Con

cuss

ion

In S

ports

Sylv

ia L

ucas

MD

, PhD

C

linic

al P

rofe

ssor

of N

euro

logy

& N

euro

logi

cal S

urge

ry

Adj

unct

, Reh

abili

tatio

n M

edic

ine

Uni

vers

ity o

f Was

hing

ton

Med

ical

Cen

ter

Seat

tle S

ports

Con

cuss

ion

Clin

ic

Get

ting

your

bel

l run

g is

not

alw

ays a

bout

get

ting

your

bel

l run

g

3.8

mill

ion

conc

ussi

ons

per y

ear a

mon

g 44

mill

ion

child

ren

and

170

mill

ion

adul

ts

parti

cipa

ting

in o

rgan

ized

spo

rts

Def

initi

on o

f Con

cuss

ion

Con

cuss

ion

is a

mild

trau

mat

ic b

rain

inju

ry (m

TBI):

is

a tr

aum

atic

ally

indu

ced

disr

uptio

n of

bra

in

func

tion

Com

mon

feat

ures

incl

ude:

– 

Rap

id o

nset

of u

sual

ly s

hort-

lived

neu

rolo

gica

l im

pairm

ent w

hich

typi

cally

reso

lves

sp

onta

neou

sly.

– 

Acu

te c

linic

al s

ympt

oms

that

usu

ally

refle

ct a

fu

nctio

nal d

istu

rban

ce ra

ther

than

stru

ctur

al

inju

ry. N

euro

imag

ing

stud

ies

are

typi

cally

no

rmal

. – 

A ra

nge

of c

linic

al s

ympt

oms

that

may

or m

ay

not i

nvol

ve lo

ss o

f con

scio

usne

ss (L

OC

).

SIG

NS

AN

D S

YMPT

OM

S SU

GG

ESTI

VE O

F C

ON

CU

SSIO

N

CO

GN

ITIV

E SO

MAT

IC

AFF

ECTI

VE

SLEE

P C

onfu

sion

Po

st-tr

aum

atic

am

nesi

a (P

TA)

Ret

rogr

ade

amne

sia

(RG

A)

Loss

of

cons

ciou

snes

s (L

OC

) D

isor

ient

atio

n Fe

elin

g �in

a fo

g,�

Diff

icul

ty w

ith

mem

ory

Vaca

nt s

tare

In

abili

ty to

focu

s D

elay

ed v

erba

l an

d m

otor

re

spon

ses

Slur

red/

inco

- he

rent

spe

ech

Hea

dach

e Fa

tigue

D

iseq

uilib

rium

, di

zzin

ess

Nau

sea/

vom

iting

Vi

sual

dis

turb

ance

s (p

hoto

phob

ia,

blur

ry/d

oubl

e vi

sion

) Ph

onop

hobi

a

Emot

iona

l lab

ility

Irr

itabi

lity

Anx

ious

Sa

d

Dro

wsi

ness

Sl

eepi

ng le

ss

Slee

ping

mor

e Tr

oubl

e fa

lling

as

leep

Epid

emio

logy

of C

oncu

ssio

ns

in H

igh

Scho

ol a

nd C

olle

giat

e Sp

orts

• 

Dat

a fr

om th

e H

igh

Scho

ol R

epor

ting

Info

rmat

ion

Onl

ine

Syst

em a

nd th

e N

CA

A In

jury

Sur

veill

ance

Sy

stem

– 

5.9%

of a

ll co

llegi

ate

athl

etic

inju

ries

– 8.

9% o

f all

high

scho

ol a

thle

tic in

jurie

s – 

Con

cuss

ion

rate

s wer

e hi

gher

in c

olle

ge, b

ut

conc

ussi

ons w

ere

a hi

gher

pro

porti

on o

f all

high

scho

ol a

thle

tic in

jurie

s.

Ges

sel L

M e

t al. �C

oncu

ssio

ns A

mon

g U

nite

d St

ates

Hig

h Sc

hool

and

C

olle

giat

e Ath

lete

s��J

ourn

al o

f Ath

letic

Tra

inin

g 20

07; 4

2:49

5-50

3

Epid

emio

logy

of S

ever

e In

jurie

s Am

ong

Uni

ted

Stat

es H

igh

Scho

ol A

thle

tes

spor

t C

oncu

ssio

n (%

>21

day

s)

Boy

’s fo

otba

ll 5.

9%

Boy

’s so

ccer

11

.8%

G

irl’s

socc

er

7.7%

G

irl’s

vol

leyb

all

8.9%

B

oy’s

bas

ketb

all

1.2%

G

irl’s

bas

ketb

all

6.6%

B

oy’s

wre

stlin

g 3.

3%

Boy

’s b

aseb

all

1.4%

G

irl’s

softb

all

1.2%

Epid

emio

logy

of C

oncu

ssio

ns

in H

igh

Scho

ol S

ports

• C

oncu

ssio

n ra

te p

er 1

000

athl

ete-

expo

sure

s – 

Foot

ball

0

.47

– G

irl�s s

occe

r

0

.36

– B

oy�s s

occe

r

0

.22

– G

irl�s b

aske

tbal

l

0.21

– 

Boy�s b

aske

tbal

l

0.07

60%

hig

her

300%

hig

her

Ges

sel L

M e

t al. �C

oncu

ssio

ns A

mon

g U

nite

d St

ates

Hig

h Sc

hool

and

C

olle

giat

e Ath

lete

s��J

ourn

al o

f Ath

letic

Tra

inin

g 20

07; 4

2:49

5-50

3

Epid

emio

logy

of C

oncu

ssio

ns

in H

igh

Scho

ol S

ports

• 16

.8 %

of c

oncu

ssed

ath

lete

s had

suff

ered

a

prev

ious

con

cuss

ion

in th

at se

ason

or i

n a

prio

r sea

son:

– 

Gre

ater

than

20%

of c

oncu

ssio

ns in

boy

s� a

nd

girls� b

aske

tbal

l wer

e re

curr

ent c

oncu

ssio

ns

• G

irls t

ook

long

er th

an b

oys t

o re

cove

r.

Ges

sel L

M e

t al. �C

oncu

ssio

ns A

mon

g U

nite

d St

ates

Hig

h Sc

hool

and

C

olle

giat

e Ath

lete

s��J

ourn

al o

f Ath

letic

Tra

inin

g 20

07; 4

2:49

5-50

3

Rec

urre

nt In

jurie

s H

igh

Scho

ol A

thle

tes

• 11

.6%

of t

he re

curr

ent i

njur

ies w

ere

conc

ussi

ons

– Sw

enso

n, D

M e

t al.

Am

J Sp

orts

Med

icin

e 20

09;3

7(4)

The

Chi

ld-S

CA

T3

Sta

ndar

dize

d to

ol fo

r eva

luat

ing

inju

red

child

ren

for

conc

ussi

on

Use

d in

chi

ldre

n 5-

12 y

ears

old

M

edic

al p

rofe

ssio

nals

Gam

e-D

ay E

valu

atio

n &

Tre

atm

ent

Pre

-Gam

e

– Im

plem

ent a

gam

e-da

y m

edic

al p

lan

spec

ific

to c

oncu

ssio

n.

– U

nder

stan

d th

e in

dica

tions

for c

ervi

cal

spin

e im

mob

iliza

tion

and

emer

genc

y tra

nspo

rt.

Gam

e-D

ay E

valu

atio

n &

Tre

atm

ent

Pre

-Gam

e

• 

Eva

luat

e th

e in

jure

d at

hlet

e on

-the-

field

in a

sy

stem

atic

fash

ion:

– 

Ass

ess

for a

dequ

ate

airw

ay, b

reat

hing

, and

ci

rcul

atio

n (A

BC�s)

. – 

Follo

wed

by

focu

sed

neur

olog

ical

ass

essm

ent

emph

asiz

ing

men

tal s

tatu

s, n

euro

logi

cal d

efic

it,

and

cerv

ical

spi

ne s

tatu

s.

– D

eter

min

e in

itial

dis

posi

tion

(em

erge

ncy

trans

port

vs. s

idel

ine/

dugo

ut e

valu

atio

n).

Gam

e-D

ay E

valu

atio

n &

Tre

atm

ent

Sid

elin

e/D

ugou

t

• O

btai

n a

mor

e de

taile

d hi

stor

y an

d pe

rform

a m

ore

deta

iled

phys

ical

exa

min

atio

n (C

hild

-SC

AT3

) – A

sses

s fo

r cog

nitiv

e, s

omat

ic, a

nd a

ffect

ive

sign

s an

d sy

mpt

oms

of a

cute

con

cuss

ion

with

par

ticul

ar

atte

ntio

n to

retro

grad

e am

nesi

a (R

GA

), po

st-

traum

atic

am

nesi

a (P

TA),

and

mor

e th

an b

rief L

OC

(m

inut

es, n

ot s

econ

ds),

beca

use

of th

eir p

rogn

ostic

si

gnifi

canc

e.

– Spe

ak w

ith o

ther

s w

itnes

sing

the

conc

ussi

on

Gam

e-D

ay E

valu

atio

n &

Tre

atm

ent

Sid

elin

e/D

ugou

t

• N

ot le

ave

the

play

er u

nsup

ervi

sed.

• 

Per

form

ser

ial n

euro

logi

cal a

sses

smen

ts.

• D

eter

min

e di

spos

ition

for s

ympt

omat

ic a

nd

non-

sym

ptom

atic

pla

yers

, inc

ludi

ng p

ost-

inju

ry fo

llow

-up

(opt

ions

incl

ude

hom

e w

ith

obse

rvat

ion

or tr

ansp

ort t

o ho

spita

l).

• P

rovi

de p

ost-e

vent

inst

ruct

ions

to th

e at

hlet

e an

d ot

hers

(e.g

., re

gard

ing

alco

hol,

med

icat

ions

, phy

sica

l exe

rtion

and

med

ical

fo

llow

-up)

.

Ret

urn-

To-P

lay

Sam

e-D

ay

It is

ess

entia

l to

unde

rsta

nd:

• It

is th

e sa

fest

co

urse

of a

ctio

n to

ho

ld a

n at

hlet

e ou

t. • 

Whe

n in

dou

bt, s

it th

em o

ut.

It ta

kes

time

for s

igns

and

sym

ptom

s to

fully

dev

elop

, an

d co

ncus

sed

yout

h at

hlet

es re

cove

r mor

e sl

owly

th

an c

olle

giat

e or

pro

fess

iona

l ath

lete

s

Ret

urn-

To-P

lay

Sam

e-D

ay

It is

ess

entia

l to

unde

rsta

nd

• A

(you

th) p

laye

r with

a (s

uspe

cted

) or

diag

nose

d co

ncus

sion

shou

ld n

ot b

e al

low

ed

to re

turn

to p

lay

on th

e sa

me

day

as th

e in

jury

. – 

McC

ory

P, e

t al.

Con

sens

us S

tate

men

t on

Con

cuss

ion

in S

port

3rd

Inte

rnat

iona

l Con

fere

nce

on C

oncu

ssio

n in

Sp

ort H

eld

in Z

uric

h, N

ovem

ber 2

008.

Clin

J Sp

ort

Med

200

9;19

:185

-200

Man

agem

ent P

rinci

ples

• A

ll re

turn

to p

lay

guid

elin

es a

re e

mpi

ric

• O

rigin

ally

des

igne

d to

pr

even

t Sec

ond

Impa

ct

Synd

rom

e • 

Non

e w

ere

deve

lope

d sp

ecifi

cally

for t

he

youn

g at

hlet

e

Ret

urn-

To-P

lay

P

ost-

Gam

e D

ay

• D

eter

min

e th

e at

hlet

e is

asy

mpt

omat

ic a

t-res

t bef

ore

resu

min

g an

y ex

ertio

nal a

ctiv

ity.

- am

nesi

a m

ay b

e pe

rman

ent.

• U

tiliz

e pr

ogre

ssiv

e ae

robi

c an

d re

sist

ance

exe

rcis

e ch

alle

nge

test

s pr

ior t

o fu

ll R

TP.

Ret

urn-

To-P

lay

P

ost-

Gam

e D

ay

• C

onsi

der f

acto

rs w

hich

may

affe

ct R

TP, i

nclu

ding

: – 

Sev

erity

of t

he c

urre

nt in

jury

– 

Pre

viou

s co

ncus

sion

s (n

umbe

r, se

verit

y, p

roxi

mity

) – 

Sig

nific

ant i

njur

y in

resp

onse

to a

min

or b

low

– 

Age

(dev

elop

ing

brai

n m

ay re

act d

iffer

ently

to tr

aum

a th

an

mat

ure

brai

n)

– S

port

– Le

arni

ng d

isab

ilitie

s

– A

DD

/AD

HD

– 

Anx

iety

/Dep

ress

ion

– M

igra

ine

Hea

dach

e • 

Und

erst

and

cont

rove

rsy

exis

ts fo

r pos

t-gam

e R

TP d

ecis

ions

.

Ret

urn-

To-P

lay

P

ost-

Gam

e D

ay

Con

cern

s

• Pr

olon

ging

reco

very

from

th

e cu

rren

t con

cuss

ion

• 2-

4X

incr

ease

d ris

k fo

r re

curr

ent c

oncu

ssio

n • 

Post

-con

cuss

ive

synd

rom

e – 

5- 8

% o

f MTB

I

• C

umul

ativ

e br

ain

traum

a

Con

cuss

ion

• R

emov

e fr

om p

ract

ice

or p

lay.

• 

Do

not l

eave

the

play

er a

lone

: – 

Ass

ess,

re-a

sses

s, an

d re

-ass

ess

• Se

e a

licen

sed

heal

thca

re p

rovi

der t

rain

ed in

th

e ev

alua

tion

and

man

agem

ent o

f co

ncus

sion

. • 

Ret

urn

to p

lay-

med

ical

ly su

perv

ised

st

epw

ise

proc

ess.

Con

cuss

ion

• Th

e yo

unge

r the

ath

lete

, the

mor

e co

nser

vativ

e th

e tre

atm

ent.

No

sam

e da

y re

turn

to p

lay

for y

outh

at

hlet

es.

• Th

ere

is n

o si

mpl

e te

st:

– U

se si

gns &

sym

ptom

s, no

t gra

des

• B

e al

ert t

o su

btle

def

icits

: – 

e.g.

neu

rops

ycho

logi

cal d

ata

for c

ogni

tive

asse

ssm

ent

• C

linic

al ju

dgm

ent i

s the

fina

l det

erm

inan

t of

retu

rn to

pla

y.

May

14th

200

9

Z

acke

ry L

yste

dt L

aw

Res

ourc

es

• SC

AT3

. Br J

Spo

rts M

ed 2

013;

47:2

59.

• C

hild

- SC

AT3

. Br

J Sp

orts

Med

201

3;47

:263

. • 

McC

rory

P, e

t. al

. Con

sens

us st

atem

ent o

n co

ncus

sion

in sp

ort:

the

4th

Inte

rnat

iona

l C

onfe

renc

e on

Con

cuss

ion

in S

port

held

in Z

uric

h,

Nov

embe

r 201

2.