Is it Safe for Your Patient’s Brain to Play Sports? Andrew Cannon, MHS, PT, SCS Dir., Sports Medicine, NRHN Team PT, Lecturer, Merrimack College NHIAA Sports Medicine Board NH-SCAC
Northeast Rehabilitation Hospital Acute Care Rehabilitation – We have, on-site: Pain Clinic Pharmacy Outpatient Therapies Orthotics & Prosthetics 23 Outpatient Clinics Clinic, Wheelchair Clinic, Home Care Low-Vision Clinic, Driving Assessments and more… Programs consist mainly of: Stroke Neurological Brain Injury Spinal Cord Injury General Rehab Multi-trauma
New Hampshire Sport Concussion Advisory CouncilMission: Improve concussion-related safety of NH athletes
Does academic performance relate to physical activity? 7,961 school kids Age 7-15 Consistently across age groups and gender academic performance was correlated with physical activity and fitness measurementsDwyer T, Relation of academic performance to physical activity and fitness in children.Ped ExSci 13:225-237 2001
What is a Concussion CDC A type of brain injury that changes the way the brain normally works. Caused by a bump, blow, or jolt to the head that causes the head and brain to move rapidly back and forth. Children and adolescents are among those at greatest risk for concussion Sport related concussion in US 1.6 - 3.8 million 6-10% of all sports related injuries Ages 5-18 the 5 leading sports/recreational activities resulting in concussion are?
What % of concussions in children are sport related? < 10 YO = 18.2% 10-14 YO = 53.4% 15-19 YO = 42.9% In contact sports 20% suffer concussion each season Estimated concussions are under reported by 65%! 60 % high school students participate in sports The sheer volume makes sport related concussion a public health issue!
Zurich Consensus Statement Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Direct or indirect blow to the head or body with “impulsive” force to the head Typically rapid onset of short-lived impairment of neurological function that resolves spontaneously – 90% resolve 1-2 weeks – 10% suffer prolonged post-concussive symptoms
Zurich Consensus Statement Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course however it is important to note that in a small percentage of cases however, postconcussive symptoms may be prolonged. Acute clinical sx’s largely represent a functional disturbance, not a structural one No abnormality on standard structural neuroimaging studies is seen in isolated concussion SOFTWARE NOT HARDWARE
Chelsea Davis, 16 year old American diver, 2005 world championships broken nose, laceration, no concussion!
Evolving Knowledge LOC not required “Mild” traumatic brain injury (mTBI) – With some disagreement? PCS Neurometabolic/neurochemical imbalance – Neuronal depolarization, impaired axonal function – Energy crisis: cerebral blood flow; glucose demand – Problem with the software, not the hardware
TheMolecularPathophysiologyof ConcussiveBrainInjuryGarni Barkhoudarian, MD, David A. Hovda, PhDChristopher C. Giza, MDClin Sports Med 30 (2011) 33-48
Evolving Knowledge Second Impact Syndrome – Further impact before resolution may be catastrophic – Diffuse cerebral edema – Does it exist? Multiple Concussions – Subsequent concussions with less provocation – Prolonged recovery – PCS
Seminal Study (Barth et al., 1989) Problem in MTBI: Adequate controls, controlling for premorbid functioning, detecting change Test-retest design – collegiate football players Baseline neuropsychological testing, serial post- injury testing 10 universities – n=2350 players baseline tested Neurocognitive deficits at 24 hrs and 5 days post- injury, with return to preseason baseline by Day 10 Sports arena recognized as a unique, relatively well- controlled lab for assessing mTBI.
Recovery From Concussion: How Long Does it Take? WEEK 5 WEEK 4 WEEK 1 WEEK 3 WEEK 2N=134 High School athletes Collins et al., 2006, Neurosurgery
Studies Reporting Individual Recovery Rates Authors Sample Population Tests Utilized Total Days Total Days Individual Size Cognitive Symptom Recovery Resolution Resolution Rates McCrea, 94 College Paper and Pencil 3-5 Days 7 Days 91%Guskiewicz et recovered al. w/in 7 days 2003Iverson et al. 30 High School Computer 10 days 7 Days 50% 2006 ImPACT recovered w/in 7 days Collins 134 High School Computer NR NR 40%Lovell, et al. ImPACT recovered 2006 w/in 7 days
Concussion Epidemiology 7.5 million kids participate in HS sports, 3.1, 4.4 Published estimates – CDC: 100,000 annual HS concussions – 9% of high school sports injuries – 19.3% high school football injuries! Only MVAs cause more in 15-24 age group 1 in 20 HS football players per season Under-reported!!! – Especially in football…don’t ask, don’t tell!
Concussion Epidemiology Injury rate per 100,000 player games in high school athletes – Football 47 – Girls soccer 36 – Boys soccer 22 – Girls basketball 21 – Wrestling 18 – Boys basketball 7 – Softball 7Data from HS RIO, JAT, 2007
Concussion Epidemiology Head injury in younger players may impair developing brain Females at higher risk for sustaining a concussion than males in the same sport - especially at lower levels of competition
Explosion girls sports in NH since Title IX in 1971, now in NH, 1 in 3 girls participate Girls sustain concussion 68% more often than boys Youth basketball rate is 3x higher for girls Lacrosse, soccer, hockey
Signs and Symptoms of Concussion Signs Observed by Others – Appears dazed or stunned – Confused about events – Answers questions slowly – Repeats questions – Can’t recall events prior to injury – Can’t recall events after injury – Loss of consciousness – Shows behavior or personality changes – Forgets class schedule or assignments
4 Symptom CategoriesCognitive Emotional• Difficulty remembering • Irritability• Difficulty concentrating • Sadness• Feeling slowed down • Feeling more emotional• Feeling mentally foggy • NervousnessPhysical • Sleep• Headache • Drowsiness• Fatigue • Sleeping less than usual• Dizziness • Sleeping more than usual• Sensitivity to light and/or • Trouble falling asleep noise• Nausea• Balance problems
What grade is it? Demonstrating true international consensus on this issue, the Zurich statement makes no mention whatsoever of concussion grading scales. Prague, 2004 put forth simple and complex as an option to I, II, III The NH State Advisory Council on Sport‐Related Concussion agrees with the individual‐athlete management and decision‐making approach and supports the use of careful monitoring of clinical symptoms (somatic, cognitive, emotional), physical signs, behavior, balance, sleep and cognition in the assessment and monitoring of concussion.
Why worse in kids?Traditionally, young age at the time of brain injury has been thought to have protective benefitsHowever, growing literature, strongly indicates that the immature brain is more vulnerable
Hypotheses Skills not yet well established at the time of insult could be more susceptible to disruption than well‐established ones The brain systems responsible for skill acquisition could be affected directly by diffuse injury Functional recovery may be restricted by the injured child’s smaller repertoire of existing skills Injury to the immature brain could interfere neurobiologically with the intricate sequence of chemical and anatomic events necessary for normal development.
Acute Management Call 911: – Extended (or late) loss of consciousness(15 seconds) – Seizure/posturing – Vomiting (?repeated?) – Any worsening of symptoms (e.g., headache getting worse, increased disorientation, etc…) – Frank amnesia – If you think you should!
On-Field or Sideline Evaluation Medically evaluated using standard emergency management principles After addressing first aid issues, assessment of the concussive injury using a standardized assessment tool (SCAT, BESS, SAC, etc) Serial monitoring for deterioration over the the initial hours following injury
ER/ Medical Evaluation Medical assessment should include – Comprehensive history – Detailed neurological examination – Assessment of mental status and cognitive functioning – Assessment of gait and balance
Treatment Current Cornerstones: – Physical & cognitive rest until symptoms resolve and then – Graded program of exertion prior to medical clearance and return to play
Treatment Physical Rest – NO activity: No gym class No bike riding No weightlifting No sports – games or practice Controversy – light activity? Leddy, et al, 2010 – CJSM – Sub-symptom activity
Concussion/ mTBI Definition Disturbance of brain function is related to: – neurometabolic dysfunction, rather than structural injury – typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). Concussion results in a constellation of symptoms: – physical, cognitive, emotional and sleep-related
Zurich CIS Consensus Child and adolescent student-athlete – Strongly endorsed view no return to practice or play until clinically completely symptom free – Cognitive rest highlighted – More conservative return to play approach; appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. – It is not appropriate for a child or adolescent student- athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance. – Concussion modifiers apply even more than adults and may mandate more cautious RTP advice.
Return to School Resume activities as tolerated – No symptom exacerbation or recurrence – Increase task time/complexity as tolerated Requires coordinated effort – Nurse – Guidance/Psychologist – Teachers – Administration ACE (Acute Concussion Eval) CDC Tool kit
Return to Sport [Young] athletes: NO same day return
Return to Sport Tolerating full school activities – student-athlete! Complete resolution of symptoms Return to baseline on neurocognitive tests Stepwise progression – gradual return Supervised by athletic trainer, team/ personnel MD, neuropsychologist, sports PT, RN – Athletic trainer – licensed medical professional – not coach or fitness!!
Return to Play Protocol First few days after injury physical and cognitive rest is required Proceed to next level only if asymptomatic at the current Any post concussive symptoms occur, drop back to the previous asymptomatic level, try again in 24 hours Age 5-18, slower recovery, worse injury, more conservative care – 1. No activity, complete rest. – 2. Light exercise such as walking or stationary cycling. – 3. Sport specific activity (i.e. running, skating in hockey). – 4. "On surface" practice without body contact. – 5. "On surface" practice with body contact, once cleared to do so by a physician. The time required to progress from full non-contact exercise to contact will vary with the severity of the concussion. – 6. Game play.
Neurocognitive testing comparing the injured athlete to their own baseline data is the cornerstone concussion management
Tools Standardized assessment of concussion(SAC) BESS SCAT II Computerized – Impact – CogState – Etc.
Contribution of Neuropsychological Testing to Concussion ManagementImPACT revealscognitive deficitsin asymptomaticathletes within 4days post-injury N=115 MANOVA p<.000000
ImPACT Reaction Time ImPACT Processing SpeedN=115 MANOVA p<.000000
To evaluate concussion recovery, we cannot rely on athlete symptom report alone! (How many other injuries do we allow the athlete to decide when they can return to play?)
Clinicians’ Return to Play Decisions 100 80 ATC used GSC, SAC, BESS (testing w/ symptom report) 60 40 ATC used only GSC 20 (player symptom report) 00 Marshall, Guskiewicz, & McCrea; In Review, 2006.
Preseason Baseline computerized Neuropsychological Testing 25 minute computer-based test – Memory, Processing Speed, Reaction Time – Baseline symptoms Conducted in group format (up to 15 per) Load on computers in lab Baseline data available for comparison post- injury Ages 11-18 (currently) 11-14 15-18
Concussions And Heading Exposure Cause Cognitive Impairments In Soccer Players Reductions in soccer players compared to the non contact sport athletes reflects subtitle deficits in the attention processes related to updating information in working memory. These results also suggest that heading exposure alone affects cognitive processing in soccer athletes. AYSA over 10 to headDo Minor Head Impacts in Soccer Cause Concussive Injury? A Prospective Case-Control Study Neurosurgery: April 2009 - Volume 64 - Issue 4 - p 719-725
Post-Concussion Syndrome 85-90% of concussed young athletes will recover within 1 to 2 weeks The remainder may have symptoms lasting from weeks to months interfering with school and daily life Subtle deficits may persist a lifetime
Post Concussion Syndrome 3 or more sx’s lasting greater than 3 or 6 weeks with or without exertion Often considered if just 1 sx lingers with or without exertion Acute care rest, when is rest not enough Meds, NP for skill adjustment Sub Threshold Exercise?
University Buffalo Sports Medicine PCS TreatmentThe athlete with PCS performs graded stationary cycleexercise under close observation, attempting to reach aheart rate target of 85% of age-predicted maximum. Bloodpressure and perceived state of effort are measured every2 minutes, and the athlete is instructed to stop the activitythe moment he or she feels any symptoms of concussion.Typical symptoms at the threshold are localized headache,feeling pressure in the head or the eyes, visualdisturbance, and foggy thinking. The symptom-free exer-cise duration and intensity become the threshold forsymptom regeneration, and we have the athlete return tothe laboratory to exercise at 15% below threshold for 2 or 3weeks.
Progression? The opportunity to exercise is perceived as a very positive activity (often leading to an immediate reduction in depressive symptoms). It is imperative that the athlete not go beyond the new exercise limit, which most athletes are keen to do. After the 2 or 3 weeks of sub-threshold exercise, the athlete is reassessed to see if the threshold has changed. The exercise program is then realigned to be 15% less than the new threshold. Integrate BESS as well We started this evening by agreeing that exercise is a cornerstone!
Heads Up: Concussion in High School Sports Parent Fact Sheet Athlete Fact Sheet Guide for Coacheswww.cdc.gov/ncipc/tbi/coaches_tool_kit.htm
NHSCAC Organizational Structure NH State Advisory Sport Concussion Advisory Council Advisory Council Chair Art Maelender, Ph.D. Advisory Council Vice-Chair Laura Decoster, ATC Coordinating Agency/Project Director Brain Injury Association of NH/Steven Wade
The New Hampshire State Advisory Council on Sport‐ Related Concussion was created to provide guidance for school and youth league administrators, coaches, parents and athletes on this very important topic. The purpose of this consensus statement is to guide the creation and implementation of a best‐practice model for sport‐related concussion management including safe return to sports and return to school. This statement does not include specific protocols but serves as the basis for such protocols. Medical science concerning sport‐related concussion is a rapidly growing field; the most recent research was used in the preparation of this statement. Statements are based on evidence but users should be aware that there are still many areas of controversy in this relatively young research field. Because of this fact, this document will be reviewed at least yearly to take advantage of advances in our knowledge about concussions.
Executive Summary A concussion is a serious injury. Colloquial terms such as "ding" or "bell ringer" minimize and trivialize an injury that may have lasting consequences. Those terms should be eliminated from the concussion vocabulary. All injuries to the brain, regardless of how apparently minor they seem, should be managed appropriately. Neither loss of consciousness nor amnesia is a required element for the diagnosis of a concussion. In the majority of concussions, neither is present.
A young athlete (through high school) who experiences concussion signs or symptoms after a direct or indirect blow to the head should not return to activity on the same day. Some brain injuries evolve slowly and the true severity of an injury may not be apparent initially. Signs and symptoms of concussion may fall into multiple categories in somatic, cognitive and emotional domains. Headache, fatigue, irritability, difficulty concentrating and sleep disturbance are a few examples. Coaches, athletes, parents and school officials should be familiar with common signs and symptoms so concussions and/or their sequelae do not go unrecognized.
Each concussion is unique. Concussion grading scales fail to account for the individuality of this injury and may result in an athlete being sent back to activity too soon or held out too long. In place of concussion grading scales, healthcare providers are advised to manage concussions on an individual basis including careful monitoring of clinical symptoms, physical signs, behavior, balance, sleep and cognition in the assessment and monitoring of concussion. Once all signs and symptoms have resolved, a monitored gradual, structured return to activity is recommended.
School personnel (nurse, guidance, teachers) should be informed of the occurrence of a concussion and student‐ athletes who have suffered a concussion should be monitored at school for academic performance difficulties and behavior changes. Evidence suggests that pediatric athletes may be more vulnerable to concussion, may require a longer recovery period and may suffer more long‐term sequelae than adults. There may also be an increased risk of second‐ impact syndrome, an often‐fatal brain swelling, which has almost exclusively been documented in young athletes.
Neurocognitive baseline assessment of athletes who participate in collision or contact sports is recommended whenever it is feasible as it can be used by healthcare providers as objective evidence of an injured athlete’s return to cognitive normalcy. However, neurocognitive testing is only one element of what should be a multipronged approach to assessing and managing sport concussion. Neurocognitive test administration should be appropriately supervised and test results should be interpreted by neuropsychologists.
Athletic programs, both school and community‐based, should adopt a sport concussion management protocol. The NH Council has developed a template for such a program that should be adapted according to each programs resources and in consultation with team physicians. Coaches, athletes and interested parties (parents, administrators, etc.) should receive current basic education on the topic of sport‐related concussion. Physicians must stay abreast of current practice guidelines and topics regarding the appropriate management of athletes who have suffered a concussion, especially return‐to‐play decision‐making.
A few take home’s You need an office plan! Amnesia important for subacute recovery, not predcitive of protracted On field dizziness best predictor of protracted recovery! Sub acute it is “fogginess” LOC <30 sec not predictive