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Concussion: Where are we in 2012?
Alex A. Homaechevarria MD
St.Luke’s Sports Medicine
US Ski Team Physician
Kurt J. Nilsson, MD, MS
Medical Director, St. Luke’s Concussion Clinic
October 5, 2012
• “The occurrence and management of sports concussion provokes more debate and concern than virtually all other sports injuries combined.”
• Paul McCrory, Clin Sports Med, 2011
Objectives
• Discuss the epidemiology and pathophysiology of concussion
• Discuss short and long term implications of concussion
• Discuss the role of neurocognitive testing in concussion
• Discuss management of sports related concussion, with attention to return to play issues
• Discuss issues surrounding the current and future approach to concussion
Concussion Re-defined:
• Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces
Concussion Re-defined:
• Complex pathophysiological process affecting the brain caused by direct or indirect biomechanical forces
Concussion Re-defined:
• Typically results in the rapid onset of short-lived neurological impairment that resolves spontaneously
Concussion Re-defined:
• The acute clinical symptoms largely reflect a functional disturbance rather than a structural injury
Concussion Re-defined:
• May or may not involve LOC
• Grossly normal neuroimaging studies
McCrory, J Neurosci, 2009
Epidemiology
• 8.9% of high school sports injuries,
• 5.8% of collegiate (Gessel, JAT, 2007)
• Majority of concussions come from 4 sports:
• football (47.1%)• girl’s soccer (8.2%) • boys wrestling (5.8%)• girl’s basketball (5.5%)
(Marar)
Epidemiology
In sports played by both genders, In sports played by both genders, girls actually run a higher risk girls actually run a higher risk of of sustaining concussion sustaining concussion
U.S. female high school soccer U.S. female high school soccer athletes suffered almost 40% athletes suffered almost 40% more concussions than males more concussions than males
In high school basketball, female In high school basketball, female concussions were nearly 240% concussions were nearly 240% higher higher
Female college athletes who play Female college athletes who play soccer, basketball, softball and soccer, basketball, softball and hockey also bear higher hockey also bear higher concussion risks than their male concussion risks than their male counterparts counterparts
Gessel, Journal of Athletic Training, 2007
Complications
Collins, Neurosurgery, 2002; Guskiewicz, JAMA, 2003
• Decreased threshold for recurrent concussion: Athletes with 3 or more concussions were 9.3 times more likely to have prolonged loss of consciousness, anterograde amnesia, or confusion with subsequent concussion
• Also 4-6 times more likely to have recurrent concussions and take longer for symptoms to clear
Post-concussion syndrome
• ICD-10 criteria: Head injury and 3 of following 8 within 4 weeks: headache, dizziness, fatigue, irritability, sleep disturbance, difficulty concentrating, memory problems, low tolerance for stress, emotion, or alcohol
Second Impact Syndrome
• Occurs in athlete who return to play before symptoms from 1st concussion completely resolve
• Second blow/impact can be minor• Loss of autoregulation of the brain’s blood supply leading
to vascular engorgement and subsequent brain swelling, increase intracranial pressure and herniation of the brain stem
• Usually fatal• All cases in the literature <22 yr old
Longer term consequences?
– Retired football players reporting a history of 3+ previous concussions were 5X more likely to be diagnosed with mild cognitive impairment (Guskiewicz et al. Neurosurgery. 2005;57:719-24)
– Retired football players reporting a history of 3+ previous concussions were 3X more likely to be diagnosed with depression (Guskiewicz et al. Med Sci Sports Exerc. 2007;39(6):903-9)
– Increased prevalence of Alzheimer’s Disease in retired football players (Guskiewicz et al. Neurosurgery. 2005;57:719-24)
Diagnosis
• Clinical
Diagnosis
• Clinical
Diagnosis
• Clinical• Imaging• Postural / Balance testing / Vestibular testing• Neurocognitive testing
Role of Neuroimaging
• Initial CT/MRI: prolonged disturbance of consciousness, focal neurologic deficit, clinical deterioration, persistent clinical or cognitive symptoms
• Most typically contributes very little to the evaluation of concussion
Neuroimaging
• Based on study of > 42,000 ED visits, CT is unnecessary :
– in children <2 with normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents
– in children >2 with normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache
Kuppermann, et al, Lancet, 2009
Postural control
• Regulated by visual-spatial, somatosensory, and vestibular input
• Inefficient integration of vestibular information likely cause of observed deficits in postural control
Guskiewicz, CJSM, 2001; Sosnoff, JAT, 2011
Postural control
• Impaired postural stability (ie balance deficit) is present for at least 72 hours following concussion
• BESS – Balance Error Scoring System
Riemann, JSR, 1999
Diagnosis
• Clinical• Imaging• Postural / Balance testing / Vestibular testing• Neurocognitive testing
Neurocognitive testing
• Baseline tests administered to high risk athletes and utilized for comparison in the event of concussion
• Baselines encouraged as part of concussion programs (McCrory, PMR, 2009)
Neurocognitive testing issues
• Baseline performance affected by group testing, amount of sleep, psychological distress, effort
• Can have learning effect across testing sessions (Register-Mihalik, JAT, 2012)
• 6-11% can have indicator of invalidity (Schatz, JAT, 2012)
Moser, AJSM, 2011; Brown, JAT, 2007; Bailey, CJSM, 2010,
Neurocognitive testing issues
• 8/75 athletes able to sandbag without triggering internal validity indicators (Erdal, Arch Clin Neuropsych, 2012)
Neurocognitive testing issues
• Utility - some suggest not only not helpful, but has capacity to worsen outcome (Randolph, Curr Sports Med Rep, 2011)
• Has no utility as a diagnostic or screening tool when used in isolation in the military (Coldren, Mil Med, 2012)
Example:
ImPACT Clinical Report
Exam Type: Baseline
Composite Scores: Memory composite (verbal): 99%ile
Memory composite (visual): 94%ile
Visual motor speed composite: 98%ile
Reaction time composite: 73%ile
ImPACT Clinical Report
Exam Type: Post-Injury 2
Composite Scores:
Memory composite (verbal): 99%ile
Memory composite (visual): 93%ile
Visual motor speed composite: 99%ile
Reaction time composite: 86%ile
Recovery From Concussion:How Long Does it Take? How long do symptoms last?
N=134 High School athletes
WEEK 1
WEEK 2
WEEK 3
WEEK 4
WEEK 5
Collins et al., 2006, Neurosurgery
Duration of Neurocognitive DeficitsDuration of Neurocognitive Deficits
• Average number of days to return to baseline (ImPACT) were greater for 13 to 16 year-olds than for 18 to 22 year-olds on the following variables: Verbal Memory (7.2 vs 4.7, P = 0.001), Visual Memory (7.1 vs 4.7, P = 0.002), Reaction Time (7.2 vs 5.1 P = 0.01), and Post Concussion Symptom Scale (8.1 vs 6.1, P = 0.026). (Zuckerman, Neurosurg, 2012)
Duration of Neurocognitive DeficitsDuration of Neurocognitive Deficits
• Prolonged neuropsychological impairments following Prolonged neuropsychological impairments following a first concussion in female university soccer a first concussion in female university soccer athletesathletes
• Concussed athletes were significantly slower on Concussed athletes were significantly slower on tasks that required decision making (complex tasks that required decision making (complex reaction time), inhibition and flexibility, and planning reaction time), inhibition and flexibility, and planning for for up to 6-8 months post concussionup to 6-8 months post concussion
• Short- and long-term verbal memory, attention, and Short- and long-term verbal memory, attention, and simple reaction time were simple reaction time were normal – Impact test normal – Impact test
– Ellumburg et al., Clin J Sports Med, Sept. 2007Ellumburg et al., Clin J Sports Med, Sept. 2007
Duration of Neurologic DeficitsDuration of Neurologic Deficits
• Differential rate of recovery in athletes after first and Differential rate of recovery in athletes after first and second concussion episodes second concussion episodes
• All patients asymptomatic at Day 10, cleared for All patients asymptomatic at Day 10, cleared for sport participation based on clinical symptoms sport participation based on clinical symptoms resolution. resolution.
• Balance deficits, were present at least 30 days after Balance deficits, were present at least 30 days after injury (P < 0.001). injury (P < 0.001).
• Most importantly, the rate of balance symptom Most importantly, the rate of balance symptom restoration was significantly reduced after a restoration was significantly reduced after a recurrent, second concussion (P < 0.001) compared recurrent, second concussion (P < 0.001) compared with those after the first concussion with those after the first concussion
•Slobounov et al., Neurosurgery Aug 2007Slobounov et al., Neurosurgery Aug 2007
Concussion management
• The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter
Management
• At least 26 professional guidelines on the diagnosis and management of concussion– The number of treatments for any disease is inversely
proportional to how much we know about that disease
Returning the asymptomatic athlete to play:
What does asymptomatic mean? (Alla, BJSM, 2012)
If we cannot agree on what asymptomatic means, how can we agree on safety of contact sports?
International Conference on Concussion in Sport
Management
• Use of multifaceted system – Neurocognitive, vestibular, postconcussion symptom scale – more reliable than any test used alone (Register-Mihalik, J Head Trauma Rehab, 2012)
Stepwise Return to Play
1. No activity. Complete physical & cognitive rest
2. Light exercise, walking or stationary bike
3. Sport-specific activity such as running or skating.
– Progressive addition of resistance training at steps 3 or 4.
4. On the field practice, without body contact.
5. On-field practice, with body contact.
– Often progress from controlled hitting/drilling to full contact.
– Must be cleared by physician before this step.
6. Game Play.
Goldberg, LD & Dimeff RJ: Sideline Management of Sport-related Concussions. Sports Med Arthrosc Rev 2006;14:199-205
McCrory P, Johnston K, Meeuwisse W, et al: Summary and agreement statement on the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:i78-i86.
Multidisciplinary Approach
• Team approach is necessary for concussion management:
– MDs
– Athletic trainers
– Coaches
– School Nurses
– Neuropsychologist
– Parents
– Athlete
• Other disciplines might become involved with protracted symptoms:
– Speech therapy (academic issues, compensatory strategies)
– Physical therapy (i.e., whiplash, vestibular)
– Occupational therapy (i.e., vision)
– Counseling (i.e., depression, anxiety)
Concussion management
• The cornerstone of concussion management is physical and cognitive rest until asymptomatic with gradual, stepwise resumption of activities thereafter
Active treatment approaches
• Supplementation with DHA (docosahexaenoic acid) can reduce cell death in rodent model of TBI (Bailes, J Neurotrauma, 2010)
Active treatment approaches
• Amantadine 100 mg BID may facilitate more rapid resolution of neurocognitive deficits in athletes with symptoms greater than 3 weeks. (Reddy, J Head Trauma Rehabil, 2012)
Active treatment approaches
• Exercise assessment and aerobic exercise training for postconcussion syndrome (PCS) may reduce concussion-related physiological dysfunction and symptoms by restoring autonomic balance and improving cerebral blood flow autoregulation. (Leddy, Rehabil Res Practice, 2012)
Thank You
Thank YouKurt J. Nilsson, MD, MS
St. Luke’s Sports Medicine
208-383-0201
St. Luke’s Concussion Clinic
208-381-2665
Kristi Pardue,
clinical coordinator
Matthew Kaiserman,
outreach coordinator
Thank You
Concussion legislation – HB 632
• Went into effect in Idaho July 1st, 2012
• Section 1: SBOE and the IHSAA must provide a link on their websites to CDC guidelines and educational materials.
• Section 2: Applies to Middle School, Junior High School and High School athletics.
• Section 3: Mandates education to parents and athletes prior to the start of an athletic season. Coaches, AT’s and referees must review biannually.
Concussion legislation – HB 632
• Section 4: Removal from play protocols established by schools. – Must Adhere to CDC guidelines– Athlete must be removed when “reasonably suspected”
of sustaining an injury.• • Section 5: Return to play protocols
– “An athlete may be returned to play once the athlete is evaluated and authorized to return by a qualified health care professional who is trained in the evaluation and management of concussions.”
• Physician or Physician Assistant• Advanced Practice Nurse• A licensed healthcare professional trained in the
evaluation and management of concussions who is supervised by a directing physician
Concussion legislation – HB 632
• Section 6: Liability– “If an individual reasonably acts in accordance with the
protocol developed pursuant to subsection (4) of this section, then acting upon such protocol shall not form the basis of a claim for negligence in a civil action.
• Section 7: Youth Sport Organizations – Liability Protections
