1. Concussion in Sports Stephen V
Concussion in Sports Stephen V. Cantrill, MD, FACEP Associate Director Department of Emergency Medicine Denver Health Medical Center Denver, Colorado 1 1 1 1

2. On the Sidelines of a Soccer Match
Soccer forward collides with opposing player while trying to head the ball. Both players tumble to the ground.
Opposing player immediately jumps to his feet
Other player arises slowly and starts walking towards the goal, appearing dazed. Is brought to sidelines by teammates
Complains of a headache and dizziness but denies any tinnitus, nausea or vision changes.
Is oriented to person, place and time, but is unable to recall what period they are playing in or the current score.
Symptoms abate after 30 minutes. He denies any other symptoms and desperately wants to continue in the game.

3. The Questions
What is the appropriate decision about return to play for this player?
Return to this game?
Able to practice tomorrow?
What type of sideline evaluation is appropriate?
Is any follow-up needed?

4. Background
Estimated 200, ,000 concussions per year in sports in US alone
75% of concussions in sports DO NOT involve Loss of Consciousness (LOC)
May be under-recognized
Concussion with LOC is obvious
75% that do not have LOC may be much less obvious

5. Reasons for Under Reporting
Player lack of knowledge as to what compromises a concussion
Delaney, 2001: Only 16% of university football players who suffered a concussion knew what it was
Concern about being removed from play

6. Concussion - What is It?
Defined in 1966 by the Congress of Neurological Surgeons:
“A clinical syndrome characterized by immediate and transient post traumatic impairment of neural function due to brainstem involvement”
Broadened to include any posttraumatic alteration in mental status that may or may not involve loss of consciousness

7. And Now, the Updated Version
A complex patholophysiological process affecting the brain, induced by traumatic biomechanical forces….
Causes: direct or indirect force
Rapid onset of short lived impairment that resolves spontaneously
Reflects functional disturbance, not structural
Usually grossly normal structural imaging studies
First International Conference on Concussion in Sport, Vienna 2001

8. Sports at Risk: Incidence versus Concussions per 1000 player hours
Football
Soccer
Wrestling
Basketball
Baseball
Softball
Field Hockey
Ice Hockey
Lacrosse
Volleyball
Multiple others

9. The Controversy over Heading: Does it contribute to brain injury?
Much sensation in the lay press
Some poorly designed studies state emphatically: YES
Other studies are much less clear
May be a factor in players who sustain multiple concussions

10. Other Epidemiologic Factors
Concussed football players have a six fold increase in suffering yet another concussion
Cumulative effect of multiple insults
Apolipoprotein E epsilon-4: May imply increased brain susceptibility to damage (Rabadi, 2001)

11. Cerebral Forces Causing Injury
Compresssive/Direct Pressure
Tensile/Negative Pressure
Rotational/Shearing Forces
Cause of most devastating injuries

12. Cellular Effects
Metabolic dysfunction resulting in increased cellular vulnerability
Large potassium ionic flux
Increased cellular glucose demand
Decreased cerebral blood flow
Lactate accumulation
Intracellular acidosis

13. Concussion Presentation
Confusion and amnesia are cardinal features
Multiple manifestations

14. Concussion Presentation: Neurobehavioral Features
Vacant stare
Delayed verbal and motor responses
Inability to focus attention
Disorientation
Slurred or incoherent speech
Gross observable incoordination
Excessive emotionality
Memory deficits
Any period of loss of consciousness

15. Commonly Reported Symptoms
Commonly Seen Early (min to hours)
Headache
Dizziness or vertigo
Lack of awareness of surroundings
Nausea and vomiting

16. Commonly Reported Symptoms: Seen Late (days to weeks)
Persistent low-grade headache
Lightheadedness
Poor attention and concentration
Memory dysfunction
Easy fatigability
Irritability and low frustration tolerance
Intolerance of bright lights or difficulty focusing vision
Intolerance of loud noises, sometimes ringing in ears
Anxiety and depressed mood
Sleep disturbance

17. Concussion Grading and Return-to-Play Guidelines: Why Worry?
Return to play with altered cognition and physical capability
Risk of additional injury
Risk of “Second Impact Syndrome”
Blow to head of individual still symptomatic from previous mild brain injury
Rapid, diffuse brain swelling resulting most often in death
Controversial entity

18. Concussion Grading and Return to Play Guidelines
As many as 25 different sets of criteria
Little evidence-based support
Expert opinion
Consensus
Three most often referenced:
Cantu
Colorado Medical Society
American Academy of Neurology

19. Classification of Severity of Concussion

20. Return to Play - Cantu, 1998

21. Return to Play - CMS, 1991

22. Return to Play - AAN, 1997

23. Points of Commonality in Most RTP Guidelines:
Any concussed athlete should be removed from competition, examined and observed
Serial assessment of the athlete after the concussion
Any evidence of deterioration, no matter how mild the injury: transport to hospital for appropriate evaluation
Athlete with LOC, even momentary, or post-event amnesia should not be allowed to immediately return to play
Post-concussed athlete cannot return to play until completely asymptomatic, both at rest and after exertion
Multiple concussions may have a cumulative effect on the athlete

24. Sideline Assessment of Neurological Function
Glasgow Coma Scale
Lacks sensitivity
Standard orientation (X3)

25. Sideline Assessment of Neurological Function
Maddocks Questions
Which field are we at?
Which team are we playing today?
Who is your opponent at present?
Which quarter (period) is it?
Which side scored the last goal?
Which team did we play last week?
Did we win last week?
More sensitive: concussed vs nonconcussed

26. “Standardised Assessment of Concussion” - SAC - McCrea 1997
Orientation (Month, Date, Day of Week, Year, Time)
Immediate Memory (3 trials of 5 words)
Concentration (3, 4, 5 and 6 digit strings backwards)
Delayed Recall (1 trial of 5 words, used above)
Maximum of 30 points
Brief neurological screen
LOC - Amnesia - Strength - Sensation - Coordination
Exertional evocative component:
5 jumping jacks - 5 sit-ups - 5 push-ups - 5 knee-bends

27. “Standardised Assessment of Concussion”
Useable in the field
Best if individual baseline established before season starts
Decrease in 1 point or more from baseline: 96% sensitivity, 76% specificity in detecting symptomatic concussed players using AAN criteria (McCrea, 2001)

28. Neuropsychological Testing
Much development in past decades
Additional tool to evaluate recovery
But:
Best tests yet to be demonstrated
Baseline testing should be done
Time and dollar costs are high
Computer and web-based testing may help

29. Neuropsychological Testing
May be helpful in situations of:
Severe concussion
Prolonged post-concussive symptoms
Multiple concussions
Questions of athlete truthfulness
Concept endorsed by Concussion in Sport Group

30. Problems with Hospital Care
Lack of awareness of RTP guidelines by clinicians
Discharge instructions don’t address adequate follow-up and return-to-play criteria nor limitations in activities of daily living

31. Concussion in Sports Summary
Most concussions in sports do not involve LOC, but rather confusion/amnesia
Concussion grading criteria RTP criteria have limited scientific grounding but serve as useful tools for guidance
To avoid further injury and possibly the potentially lethal “second impact syndrome”, concussed athletes should not return to play until completely asymptomatic, sometimes requiring a prolonged period of time

32. Concussion in Sports Summary
The sideline use of detailed mental status screening tools allows for more sensitivity and standardization in the evaluation of the concussed athlete
Neuropsychological testing may be helpful with ongoing post-concussive symptoms, multiple concussions or severe concussions
Ongoing education of athletes is necessary to emphasize a concussion does not require loss of consciousness

33. Concussion in Sports Summary
Ongoing education of providers about guidelines for concussion in sports to insure appropriate and thorough evaluation of concussed athletes on the field, in the office and in the emergency department.
These guidelines should be utilized as part of the decision-making process of when the athlete should be allowed to return to play and to insure the adequacy of patient post-injury education.

34. Back on the Soccer Field…
Due to duration of his symptoms, the athlete sat out the rest of the game
He was administered Standardized Assessment of Concussion (SAC) instrument, scoring 23 out of 30. His preseason baseline score was 27.
The athlete was instructed by the trainer about symptoms to be aware of that could represent a worsening of his traumatic brain injury or could indicate a post-concussive syndrome.

35. And Finally...
He did have recurrence of his headache that evening, but it had abated by the next morning and he remained symptom free.
Re-administration of the SAC instrument 48 hours post-injury revealed return to his normal baseline of 27.
The athlete was counseled to not engage in contact sports for an additional week.
By the way, his team won the league title, 2-1.