Hot Topics in Sports Concussion

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Information about Hot Topics in Sports Concussion
Sports

Published on October 24, 2008

Author: aSGuest1788

Source: authorstream.com

Concussion and Return to Play Guidelines : Concussion and Return to Play Guidelines Warne Fitch, MD Assistant Professor Emergency Medicine Assistant Professor Orthopedics and Rehabilitation July 27, 2007 Objectives : Objectives Understand the complexity of concussion Discuss the natural history of concussion Identify risk factors associated with return to play decisions Discuss the evaluation and management of concussed athlete Head Injury in Sports : Head Injury in Sports 300,000 sports-related brain injuries per year 250,000 in high school football 8 fatalities yearly in college and high school football Most agree under-reported Thurman et al. The epidemiology of sports-related traumatic brain injuries in the US: recent developments. J Head Trauma Rehab. 13(2): 1-8, 1998. Middle schooler dies from softball injury : Middle schooler dies from softball injury July 23, 2007 GRAND RAPIDS -- A soon-to-be 7th grader died after suffering a head injury in a softball practice. XXX, 12, was critically injured Monday evening after being hit in the back of her head by a softball during a routine infield drill during a practice. She collapsed immediately, was taken to a hospital and died the next day. Intracranial Hemorrhage : Intracranial Hemorrhage Leading cause of traumatic death in sports 69% all fatalities in football Major Head Injury Epidural rapid progression Lucid interval Subdural delayed presentation Most common Subarachnoid excruitiating HA What is a Concussion? : What is a Concussion? Lots of terms “A trauma induced alteration in mental status that may or may not involve loss of consciousness” —AAN 1997 No uniformly agreed upon definitions Signs and Symptoms of Concussion : Signs and Symptoms of Concussion Signs Appears dazed or stunned Confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness Shows behavior or personality change Forgets events prior to play Forgets events after hit Symptoms Headache    Nausea    Balance problems or dizziness   Double vision    Sensitivity to light or noise    Feeling sluggish    Feeling “foggy”     Concentration or memory problems    Change in sleep pattern    Feeling fatigued Proposed Pathophysiology : Proposed Pathophysiology “Metabolic mismatch” Hovda,1999 Changes in cell environment Increase Na/K ATP Higher energy demand Decrease in cerebral blood flow Accumulation of Ca++ The Clinical Question : The Clinical Question When may an athlete safely return to sports following an episode (or multiple episodes) of concussion? Slide 11: Level 1 *Best evidence Level 2 Level 3 Level 4 Level 5 Literature Search: Systematic Reviews : Literature Search: Systematic Reviews Cochrane Database 0 studies ACP 0 studies Clinical Evidence 0 studies Sumsearch 0 Systematic reviews studies Pub Med 4078 Studies 0 studies validating return to play guidelines Current Limitations : Current Limitations Concussions are hard to study Can’t find volunteers Can’t consistently replicate injury pattern Can’t consistently replicate degree of severity Most of what we know is from animal studies or severe brain injuries in humans Traditional Approach : Traditional Approach *Most often cited grading and return to play guideline *Not based on validated outcomes Published evidence supporting concussion grading scales- through 7/2007 : Published evidence supporting concussion grading scales- through 7/2007 0 What We Do Know:Natural History Studies : What We Do Know:Natural History Studies High School Powell et al. JAMA. 1999 Guskiewicz et al. AJSM. 2000 College Guskiewicz et al. JAMA. 2003 Guskiewicz et al. AJSM. 2000 NFL Pellman et al. Neurosurg. 2004. High School Sports Powell et al. JAMA. 1999 : High School Sports Powell et al. JAMA. 1999 Football with highest injury rate (63%) Per 1000 athlete exposures Football 0.59 Wrestling 0.25 Girl’s soccer 0.23 Boys’ soccer 0.18 Football- 11 times higher in games than practices 693 total injuries 4 SDH, 2ICH (football only) High School : High School 5.6% HS football players had concussion Symptoms: Headache—86% Dizziness—67% Confusion—59% Amnesia—27% LOC—8.9% Return to play: 89% returned within 4 days 99% returned within 8 days 17% had repeat concussions Players with one concussion 3x more likely to sustain another Guskiewicz et al. AJSM. 2000 College Football: Guskiewicz et al. JAMA 2003—Level 2 : College Football: Guskiewicz et al. JAMA 2003—Level 2 4.4% college players had concussion Symptoms Headache 85% Dizziness 77% Amnesia 24% LOC 6% 3 x greater risk during games Return to play: Ave duration 3.5days 88% full recovery at 1 week 6.1% had repeat concussions NFL : NFL Powell et al. Neurosurg 54(1) 2004. 1996-2001 recorded concussions in NFL Broad definition: “traumatically induced alteration in brain function” 787 cases in 1913 games 131.2 +/- 26.8 concussions/year Rate of 0.41 concussion/game NFL : NFL Symptoms: Headaches (55%) Cognitive or memory problems (45.9%) Dizziness (42%) LOC (9.3%) Return to play: 56.5% no days out 93% <7 days LOC players out 2.5 times longer Powell et al. Concussion in Professional Football: Epidemiological features of Game Injuries and Review of the Literature—Part 3. Neurosurg 54(1) 2004. : Powell et al. Concussion in Professional Football: Epidemiological features of Game Injuries and Review of the Literature—Part 3. Neurosurg 54(1) 2004. NFL Concussions Met Head OnPlayers Can Report Pressure to Return : NFL Concussions Met Head OnPlayers Can Report Pressure to Return “ beginning in training camps this weekend, (the NFL) will implement a whistle-blower system. The policy will allow any athlete, coach or team personnel to anonymously report to the league incidents in which a concussed player is pressured to return to the field too soon.” JESSICA HOPP 07/25/07 Concerns Regarding RTP : Concerns Regarding RTP Second Impact Syndrome? Prolonged recovery? Risk of additional concussion? Risk of neurocognitive impairment? Second Impact Syndrome : Second Impact Syndrome “….an athlete who has sustained an initial head injury, most often a concussion, sustains a second head injury before symptoms associated with the first have fully cleared.” Coined by Saunders and Harbaugh 1984 Described college FB player who was in a fight week before then sustained minor trauma and died Only 17 cases reported Second Impact Syndrome : Second Impact Syndrome Pathophysiology Loss of autoregulation of brain’s blood supply Leads to vascular engorgement Increasing ICP and herniation May take 2-5 minutes 50% mortality 100% morbidity Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998. McCrory P. Does Second Impact Syndrome Exist? Clin J Sports Med 2001;11:144-9. Level 4 : McCrory P. Does Second Impact Syndrome Exist? Clin J Sports Med 2001;11:144-9. Level 4 Definite- A-D Probable- C&D, plus A or B Possible- C&D, Not- no C or D “Second Impact Syndrome” : “Second Impact Syndrome” McCrory P. Does Second Impact Syndrome Exist? Clin J Sports Med 2001;11:144-9. Level 4 17 published cases 0 met criteria for “definite SIS” 5 met definition of “probable SIS” 11 cases had no witnessed “second impact” No cases outside US Majority were adolescent males “Does it exist?” : “Does it exist?” Evidence for the existence of SIS is dubious Massive cerebral edema secondary to brain injury is reported, more commonly in kids Concussion management SHOULD NOT be based upon the avoidance of SIS, but available evidence and clinical experience Recovery Time : Recovery Time McCrea et al. Acute Effects and Recovery Time Following Concussion in Collegiate Football Players. The NCAA Concussion Study. JAMA. 290(19) 2556-2563. 2003 Prospective Cohort—Level 2 Concussed players tested at time of injury, 3 hours after, days 1,2,3,5,7,90. 84% followup All players had preseason tests Graded symptom checklist Standardized Assessment of Concussion Balance Error Scoring System Neuropsychological test Battery Recovery Time : Recovery Time 91% returned to baseline by day 7 Not all players demonstrated same pattern of recovery in symptoms, balance, and cognition Concussed did score lower on verbal fluency at day 90. Recovery: LOC and Amnesia : Recovery: LOC and Amnesia Those with LOC or amnesia take longer to recover Guskiewicz. JAMA. 2003.—Level 2 Prospective Cohort Presence of on field amnesia, not LOC more predictive of pronounced post-concussion sequelae Collins et al. CJSM. 2003—Level 3 Case Control Risk of Prolonged Recovery : Risk of Prolonged Recovery Multiple concussions have longer recovery P=0.03 Guskiewicz et al. Level 2 Return to Play same Day : Return to Play same Day Players returning to game have increased risk of delayed onset of symptoms 33% experienced delayed onset of additional symptoms vs 12.6% that did not return Guskiewicz. JAMA. 2003 May be at risk for prolonged recovery NFL data-Pellman et al. Neurosurg. 2005. 10/439 players who returned to same game out >7days due to symptoms Increased Risk of Additional Concussion? : Increased Risk of Additional Concussion? Dose response risk for additional concussion Guskiewicz et al..—Level 2 92% of the in-season repeat concussions occurred within 7-10 days of first Risk of Neurocognitive Impairment : Risk of Neurocognitive Impairment Unfortunately only level 4 evidence Studies report conflicting evidence 521 rugby players performed questionaire then completed 6 cognitive tasks No difference in reaction time, decision making, attention, learning and memory How should we determine return to play? : How should we determine return to play? Majority based on patient’s reporting of symptoms Should also consider objective tests: Concussion symptom checklists Brief neurocognitive tests for sideline Postural stability measurements Extensive neuropsychological testing Slide 39: McCrea. Standardized mental status testing on the sideline after sport-related concussion. JAT 2001 McCrea. JAT 2001— L 2 prospective cohort : McCrea. JAT 2001— L 2 prospective cohort 95% sensitive 76% specific Role of Neurocognitive Testing : Role of Neurocognitive Testing Randolph et al. Is neuropsychological testing useful in management of sport-related concussion. J Ath Train. 2005. Literature review including all prospective controlled studies of NP testing—Level 3 (pencil/paper, ImPACT, CogSport, HeadMinder, etc) Concluded: “no NP tests have met necessary criteria to support a clinical application at this time” Slide 42: No return to current game if symptomatic Monitor regularly for deterioration Evaluation by medical personnel: include standard assessment tool Step-wise return to activity No activity/rest until asymptomatic Light aerobic exercise Sports-specific training Non-contact drills Full-contact drills Game play On Field Evaluation : On Field Evaluation ABC’s Assume C-spine injury if LOC Neuro evaluation Transport? Standardized Assessment of Concussion (SAC) On Field Evaluation : On Field Evaluation Reassess frequently Don’t leave them alone Talk to parents/guardian before they go home Reassess in 24 hours? Who goes to ER? LOC, vomiting, persistent HA/worsening symptoms, neuro deficit Also consider social situation and location Return to Play : Return to Play No evidence-based guidelines!!!!! “Consider” RTP in game if athlete clears within 15 minutes of initial injury Stress/reassess on sideline Best evidence suggests individualize RTP Prevention:New Riddell Football Helmets : Prevention:New Riddell Football Helmets Riddell Revolution Helmet : Riddell Revolution Helmet Collins et al. Neurosurg. 2006 Prospective Cohort—Level 3 2,141 HS football players in PA 1,173 with Revolution, 968 standard Concussion significantly less in Revolution group 5.3%vs 7.6% (p=0.027) Small study (136 concussions), authors with financial disclosures, older helmets/younger athletes in standard group Prevention: Mouth Guards : Prevention: Mouth Guards Labella et al. Effects of mouth guards on dental injuries and concussion in college basketball. Med Sci Sport Ex. 34(1):41-4. 2002. Prospective cohort—Level 2 No difference in concussion rate Significantly lower rate of dental trauma Head Gear in Soccer : Head Gear in Soccer Withnall C. Effectiveness of headgear in football.Br J Sports Med. 2005 For ball impacts, no benefit to headgear. In head to head impact tests the headgear provided an overall 33% reduction in impact response. Heading in Soccer : Heading in Soccer Straume-Naesheime et al. Effects of heading exposure and previous concussions on neuropsychological performance among Norwegian elite footballers.Br J Sports Med. 2005 Level 3 Cohort CONCLUSION: Computerized neuropsychological testing revealed no evidence of neuropsychological impairment due to heading exposure or previous concussions in a cohort of Norwegian professional football players. References : References Kelly, JP. Traumatic brain injury and concussion in sports. JAMA. 282 (10): 989-991 1999. Akhavan, A et al. How should we follow athletes after a concussion? J Fam Pract 54(10): 2005 Centers for Disease Control and Prevention: Sport-related recurrent brain injuries. MMWR Morb Mortal Wkly Rep 46: 224-22,1997. Powell J, Barber-Foss K. Traumatic brain injury in hight school athletes. JAMA 282: 958-963, 1999. Pellman et al. Concussion in Professional Football: Epidemiological featrues of game injuries and review of the literature—Part 3. J Neurosurg. 54 (1): 81-94, 2004. Giza et al. The neurometabolic cascade of concussion. J Athl Train. 36(3): 228-235, 2001. Barth JT, Freeman JR, BroshekDK, Varney RN. Acceleration-deceleration sport-related concusssion: the gravity of it all. J Athl Train. 36: 253-256, 2001. Kelly et al. Concussion in Sports. Guidelines for the prevention of catastrophic outcome. JAMA 266: 2867-69, 1991. References : References McCrory P. Does Second Impact Syndrome Exist? Clin J Sports Med 2001;11:144-9 Schmitt et al. Effect of an acute bout of soccer heading on postural control and self-reported concussion symptoms. Int J Sports Med. 25: 326-331. 2004. Withnall et al. effectiveness of headgear in football. Br J Sports Med. 39(1):140-148. 2005. Collins et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. CJSM. 13:222-229; 2003. Thurman et al. The epidemiology of sports-related traumatic brain injuries in the US: recent developments. J Head Trauma Rehab. 13(2): 1-8, 1998. Lovell et al. Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med. 9(4):193-8;1999. Giza et al. The neurometabolic cascade of concussion. J Ath Train. 36(3):228-235. 2001. References : References Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998. Notebaert AJ and Guskiewicz KM. Current trends in athletic training practice for concussion assessment and management. J Athletic Training. 40(4), 2005. Randolph et al. Is neuropsychological testing useful in management of sport-related concussion. J Ath Train. 2005. Labella et al. Effects of mouthguards on dental injuries and concussion in college basketball. Med Sci Sport Ex. 34(1):41-4. 2002. Akhavan et al. How should we follow athletes after a concussion? J Family Prac. 54(10), 2005.

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