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Lecture on Concussions.
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  1. 1. Concussion and Traumatic BrainConcussion and Traumatic Brain Injury in SportsInjury in Sports Thomas A. Waters MD FACEPThomas A. Waters MD FACEP Cleveland Browns Medical Team PhysicianCleveland Browns Medical Team Physician Department of Emergency MedicineDepartment of Emergency Medicine The Cleveland ClinicThe Cleveland Clinic
  2. 2. Introduction
  3. 3. Introduction  Estimated number of Head Injuries (concussions, skull fractures and intracranial injuries) presenting to the Emergency Department per year per sport:  Hockey 9,883  Soccer 50,035  Football 128,968
  4. 4. Introduction  Other high risk sports include:  MMA  Rugby  Basketball  Wrestling  Soccer  A study done in the year 2000 looked at >1000 retired NFL players and found that around 60% of those players sustained at least one concussion during their career. AmJSportsMed201240:747
  5. 5. Introduction  Head injuries occur commonly during sports participation.  There are three important steps when dealing with head injury in sports.  Detecting Injury  Assessing severity  Making appropriate return to play (RTP) recommendation.
  6. 6. Head Injuries/Concussions
  7. 7. Helmet History
  8. 8. History of the football helmet  1893-First helmet was worn in the Army-Navy game  Made by Annapolis shoemaker for Admiral Joseph Mason Reeves  Advised by Navy Doctor that he would be risking death or “instant insanity” if he took another kick to the head.  1896  Halfback George Barclay (Lafayette College) fearing cauliflower ear had “playing hat” made by a harness maker-”Head Harness”
  9. 9. History of the football helmet 1930s-Helmets became mandatory  1948-first logo(rams horns) painted on pro leather helmet
  10. 10. History of the football helmet 1939-first plastic helmet invented by John Riddell  1940-first chin strap  1955-Paul Brown put the first face mask on a professional helmet.
  11. 11. History of the football helmet 1971 Riddell-”microfit” air helmets with valves on the crown to allow air to be pumped into vinyl cushions.  1976-four point chin straps  2002 Riddell Revolution helmet
  12. 12. Head Injury in Sports  In general, head injuries that occur in the athletic setting are mild in comparison to those that occur in other settings such as MVAs and other high velocity impacts.  Most common injury is the Concussion  Most common serious injuries include  Cervical Spine spine injuries  Vascular intracranial injuries  Vascular catastrophes can present immediately or be delayed by several hours
  13. 13. Mechanism of Head Injury Any blow to the head can cause brain injury  Injury is due to sudden head movement or cessation of movement and shifting of the brain within the skull.  Acceleration/Deceleration forces  Head vs ground  Rotational forces  Left hook  Impact forces  Bean Ball
  14. 14. Direct Injuries  Object impacts the head  Boxing, baseball, field hockey, ice hockey or  Head impacts another object:  Ground, another player-shoulder, helmet, goalpost
  15. 15. Indirect injuries  Forces can be transferred to the cranium  Rotational forces or compressive forces  Fall off balance beam onto coccyx  Rotational hit in football or hockey
  16. 16. Biomechanics  The location and degree of head injury depends upon the position of the head at the moment of impact, the direction of the forces being applied to the head combined with the structural features and integrity of the skull
  17. 17. Head injuries in Sports  Nonfocal  Concussion  Focal Injuries  Subdural Hematoma  Epidural Hematoma  Cerebral contusions  Intra-cerebral hemorrhage  Subarachnoid hemorrhage
  18. 18. Subdural Hematoma  Disruption of venous blood vessels causing low pressure accumulation of blood  Most common focal head injury in sports  Often associated with  LOC  Slow deterioration of neurologic status  Focal neurologic deficits
  19. 19. Subdural Hematoma
  20. 20. Epidural Hematoma  Not as common as subdural  High pressure vascular injuries  Middle meningeal artery  Presentation  LOC  Recovery (lucid interval)  Rapid deterioration of neurologic status
  21. 21. Epidural Hematoma
  22. 22. Other Focal Injuries  Cerebral contusions  Intracranial hemorrhages  Subarachnoid hemorrhages  Skull fractures
  23. 23. Definition of Concussion  Concussion  Latin  concutere-meaning to shake violently or agitate  concussus-action of striking together.  Definition in 1966 by the Committee on Head Injury Nomenclature: “a clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium due to mechanical forces.”
  24. 24. Definition of Concussion  Zurich Consensus Statement on Concussion from 2008:  “Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”
  25. 25. Concussion-Why do we care? 44 million children/adolescents participate in organized sports per year.  2009 in the US there were about 1.8 million participants in football  Estimated 3.8 million concussions per year in US.  Long term effects of concussions are becoming better understood and more heavily scrutinized
  26. 26. Concussion-Presentation  May be obvious but often subtle.  May not have witnessed the hit  Within the pile  Blow was not directly to head  Symptoms may be delayed  Player may not recognize symptoms  Teammates may notice “not acting right”
  27. 27. Concussion-Presentation  Player Reported  HA/pressure  Nausea  Confusion/disorientat ion  Equilibrium “off”  “Don’t feel right”/”In a fog”  Photo/phonophobia  Amnesia  Observer Reported  Dazed appearing  Thinking/moving slowly  Unbalanced  Confusion/forgetting plays  Irritability  Personality changes  “not acting right”
  28. 28. On Field Assessment  ABC’s/C-spine then get to sideline
  29. 29. Sideline Assessment  Observe behavior  Ask about Symptoms  Sideline Assessment: questions that assess  Orientation  Memory  Cognition
  30. 30. Sideline Assessment  Maddock’s Questions  What venue are we at today? (Where are we?)  What quarter/half is it?  Who scored last?  Who did we play last week?  Who won the game last week?  What was the play?
  31. 31. “Sideline” Assessement  1)Sport Concussion Assessment Tool(SCAT2) is the standard for “sideline” assessment of concussion  2)Balance Assessment- Balance Error Scoring System(BESS)
  32. 32. SCAT2
  33. 33. Sideline Assessment  NFL Sideline Concussion Assessement Tool:  Developed by the NFL Physicians Society(NFLPS) Head Neck and Spine Committee and implemented for the 2011-2012 season-modified for the 2012-2013 season.  Combination of the SCAT2, BESS.  Takes 4-8 mins  6 Go/No Go criteria
  34. 34. 6 Go/No Go Criteria  LOC  Confusion  Amnesia  *When in doubt-sit them out  New/persistent Sxs  Abnl Neuro findings  Progressive symptoms
  35. 35. Removal from play  Player should be observed for progression/development of concerning symptoms-do not leave them alone.  Player may NOT return to the field of play (Madden Rule)  Cognitive and physical rest and insure appropriate follow up with caregiver experienced in concussion follow up and parameters for return to play.
  36. 36. Imaging?  The two most commonly used evidence based clinical decision rules for head CT in adults are:  New Orleans Criteria  Canadian CT head rule
  37. 37. ACEP Summary of Indications for CT Scanning in Adults with mTBI  No loss of consciousness and one or more of the following:  GCS <15  Focal Neuro findings  Vomiting more than twice  Mod to severe HA  Age> 65  Signs of basilar skull fx  Coagulopathy  Dangerous mechanism
  38. 38. ACEP Summary of Indications for CT Scanning in Adults with mTBI  With loss of consciousness  Finding from the previous slide plus:  If one or more of the following is present:  Drug or ETOH intox  Persistent amnesia  Post traumatic Sz
  39. 39. Bottom line  Who needs to be transported from the field for head imaging  Prolonged LOC(>1min)  Seizures  Progressive neuro symptoms  Other concerning symptoms/conditions such as multiple episodes of vomiting.
  40. 40. Post Concussion Care  Cognitive rest, physical rest and sleep  Eliminate  TV/Computer  Video games  Texting  Reading  School work  Bright lights and sounds
  41. 41. Follow up  It is essential that the athlete/patient follow up with a caregiver who is up to date on the latest concussion recommendations.
  42. 42. Old Myths  When the headache is gone, you can return to play  Sit out 3 days then return to play  A player who is knocked unconscious has a worse concussion than if they were not.
  43. 43. Return to play  Each and every individual and each and every concussion is unique and predicting patterns of recovery is very difficult if not impossible  What seems to be a minor concussion may linger for weeks  What seems to be major at the outset may clear quickly  What is important is that the athlete progress through each and every step without skipping or hurrying through any step in the process
  44. 44. Return to play  Asymptomatic  Normal cognitive function/balance  Graded return to play with 24 hours between stages  Progression in younger athletes should occur at a slower pace than adults  RTP decision should be more conservative in athletes with previous history of concussion (especially if recent)
  45. 45. Asymptomatic  A symptom is a symptom, no matter how small.
  46. 46. Assessment Tools  Cognitive Tools  ImPact Test  CogSport  Headminder  Balance Testing  BESS(Balance Error Scoring System)
  47. 47. Assessment Tools  BESS(Balance Error Scoring System
  48. 48. Return to play  1)Asymptomatic at rest  2)Asymptomatic with cognitive activity  3)Asymptomatic with light aerobic activity  4)Asymptomatic with heavy aerobic activity  5)Asymptomatic with sport specific activity  Baseline on any cognitive/balance testing
  49. 49. Multiple Concussions
  50. 50. Second Impact Syndrome  Occurrence of a second head injury before an individual has fully recovered from a first insult.  First described and called SIS in 1984 by Saunders and Harbaugh.  19yo FB player had concussion, allowed to RTP died suddenly with no major second trauma  Autopsy showed diffuse cerebral edema but no focal lesion or bleeding
  51. 51. Second Impact Syndrom  The second impact can cause  Brain swelling  Persistent deficits  Death  After second impact the patient deteriorates quickly within seconds to minutes  SIS is rare and has only been reported in minors
  52. 52. Chronic Traumatic Encephalopathy(CTE)  Complication of recurrent head injury  Premature loss of normal central nervous system function  “punch drunk” in boxers in 1928  Abnormalities in the cerebellar, pyramidal and extrapyramidal systems and as well cognitive and personality deficits  Diagnosis made on autopsy
  53. 53. Future directions  Genetic testing  Apolipoprotein E  Blood/Saliva testing  glutamate  New imaging techniques  fMRI  Post injury there is an increase need for glycolysis along with decreased cerebral blood flow which may be able to be detected
  54. 54. Future Directions  Neuroprotective medications;  Magnesium, progesterone, erythropoietin, calcium channel blockers  Accelerometers  In helmets and mouth guards measure amount of g- force sustained in an individual and cumulative hits.
  55. 55. Summary  Early detection and recognition is a priority  Approach in each case must be individualized  Proper follow up is the key  Must be baseline before returning to play
  56. 56. Questions