1. Sports-Related Concussion George C. Phillips, MD, FAAP, CAQSM Clinical Associate Professor of Pediatrics Sports Medicine Rounds October 16, 2008

2. Key Questions Should a concussed athlete return to play on the day of the injury? Is there a specific number of concussions, regardless of symptom severity, that would lead you to talk with the athlete about “retirement”?

3. Sports-Related Concussion Previous studies estimated ~ 6% of athletes incurred a concussion each season (FB) More recent studies of high school athletes estimate a seasonal rate of 15% –CJSM 2004 McCrea et al Sports-related concussions estimated at 300,000 per year –Over 135,000 in high school sports (JAT 2007 Gessel et al) At least 55,000 to 60,000 concussions occur each year in high school football alone.

5. Concussion “Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” –“Summary and Agreement Statement of the 2 nd International Symposium on Concussion in Sport, Prague 2004” – Clin J Sport Med 2005

6. Concussion Mechanics: direct blow to head/face/neck or indirect force transmission (body blow) Timecourse: rapid onset, short-lived impairment, spontaneous resolution Pathophysiology: function > structure Symptoms: may or may not include LOC, sequential resolution

7. Postconcussion Symptom Scale J Head Trauma Rehabil 1999;9:193-8 Headache Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally “foggy” Difficulty concentrating Difficulty remembering Visual problems

8. Clinical Signs of Concussion Consciousness (LOC) – not required Memory – posttraumatic or retrograde amnesia Cognition (attentional deficit) Neurological Personality

9. Question #1 Should a concussed athlete return to play on the day of the injury?

12. Concussion and RTP AJSM 2000 Guskiewicz et al –30% of athletes RTP same day –For the other 70%, average RTP was 4 days JAMA 2003 McCrea et al Major deficits in balance, cognition, symptoms –Balance 3-5 days; cognition 5-7 days; symptoms 7 days 10% of athletes had symptoms > 1 week

13. Concussion and RTP JAMA 2003 Guskiewicz et al –75% of same-season repeat concussion occurred <7 days from the first; 92% < 10 days A seven-day waiting period would likely result in resolution of symptoms and normalized cognitive function A seven-day waiting period may prevent a majority of repeat concussions

14. Simple versus Complex Concussion Simple –Resolves in 7-10 days –No complications –Formal neuropsychological evaluation unnecessary –Most common form –Rest until symptoms resolve –Graded RTP Complex –Persistent symptoms –Specific sequelae Prolonged cognitive impairment –Multiple concussions, perhaps with less force –Formal neuropsychological evaluation –Sports medicine expertise

15. Are All Athletes Equal? AJSM 2004 Lovell et al Study of 43 high school athletes with Grade 1 or “ding” concussion –No symptoms within 15 minutes of injury No effects on reaction time or processing speed Memory testing and symptoms were significantly worse at 36 hours, but returned to normal at 6 days

16. Are All Athletes Equal? CJSM 2007 Iverson 114 high school football players 52% suffered complex concussions –No increased history of prior concussions –Symptoms took an average of 19 days to resolve (vs. 4.5 days for simple concussions)

17. Second Impact Syndrome Rare, controversial diagnosis Results when a second head injury occurs before resolution of first injury Rapid progression to altered sensorium, seizures, coma, brain death Abnormal or immature autoregulation of cerebral blood flow causes swelling,  ICP and cerebellar herniation (2-5 minutes)

18. Sideline Management of Concussion “When in doubt, sit them out!” –Take away their helmet Sideline assessment, including neurological and mental status exams –Orientation –Short-term memory and recall –Concentration

19. Concussion Memory Assessment Which ground (stadium) are we at? Which team are we playing today? Who is your opponent at present? How far into the quarter is it? Which quarter is it? Which side scored the last goal? Which team did we play last week? Did we win last week? Maddocks DL et al. Clin J Sports Med 1995; 5:32-5.

20. Sideline Management of Concussion Concentration: serial 7’s; months of the year in reverse order –A significant number of high school athletes will have difficulty with these tests at baseline Any sideline assessment is at best a tool to aid your judgment and not an absolute measure of function.

21. Question #2 How many concussions are too many concussions?

23. Multiple Concussions 2002 Neurosurgery Collins et al –History of ≥3 concussions = 9.3x more likely to experience 3 of 4 “onfield markers” LOC, RG amnesia, AG amnesia, or confusion –6.7x more likely to experience LOC 2003 JAMA Guskiewicz et al –≥3 concussions = 3x more likely to have another concussion –≥3 concussions: 30% had symptoms > 1 week

24. Multiple Concussions 2004 Brain Injury Iverson et al –≥3 concussions = more preseason symptoms –≥3 concussions = 7.7x more likely to have memory problems 2 days after injury 2008 J Ath Train Covassin et al –≥3 concussions = significantly slower recovery of verbal memory and reaction time –No significant change in symptom scores 5 days after the concussion

25. Multiple Concussions 2005 Neurosurgery Moser et al –Athletes with ≥2 concussions had the same neuropsych scores while symptom-free as athletes with first-time concussions one week after the injury 2006 BJSM Iverson et al –1-2 concussions versus 0 = no difference on ImPACT

26. Concussion and RTP Athletes will not report concussion –CJSM 2004 McCrea et al –Only 47 % of HS athletes reported concussion –Of those not reporting concussion: 66% thought the injury was not serious enough 41% did not want to be held out of the game 36% were not sure what a concussion was –15.3% of athletes had a concussion in 1 season –29.9% of athletes had a history of concussion

27. How Well Do We Take a History? 2008 CJSM Valovich McLeod et al

28. Symptom%(+) Responses# Episodes Headache43.53.1 ± 2.1 Dazed or Confused 23.82.6 ± 1.8 Dizziness or Balance Problems 20.82.5 ± 1.8 Trouble Concentrating 18.73.4 ± 2.1

29. Return from Concussion No physical activity while symptomatic No sports means no sports (organized and pick-up) If significant symptoms, may need a period of cognitive rest (stay home from school) Future protection from head injury (bike helmet, choice of recreational activities)

30. Return-to-Play Guidelines Recommended by Prague and Vienna committees Each step in the protocol takes 24 hours If symptoms recur, the athlete stops the protocol until asymptomatic for 24 hours When asymptomatic, the athlete restarts the protocol one step prior to where it was when the symptoms recurred

31. Return to Play Guidelines Stepwise RTP Protocol –No activity until 24 hours without symptoms –Light aerobic exercise –Sport-specific training (skating, running) –Noncontact training drills –Full contact drills after medical clearance –Return to competition Recurrence of symptoms at any stage warrants removal from participation until symptom-free for another 24 hours. Participation then resumes one stage earlier in the protocol.

32. Impact of Clinical Research A seven-day waiting period would likely result in resolution of symptoms and normalized cognitive function A seven-day waiting period may prevent a majority of repeat concussions Repeat concussions are associated with additional concussions and prolonged symptoms

33. Key Questions Should a concussed athlete return to play on the day of the injury? –No; absolutely not at the high school level. Is there a specific number of concussions, regardless of symptom severity, that would lead you to talk with the athlete about “retirement”? –Yes, at 3. Sometimes at 2, especially in the non-elite athlete.