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Concussion in sports

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  • 1. Concussion in sportsFadi Hassan – Hull York Medical School
  • 2. • “Complex pathophysiological process affecting the brain. It is the result of traumatic biomechanical forces to the head, face, neck or elsewhere on the body leading to short-lived impairment of neurological function (changes in alertness, concentration and memory)”• It may or may not involve loss of consciousness (<10%) • Loss of consciousness does not mean the case is more severe!Definition
  • 3. • 2-5 % of all athletic injuries• 300,000 sports-related concussions annually in the US only!• 900 sports-related traumatic brain injury deaths• Risk of concussion is 6x higher in players with a history of previous concussionEpidemiology
  • 4. • Risk Factors: • Male • Younger athlete • High risk sport (boxing, wrestling, football, basketball) • History of multiple concussions • Dangerous style of play • Comorbid mental health disorderRisk factors
  • 5. • Headache and Irritability• Dizziness and Lightheadedness• Nausea• Lethargy• Sleep disturbance• Visual changes• Sensitivity to light or sound• Cognitive features: • Amnesia • Disorientation • Confusion • Short attention spanSymptoms
  • 6. • Impaired attention• Vomiting• Vacant stare• Delayed responses• Decreased alertness• Disorientation• Slurred incoherent speech• Gross incoordination• Pseudobulbar affect (Emotional lability) • Uncontrollable burst of emotions like episodes of crying and/or laughing or any other emotional displays• Inappropriate playing behaviorSigns
  • 7. • Occurs when momentum of the head is changed by either • Blunt trauma • Accelerative, declarative or rotational force• The above forces are then transmitted indirectly to the brain  chemical changes in certain parts of the brain at cellular level affecting membrane stability (abnormal movements of ions)  impaired function  increased demand for glucose (for repair).• Blood supply is decreased to the injured part  less glucose delivery  mismatch in supply vs demand  brain tissue becomes vulnerable to another impact• Explaining why RTT is something teams should NOT rush intoPathophysiology
  • 8. • Brain injuries can be • Focal (Coup) • Blunt trauma to the stationary head  brain contusions, lacerations and hemorrhage • Maximal brain injury is beneath the point of cranial impact • Example: Player A goes for an overhead kick, totally missing the ball and hitting Player B’s head. • Diffuse (Contra-coup) • When the moving head strikes a stationary object (Acceleration/deceleration force with angular rotation) • Example: Corner kick position  Player A is on the far post, tries to go for a header, misses the ball and collides with the post (stationary object).Types of brain injury
  • 9. • Airway, Breathing, Circulation (ABC)• Level of consciousness and mental status• Inspect for skull, neck or back injuries• Determine the mechanism of injury• Check for prior concussion injury history (previous symptoms, number of concussions, post concussive convulsions)• Past medical history, medications, drug or alcohol use• Any player with concussion or suspected concussion is NOT allowed to return to play on the same day as the injury.Sideline assessment
  • 10. • Assess speech for fluency and lack of slurring • Eye movements and pupils reflexes (visual examination) • Examine coordination, fine movements, gait and balance • Pronator drift: • Ask the patient to hold both arms in front of them with palms up and eyes closed • Positive test is pronating the forearm, dropping the arm or drifting away from the midlineNeurological Screening
  • 11. • Orientation (Maddocks questions) • Where are we now? • Which half is it now? • What was the score of last game? • What team did you face last week? • Who scored last in this game?• Memory recall • Recite months of the year in reverse orders • Select 5 words or an address, then ask the patient later about them.Mental state testing
  • 12. • Tests to elicit possible post-concussion symptoms• When considering RTT (return to play) for an athlete who is oriented and asymptomatic (5reps) • Jumping jacks • Push-ups • Sit-ups • Up-downs • Single-leg balance with eyes closed, arms at 90 degrees abduction • Running (40 yard dash) or stationary bikeExertional maneuvers
  • 13. • Glasgow coma scale (GCS) • Tool used for initial and subsequent assessment to assess consciousness state after a head injury. 1 2 3 4 5 6 Eyes Does not open Opens eyes in Opens eyes in Opens eyes N/A N/A eyes response to response to spontaneously painful stimuli voices Verbal Makes no Incomprehensib Slurred speech Confused, Oriented, N/A sounds le sounds (muttering) disoriented converses normally • Motor Makes no Extension to Abnormal Flexion/withdra Localizes Obeys movements painful stimuli flexion to wal to painful painful stimuli commands painful stimuli stimuliSideline assessment - GCS
  • 14. • Lowest score you can get is 3 (deep coma/death) while the highest is 15 (fully awake)• Score interpretation • Severe injury: GCS <9 • Moderate injury: GCS 9-12 • Minor: GCS >=13• Tracheal inturbation and severe oedema or damage makes it hard to test for verbal and eye responses  give score of 1 with a modifier (E1c, C= closed, V= tube) • GCS 6tc (1 eyes closed, 1 inturbation, leaving 4 for motor)Sideline assessment -GCS
  • 15. • Sport Concussion Assessment Tool 2 • Standardized method for evaluating concussion • Crucial to have when assessing head injuries • it includes • a symptom evaluation • a physical sign score • GCS • Maddocks score • standardized assessment of concussion (SAC) score • Self explanatory once you get a copy • Can be downloaded from the CDC website: • http://www.cces.ca/files/pdfs/SCAT2[1].pdfSCAT2
  • 16. • It is often tricky to recognize this injury, especially in asymptomatic athletes.• Once this injury is identified: • The player shouldn’t be left alone  monitor + evaluate • The player shouldnt’t RTT while symptomatic. It is against the rules and regulations • Satisfactory rest period is crucial • Cognitive rest is crucial as most sports require concentration and attention, which could worsen the symptomsReturn To Play
  • 17. • Zurich guidelines allow 7-10 days for symptoms and signs of most concussions to resolve.• Exercise challenge is required (>60% of max predicted HR) and cognitive testing• Symptoms lasting >=7days  CT/MRI to exclude further brain damage• Reference to sports concussion specialist is useful.Return to play
  • 18. • Obs: • Recommended for at least 24-48 hours after a concussion • Awaken patient from sleep every 2 hours • Patient should avoid strenous activity for at least 24-48 hours • Warning signs: • Inability to awaken the patient • Severe or progressive headache • Restlessness +/- confusion • Visual disturbances • Vomitting, fever or stiff neck • Urinary/bowel incontinence • Weakness or numbnessReturn To Play - process
  • 19. • RTT protocol (Steps) 1. Complete rest (exertional and cognitive) 2. Light aerobic exercise (walking, stationary bike). No weight lifting 3. Sport-specific exercise with slow progressive addition of resistance training 4. Non-contact training drills 5. Full-contact training after medical clearance 6. Game play• Players only progress to the next step once they’re asymptomatic AT the current step • Symptomatic drop back to the previous step for 24 hours• Each step should take at least 1 day.• Not allowed to take medications that may modify the symptomsReturn To Play - process
  • 20. • Immediate • Concussive convulsions (non-epileptic) • Due to loss of cortical inhibition and release of brainstem activity • CT/MRI normal • Epidural hematoma • Laceration of the middle meningeal artery • Subdural hematoma • Tearing of bridging veinsComplications
  • 21. • Delayed • Post-concussive syndrome: Physical/cognitive concussive symptoms lasting days-months after the injury and is often triggered by exercise. • Treated by rest or NSAIDs, beta-blockers, Tricylclic antidepressants or calcium channel blockers • Cumulative neurocognitive impairment • Dementia pugilistica: Parkinsonism, ataxia, dysarthia, behavioural changes and Alzheimer’s disease. • Mohammed Ali? Due to repetitive concussionsComplications
  • 22. • Delayed • Second impact syndrome • Associated with premature RTT • Rapid catastrophic brain swelling due to cerebral vasculature autoregulatory dysfunction • Rapid deterioration and is often fatal • Long term memory and attention impairments • Younger athletes are at a greater riskComplications
  • 23. • Mouthguards (orofacial safety)• Helmets and head protectors• Strict regulations and punishment on reckless tackles• Low threshold in suspecting a concussion is necessary  When in doubt, give the player sufficient rest• In athletes suffering from concussion, if they are not getting better  suspect more serious damage  CT/MRIPrevention
  • 24. • Identifying a concussion is crucial in sports medicine1. Blow to the head or other part of the body that can transfer the impact to the head2. Recognize a change in player’s function (you, the manager, the player  those who know the player)3. Refer to the SCAT2 card4. Concussed?  take them outKey message
  • 25. • Very interesting paper that I recommend you reading is • “Current practices in determining return to play following head injury in professional football in the UK” • Authors: Jo Price, Peter Malliaras, Zoe Hudson • Published on 28th/August/2012Evidence Based Medicine
  • 26. • Any Questions? • hyfh1@hyms.ac.ukThank you!