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 Hooper
The Sunday Telegraph
March 15, 2014
7.
8.
9. In partnership with:
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
10. In partnership with:
• AFL – 5-6/1000 player hours
• Equals 6-7/season per team on average
BrizBrain & Spine St Andrews
Education Meeting 2006
12. In partnership with:
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
13. In partnership with:
• 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
14. In partnership with:
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
15. In partnership with:
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
16. In partnership with:
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
26. In partnership with:
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
27.
28. In partnership with:
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
29.
30. In partnership with:
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
31. In partnership with:
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
32. In partnership with:
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,
33. In partnership with:
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
34. In partnership with:
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
35. In partnership with:
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
