sports concussion -...

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Sports ConcussionUpdate on Diagnosis, Management, and

Long‐Term Health Concerns

Allen K. Sills, Jr., MD, FACSAssociate Professor

Departments of Neurosurgery, Orthopaedic Surgery and

RehabilitationVanderbilt University

Disclosures

• No commercial or research relationships with any of the products or services discussed today

• This presentation included slides and data from Dr. Warne Fitch’s presentation “Head Injury in Sports” from the 2009 Vanderbilt Sports Medicine lecture series and also from the 2010 NFL Head Injury Symposium at The Johns Hopkins Medical Center

Outline

• Treatment

• Return to Play decisions

• Computerized neurocognitive testing – state of the art or scam?

• Long term effects– Dementia and CTE

• Prevention strategies and equipment

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Scope of the problem

• Between 2 and 3.8 million mild traumatic brain injuries (MTBI) occur annually in the US

• Duration of symptoms is highly variable – Can be minutes to days, weeks, or months

• 15% of these patients will continue to have symptoms one year after the injury– An athlete who sustains a concussion is 4-6 times

more likely to sustain a second concussion

Scope of the problem…

• Some research shows that concussions among high school athletes are on the rise

• Concussion make up 9% of all sports-related injuries at the high school level

• From 2001-2005, kids ages 5 – 18 had an average of 135,000 emergency room visits per year for sports-related concussions

Athletic Brain Injury

• Extremely common problem in football

– 300,000 concussions/yr in US from football

– among Div. I college football players:

• 34% at least one concussion

• 20% two or more concussions

– 20% of all high school football players will have a concussion each season

• 5% of soccer players will have a brain injury from their sport

• Probably under‐reported• Thurman et al. The epidemiology of sports‐related traumatic brain injuries in the

US: recent developments. J Head Trauma Rehab. 13(2): 1‐8, 1998.

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Athletic Brain Injury

• 8 deaths/yr due to head injury in football

• Brain injuries cause more deaths than any other sports injury

What sports are at risk for athletic brain injury?

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• For kids ages 5 – 18, the most common activities which account for concussions are:

– Bicycling– Football– Basketball– Playground activities– Soccer

Rate of Concussion – high school athletes (per 1000 athlete‐exposures)

• Football 0.47• Girls soccer 0.36• Boys soccer 0.22• Girls basketball 0.21• Boys lacrosse 0.19• Boys wrestling 0.18• Boys basketball 0.07• Girls softball 0.07• Boys baseball 0.05• Girls volleyball 0.05

Source: Journal of Athletic Training, December 2007

Sports concussion ‐ 2012

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Definitions

• Concussion = transient traumatic-induced alteration in neurologic function– Does NOT require a loss of consciousness

American Academy of Neurology, 1997

Naming

• Other terms for concussion:– Bell ringer

– Ding

– Mild traumatic brain injury

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Concussion pathophysiology

Pathophysiology of Concussion

Figure 2. Giza, Hovda. J Ath Train. 36(3):228‐235. 2001.

Johns Hopkins NFL concussion symposium 2010

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Basic Science Studies

• Current knowledge limited due to available models– There is no existing animal or experimental model

that accurately reflects a sporting concussive injury

• Animal models:– Anesthetized

– Quantitative biomechanics of impact force

– Small brains tolerate higher accel/decel forces

– LOC used as marker

Signs and Symptoms of Concussion

Signs• Appears dazed or stunned• Confused about assignment• Forgets plays• Is unsure of game, score, or

opponent• Moves clumsily• Answers questions slowly• Loses consciousness• Shows behavior or personality

change• Forgets events prior to play

(retrograde amnesia)• Forgets events after hit

(anterograde amnesia)

Symptoms • Headache• Nausea• Balance problems or

dizziness• Double vision• Sensitivity to light or noise• Feeling sluggish • Feeling “foggy” • Concentration or memory

problems• Change in sleep pattern

(appears later)• Feeling fatigued

Part 2 today• Game site management - Preparation,

triage, and record keeping

• Pre-participation screening

• Seizures

• Scalp lacerations

• Intracranial hematomas

• Major traumatic brain injury (TBI)

• Mild TBI (concussion) – Diagnosis/assessment, pathophysiology, classification,

natural history, imaging

– treatment, RTP, long term effects, prevention

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Treatment of concussion induced symptoms

Signs and Symptoms of ConcussionSigns

• Appears dazed or stunned• Confused about assignment• Forgets plays• Is unsure of game, score, or

opponent• Moves clumsily• Answers questions slowly• Loses consciousness• Shows behavior or personality

change• Forgets events prior to play

(retrograde amnesia)• Forgets events after hit

(anterograde amnesia)

Symptoms • Headache• Nausea• Balance problems or

dizziness• Double vision• Sensitivity to light or noise• Feeling sluggish • Feeling “foggy” • Concentration or memory

problems• Change in sleep pattern

(appears later)• Feeling fatigued

Symptomatic treatment

• No good evidence based recommendations for treatment of common post-concussion symptoms

• Majority of symptoms will resolve in 24 hours and do not require intervention

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J Neurol Phys Ther. 2010 Jun;34(2):87‐93.Vestibular rehabilitation for dizziness and balance disorders after concussion.Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo‐Reddy CE, Collins MW, Lovell MR, Sparto PJ.Department of Physical Therapy, University Of Pittsburgh, Pittsburgh, Pennsylvania, USA

• Retrospective cohort review of 114 pts – LEVEL 4

• Included many non-athletic concussions

• Mean time from concussion to therapy was 61 days

• Vestibular rehab was performed

• Self reported improvements in dizziness and objective improvements in gait and balance function with directed tests

• Suggestion that vestibular rehab should be considered for those who have prolonged symptoms

J Neurol Neurosurg Psychiatry 2002;73:330-332 doi:10.1136/jnnp.73.3.330 Short reportImpact of early intervention on outcome following mild head injury in adultsJ Ponsford1, C Willmott1, A Rothwell2, P Cameron3, A-M Kelly4, R Nelms1, C Curran1+ Author Affiliations1Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Victoria, Australia 2Julia Farr Services, Fullarton, Australia 3Royal Melbourne Hospital, Melbourne, Australia 4Western Hospital, Melbourne, Australia

• Randomized prospective trial of 202 adults with mild TBI

• LEVEL 1

• Both groups seen one week after injury and given baseline tests

• One group given an information booklet about natural history and coping strategies, other received no info

• At 3 months post-injury the “informed” group had statistical improvements in self-reported symptoms and anxiety when compared to controls

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Current practices

• Headache – acetominophen, naproxen, toradol– Triptans for “refractory cases”

– Anticonvulsants may be useful if extensive previous headache history

• Nausea – phenergan, metoclopramide, scopolamine patch

• Dizziness – meclizine, scopolamine– Vestibular rehab for prolonged symptoms

• Sleep disturbance – tricyclics, short term zolpidem

• Education about expected natural history for patient and family

Computerized neurocognitive testing

State of the art or scam?

Why has computerized cognitive testing become so popular?• Concussion will produce transient alterations in objective

measures of visual attention, concentration, visual, verbal and spatial memory, and reaction time

• Measurement of these functions has historically required a paper and pencil battery of tests administered by a neuropsychologist

– Expensive, time-consuming, and subject to the limited availability of qualified practitioners who understand the unique time sensitivity of athletic team schedules

• A computerized test can provide a quick, reproducible assessment of these parameters

– Eliminates reliance on honesty of athlete’s reporting of symptoms

• Aggressive marketing, backed by a number of published reports

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Commercially available computerized neurocognitive tests

for athletes

• CNS Vital Signs (CNSVS)

• CogState Sport (formerly known as the Concussion Sentinel)

• Headminder CRI (Concussion Resolution Index)

• ImPACT (Immediate Post‐Concussion Assessment and Cognitive

Testing)

Computer‐based NC tests: Similarities

•Measures•Cost•Internet accessible•Easy to administer•Completed < 30 min•Sideline assessment•Baseline may be administered to large group

•Normative database•Typing skills not necessary•No computer experience necessary•Rapid scoring•Detailed, easy to read report•Does not provide a diagnosis

WHAT DOES ImPACT MEASURE?

Demographic/Concussion History Questionnaire

Concussion Symptom Scale- 21 Item Likert scale (e.g. headache, dizziness, nausea,

etc)

Eight Neurocognitive Measures- Measures domains of Memory, Working Memory,

Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed -Summary Scores

Detailed Clinical Report- Automatically computer scored- Outlines demographic, symptom, neurocognitive data

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24-72 Hours Day 5-10

Concussion

Beyond (if necessary)

Baseline Testing

(Normative data available for decision making when baseline data not available)

Clinical StudiesClinical Studies

ImPACTOverall Injury Sample 2000-2002

Over 4,500 athletes in baseline sample

410 athletes suffered concussion during season- Evaluated within 2 days of injury

- Re-evaluated at days 5 and 8 post-injury

- 243 high school, 141 college, 26 other athletes

272 male concussions, 138 female concussions

Compared to 100 HS and College controls

N=410

.

p.<.00001

N.S.

p.<.0001 p.<.03

Significantdifference betweengroups out to at least 8 dayspost-injury

Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

ImPACT MEMORY COMPOSITEControl vs. Concussed Athletes

*Lower score indicates poorer performance

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ImPACT REACTION TIME COMPOSITEControl vs. Concussed Athletes

Significant difference between groups out to 5 days post-injury

N=410

.

p.<.005N.S. p.<.0004 N.S.

Lovell MR, Collins MW, Maroon et al. Medicine and Sciencein Sports Exercise, 34:5;2002

*Higher score indicates poorer performance

Current ImPACT test users

• All NFL teams• All NHL teams• 31 Major League baseball teams• All MLS teams• Formula One and IRL auto racing• USA Olympic teams – soccer, hockey, skiing,

boxing, equestrian• Over 200 major US universities

So why wouldn’t everyone use this test????

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• Literature review including all prospective controlled studies of NP testing—Level 3

– (pencil/paper, ImPACT, CogSport, HeadMinder)

• Concluded: “no NP tests have met necessary criteria to support a clinical application at this time”

• Headminder

• CogSport

• ImPACT

• ANAM

• Reported “20 – 38% false positives”

Lovell's overlapping roles and financial interest in ImPACT have drawn criticism from several doctors and athletic trainers working in the field of sports concussions. Their ire has intensified as Lovell sometimes has not identified himself as one of ImPACT's developers in his scientific research. On at least seven occasions since 2003, Lovell has authored or co‐authored studies on neuropsychological testing, including papers directly evaluating ImPACT, without disclosing his roles in creating and marketing ImPACT, according to an ESPN.com review of recent medical literature. In one case, an examination of Lovell's connections prompted an academic journal to rewrite its disclosure guidelines for authors.

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• Concluded that the NONE of the 5 most commonly used pencil and paper tests were reliable in setting of concussion

• 9 studies reported that showed problems with sensitivity as well

• As to clinical utility: “No researchers have demonstrated that pencil‐and‐paper NP tests can detect concussion once players are asymptomatic”



• For CogSport and HeadMinder only ONE paper was reviewed to base conclusions about sensitivity, reliability, and clinical utility

• For ImPACT ‐ 2 papers reviewed (both on first version of test)– Found reliability same a paper and pencil tests

– Not enough data to comment on sensitivity or validity

– Noted that confidence intervals for significant change were large

• Concluded: “no NP tests have met necessary criteria to support a clinical application at this time”

• “Unless an NP battery is capable of detecting impairment after subjective symptom resolution, it cannot alter clinical decision making under any of the current management guidelines”

• “Given these data, the use of a standardized symptom checklist in addition to routine clinical examination is suggested as a reasonable approach to monitoring recovery from sport‐related concussion, until the incremental utility of NP testing (or other methods) can be established.”

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• Criticisms:

– Very small number of papers reviewed, especially for computerized tests

– Methodologic criticisms are applicable to ALL neuropsych tests, which by nature are subject to a number of variables which can never be fully controlled

– The recommendation to base RTP decisions on symptoms alone ignores the fact that symptoms may not be reliably reported, particularly among higher level athletes

– Argument about impairment detection after symptoms resolve can never be proved by any test, nor is this essential to have a useful tool

• Criticisms:

– “…in all cases, athletic trainers should evaluate the entire set of clinical, historical, and test data available and not rely on any single indicator for return‐to‐play decisions. Although the problems discussed by the authors merit serious attention, the use of neuropsychological data may help clinical decision making in some cases but not in others. Given the stated need for additional research, completely avoiding the use of neuropsychological tests in clinical practice may have the effect of preventing exploration of the very concerns identified in the current article.”

• Headminder

• CogSport

• ImPACT

• ANAM

• Reported “20 – 38% false positives”

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• 118 normal college students (but results from 40 excluded due to “invalid baseline”)

• 16% with history of previous concussion

• Retest administered 45 and 50 days after first test

• No test subject suffered a concussion in the interval before the retest

• A test result was labeled as a “false positive” if any of the measured variables showed a significant decline on the retest

• Intraclass correlation coefficients (ICC) were calculated for each separate test and used as primary measure of reliability

• Results:– Based on the ICC interpretive guidelines previously described, test‐retest

reliabilities for all indexes on all 3 computer programs fell below the levels commonly recommended for making clinical decisions

• percentages of participants with 1 or more false‐positives on any variable on the day 45 assessment were ImPACT (38.40%,n 28), CRI (19.20%, n 14), and Concussion Sentinel 21.90%, n 16). On day 50, the percentages of participants with false‐positive results on 1 or more variables were ImPACT (34.20%, n 25), CRI (23.30%, n 17), and ConcussionSentinel (32.90%, n 24).

• Criticisms:

– Other variables which are known to affect cognitive performance were not accounted for during the retest period

– Interpretation is not designed to be based upon one variable only, but rather an “overall impression” of performance across multiple domains

– ICC is not a good statistical measure of reliability for neuropsych tests – most “pencil and paper” tests have lower ICCs as well

– Several other studies have reported diametrically opposed results for similar questions (though the methodology was slightly different), including one independent study published in 2010 (next slide)

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Am J Sports Med. 2010 Jan;38(1):47-53. Epub 2009 Sep 29.Long-term test-retest reliability of baseline cognitive assessments using ImPACT.Schatz P. Department of Psychology, Saint Joseph's University, 222 Post Hall, 5600 City Avenue, Philadelphia, PA 19131, USA. [email protected]

• Case series of 95 college athletes – level 4

• Baseline ImPACT tests, 2 years apart

• No one in test group had a concussion during evaluation period

• Results:

– Reliable change index and regression analysis showed significant changes in less than 6% on each domain

– ICC was stable

• Conclusion: no need for yearly baseline

• “Until the psychometric properties of these tests can be clarified, clinicians should use a battery of evaluative measures when assessing concussion.34,35 Findings from multiple assessment techniques, such as self-reported symptoms, postural control, and neurocognitiveperformance, should be incorporated into a concussion assessment protocol. No single assessment technique should be used to the exclusion of the others or the physical examination. Once the athlete returns to baseline on all measures, a return-to-play progression can begin with careful attention paid to symptom reoccurrence, both during and after exertionalactivities. Only when the athlete is free from symptoms at rest and exertion should a full return to participation be considered.36”

Gualtieri, CT & Johnson, LG, Reliability and Validity of a Computerized Neurocognitive Test Battery, CNS Vital Signs. Archives of Clinical Neuropsychology, 21, 623-643, 2006.

• “CNT’s are extremely sensitive to virtually all of the clinical conditions associated with cognitive dysfunction. They are capable of calculating reaction times with millisecond accuracy, and can generate massive amounts of precise data. The technology, however, can be a mixed blessing. Data can be misinterpreted or misused by poorly trained clinicians. In our communications with physicians and even psychologists who have used CNT’s in their practices, we have not always been impressed by their facility at judging exactly what the tests mean and how to respond appropriately to the results they generate.”

• “No test in medicine or psychology is “diagnostic.” Diagnosis is a clinical exercise that demands the integration of data from multiple sources. The results of a test, whether it’s a blood count or a formal neuropsychological battery, may incline the clinician’s thinking in one direction or another. But test results do not, by themselves, constitute a medical diagnosis. “

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• Level 3 case control study

• HS and college athletes tested 2 days after injury

• Increased sensitivity 19% with use of ImPACT vssymptoms alone to detect concussion

Concussion (Mild TraumaticBrain Injury) and the Team

Physician:A Consensus Statement*

November 2005 Medicine & Science in Sports & Exercise

• It is desirable the team physician:• • Coordinate the care and follow-up of the athlete.

• • Understand the indications and limitations of neuropsychological

• testing.

• • Postinjury neuropsychological test data are more

• useful if compared to the athlete’s preinjury baseline.

– • It is unclear what type and content of test data are most valuable.

– • It is only one component of the evaluation process.

• “(CNTs) are highly sensitive to mild cognitive dysfunction, though, and that makes them suitable to be used as screening instruments. But a sensitive test will also generate a high percentage of false positives. In our clinics, every new patient is administered a comprehensive CNT. It is not uncommon to encounter patients with one or more cognitive domain score that is more than two standard deviations below the population mean. But that is the equivalent of discovering a mild abnormality on an MRI scan or an EEG. “Clinical correlation is needed,” as they say. Absent a clinically meaningful explanation, the best thing to do is to repeat the test at some later date, as the patient is seen in follow-up.

• Nor is CNT sufficient for the purpose of concussion management; symptom severity, neuropsychological function, and postural stability are not related nor are they affected to the same degree after concussion.15 The ability of a gifted athlete to improve his or her performance in a test that requires psychomotor speed and accuracy far exceeds that of an ordinary person, so improvement in performance with serial testing does not necessarily indicate full recovery from the effects of mild brain injury. The danger of CNT’s in sports medicine is that complex psychophysical data are interpreted by people whose qualifications are less than well-suited for that purpose (e.g., athletic trainers and high school coaches), and that a false sense of security would thus be engendered.

• …Computerized concussion management is an improvement over doing nothing. It is no substitute, though, for a medical examination, and is not the only criterion that should determine an athlete’s fitness for play. ”

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Computerized neurocognitivetesting – the bottom line

• Widely enough used to approach “standard of care”

• Clearly sensitive to detection of alteration of brain function caused b sports concussions

• Brings some objective data hat is not self reported about recovery

• Useful part of an overall concussion management strategy when used by experienced providers

• Not a “stand alone” test!

Concussion and imaging

Level 4 – case series

Noninvasive Detection of Brain Damage

• CT Scan Statistics: ‐Detects abnormalities in 1% of patients with GCS 15 ‐Detects 30% of patients with GCS 13

• Clinical Factors Predict‐CT Scan abnormalities‐Need for intervention (adults)

• No Systematic evaluation of MTBI subjects with MRI

WHO MTBI TASK FORCE J Rehabil Med 2004

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• Prospective Cohort 682 pts—Level 2

• GCS 15

• Collected prospective data on signs and symptoms

• 46 (6.7%) had abnormal CT scans– All patients had at least one risk factor:

• Postraumatic amnesia, LOC, seizure, headache, vomiting, focal neuro deficit, skull fracture, coagulopathy, age >60, anticoagulation use

Do They Need a CT Scan?

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Note well : in the overwhelming majority of cases both CT and MRI imaging modalities will be normal. This does NOT rule out a very serious brain injury, since

CT and MRI are tests of structure and not brain function

An area of very active research with DTI, PET, fMRI, and high field strength magnets

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Return to Play Decisions

Concussion grading scales

• Previous guidelines attempted to classify severity of concussions based on presenting symptoms (grade1, 2, and 3)– No standardized definitions– No correlation with outcome– Arbitrary return to play guidelines– Becoming obsolete

Coaches Poll

Table 3. McLeod et al. CJSM 2007; 17(2): 140-142

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“Looks like a grade 3 to me”

What does the literature tell us about current practice of

RTP decisions?

Return to Play: Same Game

• High School– 30% returned to play same day

– Held out average 13 minutes

• NFL

Powell et al. Neurosurg. 2004, LEVEL 2.

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Guskiewicz et al. Cumulative effects associated with recurrent concussion in collegiate football players. The NCAA study. JAMA 2003.

• Prospective Cohort— Level 2– 2905 college FB players, 25 colleges over 3 years

• Incidence: 0.81 per 1000 athlete exposure

• 196 concussions

• 12 repeat concussions (6.1%)

• 3 x greater risk during games

Guskiewicz et al. JAMA 2003—Level 2• Presentation

– Headache 85%

– Dizziness 77%

– Amnesia 24%

– LOC 6%

• Ave duration 3.5 days

• 88% full recovery at 1 week

Powell et al. Concussion in Professional Football: Epidemiological features of Game Injuries and Review of the Literature—Part 3. Neurosurg 54(1) 2004.

• Prospective Cohort—Level 2– 1996-2001 recorded concussions in NFL

– Broad definition:

• “traumatically induced alteration in brain function”

– Standardized reporting form

• 787 cases in 1913 games

• Incidence 131.2+/- 26.8 concussions/year

• Rate of 0.41 concussion/game

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Powell et al. Neurosurg 54(1) 2004.—Level 2

• Three most common symptoms:1. Headaches (55%)

2. Dizziness (42%)

3. Blurred vision (16.3)

• 45.9% experienced either cognitive or memory problems

• 9.3% had LOC

Powell et al. Neurosurg 54(1) 2004.—Level 2

• 93% <7days lost

• LOC players– Averaged 5.0 +/‐ 7.5days

– 2.6 times longer

• 56.5% no days out

Considerations for RTP decisions

• Second Impact Syndrome?

• Duration of symptoms?

• Previous concussion history?

• Risk of long term neurocognitiveimpairment?

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Second Impact Syndrome• Initially described by Schneider 1973

– 3 cases moderate impact caused almost immediate death

• Coined by Saunders and Harbaugh 1984– Described college FB player who was in a fight

week before then sustained minor trauma and died

• “….an athlete who has sustained an initial head injury, most often a concussion, sustains a second head injury before symptoms associated with the first have fully cleared.”

Second Impact Syndrome

• Pathophysiology– Loss of autoregulation of brain’s blood supply– Leads to vascular engorgement with resultant

cerebral edema– Increasing ICP and herniation

• 50% mortality• 100% morbidity

Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998.

McCrory P. Does Second Impact Syndrome Exist? Clin J Sports Med 2001;11:144-9. Level 4

Definite- A-D

Probable- C&D, plus A or B

Possible- C&D,

Not- no C or D

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Second Impact Syndrome• McCrory P. Does Second Impact Syndrome Exist?

Clin J Sports Med 2001;11:144-9. Level 4

– 17 published cases

– 0 met criteria for “definite SIS”

– 5 met definition of “probable SIS”

– 11 cases had no witnessed “second impact”

– No cases outside US despite frequent participation in rugby and other collision sports

– Majority were adolescent males

Second Impact Syndrome

• 94 catastrophic sports-related head injuries over 13 year period in US (1980 – 1993)– 71% of these had a previous concussion in the

same season

– 39% felt to be playing with residual symptoms at the time of the critical injury

Second Impact SyndromeTareg Bey, MD* and Brian Ostick, MD†

W J Emerg Med 2009, February

Second Impact Syndrome – what to do?

• Incidence data are imprecise

• There are still deaths every year in the US from uncontrolled brain edema after sports-related head injury

• Clear trend toward younger athletes

• Clinical neurosurgical experience tells us that “some” cases of apparently mild head injury will result in malignant brain edema which is very refractory to treatment– Genetic and physiologic factors obviously at work

– Susceptible host + inciting stimulus = disaster

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Second Impact Syndrome – what to do?

• In absence of clear evidence, prudent course of action would seem to be to avoid exposure to additional head trauma in athletes who remain symptomatic from a previous head injury, or who have abnormalities on brain imaging

• Extra caution in younger athletes

• Reassurance of an extremely low incidence in athletes without history of previous neurologic injury

RTP ‐ Duration of symptoms and concussion history

LOC vs Amnesia: Length of Recovery• Guskiewicz. JAMA. 2003.—Level 2 Prospective

Cohort

• Collins et al. CJSM. 2003— Level 3 Case Control– Presence of on field amnesia, not LOC more

predictive of pronounced post-concussion sequelae

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Risks for Prolonged Recovery

• Multiple concussions have longer recovery P=0.03 Guskiewicz et al. Level 2

Increased Risk of Additional Concussion?

• Guskiewicz et al..—Level 2

• Dose response risk for additional concussion

• 92% of the in-season repeat concussions occurred within 7-10 days of first

Delayed worsening of symptoms• Delayed Symptoms:

– College:• 33% experienced delayed onset of additional symptoms

vs 12.6% that did not return– Guskiewicz. JAMA. 2003

– NFL:-• 10/439 players who returned to same game out >7days

due to symptoms – Pellman et al. Neurosurg. 2005.

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Concussion management –modern thoughts

• Each concussion is assessed independently based upon:– Nature and duration of symptoms and signs

– Player’s age

– Player’s previous concussion history

How should we determine return to play? – same game• All symptoms resolve within 5 minutes

– Symptom checklist

– Brief sideline assessment (ImPACT sideline assessment or other tool)

– Consider postural stability measurement

– NOTE: no athlete should return to play until asymptomatic both at rest AND exertion

RTP same game – 2010 NCAA guidelines

• “Student‐athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan.”

• “Athletics healthcare providers should practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neurologist, neuropsychologist).”

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• Institutions should record a baseline assessment for each student‐athlete prior to the first practice in the sports of baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse, pole vaulting, rugby, soccer, softball, water polo, and wrestling, at a minimum. The same baseline assessment tools should be used post‐injury at appropriate time intervals. The baseline assessment should consider one or more of the following areas of assessment.


• At a minimum, the baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments (e.g., SAC; SCAT; SCAT II; Balance Error Scoring System (BESS); Neurocom).

• Additionally, neuropsychological testing (e.g., computerized, standard paper and pencil) has been shown to be effective in the evaluation and management of concussion. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist.

RTP same game – 2010 TSSAA guidelines

• “Any player who exhibits signs, symptoms or behaviors consistent with a concussion (such as loss of consciousness, headache, dizziness, confusion or balance problems) shall be immediately removed from the game and shall not return to play until cleared by an appropriate health‐care professional.”

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RTP same game – 2010 TSSAA guidelines

• “After studying the new rule, the state office asked the TSSAA Board of

Control to approve the enclosed “TSSAA Concussion Return to Play Form” that must be used in practice and games. The form was adapted from the Acute Concussion Evaluation (ACE) plan on the CDC website (www.cdc.gov/injury). It contains specific instructions that shall be followed before an athlete can return to sports. The form must be completed and signed by a licensed medical doctor (M.D.) or Osteopathic Physician (D.O.) before an athlete that has been removed from practice or a game may return to participate..”

RTP same game – 2010 TSSAA guidelines• Officials may remove an athlete from the contest if they

suspect the athlete has suffered a concussion.

• This athlete cannot return to the same game until cleared by a physician using the “Return to Play” form

How should we determine return to play? – post game

• Patient’s reporting of symptoms

• Concussion assessment tool (ImPACTor other)

• Postural stability (Romberg, BESS, etc.)

• Neurocognitive testing

• Stepwise increase in activity to observe for symptom re-emergence

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Systematic approach• McCrea et al. Acute Effects and Recovery Time

Following Concussion in Collegiate Football Players. The NCAA Concussion Study. JAMA. 290(19) 2556-2563. 2003

• Prospective Cohort—Level 2• Concussed players tested at time of injury, 3

hours after, days 1,2,3,5,7,90. 84% followup• All players had preseason tests

– Graded symptom checklist– Standardized Assessment of Concussion– Balance Error Scoring System– Neuropsychological test Battery

McCrea. Standardized mental status testing on the sideline after sport‐related concussion. JAT 2001

McCrea. JAT 2001— L 2 prospective cohort

• 95% sensitive

• 76% specific

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• No return to current game (* ?elite/professional adult athletes)

• Monitor regularly for deterioration

• Medical evaluation: include standard assessment tool

• Step-wise return to activity

Step-wise return to play

• No activity – rest until asymptomatic

• Light aerobic exercise – walking, stationary bike

• More strenuous aerobic activity

• Sport specific training

• Non-contact drills

• Full-contact drills

• Game action

“What do you mean, my boy can’t play no

more?”

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RTP Decisions –team approach

• Educate all stakeholders prior to the season on the concussion management plan

• Identify your “sideline team” and chain of command for clearance during game (as well as informing the coaching staff)

• Emphasize communication among athlete, parents, trainer, coaches and the medical team

Long term cognitive effects of concussion

? Neurocognitive Impairment• No correlation between LOC and

future neurocognitive impairment – Lovell. CJSM. 1999—Level 3

Retrospective Cohort

• Long term subtle neurocognitivedeficits – players with 2 or more concussions

(p=0.009)Collins et al, JAMA 1999

• Punch Drunk Syndrome – Chronic traumatic brain injury– 17% retired boxers

– Roberts AH. Pitman Medical and Scientific Publishing Co, 1969

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Recurrent Concussion in Retired Athletes

• Guskiewicz, K., et al. Neurosurgery, 2005; 57(4): 719‐726

• Guskiewicz, K., et al. Medicine and Science in Sport & Exercise, 2007; 39(6), 903‐909.

Biomarkers and Genetics

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Genetic markers for concussion susceptibility

ApoE E4 (Jordan et al., JAMA, 1997--Boxers; Kutner et al., Neurosurgery, 2000—NFL players; Terrell et al. and Kristman et al., 2008; Tierney et al., 2010—collegiate athletes, all in CJSM )

ApoA 1 (Bazarian, 2010)

CACNA1A calcium channel subunit gene (?---SIS)(Kors et al., Annals of Neurology, 2001)

Interleukin 1RN allele 2 and cerebral hemorrhage after TBI(Hadjigeorgiou et al., Neurology, 2005)

Nearly 3-fold increase in risk of history of concussions for athletes with the G-219T TT genotype relative to the GG genotype (OR= 2.8, 95% CI = 1.1-6.9), adjusted for age, sport, school, and years in primary sport

Some support for a relationship with Tau Ser53Pro polymorphism and risk of prior concussion (OR = 2.1, 95% CI = 0.3-14.5)

No relationship with ApoE genotype

ApoE e4 and cognitive functioningin professional athletes: 2 studies

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Jordan: ApoE and Boxers

• High Exposure Boxers (>12 professional bouts) had higher CTBI scores than Low Exposure Boxers

• High Exposure Boxers with positive ApoE had greater CTBI scores vs. High Exposure Boxers who were ApoE negative

• Low Exposure Boxers had Normal CTBI scores, whether positive or negative ApoE

• All Boxers with Severe CTBI scores were ApoE positive

• Conclusion: ApoE status interacts with exposure in professional boxing to produce CTBI

Serum biomarkers

Serum Biomarkers for Concussion

• S-100B: secreted from brain astrocytes (summed concentration of S-100B monomers in S-100A1B and S-100BB); typically clears from serum within 4-6 hours post trauma

• Neuron-Specific Enolase (NSE):Marker of cell regeneration

• Glial Fibrillary Acidic Protein (GFAP):Found in Glial cells (astrocytes), andhelps to maintain mechanical strengthand cell shape

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Jeff Bazarian, M.D.

NFL Concussion Conference, Washington, 2010

Great at predicting abnormal CT• High Sensitivity

‐95‐99%‐25‐35%

Bottom line: genetic typing and biomarkers

• S-100B may be the most robust biochemical marker immediately post-concussion

• ApoE and its promoter polymorphisms have the most evidence to date as a genetic marker

• None of these markers is ready to be used on a routine basis for screening or diagnosis – more study needed

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What is the maximum number of “safe”

concussions?

?(but probably zero)

Summary

• Management of sports concussions is under ever increasing scrutiny from regulatory bodies, media, and others

• Pharmacologic and other interventions may help with prolonged symptoms

• RTP decisions should be based on standard assessment tools which include self-reported symptoms, standardized scales, balance testing, and neurocognitive testing of some form– Data from each of these components must not be

considered in isolation

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Summary

• Long term effects of multiple sports concussions remain to be elucidated

• Lifetime number of “safe” concussions remains unknown, though repeated traumatic brain injuries can clearly produce delayed cognitive deficits

• Proper equipment, technique, and avoidance of exposure to another head impact while recuperating from previous concussion are all important prevention strategies

Thanks!

sports concussion -...

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