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Concussion 2017:More Questions Than

Answers?Joseph A. Congeni, MDMedical Director Sports Medicine

Akron Children’s Hospital

NAPNAP

Joseph A. Congeni, MD, FAAP

Presentation II

FINANCIAL DISCLOSURE: none

UNLABELED/UNAPPROVED USES DISCLOSURE: none

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For Handouts or References

Joseph Congeni, MD

Stephen Lutz, ATC

slutz@chmca.org

Current Position Statements AMSSM (Jan. 2013)

Position Statement for Concussion in Sport

5th International Conference on Concussion (held Fall 2016 in Zurich, published May 2017) Consensus Statement for Concussion in Sport

SCAT V/CSCAT V

American Academy of Neurology Evidence-based Guidelines for the Evaluation and

Management of Concussion in Sport (March 2013)

NATA Guidelines (due later 2013)

Definition

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What is a Concussion Functional brain injury – MRI/CT

Normal - NOT structural

Metabolic Brain Injury –slowdown of cerebral blood flow chemical “energy crisis” in the brain

Study of axonal injury

The brain is a non-renewable resource (Hovda-UCLA)

86 billion neurons in the human brain

What is not a Concussion?

Closed head injury with structural defect

(brain bleed or brain swelling) Epidural

Subdural

Parenchymal

MRI/CT Scan usually normal

Mechanism of Injury

Linear acceleration

Angular/Rotational acceleration Measured by G-Forces

(accelerometer/gyroscope)

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Mechanism of InjuryIndirect/Rotational

“a forceful blow to the body that results in rapid

movement of the head.”

Rapid acceleration / deceleration = WHIPLASH

or “SNAP-BACK”

or “JOLT” to the brain

Who Is At Risk?Incidence

CDC estimate 3.8 million concussion per year in US sports

1997-2007: (Peds 2010)

ER visits for sports concussion doubled (8-13 yrs)

Increased by greater than 200% (14-19 yrs)

Recurrence Risk 4-5x increase for 2nd injury

85-90% full clinical recovery in 1st two weeks

What is the cause of the 15%?

Diagnosis

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Diagnosis:What is the Clinical Presentation

Symptom Evaluation / Challenges

“Silent Epidemic”

“Invisible Injury”

“Subtle but Serious”

“Energy crisis in the brain”

Symptom Evaluation/ChallengesTraumatic Brain Injury is an Evolving Process NOT a Static

Injury

“If you’ve seen one concussion you’ve seen one concussion” (Herring, Seattle)

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Where is the injury in the brain?Location

Back of Head LOC (RAS)

Visual (Visual Center)

Balance (Cerebellum)

Temporal Memory Center

Frontal Repetitive Actions

Emotionality

McCrea, et al (Duke 2001)

SAC Exam

Months of the year in reverse (90%)

Serial 7’s (51%) Young et al, Clin J Sport Med.

1997 Jul;7(3):196-8

SAC replaced by SCAT

Sports Concussion Assessment Tool

Added balance testing

How Do We Assess on the Sideline?

> 12 years old

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Changes to SCAT 5

5 - 12 years old

How do we Assess in ER?

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Problems with Initial DiagnosisUniversity of Akron Study (Silent Epidemic)

What was a concussion? 461 athletes(pre-season survey 1995 - 2000)

– only 19% reported concussion

80% of concussions missed initially U of A (CJSM) Kaut, DePompei, Kerr, Congeni, 2003

60% of Athletes concussion unreported (UNC 2012)

What is the risk of sub-concussive blows to the brain?

Emergent EvaluationFirst 24 Hours(cont’d)

Double vision/blurred vision/pupils unequal

Change in consciousness/unarousable

Numbness, weakness, unequal/asymmetry one extremity or part of body

Change in breathing pattern

Seizures

Make sure athlete is not left alone for 1st 24 hrs.

10-30%

“Monday Morning Concussion”

The way the person feels Headache or fatigue

How they think Memory or concentration

Change in emotions Irritable or sad

How they sleep Trouble falling asleep

“Monday Morning Concussion”

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Office Evaluation

Three legged stool

> 30% of concussion patients with normal symptom scale had cognitive deficit

How Do We Assess In The Office?Not all patients need a full evaluation (RTP/

prolonged recovery)

Can we do a “QUICKIE” exam?

Symptom Scale(helpful, but has limitations)

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Balance Assessment

Head injury and postural stability

Model postural control (steadiness)

Firm and foam evaluation

Balance Assessment (Cont’d)

BESS (Balance Error Scoring System)

All tests are performed for 20 second trials with the score equaling the number of errors that occurred; therefore, the higher the score the worse the performance.

Number of ErrorsEyes Open Eyes Closed

1. Double leg stance on hard surface _________ _________2. Single leg stance on hard surface _________ _________3. Tandem stance on hard surface _________ _________4. Double leg stance on foam _________ _________5. Single leg stance on foam _________ _________ 6. Tandem stance on foam _________ _________

Guskiewicz, 2001, CJSM

Neuropsychological/Cognitive Testing

Manual testing (PSU/UA 1992-93)

Computerized testing (2002)

ImPACT/Axon/Headminder

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ImPACT

1. Visual Memory2. Verbal Memory3. Problem Solving4. Reaction Time

Concussion: Sub-types

#1. Cognitive/Fatigue

#2. Cervical

#3. Vestibular

#4. Occulomotor

#5. Post-Traumatic Migrane

#6. Mood Disorders

Treatment Mental Rest/Meds/Aerobic

/Neuropsychologist

Rehab/Strengthening

Vestibular Rehab/Aerobic

Eye evaluation by specialist

Meds/Neuro

Neuropsychology/Meds

Sports Traumatol. 2014Michael W. Collins

Exertional Testing

Bike, treadmill, step test

Can be done in the physician’s office or at school under the direction of the Athletic Trainer. (30% failure rate)

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When to Return to Play? (100%?)

Asymptomatic at rest Asymptomatic with

exertion Normal neurocognitive

test Normal subjective scale

(<7) Normal neurological and

cervical exams, as well normal balance testing.

When to Retire?

Consider:

Increased length of symptoms

Decreased trauma induces concussions

Decreased time between concussions

Prognosis

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Recovery From Concussion:How Long Does it Take?

N=134 High School athletes

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

WEEK 1

WEEK 2

WEEK 3

WEEK 4

WEEK 5

Collins et al., 2006, Neurosurgery

Risk Factors for Prolonged Recovery Following Sports Concussion

Age Field, Lovell, Collins et al. J of

Pediatrics 2003 (Pellman, Lovell et al.

Neurosurgery 2006 Guskiewicz. 2011 Pm R

Previous concussion Collins, Lovell et al,

Neurosurgery 2004 Iverson, Lovell, Collins, Brit J

Sport Med, 2006 Hollis. 2009 Am J of SM

Migraine History Lipton. JAMA 2004

Genetics APOE e4: Tierney. Clin J Sport Med

2010

Gender Differences Females have higher rate of

concussion 1:7:1 Females more prone to post-

concussion symptoms Neck strength differences? Lovell. Clin Sports Med 28

(2009) 95-11

Mood Disorders Kontos. Arch Phys Med Rehab

2012

Is depression, anxiety, irritability pre, post, or part of the biochemical brain injury?

Initial Management

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Can We Treat Concussion?Management

Physical Rest&

Mental Rest

Acute Treatment:Mental Rest (Brain Rest)

School and Activity Modifications

Students held from school

Full day/partial day/rest periods

Driving may be restricted

Workload/homework reduced

Tests restricted/postponed (esp SAT, PSAT, finals)

Acute Treatment:Mental Rest (“Brain Rest”) (cont’d)

Avoid loud activities (parties, dances, concerts, sports events) or (I-pods, headphones)

Avoid bright sunlight (sunglasses, shade) and computer games

Avoid spinning carnival rides. Avoid alcohol/drugs “Return to Learn”

These modifications seem to hasten recovery Moser RS, et al., J Pediatrics 2012

How long?

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Acute Treatment:Physical RestReturn To Play

Physical rest until asymptomatic

Stage I Light aerobic training (no resistance)

Stage II Sport specific training (can start resistance)

Stage III Non-contact training drills

Stage IV Full contact after physician clearance

Stage V Competition

McCrory et al, Clin J of Sp Med (2005)

Clearance Rules: Board of Nursing -9/17/2015

1. Specialty includes ages 4-19 for nurse and collaborating physician

2. Education and training – Zurich guidelines

3. Maintains CME in concussion

4. Use Medical Clearance Form

MEDICAL CLEARANCE TO RETURN TO PLAY AFTER SUSPECTED CONCUSSIONThe State of Ohio requires that a youth athlete, who has been removed from physical participation in anathletic activity, shall not return to physical activity until he or she has been evaluated by a licensed healthcare professional (LHCP) and receives written clearance from that LHCP authorizing the youth athlete’sreturn to physical participation in the athletic activity. This form is to be used after an athlete has beenremoved from an athletic activity due to a suspected concussion. http://www.healthy.ohio.gov/vipp/concussion.aspx

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Complications

Long Term Complications

Learning disability/cognitive deterioration (Neurosurg 2005)

Concentration issues Short term meds – ADHD

– (Arch Phys Med Rehabil. 2003)

Depression Psychotherapy, antidepressants

3 time increase (Medicine Science and Sports Exchange 2007)

Chronic headache – (Pain Med. 2008)

Permanent brain damage (ESPN – Outside The Lines 2007)

(CTE / Lou Gehrig’s ALS, 2ND Impact Syndrome)

University of Michigan Study 2009 “NFL Study” -Rates of Dementia

Reported Rates US MenAge 30-49

US MenAge 50+

NFL RetireesAge 40-49

NFL RetireesAge 50+

Dementia, Alzheimer's (%) 0.1 1.2 1.9 6.1

408% increase in NFL Retirees age 50+

$760 million settlement –summer 2013

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“Brain Collectors” Boston University School of Medicine,

Center for the Study of Traumatic Encephalopathy 79 deceased athletes studied

– 90% had Chronic Traumatic Encephalopathy

>400 athletes have pledged their brains (Oct 2014)

Dr. Ann McKee

Ryan Freel

CTE Study

201 out of 202

Prevention/Research

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Participation – All Sports

Youth Sports - 44 million

High School Sports - 7.8 million

College Sports - 480,000

NFHS 2013-2014

NCAA 2016

Pro Sports - 13,700Bureau of Labor Statistics 2014

JAMA Pediatrics 2015

Participation - Football

Youth Football - 3 millionJAMA Pediatrics 2015

High School Football - 1.1 million NFHS 2013-2014

College Football - 100,000NCAA 2016

Pro Football - 1,696NFL

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Pediatrics 2015

Prevention/Rules Changes Rules Changes

More strict helmet to helmet rules (2010-2013)

New kickoff rules (2012)

Targeting with crown of helmet (2013)

Strike Zone (2013)

Fines/loss of draft picks if NOT following protocol (2016)

Penalty box? (Future)

Rules Changes NFHS (Zurich)

2014 “Keep the Head Out of Football”

– Limit helmet to helmet contact and blows to upper extremity – No targeting– No hitting a defenseless player

Limit full contact to 2-3 practices/week– Limit contact on consecutive days/no more than 30 min/day or 90/week– Two-a-days = one contact session

Written EAP at school/coaches education/ATC present whenever possible

2015 Spearing revised (broadened)

2016 No clipping anywhere

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Rules Changes Youth

2012 Pop Warner/USA – no full speed head on blocking/tackling

Drills > 3 yards apart

Contact only 33% of practice

2014 Heads Up education program mandatory for coaches

2016 Eliminate kickoff age 5-10 years (ball at 35 yd line)

2017 Pilot program – decrease players from 11 to 6 or 9

Smaller fields

No special teams

Lineman crouched – not in 3 point stance

Prevention - Soccer

Prevent rough play especially with goalie

Avoid backwards “head flick”

Avoid heading with arms above head

Padded goal post

Head gear?

Prevention/Hockey/Lacrosse

Eliminate blind sided hits

No body checking until age 13 (Bantam level)

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Is concussion only a “Football” problem?

Fastest growing HS sport1. Girls Basketball

2. Girls Soccer

Top 5 Sports:1. Football

2. Ice Hockey

3. Soccer

4. Lacrosse

5. Wrestling

66% of catastrophic head injuries occur in cheerleading (J Peds 2013)

Education Legislation

Washington State – Return to play law

Zackery Lystedt’s Law 2009

– No return to contact sport following concussion without medical clearance

– 5 stage gradual return after clearance

– Mandatory education for coaches/players

Ohio 2013 – HB143

All 50 states 2014

“Seattle Study” 2014

Education “Seattle Study”

The Effect of Coach Education on Reporting of Concussions Among High School Athletes After Passage of Concussion Law. Am J Sports Med 2014

778 HS football/girls soccer 3.6/1000 athlete exposures 69% of concussed athletes played with

concussion 40% reported coaches not aware of

symptoms– Despite ALL participants signing an information

sheet on concussion symptoms

Changes in attitude toward concussion will NOT be accomplished by legislation alone

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Flag Football

Expansion of non-tackling Enjoy football (America’s passion)

Enhance flag – make it a “primer” for tackling technique

Tackling disadvantage?

Delay contact – Cantu. 2012– Because of brain development

Ban tackling before age 18 –Robbins. Real Clear Sports 2012

Enhanced flag football study – CHMCA 2016

Shoulder Girdle Strength

Reduces neck fatigue allowing for maintaining of heads up positon

Neck Strength a Predictive Factor Reducing Risk for Concussion in High School Sports. J of Primary Prevention 2014

– >6,000, >50 schools– Neck strength remains a significant predictor of concussion regardless of

gender or sport For every 1 lb > in neck strength the odds of concussion decreased 5%

(also neck circumference)

Effect Neck Muscle Strength and Anticipatory Cervical Muscle Activation on Kinematic Response of the Head to Impulsive Loads. AJSM 2014 Both strength and anticipatory activation associated with decreased

linear/angular velocity/significance (P<.001)

Prevention New Equipment

The Helmet That Can Save Football. Popular Science 2013

Stockholm, Sweden – MIPS Helmet

– Multi-directional Impact Protection System

Technology to help with diagnosis/return to play

Riddell SpeedFlex 2014

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Q-Collar Light compression of jugular veins increased

blood volume Decreases “brain slosh”/preload

Cincinnati Children’s Studies: The Effects of External Jugular Compression…

Frontier’s in Neurology 2016– 15 hockey players – diffusion tensor imaging– Accelerometer > 10g– Significantly disruption in white matter changes in

non-collar vs. collar

Analysis of Head Impact Exposure… Br J of Sports Med 2016

– Moeller vs. Xavier – 42 football players– Disruption in white matter

Collar wearing may provide protection against microstructural changes

HITS Technology

Analysis of Real-Time Head Accelerations in Collegiate Football Players. Clin J of Sp Med 2005

38 players - Virginia Tech

– 35 practices/10 games

HITS system proved effective at collecting head impacts, and providing impact parameters utilized in conjunction with existing clinical evaluation techniques

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HITS Technology

Football Player’s Head Impact Exposure After Limiting Full-Contact Practices. J Athl Train. 2016 Compared head-impact exposures (>10g) before and after limiting contact practices

50 football players – 26 prior to rule changes, 24 after

42% average decline in # impacts – 52.9% decline practice

– 24.8% decline games

Head Impact Magnitude in American High School Football. Pediatrics2016 32 athletes, 13 games

Collisions after long closing distances, especially when combined with 3-pt stance or contact to the head result in the largest magnitude impacts (>10g)

What’s New/DiagnosisSensors

Sensors Riddell InSite

Riddell Revolution (HITS)

Reebok Checklight

Shockbox

HeadSense

Non-invasive tool to assess cerebral hemodynamic parameters

Help with diagnosis and assessment 86 subjects, ages 12-17

50 concussed 36 control

Sensitivity 96% Specificity 92%

Present at PAS in San Francisco, CA

Parallel study at Vanderbilt 64 subjects – 14 concussed 86% sensitivity 91% specificity

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HeadSense

Healthy Pattern Concussed Pattern

Initial Recording

Follow-Up Recording

Initial and Follow-Up Recordings

Sync -Think

Detects reduction in cerebral function through assessing visual attention Athlete tracks 15- sec. circular visual stimulus, repeated for 60-sec.

– Performance relates to quickness and accuracy (low performance = concussion)

– Compared to baselines

Sidelines 2016:– Stanford, USC, Utah, Oregon State, Indiana University, U. Northern Colorado, Clemson, Notre Dame, UC

Santa Barbara, St. John’s College High School

– 0.8 test-retest reliability

Department of Defense

Deficits in Smooth Pursuit after Mild Traumatic Brain Injury. Neuroscience Letters 2006. 47 participants ages 15-60 (21 mTBI, 26 control)

SPEM impairments = cognitive deficits

Attention, executive function

Sync-Think

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Treatment Brain Rest/Physical Rest

Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. Pediatrics 2012

– 49 HS/College athletes, ages 14-23– Minimum 1 week – no homework,

electronics, physical activity, social interaction

– Improvement in ImPACT/symptom score

“Brain rest” may be useful for treatment for symptoms of concussion

“Cocoon Therapy”

Treatment

– A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome. Clin J Sports Med 2010 Early subsymptomatic exercise may

be safe and effective in allowing athletes to return to play sooner than prolonged physical and brain rest

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Treatment

Evaluation of the Zurich Guidelines and Exercise Testing for Return to Play in Adolescents Following Concussion. Clin J Sport Med 2014

– 91 subjects, ages 13-19

– Buffalo Concussion Treadmill Test (BCTT)

– BCTT in combination with Zurich guidelines was safe and successful assessment for return to play

TreatmentHypothermic Therapy

Hypothermic therapy has clinical efficacy in the treatment of TBI

Cold therapy can effectively dampen the cellular metabolic cascade, thereby minimizing the ensuing damage caused by the brain injury

It has been hypothesized that cold therapy could limit the damage of a mTBI or concussion

2017 study to decrease the core temperature of concussed athletes

Treatment Early Vestibular Therapy

Differential Diagnosis of Dizziness After a Sports-Related Concussion… 2015 CHMCA

86 subjects, ages 12-19

15 dizziness descriptors, 11 triggers

Description of dizziness limited to help in assessing differential diagnosis

Athletes had difficulty describing the way they felt

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Treatment Early Vestibular Rehab

Feasibility of Early Physical Therapy for Dizziness…Scand J Med SciSports 2017

Early PT for Dizziness and Sports Concussion 41 subjects, ages 10-23 Dizziness score: of 3 or greater or migraine-

cluster score of 10 or greater with dizziness 1 or greater

Vestibular PT beginning at 10d. (2x/week for maximum of 8 visits)

Median RTP– Experimental 15.5 d– Control (sham PT) 26d

Symptoms Resolved– Experimental 13.5d– Control 17d

Early PT may be effective in shortening recovery time

Objective Assessment of Brain Recovery

Motion Analysis

Trazer – Cleveland Analyze dynamic assessment of reaction

time, speed, acceleration, deceleration, HR

8 ½ min performance test (being used currently at Alabama, OSU, others)

Could it be used to simulate the demands on the athlete on the court/field (25-30% failure rate with RTP)

2 part study 2016-2017– Concussion group– Orthopedic injury

HR variability may be key in the concussed group

Compare to age matched controls vs baseline

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Dual Task Gait

Single-Task and Dual-Task Tandem Gait Test After Concussion. J Sci Med Sport 2017 10 athletes

Completed single and dual-task (adding cognitive test) at 72hr, 1wk, 2wks 1 mo, 2 mos post-concussion

– Spelling 5-letter word backwards

– Subtraction by 6-7s

– Months backwards

Adding cognitive task resulted in longer detectable deficits post-concussion

Summary

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Myths

Must have LOC to be a concussion (10-20%)

Normal MRI/CT – R/O concussion (R/O bleed)

Concussion are all brief, transient, no complications (see complications….)

No treatment (physical and mental rest)

Bottom Line DiscussionsOver-Reacting/Hysteria? Knee-Jerk Reaction Compare with MVA/ a.) “one and done” (single

Teenage Drinking concussion-out for sports season

b.) eliminate youth football (flag)

c.) eliminate all American Football

Prevention

Prevent occurrence Improve Timely Neuro/Cognitive Rehab

Recognition Significant Brain Injury

(Initial Management)

References

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