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Concussions in Sport Mitigating Risks in the Student Athlete

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  1. Concussions in SportMitigating Risks in the Student Athlete Marc Richard Silberman, M.D.

  2. Tip of the iceberg

  3. Consensus Statement on Concussions in Sport • 2001 • 1st International Conference on Concussion in Sport, Vienna • 2004 • 2nd International Conference on Concussion in Sport, Prague • 2008 • 3rd International Conference on Concussion in Sport, Zurich • Sport Concussion Assessment Tool (SCAT2)

  4. High School Concussions • Over 50% of concussed high school football athletes do NOT report their injury to medical personnel McCrea, M., Hammeke, T., Olsen, G., Leo, P., and Guskiewicz, K.M. (2004). Unreported concussion in high school football players: implications for prevention. Clin. J. Sport Med. 14, 13–17.

  5. High School Concussions JAMA. 1999 Sep 8;282(10):989-91 Concussion 5.5% of total injuries Football 63.4% of concussionsWrestling 10.5%Girls Soccer 6.2%Boys Soccer 5.7%Girls Basketball 5.2%Boys Basketball 4.2%Softball 2.1%Baseball 1.2%Field Hockey 1.1%Volleyball 0.5%

  6. H.S. Basketball Concussions • Concussion Cause • Collision with another player 65% • Contact with the floor 13% • Personal opinion this is not the truth • Concussion Activity • Rebounding 30% • Defending 20% • Illegal Activity • Total number of injuries 13% • Concussions 35% Am J Sports Med December 2008 vol. 36 no. 12 2328-2335

  7. Collegiate Concussions • Soccer, lacrosse, basketball, softball, baseball, and gymnastics • 14,591 injuries in male and female athletes • 5.9% of all injuries were classified as concussions • Males Game Injury Rate / 1000 exposures • Soccer 1.40 • Lacrosse 1.46 • Basketball 0.47 • Females • Soccer 2.10 • Lacrosse 1.05 • Basketball 0.73 J Athl Train. 2003 Jul–Sep; 38(3): 238–244

  8. Perceptions • Survey 300 players, 100 coaches, 100 parents, 100 ATCs • If a player complains of a headache , should return to play? • Players 55%, Coaches 33%, ATC 30%, Parents 24% • Percentage who would play a concussed star in a title game? • Players 54%, ATC 9%, Parents 6.1%, Coaches 2.1% • Level of concern for concussions (1 = most concerned; 4 = least) • Players 3.5, Coaches 2.4, Parents 2.1, ATC 1.6 • Is a good chance of playing in the NFL worth a decent chance of permanent brain damage? • Players 44.7%, Coaches 19.4%, Parents 15%, ATC 10%

  9. Your Brain “This is your brain. This is your brain on drugs.”

  10. Your Brain

  11. The Brain • Freely floating within the cerebrospinal fluid • Moves at a different rate than the skull in collisions • Collision between the brain and skull may occur • On the side of the impact (coup) • On the opposite side of the impact (contracoup injury) • Acceleration-deceleration may result in stretching of the long axons and in diffuse axonal injury

  12. What is a concussion? • Complex pathophysiological process affecting the brain induced by traumatic biomechanical forces • Functional disturbance of the brain • No ‘visible’ structural injury • Typically short lived impairment that resolves spontaneously • Direct blow to the head • Indirect blow with a force transmitted to the head

  13. Classification of concussions • A concussion is a concussion • There is no such thing as a mild concussion • No grading system • Most symptoms resolve in a short period of 7-10 days • Post concussive symptoms may be prolonged in children

  14. Concussion diagnosis • There is NO test to diagnose a concussion • Clinical diagnosis based on the following: • Symptoms • Physical Signs (impaired balance) • Behavioral Changes (cry, irritable) • Cognitive Impairment (slow reaction time, memory) • Sleep Disturbances (drowsiness)

  15. Symptoms • Headache (83%) • Dizzy (65%), dazed, fog • Light and sound sensitivity • Visual disturbances • “Everything seems slow” • “My colors changed” • Teammate, “Eric’s not right, coach” • Appearance can be delayed several hours

  16. Physical Signs • You do not have to lose consciousness • Amnesia (“Doc, I don’t remember the first half”) • Emotional labile (crying, talkative) • Poor balance • Difficulty concentrating • Difficulty remembering

  17. On-Field Evaluation • Standard emergency management • Exclude cervical spine injury • Return to play determined by a physician • “When in doubt, sit them out” • No player shall return to play the same day • Sideline assessment of concussion (SCAT2) • Monitor for any deterioration over time

  18. Syracuse Post-Standard Jan 16, 2005

  19. Concussion Management • Complete physical and cognitive rest until symptom free • No sports • No horseplay • No school, if necessary • No texting, video games, internet, TV, driving • Graded program of exertion prior to full return to play

  20. Exertion effects • Symptoms are worsened by • physical activity • mental effort • environmental stimulation • emotional stress

  21. Academic Accommodations • Excuse from school if necessary • Excuse from homework • Excuse from quizzes and tests • Rest breaks during school in a quiet location • Avoid re-injury in crowded hallways or stairwells • Avoid over-stimulation (cafeteria or watching games) Provide reassurance and support

  22. Recovery from Concussion • Most ‘recover’ in 1 – 2 weeks, 95% recover in 3 months • Longer in younger athletes and in female compared to male • Post-concussion syndrome is the presence of symptoms for at least 3 months post injury • Deficits in balance resolve in 5 days • Cognitive tests return to baseline in 5 – 10 days • Abnormalities in metabolic balance, oxygen consumption, and electrical responses persist for several months a ‘miserable minority’ experience persistent symptoms

  23. Post-concussion syndrome Risk factors for complicated recovery • Re-injury before complete recovery • Over-exertion early after injury • Significant stress • Unable to participate in sports • Medical uncertainty • Academic difficulties • Prior or comorbid condition • Migraine • Anxiety • ADHD, LD

  24. Multiple Concussions • Second Impact Syndrome • A concussion prior to recovery from a prior concussion • Athlete is still symptomatic • Mostly males < 21 years old • Rapid increase in intracranial pressure • Rare but almost always fatal • Cumulative effects • Risk of concussion is 4-6 times greater after one concussion • Risk is 8 times greater after sustaining two concussions • Prolonged or incomplete recovery • Increased risk of later depression or dementia How many is too many ?

  25. Chronic Traumatic Encephalopathy • Progressive degenerative disease from multiple concussions • Build up of Tau protein in brain • 35 brains of deceased athletes Center for the Study of Traumatic Encephalopathy (13 belonged to former NFL players). • 12 out of 13 brains manifested Chronic Traumatic Encephalopathy (CTE) • 3 out of 12 exhibited motor neuron disease (Chronic Traumatic Encephalomyelopathy)

  26. Return to activity • 1. No symptoms at rest • 2. Balance testing returns to baseline • 3. Neuropsychological test returns to baseline • 4. Consideration of modifiers • 5. Graded return to play protocol

  27. Neuropsychological Tests • Neuropsychological testing is an additional tool • May assist in return to play decisions • Need a baseline • Perform the follow-up test when symptom free • Cognitive recover • most overlap symptom recovery • may precede symptom recovery • may follow symptom recovery • Motivation and practice effects affect results • Do not reflect metabolic recovery of the brain You can be fooled!

  28. Graduated return to play protocol Day 1 Light aerobic exercise Light jog/stroll, stationary bicycle Goal: elevate HR Day 2 Sport-specific exercise Running drills in basketball Goal: add movement Day 3 Non-contact training drills Passing and shooting, light resistance training Goal: coordination, cognitive load, valsava Day 4 Full contact practice only after physician clearance Day 5 Return to competition Any symptoms at any stage, return to complete rest

  29. Prevention “An once of prevention is worth a pound of cure” - Benjamin Franklin

  30. Mechanism of Injury • All sports head to head collision 50% • Soccer study of 20 FIFA tournaments from ‘98 – ‘04 • Aerial challenges 55% • Use of the upper extremity 33% • Use of the head 30% • Only one injury (neck strain) as a result of ball heading • Lacrosse study of 560 games, 50 schools, 5000 athletes • Men (32/34) almost all were a result of body checks • Female (8/14) were a result of stick to head contact

  31. Mechanism of Injury Hockey • Body checking 86% of all injuries in 9 – 15 year old • Contact leagues 4x injury rate, 12x fracture rate • 45% legal body checks, 8% illegal body checks • Direct fatality and injury rates for football are half of hockey • Spinal cord injury and brain injury rate • 2.6 per 100,000 high school hockey players • .7 per 100,000 high school football players

  32. Head Down Contact and Spearing • Improved helmet technology has led to the increased use of the head at contact, intentional and unintentional • Each time a player initiates contact with his head down he risks quadriplegia • Each time a player initiates contact head firsthe risks concussion Heck et al. Journal of Athletic Training 2004;39(1):101–111

  33. Spearing • The use of the helmet (including the face mask) to punish an opponent • No player shall use his helmet (including the face mask) to butt or ram an opponent or to punish him • No player shall strike a runner with the crown or the top of his helmet in an attempt to punish him • Always make contact with your shoulder while keeping your head up Head down contact and Spearing Slide Show

  34. Head Down Contact and Spearing • Educate players, coaches, and officials • Teach fundamentals and correct contact technique • Survey of 600 Louisiana High School players • 29% using top of helmet to tackle was legal • 32% head butting was legal • 35% permissible to barrel over an opponent headfirst • Only 2 coaches showed a blocking and tackling safety video distributed free by the state federation

  35. Helmets and Mouth Guards • Helmets prevent skull fractures • Helmets do not prevent concussions, they cause concussions • Mouth guards prevent dental injuries • Mouth guards do not prevent concussions

  36. Mitigate Risk • Fundamentals • Respect Hall of Fame Coach Bob Hurley Sr.

  37. Concussions in Sport Thank you. Marc Richard Silberman, M.D. Gillette, NJ drbicycle@njsportsmed.com (908) 647 6464