• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Dr. Cantu Nhiaa Abbreviated
 

Dr. Cantu Nhiaa Abbreviated

on

  • 6,556 views

 

Statistics

Views

Total Views
6,556
Views on SlideShare
6,546
Embed Views
10

Actions

Likes
4
Downloads
0
Comments
0

1 Embed 10

http://www.slideshare.net 10

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Dr. Cantu Nhiaa Abbreviated Dr. Cantu Nhiaa Abbreviated Presentation Transcript

    • The History of Concussions and Second Impact Syndrome in High School Athletics NH Interscholastic Athletic Association 9-17-2007 Robert C. Cantu, MA, MD, FACS, FACSM Chairman Department of Surgery Chief Neurosurgery Service Director Service of Sports Medicine Emerson Hospital, Concord, MA Co-Director, Neurologic Sports Injury Center Brigham and Women’s Hospital Boston, MA Medical Director National Center for Catastrophic Sports Injury Research, Adjunct Professor Department of Exercise and Sport Science University of North Carolina at Chapel Hill Copyright © 2003 by Robert C. Cantu, M.D . This presentation cannot be used or copied without written permission from Dr. Cantu. Neurosurgery Consultant Boston College Football and Boston Cannons
    • Source: Pub Med Central
    • Teach Players to Help Each Other
        • “ In case any man in any game got hurt by a hit on the head so that he did not realize what he was doing, his teammate should at once insist that time be called and that a doctor come onto the field to see what is the trouble, also that every man on the
      • squad must make up his mind in case he gets hurt, to have a friend with him from the time the injury occurred until noon of the next day, to prevent any serious results from beginning without anybody being around.”
      • Dr Edward Nichols Harvard Football Team Physician
      • 1905
    • Misconceptions
      • Concussions only occur in football,boxing, and hockey
      • Males experience more concussions than females competing in the same sport
      • Older athletes are at less risk of concussion than children
      • One must be rendered unconscious to sustain a concussion
      • Helmets are made to a standard to prevent concussion
    • Comparing NCAA Game Concussion Rates by Gender Across Similar Sports 2005-2006
      • 2005/2006 Games/Concussion
      • Soccer (W) (20) 1.8 28
      • Soccer (M) (20) 1.4 36
      • Basketball (W) (10) 0.9 111
      • Basketball (M) (10) 0.4 250
    • Sports-Related Head Injuries:
      • Children under 5 suffer relatively few TBI from participating in sports and recreation.
      • The number of TBI increases as age increases and peaks between the years of 15-24.
      • Sports and recreation accounted for
      • - 0.8 injuries per 100,000 persons in children under 5
      • - 5.1 per 100,000 in youth ages 5-14
      • - 6.6 per 100,000 in those aged 15-24.
      • - After age 24, the number of sports related brain injuries decreases as age increases.
    • ER-attended sports/rec injury
        • NEISS-AIP data. CDC. Morb Mort Weekly Report 2002;51:736-40.
    • Helmets Made to Severity Index of 1200
      • To prevent concussion helmets need to be made to a severity index of 300 = 100g = HIC 250
      • What current helmets (SI 1200 ) prevent are:
      • - All skull fractures
      • - Most subdural hematomas
    • Cerebral Concussion Concussion is caused by a variety of mechanisms: Contact with an opponent (64%) Contact with a teammate (17%) Contact with ground (10%) Contact with objects on field (4%) Most concussions caused by poor technique Guskiewicz et al, 2000
    • Concussion Prevention
      • Since most concussions occur in collision sports and are due to poor technique, usually head to head or head to other body part contact
      • To prevent concussions avoid collision sports and if not use proper technique
    • Concussion Prevention
      • Maximal strengthening of neck muscles
      • Proper fit and fastening of headgear
      • Stay well hydrated
      • Genetics
      • Luck
    •  
    • My Story (continued)
    •  
    • Ommaya Grading System for Concussion Grade 1 Confusion without amnesia (stunned) Grade 2 Amnesia without coma. Grade 3 Coma lasting less than 6 hours (includes classic cerebral concussion, minor and moderate head injuries) Grade 4 Coma lasting 6-24 hours (severe head injuries) Grade 5 Comas lasting more than 24 hours (sever head injuries) Grade 6 Coma, death within 24 hours (fatal injuries) From Ommaya AK. Biomechanics of Head Injury: Experimental Aspects . In Nahum AM, Melvin J (eds): Biomedics of Trauma. Appleton & Lange, 1985, pp 245 -269
    • Colorado Medical Society Grading System for Concussion Grade 1 Confusion without amnesia; no loss of consciousness Grade 2 Confusion with amnesia; no loss of consciousness Grade 3 Loss of consciousness From report of the Sports Medicine Committee. Guidelines for the management of concussion in sports. Colorado Medical Society, 1991
    •  
    •  
    •  
    •  
    • Conclusions
      • The guidelines expressed in this paper are minimum for return to competition.
      • I have counseled many athletes who are slow, of limited dexterity, and of slight build to strongly consider terminating a season and even dropping a contact sport in favor of another athletic persuit
    • Conclusions
      • After a concussion the rapid processing and recall of new information is most impaired. Thus for athletes who play certain positions (ie. quarterback) return to competition may be delayed longer than the guidelines recommend .
    • Conclusions
      • A continued aggressive educational effort directed at team physicians, athletic trainers, and coaches is needed. These individuals often lack special training in recognizing mild concussions and their associated symptoms
    • Conclusions
      • Much more data on concussion is needed. Also needed is the adoption of uniform definitions so that interpretation of the data can be as meaningful as possible .
    • Conclusions
      • More research is needed on the cumulative effects of concussion. In 22 (now 45) years of neurosurgery, largely as a football team physician, I have noted that once an athlete has fully recovered from a concussion, a subsequent concussion may not necessarily occur more easily or be as severe. Furthermore, I have found the improper use of the head is the most common cause of repeated concussion
    • Physiology of Cerebral Concussion
      • Neurotransmitters / neurochemicals are released in excessive (excitotoxic) amounts, driving up cellular metabolism (hyperglycolysis) and lactic acid levels
    • Physiology of Cerebral Concussion
      • NA-K pump failure and axonal stretch injury lead to Calcium influx and axonal swelling or disintegration
    • Physiology of Cerebral Concussion Hovda
    • Concussion + secondary insult day 1-7, = cell death or while still symptomatic Secondary Insults Include a second brain injury hypotension loss of autoregulation ischemia increased intracranial pressure anoxia
    • Cantu Guidelines of Return to Play After a First Concussion
      • Grade Guidelines for Return to Play after a First Concussion
      1 May return to play if asymptomatic* for one week 2 May return to play if asymptomatic* for one week 3 Should not be allowed to play for at least one month. May then return to play if asymptomatic* for one week * rest and exertion From Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed 1986;12:76-79. Used with permission of McGraw-Hill, Inc.
    •  
    •  
      • What Saunders and Harbaugh called the second impact syndrome of catastrophic head injury in 1984 was first described by Schneider in 1973.
      • Schneider RC: Head and Neck Injuries in Football: Mechanisms, Treatment and Prevention. Baltimore, Williams & Wilkins, 1973
      • Saunders RL, Harbaugh RE: The second impact in catastrophic contact-sports head trauma. JAMA 1984;252(4):538-539
      • Definition
      • Typically, the athlete suffers post-concussion symptoms after the first head injury
      • These may include visual, motor, sensory or labyrinthine symptoms and/or difficulty with thought and memory
      • Before these symptoms resolve – which may take days or weeks – the athlete returns to competition and receives a second blow to the head.
      • Definition
      • The second blow may be remarkably minor
      • Perhaps involving a blow to the chest, side, or back that merely snaps the athlete’s head and imparts accelerative forces to the brain
      • The athlete may appear stunned but usually remains on his or her feet for 15 seconds to a minute or so but seems dazed, similar to someone suffering from a grade 1 concussion without loss of consciousness.
      • Once brain herniation and brainstem compromise occur, coma, ocular involvement, and respiratory failure precipitously ensue
      • This demise occurs far more rapidly than that usually seen with an epidural hematoma
      • Outcome is 50% mortality and nearly 100% morbidity
    • "To know what you know and to know what you don’t know, that is knowledge” Confucius (551-479 BC)
    • While statistics don’t lie, they don’t necessarily tell the truth RCC
      • Concussion Incidence
      Photo: A. Klepsteen
    • Incidence of Concussion in Football – Trainer Data
      • Powell et al (1999)
      • Guskiewicz et al (2000)
      • Guskiewicz et al (2003)
      • McCrea et al (2002)
      • Zemper (2003)
      • Gerberich et al (1983)
      Source Level Incidence High School HS/College NCAA HS/College HS/College High School 3.6 % 5.6 % 6.3 % 3.8 % 4.1 % 2.4 %
    • Incidence of Concussion in Football – Player Data
      • Langburt et al (2001)
      • Delaney et al (2002)
      • Delaney et al (2000)
      • Gerberich et al (1983)
      • Woronzoff (2001)
      • McCrea et al (2004 )
      Source Level Incidence High School College CFL High School College High School 47.2 % 70.2 % 47.8 % 19.0 % 61.2 % 15.3 % Sallis and Jones (2000) found that 21% of football players suffered a headache in the last game, yet only 19% told anyone Average 3 4
    • Incidence – Data Source Comparison Source: Trainer Athlete 47.2 % 70.2 % 47.8 % 19.0 % 61.2 % 15.3 % 3.6 % 5.6 % 6.3 % 3.8 % 4.1 % 2.4 % Incidence:
    • Gerberich et al Study (1983)
      • Concussion reporting is affected by the question
      • Incidence when players were asked if they’d suffered a “concussion”
      • Incidence when players were asked: Did you have these symptoms following a blow to the head?
      • Only study to survey both diagnosed and undiagnosed concussions
        • Loss of consciousness
        • Loss of awareness
        • Dizziness
        • Headaches
        • Blurred vision
        • Double vision
      • Langburt (47%) vs. McCrea (15%)
      2.4% 19.0%
    • Concussion Definition Symptom Breakdown Objectively Observable by Coach or Trainer Loss of Consciousness Seizure Loss of Balance Syncope “ Ding” Near-syncope Dazed Personality Change Stunned Drowsiness “ Fogginess” Visual Loss Amnesic period Headache Blurred Vision Dizziness Lethargy Light-headed Fatigue Unsteadiness Cognitive Dysfunction Tinnitus Hearing Loss Double Vision Probably Only Known by Player
    • Concussion Observation Across Sports Basketball Flow of Game Football Distance From Players Collisions View of Face Changes in Behavior Intermittent > 20 yards Too many to monitor Hidden by helmet Less visible More continuous < 10 yards Rare Unobstructed More visible The sport itself and the sport’s injury culture both affect reporting rates
    • Why Players Don’t Report Concussions
      • Did not think it was serious enough
      • Did not want to leave the game
      • Did not know it was a concussion
      • Did not want to let down teammates
      Why Concussion Not Reported 66% 41% 36% 22% Source: McCrea M (2004)
    • NCAA Game Concussion Rates by Sport 1998 vs. 2005- 2006 (Concussions/1000 exposures) 1998 Rate 2005 Rate Football (50) 2.6 3.1 Lacrosse (M) (20) 1.9 3.1 Ice Hockey (M) (20) 1.4 2.0 Lacrosse (W) (20) 0.8 2.0 Soccer (W) (20) 2.0 1.8 Ice Hockey (W) (20) 1.8 1.8 Soccer (M) (20) 1.3 1.4 Field Hockey (20) 0.8 0.9 Basketball (W) (10) 0.8 0.9 Basketball (M) (10) 0.4 0.4
    •  
    •  
    • Traumatic Brain Injury Mod Mild Severe Severe GCS < 8 Moderate GCS 9 - 12 Mild GCS 13 - 15 Teasdale et al Lancet 1974; ii: 81-4 Sports concussion ? “ Minimal” Glasgow Coma Scale
    •  
    • So what’s the big problem??
      • How to determine if the player is truly asymptomatic
    • Why Concussion Research Has Progressed So Slowly?
      • No biological marker of mTBI
      • It is a clinical diagnosis
      • Incidence recognized by medical staff is
      • a fraction of total mTBI
      • Single center/school studies involves a small numbers
      • but the same observers
      • Multiple center/school studies involve larger numbers but multiple observers with varying excellence in diagnosing mTBI
    •  
    •  
    •  
    •  
    • Prague 2004 Concussion Recomendations
      • Concussion severity can only be determined after all s/s have cleared, neuro exam nl, cog. function returned to baseline.
      • LOC is associated with early deficits but not concussion severity
      • Pediatric concussion guidelines similar to adults with concept of “cognitive rest” with scholastic and ADL while symptomatic
    • MANAGEMENT PRINCIPLES It is essential the team physician
      • Understand :
        • Brief LOC (seconds, not minutes) is associated with specific early deficits, but does not predict the severity of injury; therefore classification systems or RTP guidelines based solely on brief LOC are not accurate.
        • RGA, PTA, as well as the number and duration of additional signs and symptoms, are more accurate in predicting severity and outcome. RTP guidelines which address these issues are more useful.
        • Duration of symptoms is a major factor in determining severity, therefore severity of injury should not be determined until all signs and symptoms have cleared.
        • The treatment of and the RTP decision for the athlete with concussion must be individualized.
    • RETURN-TO-PLAY SAME-DAY It is essential the team physician understand:
      • It is the safest course of action to hold an athlete out.
    • RETURN-TO-PLAY POST-GAME DAY It is essential the team physician
      • Determine the athlete is asymptomatic at-rest before resuming any exertional activity.
      • - amnesia may be permanent.
      • Utilize progressive aerobic and resistance exercise challenge tests prior to full RTP.
    • Above the Neck vs. Below the Neck Injured vs. hurt Always Injured
    • Concussion Grading Scales
      • Cantu
        • Emphasizes Post-Traumatic Amnesia & Duration PCSS
          • Mild= No LOC PTA/PCSS <30 min
          • Moderate =LOC<1min PTA>30 min<24hr PCSS>30min<7d
          • Severe= LOC>1min PTA >24h PCSS>7d
      • American Academy of Neurology (AAN)
        • Emphasizes loss of consciousness
          • Mild= sx <15min,
          • Moderate= sx >15min,
          • Severe= Any LOC.
    • Data Driven Cantu Revised Concussion Grading Guidelines Grade 1 No LOC* PTA ‡ /PCSS ‡‡ < 30 min (Mild) Grade 2 LOC <1 min or PTA > 30 min <24hrs, other (Moderate) PCSS >30 min <7days Grade 3 LOC > 1 min or PTA > 24 hrs, PCSS > 7 days (Severe) * Loss of consciousness ‡ Post-traumatic amnesia (antrograde/retrograde) ‡‡ Post-concussion sign/symptoms Cantu RC Post-tramatic (retrograde and anterograde) amnesia: pathophysiology and implications in grading and safe return to play. J of Athletic Training 36(3)244-248,2001 `
      • Look for disproportionate impact vs S/S severity
      • ? vulnerability
      • Look carefully for on field amnesia – it correlates
      • with number S/S, duration S/S, abnormal
      • neuropsych tests at 48 hrs *
      Erlanger D Cantu R Barth J Kaushki T and Kroger H: Loss of Consciousness, Anterograde Memory Dysfunction, and History of Concussion: Implications of Return-to-Play Decision Making (submitted JAMA 2002) Lovell MR Collins MW Iverson GL Field M Maroon J Cantu R Podell K Powell J Fu FH Recovery from Concussion in High School Athletes (submitted JAMA 2002)
    • Post Concussion Signs/Symptoms Checklist Bell rung Depression Dinged Dizziness Drowsiness Excess sleep Fatigue Feel “in a fog” Feel “slow down” Headache Inappropriate emotions or personality change Irritability Loss of consciousness Loss of orientation Memory problems Nausea Nervousness Numbness/Tingling Poor balance or coordination Poor concentration, easily distracted Ringing in the ears Sadness Seeing stars Sensitivity to light Sensitivity to noise Sleep disturbance Vacant stare/glassy eyed Vomiting A PCSS checklist is used not only for the initial evaluation but for each subsequent follow-up assessment which is periodically repeated until all PCSS have cleared at rest and exertion..
    • Conclusion The final decision regarding when and if a concussed athlete can return to competition is made on an individual basis and will depend on:
      • The athlete’s concussion history
      • The severity of the injury
      • The duration of signs and symptoms
      • The time between injuries
      • The severity of blow causing concussion
      • The availability of experienced personnel to conduct repeated assessments and monitoring recovery.
    • Guskiewicz K McCrea M Marshall S Cantu R Kelley J Randolph Barr W Onate J. Cumulative Consequences of Recurrent Concussion in Collegiate Football Players: The NCAA Study JAMA 290:2549-2555, 2003
      • 186 concussed football players studied by graded symptom checklist, number and duration of symptoms until asymptomatic, days lost to inj.
      • Players with 3 or more concussions 3.5 xs chance another concussion compared to no concussion history
      • Players with 3 or more concussions tended to experience a slower recovery after subsequent injury (p=.06)
      • Results suggest history of concussions is predisposition to future concussions and 3 or more concussions may lead to slowed recovery
      Cumulative Effects of Concussion
    • Relative Contraindication to Return to Play after Concussion Duration of post concussion symptoms progressively last longer (months not days) Mild indirect blows (not directly to head) produce post concussion symptoms.
    • Retired NFL Players with a History of 3 or More Concussions Compared to Players with No History of Concussion Had:
      • 5 X INCREASE IN MILD CONGITIVE IMPAIRMENT
      • 3 X INCREASE IN SIGNIFICANT
      • MEMORY IMPAIRMENT
      • 3 X INCREASE IN THE DIAGNOSIS OF DEPRESSION
    • USA TODAY 9/24/02 “ Webster was diagnosed in 1999 as having brain damage caused by repeated head injuries during his playing days.” According to his doctors, several concussions damaged his frontal lobe causing cognitive dysfunction. His doctors said the progressively worsening injury caused him to behave erratically at times.” USA TODAY
    • Sports with Cases of Traumatic Encephalopathy Reported in the Literature
      • Boxing
      • Horse racing especially steeplechase jockeys
      • rugby
      • professional soccer
      • professional wrestlers
      • parachuting
      • Corsellis, JAN, Brain Damage in Sport. Lancet 1976;1:401-402
    • If Other Sports Where Head Trauma Is Common Have Traumatic Encephalopathy – Why Not Professional Football ?
              • One would expect to see traumatic encephalopathy in ex NFL players
      • Accusations of
        • Missing/withheld data (Part 6) ( Peter Keating, ESPN The Magazine. October 28, 2006 )
        • Fraud - “filling cells” (Part 6) (Dr. Bill Barr, in Peter Keating, ESPN The Magazine. October 28, 2006 )
        • Inappropriate - “worrisome, perplexing” - statistical analysis (Part 6) (Peer reviewer Dr. Joseph Bleiberg)
      • “ Flaws with respect to the study design, data collection, and data analysis.” (Peer reviewer Dr. Kevin Guskiewicz)
        • Only studied active players (The 3 verified cases of CTE have been found in retired players)
        • Potentially inappropriate test battery selection
        • Only followed players for a maximum of 6 years
        • Did not study the same 650 players for 6 years due to turnover
      Why Didn’t the NFL Find Cumulative Effects or CTE ??
    •  
    • B). Benoit Micro 1: Slides detailing x600 magnification of Chris Benoit's Tau-immunostained neocortex showing Neurofibrillary Tangles, Neuritic Threads, and several Ghost Tangles indicating CTE. For media inquiries or further questions please contact: Patrick Brady Widmeyer Communications 202-256-7824 Rexy Legaspi Widmeyer Communications 646-213-7245
    • C). Benoit Micro 2: Slides detailing x600 magnification of Chris Benoit's Tau-immunostained neocortex showing Neurofibrillary Tangles, Neuritic Threads, and several Ghost Tangles indicating CTE. For media inquiries or further questions please contact: Patrick Brady Widmeyer Communications 202-256-7824 Rexy Legaspi Widmeyer Communications 646-213-7245
    •  
    • Conclusions
      • A continued aggressive educational effort directed at team physicians, athletic trainers, and coaches is needed. These individuals often lack special training in recognizing mild concussions and their associated symptoms
    • Conclusions
      • More research is needed on the cumulative effects of concussion. In 22 (now 45) years of neurosurgery, largely as a football team physician, I have noted that once an athlete has fully recovered from a concussion, a subsequent concussion may not necessarily occur more easily or be as severe. Furthermore, I have found the improper use of the head is the most common cause of repeated concussion
    • Research Questions
      • Is there an acceleration tolerance level for concussions?
      • If so, what risk factors modulate tolerance level?
        • Impact location
        • Concussion History- -*Number,**Proximity,***Severity
        • History of sub-concussive blows
        • Playing position
        • Age
      • Does clinical outcome correlate with impact severity?
      • What is impact exposure vs athlete exposure for football players?
      • Are some cases of prolonged post concussion syndrome due to pituitary gland injury?