View
219
Download
3
Category
Tags:
Preview:
Citation preview
DISCUSSION ON ...
SPORTS
CONCUSSION
Dr Isstelle JoubertSports Meds, UFS
1st year, 2011
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
Cerebrum
Cerebellum
Parietal Lobe
Occi-pital lobe
Frontal lobe
Temporal lobe
PonsMedulla
Brainstem
Spinal Cord
Surface anatomy of the Brain
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:
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:
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:
Internal structure of
brain
Spinal cord
Medulla oblongata
Cerebrum
Midbrain
Diencephalon
Cerebellum
Pons
VASCULAR SUPPLY OF THE BRAIN
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)
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
SYNONYMS:
brain concussion
mild head injury
minor head injury
mild or minimal traumatic brain injury
(Signoretti et al, 2010)
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
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)
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
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)
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)
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)
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
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
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
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
Early complications
impact convulsions
• seizures not common
• not associated with structural damage
• good outcome
• anti-convulsant - not indicated
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)
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)
SYMPTOMS AND SIGNS ASSOCIATED WITH CONCUSSION
reported in the concussed athlete
by the athlete self
observed by family members, coaches or teammates
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
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
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
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:
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
WHAT IS NEW IN CONCUSSIONS...?
Prevention possibilities
Evaluation possibilities
Medication possibilities
Management possibilities
Fighting the Ghosts
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...
Evaluation possibilities... CogState
Impact
SCAT
steroids
anti-oxidants
glutamate receptor antagonists
hyperbaric oxygen
hypothermia
calcium channel blockers
Medication possibilities...
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...
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...
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
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
Recommended