Richard G. Ellenbogen, M.D.Chairman, UW Department of Neurological SurgeryCo-Chairman NFL Head, Neck and Spine Committee

Samuel R. Browd, M.D., Ph.D.UW Assistant Professor Neurological Surgery

Attending Neurosurgeon, Seattle Children's Hospital

Sports Concussion:Injury

Signs & SymptomsReturn to Play

OBJECTIVES

1. A REVIEW OF HEAD INJURY IN THE ATHLETE

2. A REVIEW OF THE SYMPTOMS AND SIGNS OF CONCUSSION

3. A REVIEW OF THE TOOLS AND GUIDES IN RETURN TO PLAY DECISIONS

THE CONCUSSION CONTROVERSY IN SPORTS TODAY

Any Given Sunday

• 17+ ARTICLES IN 2009 ALONE

• Forum for Football Brain Injuries Set for Houston– 01/07/10

• Lawmakers Grill Doctor for His Views on Concussions– 01/04/10

• Silence on Concussions Raises Risks of Injury – Alan Schwarz 09/15/07

Richard Ellenbogen, M.D.

Zackery Lystedt

ConcussionInternational Conference on Concussion in Sport– Vienna 2001, Prague 2004, Zurich 2008

– “THIS IS A WORLDWIDE PROBLEM AFFECTING BOTH SEXES, STUDENT/ATHLETES, PROFESSIONALS AND THE MILITARY“

• (Ellenbogen, NFL Committee)

– CONCUSSION: • “Complex pathophysiologic process

affecting the brain, induced by traumatic biomechanical forces.”

Concussion Definition

– COMPLEX COMPLEX • no “easy” concussions!no “easy” concussions!

– PATHOPHYSIOLOGY PATHOPHYSIOLOGY • RARELY structural!RARELY structural!

– TRAUMA INDUCEDTRAUMA INDUCED• an impact to the head or body that is transmitted to the headan impact to the head or body that is transmitted to the head

– LOSS OF CONSCIOUSNESSLOSS OF CONSCIOUSNESS• < 10% of players < 10% of players

Concussion Definition

Common features include:

• Rapid onset of usually short-lived neurological impairment which typically resolves spontaneously.

• A range of clinical symptoms that may or may not involve loss of consciousness (LOC).

Less than 10% of sports concussions involve loss of consciousness Less than 10% of sports concussions involve loss of consciousness

Epidemiology of Severe Injuries Among United States High School Athletes

• National High School Sports-Related Injury Surveillance System 2005-2007

• Nationally representative sample of 100 US high schools

• 9 sports (football, wrestling, baseball, softball, girls’ volleyball, and boys’ and girls’ soccer and basketball)

• Loss of >21 days of sports participation

Darrow, CJ et al. Am J Sports Medicine Vol 7, #9 2009

Sport Concussion (% >21 days)

Boy’s football 5.9%

Boy’s soccer 11.8%

Girl’s soccer 7.7%

Girl’s volleyball 8.9%

Boy’s basketball 1.2%

Girl’s basketball 6.6%

Boy’s wrestling 3.3%

Boy’s baseball 1.4%

Girl’s softball 1.2%

World-Wide:Australia

Epidemiology of Concussionsin High School and Collegiate Sports

• Data from the High School Reporting Information Online System and the NCAA Injury Surveillance System

– 5.9% of all collegiate athletic injuries

– 8.9% of all high school athletic injuries

– Concussion rates were higher in college, but concussions were a higher proportion of all high school athletic injuries

Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503

High School Sports

• Concussion rate per 1000 athlete-exposures

• Football 0.47• Girl’s soccer 0.36• Boy’s soccer 0.22• Girl’s basketball 0.21• Boy’s basketball 0.07

Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503

High School Sports

• 16.8 % of concussed athletes had suffered a previous concussion in that season or in a prior season

– Greater than 20% of concussions in boys’ and girls’ basketball were recurrent concussions

• Girls took longer than boys to recover

Gessel LM et al. “Concussions Among United States High School and Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503

Recurrent Injuries:High School Athletes

• 11.6% of the recurrent injuries were concussions• Swenson, DM et al. Am J Sports Medicine 2009;37(4)

Brain Injury-Related Fatalities American Football Players

Different Levels of Play (1945-1999)

0

50

100

150

200

250

300

350

400

fatalities

High schoolSandlotCollegeProfessional

374

76 3314

Cantu and Mueller. Neurosurgery 2003;52:846-853

0

50

100

150

200

250

300

350

400

450

Fatalities

SubduralUnknownFractureAneurysmEdema

Cantu and Mueller. Neurosurgery 2003;52:846-853

429

40 18 6 4

Brain Injury-Related Fatalities American Football Players

Injury Type (1945-1999)

Catastrophic Head InjuriesHigh School and College Football

• National Center for Catastrophic Sports Injury Research data from 1989-2002

– 94 cases• 75 subdural hematomas • 10 subdural with diffuse brain swelling• 5 diffuse brain swelling• 4 AVM or aneurysm

– 92 cases were in high school players

» Boden et al. AJSM 2007; 35: 1075 - 1081

• 59% of athletes had a previous history of concussion(s)

• 71% of those injuries occurred in the same season as the catastrophic injury

• 39% of athletes at time of catastrophic injury were playing with residual symptoms from a previous concussion

» Boden et al. AJSM 2007; 35: 1075 - 1081

Catastrophic Head InjuriesHigh School and College Football

Classification/Grading Guides Conflicting and do NOT guide therapy!!!

Guideline Grade 1 Grade 2 Grade 3

Cantu 1. No LOC

2. Posttraumatic amnesia <30 min

1. LOC > 5 min OR

2. Posttraumatic amnesia > 30 min

1. LOC > 5 min OR

2. Posttraumatic amnesia >24˚

Colorado 1. Confusion w/out amnesia

2. No LOC

1. Confusion w/ amnesia

2. No LOC

1. LOC

(of any duration)

AAN 1. Transient confusion

2. No LOC

3. Concussion syx, ms change resolve w/in 5 min

1. Transient confusion

2. No LOC

3. Concussion syx, ms change >15 min

1. LOC

(brief or prolonged)

Cantu

(Revised)

1. No LOC OR

2. Posttraumatic amnesia signs/syx < 30 min

1. LOC < 1 min OR

2. Posttraumatic amnesia >30 min, <24˚

1. LOC > 1min OR

2. Posttraumatic amnesia >24˚

OR

3. Post concussion signs/syx > 7d

A Ding Is Not Always Just A Ding

1.6 to 2.3 million sports concussions per year Center for Disease Control 2006

Acute Signs and Symptoms:Suggestive of Concussion

COGNITIVE SOMATIC AFFECTIVE

•Confusion•Post-traumatic amnesia •Retrograde amnesia Loss of consciousness •Disorientation•Feeling “in a fog,” “zoned out”•Vacant stare•Inability to focus•Delayed verbal and motor responses•Slurred/incoherent speech•Excessive drowsiness

•Headache•Fatigue•Disequilibrium, dizziness•Nausea/vomiting•Visual disturbances (photophobia, blurry/double vision)•Phonophobia

•Emotional lability•Irritability

PathophysiologyPathophysiology

• In a concussion, certain chemical levels are altered at the In a concussion, certain chemical levels are altered at the cellular levelcellular level

• Blood supply to the brain decreasesBlood supply to the brain decreases

• The brain’s demand for glucose increasesThe brain’s demand for glucose increases

• Mismatch in fuel supply and demandMismatch in fuel supply and demand– Neuronal tissue vulnerabilityNeuronal tissue vulnerability

• Brain needs time to recoverBrain needs time to recover

Game-Day: Evaluation & Treatment

Pre-Game

It is essentialessential to:

– Implement a game-day medical plan specific to concussion.

– Understand the indications for cervical spine immobilization and emergency transport.

Game-Day: Evaluation & Treatment

On-Field

It is essentialessential to:

• Evaluate the injured athlete on-the-field in a systematic fashion

• Determine initial disposition – emergency transport vs. sideline evaluation

Recognizing a Concussion Recognizing a Concussion Signs and SymptomsSigns and Symptoms

Signs observed by trainer preferably, coach, parent, teammates include:

• Appears dazed or stunned

Is confused about assignment

Forgets plays

Is unsure of game, score, or opponent

Moves clumsily

Answers questions slowly

Loses consciousness

Shows behavior or personality changes

Can’t recall events prior to hit

Can’t recall events after hit.

Symptoms reported by athlete include:

• Headache

Nausea

Balance problems or dizziness

Double or fuzzy vision

Sensitivity to light or noise

Feeling sluggish

Feeling foggy or sluggish

Concentration or memory problems

Confusion

Game-Day: Evaluation & Treatment

Sideline

It is essentialessential to:

– Not leave the player unsupervised

– Determine disposition • home with observation

• transport to hospital

– Provide post-event instructions to the athlete and others • e.g., regarding alcohol, medications, physical exertion and

medical follow-up

THE EVIDENCE FOR RETURN TO PLAY

THERE IS NONE

IT IS:

JUDGEMENTJUDGEMENTEXPERIENCEEXPERIENCE

Return to PlayReturn to Play

Same Day

It is essentialessential to understand:

– A (youth) player with diagnosed (or suspected) concussion should should not be allowed to return to playnot be allowed to return to play on the same day as the injury.

• McCory P, et al. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport

– Held in Zurich, November 2008. » Clin J Sport Med 2009;19:185-200

Post-GamePost-GameManagement by Healthcare Provider: Return to Play

• Obtain a comprehensive history• current concussion• any previous concussion

• Determine the need for further evaluation and consultation.

• Determine return-to-play status

– ***CONCUSSION FOLLOWED BY ***CONCUSSION FOLLOWED BY SYMPTOMSSYMPTOMS AFTER 20 MINUTES OF REST… AFTER 20 MINUTES OF REST…

• DISQUALIFIED FROM PLAYING ON THE DAY OF INJURY– COGNITIVE REST AS WELL (NO SCHOOL!)

• HIGH SCHOOL IS EASY: “WHEN IN DOUBT, SIT THEM OUT”“WHEN IN DOUBT, SIT THEM OUT”

– COLLEGE/PROS IF AFTER 20 MINUTES OF REST AND THEY HAVE NO EXERTIONAL SYMPTOMS THEY MAY RETURN

Post-GamePost-GameManagement by Healthcare Provider: Return to Play

– LOC or AmnesiaLOC or Amnesia

• Disqualified from immediate RTPDisqualified from immediate RTP– no tool is sufficient to determine RTPno tool is sufficient to determine RTP

» SCATII, SAC or BESSSCATII, SAC or BESS

• Athletes under 18 years old and Females Athletes under 18 years old and Females – longer period of neurocognitive longer period of neurocognitive

recovery after concussionrecovery after concussion

Copyright restrictions may apply.

McCrea, M. et al. JAMA 2003;290:2556-2563.

Symptom, Cognitive, and Postural Stability Recovery in Concussion and Control Participants

PRINCIPALS OF RTP

• 3 or more CONCUSSIONS in a SEASON– 3 MONTH SYMPTOM FREE PERIOD BEFORE THEY RETURN TO A COLLISION SPORT

• 3 or more CONCUSSIONS in a SEASON with SLOWED RECOVERY– THEY SIT OUT FOR THE SEASON OR MAYBE PERMANENTLY

• DISQUALIFY:– NEURO EXAM IS NOT RETURNED TO NORMAL– NEUROPSYCH BATTERY IS ABNORMAL– SYMPTOMS

• Take into account the SEVERITY OF THE BLOW AND PROLOGNATION OF THE AMNESIA

• ABNORMAL MRI: 1 YEAR OF REST

PRINCIPALS OF RTP

• Understand:

– Brief LOC (seconds, not minutes)

– Amnesia, as well as the number and duration of additional signs and symptoms (and neuropsychological data) are more accurate in predicting severity and outcome.

– The treatment of and the RTP decision for the athlete with concussion must be individualized

– Manage by symptoms, not by grades

• Many return to play guidelines are weighed to LOC– NOT A GOOD IDEA!

PRINCIPALS OF RTP

• Consider factors which may affect RTP, including:

– Severity of the current injury– Previous concussions (number, severity, proximity)– Significant injury in response to a minor blow– Age (developing brain may react differently to trauma than mature

brain)– Sport– Learning disabilities– Depression, anxiety– Migraine headaches

PRINCIPALS OF RTP

• Neuropsychological testing

– Post-injury neuropsychological test data are more useful if compared to the athlete’s pre-injury baseline.

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

– It is only one component of the evaluation process.

Graduated Return to Play in 1 Slide

Rehab Stages (1-6) Functional Exercise Objective

1. No activity Complete physical & cognitive rest (No school, if indicated!)

Recovery of cognitive function

2. Light aerobic exercise Walking, swimming or stationary bike; no resistance training

HR

3. Sport-specific exercise Running drills; no head impact activity

Add movement

4. Non-contact training drills

Progression to more complex training drills; start progressive resistance training

Exercise, coordination, cognitive load

5. Full contact practice After Medical Clearance Only; Normal activity

Restores confidence & assess functional skills

6. Return to play Normal game/competition Prevent Next Injury

PRINCIPALS OF RTP

• Physical and cognitive rest may be necessary including cognitive rest from school

• Determine the athlete is asymptomatic at rest before resuming any exertional activity.

• Utilize progressive aerobic and resistance exercise challenge tests prior to full return to play.

Sport Concussion Assessment Tool

• SCAT 2

• Developed from International Conference on Concussion in Sport

– Zurich 2009

• Used during and after game time for RTP

• Update of the 2005 SCAT1

• Used by medical and health professionals

• 4 pages

• 20 minutes to administer

• Athletes 10 years old and above

• Preseason baseline

Sport Concussion Assessment Tool

• Evaluates for one or more of the following:– Symptoms– Signs– Impaired brain function– Abnormal behavior– Impaired Neuro Function

22 questions

Do the symptoms get worse with physical activity? Yes No☐ ☐Do the symptoms get worse with mental activity? Yes No☐ ☐

At what venue are we today?

Which half is it now?

Who scored last?

What team did we play last week?

Did we win last week?

0 1

0 1

0 1

0 1

0 1

Scoring: 1 point for each correct answer (maximum of 5)Validated for sideline diagnosis

1. Orientation

2. Immediate Memory

3. Concentration

• What month is it?• What is the date today?• What is the day of the

week?• What year is it?• What time is it right now?

(within 1 hour)

0 1

0 1

0 1

0 1

0 1

Scoring: 1 point for each correct answer (maximum of 5)

List Trial 1

Trial 2

Trial 3 Alternative Word List

elbow 0 1 0 1 0 1 candle babyapple 0 1 0 1 0 1 paper monkeycarpet 0 1 0 1 0 1 sugar perfumesaddle 0 1 0 1 0 1 sandwich sunsetbubble 0 1 0 1 0 1 wagon iron

Scoring: 1 point for each correct answer (maximum of 15)

List Alternative Digit List4-9-3 0 1 6-2-9 5-2-6

3-8-1-4 0 1 3-2-7-9 1-7-9-56-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7

7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4

Scoring: 1 point for each correct answer (maximum of 4)

Digits Backward

• Months in reverse order

Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan

Scoring: 1 point for entire sequence correct

Instructions:• “Which foot do you kick with?” (i.e.

dominant foot)• 20 seconds per stance• Shoes off• Remove ankle taping• Place hands on hips• Close eyes

A. Double leg stanceFeet shoulder-width apart

B. Single leg stanceLift the dominant foot (30° hip flexion, 45° knee

flexion)

C. Tandem stanceDominant foot in the front

Scoring: 1 point for each error (max. of 10 per stance) Final score is 30 minus total errors

Finger-to-nose task:

• Athlete is to touch their nose and then your finger

• Athletes fail if they don’t touch their nose, don’t fully extend the elbow, or don’t perform 5 repetitions

Scoring: 1 point for five repetitions in < 4 seconds (maximum of 1)

• Delayed recall

List

elbowapplecarpetsaddlebubble

Scoring: 1 point for each recalled word (maximum of 5)

• Symptom score (22)• Physical signs score (2)• GCS (15)• Maddocks’ score (5)• Orientation (5)• Immediate memory (5)• Concentration (5)• Balance examination (30)• Coordination exam (1)• Delayed recall (5)

Max is 100/100Lowest is 3/100

SCAT 2: Scoring

• Recognition of a potential concussion

• Initial screening (SCAT2, SAC, Maddocks) to obtain post-injury baseline

• Avoid leaving the athlete unsupervised

• Serial neurologic exams

• Determine disposition

• Post-game instructions and follow-up screening

Goals

• SCAT2 is just a screening tool

• It won’t catch every concussion– Use your judgment

• Only gives you one moment in time– Things change and they change quickly

–“When in doubt, sit them out"

SECOND IMPACT SYNDROME• Rare

• Limited to teenagers or under 18 in all cases

• No cases in NFL/NHL/MLB

• Medical review after witnessed 1st impact

• Documented ongoing symptoms until 2nd impact

• Witnessed 2nd impact followed by rapid deterioration

• Evidence of cerebral swelling without other cause

Recurrent Concussion: Who Cares?

• 2- 4X increased risk for recurrent concussion

– More symptoms

– Last longer

– Small but repetitive hits

• Cumulative brain trauma: – CHRONIC TRAUMATIC

ENCEPHALOPTHY

Sports Concussions: Education, Awareness, Action

Washington State Heads Up:

Concussion in Youth Sports Campaign

Washington State Road Show

Educate or Legislate?

Stan Herring, M.D.

Richard Adler, J.D.

wsata

Engrossed House Bill 1824Requiring the adoption of policies for the management of

concussion and head injury in youth sports.

• All student athletes and parents/guardians sign an information sheet regarding concussion prior to each season

• School districts to work with the Washington Interscholastic Activities Association (WIAA) to develop information and policies on educating coaches, youth athletes, and parents about the nature and risk of concussion including the dangers of premature return to practice or play after a concussion

• Any athlete suspected of suffering a concussion is removed from play until they receive written clearance for return to practice and play by a licensed health care provider trained in the evaluation and management of concussions

Zackery Lystedt Law

May 14th, 2009

Is This Practice/Game More Important Than:Is This Practice/Game More Important Than:

• The rest of the season?The rest of the season?

• The rest of the athlete’s career?The rest of the athlete’s career?

• The rest of the athlete’s life?The rest of the athlete’s life?

CONCLUSIONCONCLUSION

Do not let a injured athlete back into practiceDo not let a injured athlete back into practice or games until they have been evaluated and cleared or games until they have been evaluated and cleared

in writing by a licensed healthcare provider trained in in writing by a licensed healthcare provider trained in the evaluation and management of concussions.the evaluation and management of concussions.

That is not only the LAW; That is not only the LAW; It Is The Right Thing To Do!It Is The Right Thing To Do!