Concussion: return-to-play guideline

Thao M. Nguyen, MDPEM fellow

Fellows’ ConferenceJune 20, 2007

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Case

17 yo male with LOC following a football tackle. He has retrograde amnesia to the day’s event, confusion, and initial weakness. This is his 2nd concussion. Brought to the ER by the family for evaluation

Exam VSS; alert and oriented x 4; follows command but slightly slow in response from his baseline; nonfocal neurological exam.

Head CT negative Final diagnosis: closed head injury with LOC You plan to discharge pt home in family’s care with

head injury sheet. What further discharge instructions should you provide?

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Objectives

Definition & epidemiology Review the symptoms & complications of concussion Discuss the evolution of the return-to-play guidelines Acute and long-term management

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Definition

“Trauma-induced alteration in mental status that may or may not involve loss of consciousness.”

AAN 1997

< 10% of concussions result in LOC Confusion and amnesia are the hallmarks of

concussion “Type of mild traumatic brain injury (TBI) caused by an

impact or jolt to the head.”Pediatrics

2006

“a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.”

CISG 2001

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Epidemiology

2:1 male:female most common head injury in sports >300,000 sport-related mild-to-mod TBIs high school football alone

• 20% of players or 250,000 concussions/year

• 10% in college football players Other risky sports: equestrian, boxing, ice hockey,

wrestling, gymnastics, lacrosse, soccer and basketball 4-6x more likely to sustain a 2nd concussion

Cantu. Br J Sports Med 1996

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Epidemiology

Sports Rate of concussions/1000 athlete-exposures

Ice hockey 0.27

Football 0.25

Men’s soccer 0.25

Women’s soccer 0.24

Field hockey 0.20

Wrestling 0.20

Men’s lacrosse 0.19

Women’s softball 0.11

Kelly, Neurology 1997

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Observed symptoms

Vacant stare Delayed verbal and motor responses Confusion and inability to focus attention Disorientation Slurred or incoherent speech Gross observable incoordination Emotions out of proportion to circumstances Memory deficits Any period of loss of consciousness

AAN Practice Parameter, Neurology 1997

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Early symptoms: minutes to hours

Headache Dizziness or vertigo Lack of awareness of surroundings Nausea or vomiting

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Late symptoms: days to weeks

Persistent low grade headache Light-headedness Sleep disturbance Easy fatigability Intolerance of bright lights or difficulty focusing vision Intolerance of loud noises, tinnitus Irritability and low frustration tolerance Anxiety and/or depressed mood Poor attention and concentration Memory dysfunction

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Second Impact Syndrome

case series of head and neck trauma in football players. Death after minor second impacts in players with

previous concussion syndrome who return prematurely to competition

Schneider 1973

17 cases of SIS from 1991-1998 or 1-2 cases/yearCantu

1998

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Second impact syndrome

Pathophysiology (from animal models):

• loss of autoregulation of the brain’s blood supply

• cerebrovascular congestion

• malignant brain swelling and marked increase in intracranial pressure

• herniation described only in adolescents and adults

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Postconcussive Syndrome

Fatigue Headaches Disequilibrium or difficulty in concentrating that may

persist for weeks to months after the initial injury

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Cumulative neuropsychological impairment

20 adults (16-26 yo) after a 2nd concussion vs matched controls (1st concussion);

decrease in rate of information processing longer recover time deficits with increasing severity and duration of mental

status abnormalities subsequent to each separate concussion

Gronwall, Lancet 1975

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Cumulative neuropsychological impairment

Brain damage in boxers. “punch-drunk” syndrome, dementia pugilistica

Head blows throughout a career may result in early degenerative neurological conditions and gross cognitive impairment

Muhammad Ali’s form of Parkinson’s AAN ban on boxing

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When is it appropriate for an athlete who has a concussion to return to play?

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Guidelines

management of concussion remains a matter of controversy due to absence of evidence-based data

plethora of guidelines (> 20) based on clinical judgment and experience variable emphases on assessment of confusion, LOC,

and/or post traumatic amnesia

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Guidelines

3 main management issues:

• the appropriate management of the acutely injured athlete to identify potential neurosurgical emergencies

• the prevention of catastrophic outcome related to acute brain swelling

• the avoidance of cumulative brain injury related to repeated concussions

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Quigley’s rule 1945

Athletes should discontinue participation in sports after 3 cerebral concussions

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Cantu 1986

• Widely used and adopted by the American College of Sports Medicine (ACSM)

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Colorado Medical Society 1991

formulated in response to several deaths secondary to head injuries in Colorado high school football players

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American Academy of Neurology 1997

Consensus group of neurologist, neurosx, sports med, athletic trainers, players, etc

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Concussion in sport group (CISG)

Vienna 2001, Prague 2004 International symposium on concussion in sport,

organized by the IIHF, FIFA, IOC Revised consensus definition: “a complex

pathophysiologic process affecting the brain, induced by traumatic biomechanical forces.”

Emphasized the detailed concussion history

• specific ?s as to previous concussive symptoms rather than perceived number of past concussions

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CISG

Recommendations:

• Injury grading scales be abandoned in favor of combined measures of recovery

• Individualized return-to play guide

• Concussion severity retrospectively determined after: all concussion symptoms have cleared, the neuro exam is normal, cognitive function has returned to baseline.

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CISG

New classification of concussion in sport

• Simple concussion: Injury resolves without complication over 7-10 days Cornerstone of management is rest until all symptoms resolve

and then graded program of exertion before return to sport

• Complex concussion: Persistent sx (including sx recurrence with exertion) Specific sequelae (seizures, prolonged LOC > 1min, prolonged

cognitive impairment) H/O multiple concussions or repeated concussions with

progressively less impact force Formal neuropsychological testing plus other investigations

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Concussion Management: Acute injury

ANY signs or symptoms of a concussion:

• Should not be allowed to return to play in the current game or practice

• Should not be left alone; regular monitoring for deterioration

• Should be medically evaluated

• Return to play must follow a medically supervised stepwise process

“When in doubt, sit them out!”

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Sideline evaluation

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Sport Concussion Assessment Tool

SCAT: developed by combining existing tools into a new standardized tool for

• Patient education

• Physician assessment of sports concussion

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SCAT

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SCAT

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Return to play protocol

physical and cognitive rest Step-wise process*:

1. No activity, complete rest. Once asymptomatic, proceed to step 2

2. Light aerobic exercise (walking, stationary cycling, no resistance training)

3. Sport specific exercises; progressive addition of resistance training at steps 3 &4

4. Non-contact training drills

5. Full contact training after medical clearance

6. Game play* if any sxs, drop back to previous asymptomatic level and try to progress in 24 hrs

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Neuropsychological testing

Assessment of cognitive function Should not be the sole basis of a return to play decision

but rather as an aid to the clinical decision making Should not be done while the athlete is symptomatic

since it adds nothing to return-to-play decisions benefit of baseline pre-injury testing and serial post-

injury follow-up

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Neuroimaging

Conventional modalities usually normal Head CT (or MRI) contributes little to concussion

evaluation except whenever suspicion of an intra-cerebral structural lesion exists:

• Prolonged disturbance of conscious state

• Focal neurologic deficit

• Worsening symptoms Newer structural MRI modalities (gradient echo,

perfusion, and diffusion weighted) have greater sensitivity for structural abnormalities but limited use currently

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Conclusions

Repetitive concussions increase the risk of second impact syndrome and post-concussive syndromes

NO athlete should return to sport until all concussive symptoms have resolved at rest and with exertion

Goal: to prevent catastrophic outcomes of acute structural brain injury, second impact syndrome, and cumulative brain injury due to repetitive trauma.

All athletes suspected of having sustained concussions should undergo thorough evaluation, including neurologic screening exam, neuropsychological testing, and exertional provocative maneuvers.

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Back to the case…

Concussive severity: grade 3 or complex concussion Discharge instructions should include:

• No activity, complete rest until seen by PMD in 1-2 days

• May return-to-play only when asymptomatic > 1-2 weeks and only with medical clearance

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Questions?

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Bibliography

American Academy of Neurology. Practice parameter: the management of concussion in sports. Neurology 1997;48:581-5

Aubry M. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. British Journal of Sports Medicine 2002;36:3-7

Cantu R. Second-impact syndrome. Clinical Sports Med 1998;1:37-44 Evans R. Concussion and mild traumatic brain injury. UpToDate version 15.1, 2007 Gronwall D. Cumulative Effect of Concussion. Lancet 1975;2:995-7 Harmon K. Assessment and Management of Concussion in Sports. American Family

Physician 1999;60:?? Kelly J. Diagnosis and management of concussion in sports. Neurology

1997;48:575-80 Kirkwood M. Pediatric sport-related concussion: a review of the clinical management

of an oft-neglected population. Pediatrics 2006;117:1359-71 LeBlanc C. The management of minor closed head injury in children. Pediatrics

2000;106:1525-5 McCrory P. Summary and Agreement Statement of the 2nd International Conference

on Concussion in Sport, Prague 2004. Clinical Journal of Sports Medicine 2005;15:48-55

Ruchinskas R. Mild head injury in sports. Applied Neuropsychology 1997;4:43-49 Saunders R. The second impact in catastrophic contact-sports head trauma. JAMA

1984; 254:538-9