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  1. 1. HEAD INJURY Thomas M. Howard, MD Sports Medicine
  2. 2. Objectives <ul><li>To understand the epidemiology and classification of closed head injuries in athletes. </li></ul><ul><li>To understand the field-side and clinical evaluation and management of the athlete with a closed head injury. </li></ul><ul><li>To gain a basic understanding of the return to play recommendations and the controversy over this issue. </li></ul>
  3. 3. Definition #1 ...“a clinical syndrome characterized by immediate and transient post-traumatic impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, etc. due to brain stem involvement” or traumatically altered mental status Committee of Head Injury Nomenclature of the Congress of Neurologic Surgeons
  4. 4. Definition #2 … a complex pathophysiological process affecting the brain, induced by traumatic biomechanical force…from direct blow or transmitted force…with rapid onset of short-lived impairment of neurologic function that resolves spontaneously 1 st International Conference on Concussion in Sports
  5. 6. Epidemiology <ul><li>1 mil traumatic brain injuries per yr in US </li></ul><ul><li>Incidence=100:100,000 </li></ul><ul><li>50,000 deaths </li></ul><ul><li>M:F 2:1 </li></ul><ul><li>Bimodal peak </li></ul><ul><ul><li>15-24 & >75 </li></ul></ul>
  6. 7. Epidemiology <ul><li>250,000 concussions/yr in contact sports </li></ul><ul><li>50-80% minor head injuries </li></ul><ul><li>1.5 mil HS football players/yr </li></ul><ul><li>1 in 5 HS football players </li></ul><ul><li>8 deaths/yr in football </li></ul>
  7. 8. High Risk Team Sports <ul><li>Football/Rugby </li></ul><ul><li>Gymnastics </li></ul><ul><li>Hockey </li></ul><ul><li>Wrestling </li></ul><ul><li>Lacrosse </li></ul><ul><li>Equestrian Sports </li></ul><ul><li>Martial Arts </li></ul>
  8. 9. High Risk Recreational Sports <ul><li>Skiing </li></ul><ul><li>Cycling </li></ul><ul><li>Auto racing </li></ul><ul><li>Sport diving </li></ul><ul><li>Playground </li></ul>
  9. 10. Closed Head Injury <ul><li>Concussion </li></ul><ul><li>Subarachnoid Hemorrhage </li></ul><ul><li>Subdural/Epidural Hematoma </li></ul><ul><li>Contusion </li></ul><ul><li>Reactive Hyperemia </li></ul><ul><li>Diffuse Swelling </li></ul>
  10. 11. Glascow Coma Scale Spontaneous 4 To speech 3 To pain 2 None 1 Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Obeys 6 Localizes 5 Withdraws 4 Flexion 3 Extends 2 None 1 Eye Opening Verbal Motor
  11. 12. Glascow Coma Scale <ul><li>Scaled 3-15 </li></ul><ul><li>13-15 MBI (Minimal Brain Injury) </li></ul><ul><li>9-12 Moderate Injury </li></ul><ul><li><8 Severe Injury </li></ul>
  12. 13. Minimal Brain Injury <ul><li>50% - 80% of head injuries </li></ul><ul><li>LOC 0- 20 minutes </li></ul><ul><li>GCS > 13 </li></ul><ul><li>Normal neurologic exam </li></ul><ul><li>PTA < 48 hours </li></ul>
  13. 14. Histology of Damage <ul><li>Traction and shearing of axons </li></ul><ul><li>Microinfarcts </li></ul><ul><li>Edema </li></ul><ul><li>Scar formation </li></ul><ul><li>Local metabolic dysfunction </li></ul><ul><ul><li>Glycolysis and abn blood flow </li></ul></ul>
  14. 15. Presentation <ul><li>Loss of Consciousness (LOC) </li></ul><ul><li>Altered Consciousness (Dinged) </li></ul><ul><li>Amnesia </li></ul><ul><ul><li>Retrograde </li></ul></ul><ul><ul><li>Post traumatic (PTA) </li></ul></ul><ul><li>Disorientation </li></ul><ul><li>Sleepiness </li></ul><ul><li>Abnormal coordination/balance </li></ul><ul><li>Abnormal reaction time </li></ul><ul><li>Poor concentration & comprehension </li></ul><ul><li>Opposition or other behavior change </li></ul><ul><li>Diplopia </li></ul><ul><li>Incontinence </li></ul>
  15. 16. On Field Observations <ul><li>Vacant stare </li></ul><ul><li>In coordination </li></ul><ul><li>Poor performance </li></ul><ul><li>Wrong huddle </li></ul><ul><li>Distracted </li></ul><ul><li>Inappropriate behavior </li></ul><ul><li>Slurred speech </li></ul>
  16. 18. Immediate Transport <ul><li>Diplopia </li></ul><ul><li>Severe or increasing emesis </li></ul><ul><li>Seizure </li></ul><ul><li>Focal neurologic findings </li></ul><ul><li>Pupillary changes </li></ul><ul><li>Rapidly progressive headache Penetrating injury </li></ul><ul><li>LOC > 5 min </li></ul><ul><li>Confusion > 30 min </li></ul><ul><li>High risk patient </li></ul><ul><li>> 1 concussion this season </li></ul>
  17. 19. Sideline Evaluation <ul><li>Maddocks Questions </li></ul><ul><li>SAC </li></ul>
  18. 20. Maddocks Questions <ul><li>What field are we at? </li></ul><ul><li>What team are we playing? </li></ul><ul><li>What period is it? </li></ul><ul><li>How far into the period is it? </li></ul><ul><li>Who scored last? </li></ul><ul><li>Who did we play last week? </li></ul><ul><li>Did we win last week? </li></ul>
  19. 21. SAC <ul><li>Standardized Assessment of Concussion </li></ul>
  20. 29. Balance Error Scoring System
  21. 30. Application of BESS <ul><li>Learning effect does exist (Valovich McLeod et al. Clin J Sport Med . In Press) </li></ul><ul><li>Practice effect does exist. ( Valovich McLeod et al. Clin J Sport Med . In Press) </li></ul><ul><li>More difficult tasks (tandem or single foot) show greater effect. </li></ul><ul><li>Fatigue from exercise can decrease performance so test should be postponed until 20 minutes of rest. (Susco, Valovich McLeod, et al JAT 39:241-46, 2004) </li></ul><ul><li>Adult studies show can differentiate concussed and non-concussed athletes </li></ul>
  22. 31. GRADING
  23. 32. Grading (Cantu) PTA > 24 hrs PTA 1-24 hrs PTA <1hr LOC > 5 min LOC < 5 min No LOC Severe Grade III Moderate Grade II Mild Grade I
  24. 33. Grading (Colorado) + none none LOC + none Amnesia + + Confusion Grade III Grade II Grade I
  25. 34. American Academy of Neurology LOC <15 min Grade IIIa LOC >15 min Transient Confusion No LOC Sx > 15 min Transient Confusion No LOC Resolve <15 min Grade IIIb Grade II Grade I
  26. 35. Is LOC Important? <ul><li>Neuropsychological testing on 383 pts over 5 yrs with MBI </li></ul><ul><li>LOC, no LOC or uncertain </li></ul><ul><li>No relationship between LOC and neurological sequelae as evidence by testing </li></ul>Clin J Sport Med 1999; 9:193
  27. 36. <ul><li>Short term follow up of 78 concussed athletes </li></ul><ul><li>Amnesia and not LOC more predictive of deficits 2 days post injury </li></ul><ul><li>? Importance of duration of LOC </li></ul>“ On Field Predictors of Neuropsychological and Symptom Deficit Following Sport-related Concussion” Cl J of Sport Med 13:222-229, 2003 Duration of LOC LOC=15/78 or 19% 7 < 30 seconds 4 30-60 seconds 3 1-2 minutes 1 > 2 minutes
  28. 37. Who to Scan? <ul><li>GCS < 15 </li></ul><ul><li>Abnormal MSE </li></ul><ul><li>? Any LOC </li></ul><ul><li>Focal neurologic findings </li></ul>
  29. 38. Canadian CT Head Rule <ul><li>High risk (for neurologic intervention) </li></ul><ul><ul><li>GCS < 15 2 hrs p injury </li></ul></ul><ul><ul><li>Open/depressed skull fx </li></ul></ul><ul><ul><li>Sign of basilar fx </li></ul></ul><ul><ul><li>Vomit >2 </li></ul></ul><ul><ul><li>Age>65 </li></ul></ul><ul><li>Med risk (for brain injury) </li></ul><ul><ul><li>Amnesia > 30 min </li></ul></ul><ul><ul><li>Dangerous mechanism </li></ul></ul>Lancet May 5, 2001;357: 1391 2078 CT’s performed over 3 years 348 abn 320/348 identified by applying these rules
  30. 39. CT <ul><li>More useful in the acute setting for significant injury </li></ul><ul><ul><li>SDH/EDH/SAH </li></ul></ul>
  31. 40. MRI <ul><li>75% abnormal within days </li></ul><ul><li>Most findings resolve in 3 months </li></ul><ul><li>May help predict clinical course </li></ul><ul><li>Abnormal findings may not correlate with neuropsychiatric findings </li></ul><ul><li>Unknown long term issues </li></ul>
  32. 41. Consider MRI for… <ul><li>Prolonged post-concussive symptoms </li></ul><ul><li>Marked or persistent neuropsychiatric problems </li></ul>
  33. 42. Post-concussive Syndrome <ul><li>20% to 40% @ 3 months post injury </li></ul><ul><li>Neuropsychiatric impairments </li></ul><ul><ul><li>attention concentration </li></ul></ul><ul><li>Somatic </li></ul><ul><ul><li>headache (71%) </li></ul></ul><ul><ul><li>fatigue (60%) </li></ul></ul><ul><ul><li>dizziness (53%) </li></ul></ul><ul><li>Affective – depression or anxiety </li></ul>
  34. 43. Epilepsy <ul><li>Seizure with 1 week post injury </li></ul><ul><li>PTA > 12 hrs </li></ul><ul><li>Intracranial hemorrhage </li></ul><ul><li>Fixed neurologic deficit </li></ul><ul><li>EEG not helpful </li></ul>
  35. 44. Psychiatric <ul><li>Depression </li></ul><ul><li>Headaches </li></ul><ul><li>Anxiety </li></ul><ul><li>Poor dreaming </li></ul>
  36. 45. Monitoring Brain Dysfunction <ul><li>Cortical </li></ul><ul><ul><li>Neuropsychiatric testing </li></ul></ul><ul><ul><ul><li>attention, STM, concentration, viso-spatial ability, motor function </li></ul></ul></ul><ul><ul><ul><li>Trail A&B, Stroop color-word test, VIGIL-W </li></ul></ul></ul><ul><li>Brain Stem </li></ul><ul><ul><li>BAEP’s </li></ul></ul><ul><ul><ul><li>degree of abnormality correlates with severity </li></ul></ul></ul><ul><ul><ul><li>abnormal 27-44% of MHI </li></ul></ul></ul><ul><ul><li>ENG’s </li></ul></ul><ul><ul><ul><li>abnormal in 40-50% MHI & whiplash </li></ul></ul></ul><ul><ul><ul><li>may be more sensitive than BAEP </li></ul></ul></ul>
  37. 46. Cognitive/Neurobehavorial <ul><li>Unknown long term effects </li></ul><ul><li>Abnormal testing noted in F/U testing up to 4 months </li></ul><ul><li>Poor memory, info processing speed, attention, problem solving, and word fluency </li></ul>
  38. 47. Neuropsychiatric Testing <ul><li>ImPACT </li></ul><ul><ul><li>www.impacttest.com </li></ul></ul><ul><li>HeadMinder </li></ul><ul><ul><li>www.headminder.com </li></ul></ul><ul><li>CogSport </li></ul><ul><ul><li>www.cogsport.com </li></ul></ul><ul><li>ANAM </li></ul>
  39. 48. ImPACT www.impacttest.com Im mediate P ost Concussion A ssessment & C ognitive  T esting
  40. 49. HeadMinder
  41. 50. CogState
  42. 51. ANAM <ul><li>Automated Neuropsychological Assessment Metrics </li></ul>
  43. 52. Computer-based Neuropsychiatric Testing <ul><li>No learning effect </li></ul><ul><li>Data storage and comparison to baseline </li></ul><ul><li>Easy to administer in Training Room </li></ul><ul><li>15-20 minutes </li></ul>
  44. 53. Neuropsychiatric Testing <ul><li>Acute injury </li></ul><ul><ul><li>Memory and attention </li></ul></ul><ul><li>Recovery/RTP </li></ul><ul><ul><li>Information processing </li></ul></ul>
  45. 54. Follow up Care <ul><li>First 24 hrs </li></ul><ul><ul><li>Serial neurologic evaluations </li></ul></ul><ul><ul><li>Every 2-3 hrs </li></ul></ul><ul><li>Avoid sedating medications, </li></ul><ul><ul><li>narcotics, alcohol, antihistamines </li></ul></ul><ul><li>Ice, Tylenol, light diet </li></ul>
  46. 55. Follow-up Care <ul><li>Avoid contact activities </li></ul><ul><li>Warn about possible difficulty with reading, homework, and testing </li></ul>
  47. 56. Disposition and Treatment <ul><li>Second Impact Syndrome </li></ul><ul><li>Cumulative Effect? </li></ul>
  48. 57. Second Impact Syndrome <ul><li>Pathology </li></ul><ul><ul><li>Abnormal autoregulation </li></ul></ul><ul><ul><li>Cerebral vascular congestion </li></ul></ul><ul><ul><li>Diffuse edema/ ICH </li></ul></ul><ul><ul><li>Midbrain herniation </li></ul></ul><ul><li>Adolescent athletes </li></ul><ul><li>Sudden collapse </li></ul><ul><li>Dilated pupils </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Rapid deterioration and death </li></ul>
  49. 58. Recurrent Injury <ul><li>MBI may diminish cerebral reserve </li></ul><ul><li>2-4 times more likely to sustain a second injury </li></ul><ul><li>More prolonged disability with repeat injuries </li></ul><ul><li>Consider cognitive testing </li></ul>Retrospective study of 2905 football players over 3 seasons 1 in 15 will have second concussion in same season with slower recovery of neurological function JAMA 290:19;2549, 2003
  50. 59. Return to Play No symptomatic athlete should be allowed to compete until symptoms have cleared
  51. 60. Playing While Symptomatic <ul><li>Male football players </li></ul><ul><ul><li>Dizziness-29% </li></ul></ul><ul><ul><li>Headache-61% </li></ul></ul><ul><li>Male Soccer </li></ul><ul><ul><li>Dizziness-18% </li></ul></ul><ul><ul><li>Headache-26% </li></ul></ul><ul><li>Female athletes </li></ul><ul><ul><li>Dizziness-19% </li></ul></ul><ul><ul><li>Headache-35% </li></ul></ul>Clin J Sport Med 2003;13:213-221 Denial vs. deficiency in symptom recognition and knowledge of consequences/sequelae
  52. 61. Factors Influencing RTP <ul><li>Age </li></ul><ul><ul><li>Younger brains recover slower </li></ul></ul><ul><ul><li>Children with more prolonged and diffuse cerebral swelling </li></ul></ul><ul><ul><li>60X more sensitive to glutamate </li></ul></ul><ul><ul><li>? Risk of permanent neurological deficit </li></ul></ul><ul><li>Concussion history </li></ul>
  53. 62. Return to Play (Cantu) Terminate season; Return next season if asx Severe Return in 1 month if asx for 1 week Grade 3 Terminate season; Return next season if asx Return in 1 month if asx for 1 week Return if asxfor 1 week Grade 2 Moderate Terminate Season Return next season if asx Return in 2 weeks if asx for 1 week Return if asx for 1 week Grade 1 Mild 3 rd Concussion 2 nd Concussion 1 st Concussion Grade
  54. 63. Return to Play (Colorado) Transfer to Hosp; RTP 2 wks if Asx RTP 1 wk if Asx Exam q5 min; RTP 20 min if Asx Recommendation Grade III Grade II Grade I Grade
  55. 64. American Academy of Neurology ? ? Asx for 2 weeks Grade III b Prolonged LOC 1 month or longer 1 month or longer Asx for 1 wk Grade III a Brief LOC 2 weeks Asx for 1 wk 2 weeks Asx for 1 wk Asx for 1 wk Grade II No LOC Sx >15 min Asx for 1 wk Asx for 1 wk RTP if Asx in 15 min Grade I No LOC Sx <15 min 3 rd Concussion 2 nd Concussion 1 st Concussion Grade
  56. 65. 1 st International Conference <ul><li>No activity with complete rest </li></ul><ul><li>Light aerobic exercise-walk or stationary bike </li></ul><ul><li>Sport-specific exercise (skate, run, swim, …) </li></ul><ul><li>Non-contact training drill </li></ul><ul><li>Full contact training after medical clearance </li></ul><ul><li>Game play </li></ul>
  57. 66. Return to Play Process Symptom free at rest Symptom free with exercise Normal neuropsychiatric Testing Return
  58. 67. 2nd International Conference on Concussion in Sport Prague 2004 Eliminate Grading Simple or Complex Concussion More emphasis on amnesia “ Cognitive rest” in Pediatric Concussion SCAT Individualized stepwise RTP No same game RTP Neuropsychological testing for complex concussions on asymptomatic athletes
  59. 68. Future Trends <ul><li>Pro-activity </li></ul><ul><ul><li>Rules (spearing) </li></ul></ul><ul><ul><li>Equipment </li></ul></ul><ul><ul><li>Coaching </li></ul></ul><ul><ul><li>Strength Training </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Staging? </li></ul></ul><ul><ul><li>Use of Neuropsychiatric testing </li></ul></ul>
  60. 69. Future Trends <ul><li>Return to play </li></ul><ul><ul><li>More use of neuropsychiatric testing </li></ul></ul><ul><ul><li>Imaging-f MRI, PET, SPECT) </li></ul></ul><ul><ul><li>RTP recommendations </li></ul></ul>
  61. 70. Concussion Scenario # 1 <ul><li>History </li></ul><ul><ul><li>19 yr old gymnast during vault under rotates and lands head first on mat </li></ul></ul><ul><ul><li>Does not move following injury, no seizure </li></ul></ul><ul><ul><li>Conscious and able to communicate </li></ul></ul><ul><ul><li>Complains of neck pain and a headache </li></ul></ul><ul><ul><li>Is confused and having problems focusing her eyes </li></ul></ul>
  62. 71. Concussion Scenario # 1 <ul><li>Evaluation </li></ul><ul><ul><li>Normal upper and lower extremity neurological evaluation </li></ul></ul><ul><ul><li>After 5 minutes can recount incident and is alert </li></ul></ul><ul><ul><li>Does not complain of nausea but feels “dazed” </li></ul></ul><ul><ul><li>After another 10 minutes becomes irritable and angry (she is normally quiet and sweet) </li></ul></ul>
  63. 72. Concussion Scenario # 2 <ul><li>History </li></ul><ul><ul><li>20 yr old football player is going for a tackle, collided heads with an opposing player </li></ul></ul><ul><ul><li>Player remains down on the field after incident, no seizure </li></ul></ul><ul><ul><li>Upon your arrival, athlete is conscious, but seems confused about what happened </li></ul></ul><ul><ul><li>Complains of being dizzy and unable to concentrate </li></ul></ul>
  64. 73. Concussion Scenario # 2 <ul><li>Evaluation </li></ul><ul><ul><li>Pupils are equal and reactive </li></ul></ul><ul><ul><li>No neck pain, normal neurological evaluation of upper and lower extremities </li></ul></ul><ul><ul><li>States that they feel extremely tired and “in a fog” </li></ul></ul><ul><ul><li>Does not remember the collision and slow to respond to questioning </li></ul></ul>
  65. 74. Concussion Scenario # 3 <ul><li>History </li></ul><ul><ul><li>18 yr old pole vaulter landed on his head the previous day, no seizure </li></ul></ul><ul><ul><li>Has had a headache and dizziness since incident </li></ul></ul><ul><ul><li>Try to continue to practice but was to “unsteady” </li></ul></ul><ul><ul><li>Complains of minor neck pain </li></ul></ul>
  66. 75. Concussion Scenario # 3 <ul><li>Evaluation </li></ul><ul><ul><li>Having trouble sleeping and sensitivity to light </li></ul></ul><ul><ul><li>Complains of headache and lack of appetite </li></ul></ul><ul><ul><li>Having difficulty remembering things and concentrating in class </li></ul></ul><ul><ul><li>States he starting crying this morning when he couldn’t find “the right” t-shirt to wear </li></ul></ul><ul><ul><li>Has occasional ringing in his ears </li></ul></ul>