suffered concussion to be tested for potential trauma James HooperThe Sunday TelegraphMarch 15, 2014

  7. What is concussion? • Subset of mechanical brain injury • Can be direct or transmitted force to head • Typically rapid onset of neurological impairment which resolves spontaneously, but may evolve over minutes/hours • Acute symptoms usually due to functional disturbance rather than structural • May or may not involve LOC • Occasionally symptoms may be prolonged BrizBrain & Spine St Andrews Education Meeting 2006

  8. AFL – 5-6/1000 player hours • Equals 6-7/season per team on average BrizBrain & Spine St Andrews Education Meeting 2006

  9. Symptoms & Signs • Symptoms - somatic (eg headache) - cognitive (eg “feeling foggy”) - emotional (eg lability) • Signs eg loss of consciousness, amnesia • Behavioural change (eg irritability) • Cognitive impairment (eg slowed reaction times) • Sleep disturbance (eg insomnia) BrizBrain & Spine St Andrews Education Meeting 2006

  10. On field/Sideline evaluation If ANY features of concussion: • Player requires evaluation; if none available, remove from play and arrange assessment • Standard emergency evaluation (ABC’s), Cx spine assessment • Assessment using appropriate tool (eg SCAT 3) • Player not left alone • If concussion – no return to play that day BrizBrain & Spine St Andrews Education Meeting 2006

  11. Diagnosis is a medical decision based on clinical judgement • Traditional questions to assess orientation (T,P, P) unreliable • Can be delayed BrizBrain & Spine St Andrews Education Meeting 2006

  12. In Emergency Room/Surgery • Good history, detailed neuro exam (including mental status, cognition, gait, balance) • Improving or deteriorating? • Assess need for neuroimaging if need to exclude structural injury (prolonged disturbed LOC, focal deficit, deteriorating) (SCAT 3) BrizBrain & Spine St Andrews Education Meeting 2006

  13. Other Investigations • Balance Error Scoring System (BESS) – postural stability correlates well with overall neurological motor function • Biomarkers – genetic (eg Apo 4) - cytokines (eg IGF-1, S-100), in serum, CSF • Electrophysiological – EEG, evoked responses) - interesting, but significance unknown BrizBrain & Spine St Andrews Education Meeting 2006

  14. Neuropsychological Assessment • Useful, but not practical except in professional setting • Symptoms usually resolve first, so when used usually after player asymptomatic • No evidence to support baseline neuropsych testing BrizBrain & Spine St Andrews Education Meeting 2006

  15. Concussion

  16. Management • Key Points – physical and cognitive rest until acute symptoms resolve - then graduated exertion to normal play • No return to play on day of a concussion, esp school age, where cognitive deficits may not be present on the sideline, but may be delayed, more so than in adults BrizBrain & Spine St Andrews Education Meeting 2006

  17. Graduated RTP • Usually 24 hrs for each level, so 1 week to progress to RTP from when asymptomatic at rest • If symptoms recur, rest 24 hrs, and restart one level back, where was asymptomatic • Elite v non-elite – elite may have more resources, but their brains are the same, so management no different BrizBrain & Spine St Andrews Education Meeting 2006

  18. Persisting symptoms (>10 days) • 10-15 % of concussions • Consider other pathologies (imaging) • Maybe multi-disciplinary approach – physio, psychologist, neuropsychologist, vestibular rehab etc • Pharmacology – specific symptoms (eg sleep disturbance, anxiety) - modify pathophysiology to shorten symptoms - methylphenidate (Ritalin), amantadine. But……. BrizBrain & Spine St Andrews Education Meeting 2006

  19. Children (<13 yrs) • Ist step is successful return to school, prior to physical activity, even physical ADL’s • Increased risk of cerebral swelling • Need to be entirely symptom free before return to sport • May take longer to recover than adults • Child SCAT – neuropsych more difficult as brain not mature, so hard to standardise tests • Generally be more cautious BrizBrain & Spine St Andrews Education Meeting 2006

  20. Risks of too soon RTP • Impaired performance, re-injury due to slower reaction times, for example • 2nd impact – acute severe cerebral swelling - ? disturbed auto regulation - case report level • ?CTE – seems to be greater risk of cognitive impairment, depression/other mental health issues amongst NFL players with multiple concussions; but we don’t know the type, number or severity of concussions required, and why a small # only get CTE. So, err on the side of caution BrizBrain & Spine St Andrews Education Meeting 2006,

  21. Chronic traumatic encephalopathy (CTE) • Distinct tau-opathy • Incidence in athletes unknown • Cause and effect unknown • ?Genetic disposition • Other factors – age, mental health, alcohol/drug use, medical co-morbidities – largely not accounted for in studies to date BrizBrain & Spine St Andrews Education Meeting 2006

  22. Prevention • Unfortunately, little evidence for protective gear. Mouthguards, football helmets good for dental, facial protection, but no evidence they decrease concussion. Also “risk compensation”, esp children, adolescents • Skiing, snowboarding – evidence, so recommended • Cycling, equestrian, motor sports - prob protect against falls against hard surfaces, less skull #’s BrizBrain & Spine St Andrews Education Meeting 2006

  23. Thank you Visit BBS Website to download: • Pocket Concussion Recognition Tool • SCAT 3 • Child SCAT 3 • Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, held in Zurich, November 2012 BrizBrain & Spine St Andrews Education Meeting 2006

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