DISCUSSION ON... SPORTS CONCUSSION Dr Isstelle Joubert Sports Meds, UFS 1 st year, 2011.
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Transcript of DISCUSSION ON... SPORTS CONCUSSION Dr Isstelle Joubert Sports Meds, UFS 1 st year, 2011.
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DISCUSSION ON ...
SPORTS
CONCUSSION
Dr Isstelle JoubertSports Meds, UFS
1st year, 2011
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SURFACE ANATOMY:
Cerebrum:
largest + developmentally advanced portion
controls higher functions
• speech, emotion, integration of sensory stimuli,
• initiation of final common pathways for movement
• fine control of movement
left hemisphere• controls the majority of functions on right side of the body
right hemisphere • controls most of functions on left side of the body• injury to left: sensory and motor deficits on right side, vice versa
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Cerebrum
Cerebellum
Parietal Lobe
Occi-pital lobe
Frontal lobe
Temporal lobe
PonsMedulla
Brainstem
Spinal Cord
Surface anatomy of the Brain
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o frontal: planning, organizing, problem solving and selective attention
• prefrontal cortex: personality, behaviour and emotions
• back of frontal lobe: pre-motor, motor areas - produce / modify
movement
o parietal: primary sensory cortex
controls sensation (touch and pressure) +
fine sensation (judgment of texture, weight, size, and shape)
• damage to R: visuo-spacial deficits, difficult in new / familiar places
• damage to L: inability to understand spoken / written language
SURFACE ANATOMY:
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o temporal: differentiate smells + sounds
help in sorting new information / short-term memory
• right lobe: visual memory (i.e., memory for faces and pictures)
• left lobe: verbal memory (i.e., memory for words and names)
o occipital:
• visual information - reception, recognition of shapes, colours
damage: visual deficits
SURFACE ANATOMY:
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Cerebellum:
second largest area of brain
controls
• reflexes, balance and
aspects of movement /
coordination
Brain Stem:
automatic functions
• breathing, digestion and heart beat
• alertness and arousal (the state of being awake)
SURFACE ANATOMY:
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Internal structure of
brain
Spinal cord
Medulla oblongata
Cerebrum
Midbrain
Diencephalon
Cerebellum
Pons
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VASCULAR SUPPLY OF THE BRAIN
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DEFINITION – SPORTS CONCUSSION:
type of minor head injury
complex patho-physiological process affecting the brain
process is induced by traumatic bio-mechanical forces
(brukner and khan 2009)
trauma-induced change in mental state
a mild form of brain injury
with or without loss of consciousness
(Patricios & Kohler et al, 2010)
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DEFINITION:
Consensus statement on Concussion in Sport
(Zurich Nov 2008)
common features:
direct blow being a causative factor;
rapid onset of neurologic impairment of short duration
neuropathological changes - functional > structural
graded set of clinical symptoms with / without LOC
structurally normal neuro-imaging studies
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SYNONYMS:
brain concussion
mild head injury
minor head injury
mild or minimal traumatic brain injury
(Signoretti et al, 2010)
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INCIDENCE:
varies - level of play / different management protocols
reported in all sports
studied most widely in American football
mostly ice hockey + American football
(Meehan, Bachur, 2009)
1.74 million concussions annually USA (2010) CDC
football: 10% in US College athletes
20% in US high school athletes each season
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INCIDENCE:
sex of athlete (soccer)
2 – 4 % concussions in male
3 – 5% in female players
non-reporting of concussions
American football, only 47%, reported the injury
(Meehan, Bachur, 2009)
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INCIDENCE:
level of play
4 – 14% in sport at school level
3 – 23% at adult level
(Shuttleworth-Edwards & Noakes et al, 2008)
level of play
higher level of play – associated:
increased strength and body size
increased impact and momentum
increased competitiveness
longer seasons
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PATHOPHYSIOLOGY:
precise mechanism - not clear
neurological deficit due to biomechanical injury
• shearing forces
• external forces transferred
• to intracranial contents
usually transient in character
(brukner and khan 2009)
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PATHOPHYSIOLOGY:
shearing force -> diffuse axonal injury
functional > structural injury
molecular level:
• in-flux of Ca2+ , out-flux of K+
• due to depolarization
• caused by excitatory neurotransmitters
such as glutamate, acetylcholine and aspartate
mitochondrial dysfunction
inflammatory responses
therefore changes in cellular physiology
(Hayes & Dixon, 1994)
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PATHOPHYSIOLOGY:
restore pre-injury cell physiology + metabolism
cell metabolism increase drastically:
“hyper-metabolism”
sodium-potassium-pump is in overdrive
to increase the glucose metabolism
to restore neuronal membrane potential
↑ cell metabolism + ↓ blood flow +
disrupted glucose-supply-and-demand
= energy crisis (cellular level)
concussion symptoms and signs
(Patricios & Kohler et al, 2010)
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MECHANISMS OF INJURY:
coup injury
direct blow to head - max injury at point of impact
contre-coup injury
direct blow to head - max injury opposite site of impact
combined contre-coup injuries
No one type is more
serious than the other type
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MECHANISMS OF INJURY:
3 types of stresses :
compressive or crushing force
shearing
force across parallel organization of brain tissue
tensile stress
pulling / stretching of brain tissue
Uniform compressive stress –
fairly well tolerated by neural tissue
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POSSIBLE COMPLICATIONS OF CONCUSSION:
intracranial space occupying lesion ↑ ICP due to damage to veins / arteries with bleeding -
epidural / subdural / intracerebral second impact syndrome
impact convulsions
post-concussion syndrome
chronic traumatic encephalopathy
risk of 2nd concussion
Late complications
Early complications
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Early complications
intracranial space occupying lesion
second impact syndrome (1st in 1984)
• athlete suffers another blow to head
• before the previous concussion resolved completely
• increased brain oedema from first injury didn’t disappear
• 2nd injury increases the oedema + ICP further
• existence of syndrome questioned (Ropper 2009)
• current literature recommend: concussed athletes do not
RTP until / after all Sx and neuro-abN have resolved
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Early complications
impact convulsions
• seizures not common
• not associated with structural damage
• good outcome
• anti-convulsant - not indicated
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Late complications
post-concussion syndrome
• Sx / Tx persist : few days to weeks
• patient feels disturbed and debilitated
• mostly in young concussed athletes
• should rest completely from cognitive (thinking processes)
and physical stress
chronic traumatic encephalopathy
• boxing - repeated concussions
• eventually cognitive dysfunction
• ? genetic factors could play a role (Apo E4 genes)
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Late complications
risk of 2nd concussion
• very controversial statement
• risk factors not clear
• athlete’s style of play predispose him to concussion
• age and level of play - expose athletes to greater forces
• ? one brain injury - ↑ susceptibility for another injury
(Schulz and Marshall, 2004)
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SYMPTOMS AND SIGNS ASSOCIATED WITH CONCUSSION
reported in the concussed athlete
by the athlete self
observed by family members, coaches or teammates
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Physical CognitiveEmotional / behavioural
Sleep disturbances
headache /LOC
poor concentration
depression drowsy
dizziness amnesia irritability insomniadisturbed
vision“foggy”
disturbed mood
increased sleep
light & noise sensitive
“slowed down” aggressiondifficulty getting to
sleep
Nausea & vomiting
difficulty remembering
new informationnervousness
fatigue disorientation anxiety poor balance
seizures
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MANAGEMENT OF CONCUSSION:
Before the game:
Pre participation evaluations
Preparedness before onset of the game
Immediate management of the injured player:
Exclude serious head and spinal injury,
ATLS approach
Remove player from field of play
Assess severity of head injury
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MANAGEMENT OF CONCUSSION:
Early management:
Decide on :
• urgent referral or not
• return to play or not
• baseline symptom analysis
Hospital management
Post-injury discharge information
Follow-up consultations
Neuropsychological evaluations
Late management
Return to play indications
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neuro-psychological evaluations:
traditional DSST - digit symbol substitution testing
newer computerised testing like ImPACT
• assess degree of recovery – baseline / data
• serial evaluations by an experienced
• clinical assessment of brain’s ability to process information
SCAT2 assessment forms
Acute Concussion Evaluation Forms (Gioia & Collins of CDC)
CogState Sport as used by SA Rugby Union
• neuropsychologist part of holistic management team
• not via internet or telephone conversations
MANAGEMENT OF CONCUSSION:
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neuro-psychological evaluations:
ImPACT (Immediate Post concussion assessment and cognitive testing)
software program - University of Pitsburgh Medical Centre
baseline test: brain processing, speed, memory, visual and motor skills
some schools request baseline
does not prevent concussion - detect subtle cognitive impairment
aid to clinical decision - aid in determining safe return to play
measure performance variability
baseline data not affected by
disease, medication, practice effects or malingering
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WHAT IS NEW IN CONCUSSIONS...?
Prevention possibilities
Evaluation possibilities
Medication possibilities
Management possibilities
Fighting the Ghosts
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ethical values - address violence, fair play and respect for other players
muscle conditioning:
• appropriate level of exercise tolerance
• reduction of adiposity
• increased flexibility, strength and aerobic capacity
prevention of fatigue:
• earlier substituting of fatigued player
• attention to recovery of previous head injuries
• attention to fitness, nutrition and hydration
mouth guard /helmets: ↓ severity of concussion, doesn’t prevent
• fit snugly, not move easily on head during the game
• secured with neck + chin strap; tested to safety standards
rules:
• prevent front-on tackling / techniques of going to ground during a tackle
Prevention possibilities...
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Evaluation possibilities... CogState
Impact
SCAT
steroids
anti-oxidants
glutamate receptor antagonists
hyperbaric oxygen
hypothermia
calcium channel blockers
Medication possibilities...
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Management possibilities...
education of athletes, trainers or coaches and parents
implementing the baseline testing that is available
“winna-mania” – player, coach, parent, media
“winning isn’t everything, it’s the only thing”
“play the man, leave the ball”
Fighting the Ghosts...
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THE TAKE HOME MESSAGE IS...
Concussion is real
and not always preventable,
but with the correct knowledge
and management tools applied
– the outcome is not necessarily poor...
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REFERENCES:
Brukner & Khan. Clinical sports medicine 3rd revised ed. 2009(13)201-206
Hayes RL, Dixon CE. Neurochemical changes in mild head injury. Semin
Neurol 1994;14:25
Meehan WP & Bachur RG. Sport-Related Concussion. Pediatrics
2009;123:114-123
Patricios JS, Kohler RMN, Collins RM. Sports-related concussion relevant to
the South African rugby environment - A review. SAJSM 2010;22(4):88-94
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Ropper A, Gorson H. Concussion. N Engl J Med. 2007;356:166–172
Schulz MR, Marshall SW et al. Bowling Incidence and risk factors for concussion in
high school athletes, North Carolina, 1996-1999. American Journal of
Epidemiology. 2004;160(10):937-944
Shuttleworth-Edwards AB, Noakes TD, Radloff S et al. The Comparative
Incidence of Reported concussions presenting for Follow-up management in SA
Rugby Union. Clinical Journal of Sport Medicine. Sept 2008;18(5):403-409
Signoretti S, Vagnozzi R, Tavazzi B et al. Biochemical and Neurochemical
Sequelae following mild traumatic brain injury: summary of experimental data and
clinical implications. Neurosurg focus. 2010;29(5):e1