Sport-Related Concussion: An Overview and Update for the PCP
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Sport-Related Concussion:An Overview and Update for the PCP
Kristopher Fayock, MDAssistant Program DirectorSports Medicine Fellowship
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Disclosures
I do not have any financial disclosures.
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Objectives
Understand the basic pathophysiology of concussions
Be aware of the signs and symptoms of concussions
Be aware of the risk factors for concussions Be able to perform a physical exam for patients
that may have a concussion Be able to confidently diagnose a concussion in the
office or on the sideline of a game To know when it is safe to return an athlete to his
sport or when to refer to a specialist Understand the Delaware laws associated with
sport-related concussion
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Introduction
CDC estimates 1.6-3.8 million sports-related concussions annually in USA 5-9% of all sports injuries
Increased rates over last decade likely due to education and awareness
Sports with majority of concussions: Football Wrestling Boys’ and Girls’ Soccer Girls’ Basketball
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Concussion Guidelines
1st International Conference on Concussion in Sport held in Vienna in 2001 Consensus statement created
2nd: Prague – 2004 No more grading of concussion Simple vs Complex
3rd: Zurich – 2008 All classifications removed
Most recent – 4th: Zurich 2012 New tools – SCAT3, child version Timing of treatments
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Definition of Concussion
A complex pathophysiological process affecting the brain, induced by biomechanical forces, that may include: May be caused by direct blow to head or body
with impulsive force transmitted to head Rapid onset of short-lived impairment of
neurological function Neuropathological changes with a functional
disturbance, rather than structural injury Graded set of clinical symptoms that may or
may not involve LOC.
Subset of mild traumatic brain injury
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Pathophysiology Forces to the brain are linear
and/or rotational
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Pathophysiology
Neurometabolic cascade Complex cascade of ionic and metabolic events accompanied by microscopic
axonal injury Causes vasoconstriction
Requires energy to re-establish homeostasis Increased need for energy in the presence of decreased cerebral blood flow
Leads to “Energy Crisis” Brain has to work harder to meet same demands
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Pathophysiology
Brain has increased vulnerability in the post-concussion state
2nd injury before brain is recovered may result in worse cellular changes and cognitive deficits Second Impact Syndrome
Excessive cognitive or physical activity before complete recovery may result in prolonged dysfunction
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Signs and Symptoms
Physical
Cognitive
Emotional
Sleep
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Signs and SymptomsPhysical
Headache Nausea Vomiting Balance problems Dizziness Visual Problems
Fatigue Sensitivity to light Sensitivity to noise Numbness/tingling Dazed Stunned
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Signs and SymptomsCognitive
Feeling mentally “foggy” Feels like standard TV, instead of HD TV
Feeling slowed down Difficulty concentrating Difficulty remembering Forgetful of recent information Confused about recent events Answers questions slowly Repeats questions
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Signs and Symptoms
Emotional Irritable Sadness More emotional Nervousness
Sleep Drowsiness Sleeping more or less
than usual Difficulty falling asleep
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Headaches
Most commonly reported symptomUp to 70% of concussed athletesCan worsen with physical or
cognitive exertion Types of Headaches
Myofascial tension or CervicogenicPain located posterior neck
Post-traumatic migraineDescribed as pressure in front or top of
head
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Risk Factors for Concussions
Previous concussion 2 - 5.8x higher risk of sustaining another concussion May have progressively prolonged recovery with each
concussion Symptoms may predict prolonged recovery
Greater number, severity, and duration of symptoms Symptoms that predict protracted recovery > 3 weeks
On-field – Dizziness (OR 6.4) Post-traumatic Migraine – HA, nausea, and sensitivity to
light or noise (OR 7.29) History of Migraines
May complicate diagnosis or when recovered
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Risk Factors for Concussions
Sex Female athletes sustain more concussions
than males in sports with similar rules Age < 18yo
May have prolonged recovery compared to adults
Sport and Position Most common mechanism is player-to-player
contact Mood disorders Learning and attention disorders
May complicate diagnosis and do worse on testing
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Diagnosis of a Concussion
Sideline Office
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Diagnosis of a Concussion
Symptoms Physical Signs
LOC or amnesia LOC only occurs 10% of the time
Trouble with balance or vestibular system Behavioral changes
Irritability Cognitive impairment Sleep disturbance
If any one or more of these components are present, a concussion should be suspected
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Acute Assessment
If the athlete is collapsed:ABC’sAssess for cervical spine injury
If concerned immobilize the neck and transfer to ED
Assess for more serious brain injuryDeteriorating mental statusFocal neurological findings
Abnormal or unequal pupil reaction Abnormal extraocular movement Abnormal motor/sensory exam
If concerned Send to ED for neuroimaging
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Sideline Assessment If concussion suspected
Athlete should be removed from play
Evaluated by a physician or licensed healthcare provider
If none availableShould not return to playUrgent referral to a physician should be
arranged
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Sideline Assessment
Useful to have standardized approachHistoryPhysical ExamCognitive TestingBalance Testing
Common tool is SCAT3Child SCAT3 for Ages 5 – 12 yoApp available for iPhone and iPad
SCAT2
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Detailed clinical assessment outlined in SCAT3
http://bjsm.bmj.com/content/47/5/259.full.pdf
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Sideline Assessment
If no evidence for concussionCan return to playShould still have serial evaluations
to ensure decision was correct If diagnosed with concussion
Should not return to playArrange follow-up appointment
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Patient Instructions - Acute
No longer recommended to have frequent awakenings Sleep is restorative Desirable to let athlete sleep
If level of consciousness is a concern Athlete should be sent to ED for neuroimaging Be monitored in hospital setting
Avoid Aspirin or NSAIDs Theoretical risk of bleeding Possible rebound headaches OK to use Acetaminophen
Physical and Mental Rest
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Office Management
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Office Evaluation
History Physical Exam Tools
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Office Evaluation
History Event mechanism Course of symptoms Previous history of concussion May need to speak with parents or
athletic trainer if need more info
Concerning symptoms for imaging Worsening symptoms
Increased nausea and vomiting Pronounced amnesia
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Office Evaluation
Physical ExamNeuro exam
Evaluate for focal deficitsBalance
BESS Testing (In SCAT3)Vestibular-Ocular Exam
Concerning symptoms for imagingProgressive balance dysfunctionFocal neurological deficits
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Vestibular System
Works with vision and somatosensory system to maintain balance
Coordinates eye and head movements
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Vestibular-Ocular Exam
Smooth Pursuit/”H” Test Saccades: Horizontal/Vertical Gaze Stability: Horizontal/Vertical Optokinetic Stimulation Convergence (Near Point)
Normal < 6 cm
From UPMC Concussion Program
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Office Evaluation
ToolsSymptom scores – SCAT3
Objective measureMay be helpful for serial monitoring
Computerized neuropsychiatric testing (NP)
Tool to assess cognitive function Usually follows clinical symptom resolution
Usually performed when clinically asymptomatic
May help early when deciding on school restrictions
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Computerized NP Testing
Zurich Guidelines Not mandatory, but may be helpful
AMSSM Position Statement Majority of concussions can be managed
appropriately without NP testing Aid to the clinical decision-making
process Should not be sole basis for management
decisions
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Neuroimaging
Imaging is typically normal in concussed athlete
Head CT Used to evaluate for:
Intracranial bleeding Skull fracture
MRI Brain May obtain if prolonged symptoms > 4 weeks
Used in concussion research fMRI, PET scan, SPECT Diffusion tension imaging
White matter fiber tracts MR spectroscopy - neurometabolites
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Concussion Management
Physical restBut don’t sit in dark room entire
time Cognitive rest
May need school accommodationsNo tests or homeworkHalf-days
Sleep7-9 hours, no naps
Regular diet and hydration
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Concussion Management
Medications Usually not started until 2-4 weeks post-
concussion Headaches
Can use acetaminophen Sleep
Melatonin Vitamin/Supplement Therapy
Vitamin B-2 – 200mg BID Magnesium – 100mg BID Fish Oil – 1 capsule daily Coenzyme Q10 – 100mg BID
Vestibular Therapy If prolonged vestibular symptoms
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Concussion Recovery
Majority of concussions resolve in 7-10 days: 80-90% May be longer in adolescents
Collins et al. Neurosurgery 2006134 High school football players
40% at week 160% at week 280% at week 3
Each concussion is uniqueEven with the same athlete
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When can they return to play?
No symptoms Normal Physical Exam If NP testing done
Returned to baseline or normative data Off all medications
Symptoms cannot be masked
Then athlete can start return to play protocol Usually guided by ATC
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Graduated RTP Protocol
• 24 hours per step (therefore about 1 week for full protocol)• If recurrence of symptoms at any stage, return to previous
asymptomatic level and resume after further 24 hr period of rest
Rehabilitation stage
Functional exercise at each stage of rehabilitation
Objective of each stage
1. No activity Symptom limited physical and cognitive rest.
Recovery
2.Light aerobic exercise
Walking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training.
Increase HR
3.Sport-specific exercise
Skating drills in ice hockey, running drills in soccer. No head impact activities.
Add movement
4.Non-contact training drills
Progression to more complex training drills e.g. passing drills in football and ice hockey. May start progressive resistance training
Exercise, coordination, and cognitive load
5.Full contact practice
Following medical clearance participate in normal training activities
Restore confidence and assess functional skills by coaching staff
6.Return to play Normal game play
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When to refer to specialist?
When symptoms have not resolved after 2-3 weeks restSooner if concerning symptoms or
unsure when safe to return to play Who do you refer to?
Primary Care Sports MedicineNeurologyPhysical Medicine and RehabNeuropsychiatry
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Chronic traumatic encephalopathy (CTE)
Acknowledge potential for long-term problems in all athletes
Unknown incidence of CTE in athletic populationscause/effect not yet demonstrated
between CTE and concussions or exposure to contact sport
May be due to long-term sub-concussive blows
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Patient Education
With each subsequent concussionSymptoms may last longerLower threshold for concussion
Important to be aware of new symptoms and seek care right awayDon’t try to play through symptomsMay prolong recovery
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Prevention??
No evidence that special helmets or mouth guards protect against concussions Making sure helmets are properly fitted is
most important Proper technique in their sport
Football: Tackling with head up
Neck strengthening is being researched
Educate athletes, parents, coaches, administrators, ATC’s
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Rule Changes in Sports MLB
2011 - Created 7 day disabled list New protocol for testing players
NFL 2013 – Can’t lower head to hit if outside
tackle box 2011 – Kickoffs moved up 5 yards
43% less concussions on kickoff the next year NHL
2010 – Created blind-side hit rule FIFA
2006 – Red card for deliberate elbowing
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Delaware Concussion Law
Senate Bill 111 Gov. Jack Markell
Sets regulations for schools in the Delaware Interscholastic Athletic Association for recognizing and managing student-athletes exhibiting signs and symptoms of sports-related concussions during practices, scrimmages and games. requires mandatory concussion training for all
interscholastic coaches awareness training for parents and athletes sets some rules around written medical
clearance before returning to play Private non-profit groups are encouraged
but NOT required to follow this act
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DIAA Rules – Day of Event
If a concussion is suspected - remove and evaluation by a qualified healthcare professional is required prior to return
Qualified healthcare professional MD/DO School nurse, nurse practitioner, physician
assistant, athletic trainer With collaboration and/or supervision by a
MD/DO as required by professional licensing Must be approved or appointed by the
administrative head of school or designee, or the DIAA executive director/assistant executive director
Qualified healthcare professional determines if it was a concussion
If determined to be a concussion, no return-to-play on the same day
In absence of qualified health professional, treat as if it is a concussion
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DIAA Rules on Return-to-Play
DIAA Reg 3.1.5 – “the athlete may only return to practice/game after the administrative head of school or designee receives ‘written clearance’ from a qualified physician.”
http://www.doe.k12.de.us/infosuites/students_family/diaa/files/DIAAConcussPrtcl2010.pdf
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Summary
Each concussion is unique, even for the same athlete
Educate your athletes and parents about the signs and symptoms of concussionSooner rest starts, sooner RTP
Educate what is proper rest Refer your patient to specialist if
symptoms don’t improve after 2-3 weeks
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Questions???
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References
Harmon KG, Drezner JA, Gammons M, et al. Br J Sports Med 2013, 47, 15-26
McCory P, Meeuwisse WH, Aubry M, et al. Br J Sports Med 2013, 47: 250-258.
Lau B, Collins MW, Lovell MR. Neurosurgery. 2012 Feb;70(2):371-9.
Lau, Kontos, Collins, Lovell , AJSM. 2011 Nov;39(11):2311-8.
Collins, Lovell, Iverson. Neurosurgery 58:275-286, 2006.
DIAA Concussion Protocol. http://www.doe.k12.de.us/infosuites/students_family/diaa/files/DIAAConcussPrtcl2010.pdf