Sport Related Concussion
Michael Pleacher, MD, FAAP, FACSM
OA Centers for Orthopaedics
April 28, 2017
Goals/Objectives
 Understand definition of concussion
 Identify common signs/symptoms of
concussion
 Gain familiarity with evaluation tools
used in concussion
 Understand current concussion
management strategies
 Gain familiarity with return to learn
Sport Related Concussion
McCrory P et al, BJSM, 2013
Definition
 Complex pathophysiologic process
affecting the brain induced by
biomechanical forces
 May be caused by direct or indirect blow
 Rapid onset temporary neurologic
dysfunction
 Functional rather than structural injury
 Clinical presentation involving cognitive
and physical symptoms is variable
McCrory P et al, BJSM, 2013
Epidemiology
 CDC Data:
 1.1 million TBIs treated in ERs
 235K TBIs hospitalized
 Sport related concussion
 Estimated 207K / yr treated in ERs
between 2001-2005
 135K were kids aged 5-18
 5.1% of all sport-related ER visits
MMWR July 27, 2007: 56(29);733737
Epidemiology
 Most sport-related concussion is not
evaluated in ER
 Best estimate: 1.6-3.8 million sport related
concussions annually (Langlois 2006)
 Still likely an underestimate
 Concussions represent 8.9% of all high school
athletic injuries and 5.8% of all collegiate athletic
injuries. (Gessel, et. al., 2007)
Gessel L et al. JATA 2007
Youth, HS, and College Football:
Incidence Data
 Concussions account for:
 9.6% of youth football injuries
 4% of HS football injuries
 8% of NCAA football injuries
Dompier TP et al, JAMA Pediatr,
2015
Risk Factors for Concussion
 Male Gender
 Participation in high-risk sports
 Boxing, Football, Ice Hockey, Soccer,
Rugby, Aussie Rules Football
 Aggressive style of play
 Prior concussion (RR = 5.8)
 Position played
Zemper ED, Am. J. Phys. Med
Rehab., 2003, 82:653-659
Risks of Concussion
 Second Impact Syndrome
 Long term neurologic deficits due to
recurrent concussions
Second Impact Syndrome
 Identified by Schneider in 1973
 Term coined by Saunders, 1984
 Football player with a mild concussion
returned to play 4 days post injury
and sustained a second minor
concussion
 He developed “malignant cerebral
edema” and died despite maximal
medical and surgical intervention
Saunders et al., JAMA 252:4, July
1984.
Second Impact Syndrome
 Cantu reported 17 cases of probable
second impact syndrome
 The US National Center for
Catastrophic Sport Injury Research
reports another 35 probable cases
 Most cases of SIS have occurred in
adolescent males
Second Impact Syndrome
 Each occurred in an athlete
incompletely recovered from prior
injury who then sustained another
head injury
 Presumed due to widespread death of
vulnerable neurons leading to
massive cerebral edema & brainstem
herniation
Cantu et al., Physician and
Sportsmedicine, 1995
Second Impact Syndrome:
Is it real?
 McCrory reviewed cases of suspected
SIS- found only 5 cases of the
original 17 reported that were “highly
likely” to be SIS
McCrory PR, Neurology 1998;
50:677-683.
Risk of Recurrent Concussions:
Chronic Traumatic Encephalopathy
 “Punch Drunk” boxers identified in
1928
 Cognitive, motor and behavioral
impairments which become evident
after repetitive head trauma
 Dementia puglistica, CTBI
Rabadi MH, Clinical Journal of
Sports Med., 2001, 194-198.
Risk of Recurrent Concussions
 CTE most often associated with
boxing
 CTE may occur in frequently
concussed soccer, football, and
hockey players as well
 Athletes with the Apolipoprotein E4
allele are at higher risk for CTE
Jordan BD et al. JAMA 1997.
Recurrent Sub-concussive
blows and cognitive impairment
 Matser JT et al. Neurology, 1997:
 Pro soccer players have impairments in memory,
planning, visual processing compared to noncontact controls
 Matser JT et al. JAMA, 1999:
 Amateur soccer players had impaired memory
and planning skills compared to controls
Concussion: Risk of Depression
 Guskiewicz KM et al. MSSE 2007
 Surveyed retired NFL players
 Players with concussions at increased
risk for depression when compared to
players with no concussion history:
 >= 3 concussions, 3x more likely
 1-2 concussions, 1.5x more likely
Concussion
Mechanism of Injury
Biomechanics of concussion
Pathophysiology
Mechanism of Injury
Magnitude of Forces
 Concussion research center at Virginia
Tech uses sensors in helmets to record
forces (HIT system)
 Early data shows average football player
sustains 30-50 blows to the head each
game
 >50% of hits had a force measured at 30
Gs or more, the hardest hits were
measured at >130 Gs
 Rotational forces also induce concussion
Duma S, CJSM, 2005
Magnitude of Forces
 Schnebel B et al. Neurosurgery, 2007
 Measured magnitude in HS and College
football players
 Skill players sustained higher magnitude
forces compared to lineman
 Lineman sustained lower magnitude
forces, but had more impacts
 Impacts measuring >98 g occur 1 out of
every 70 hits
Magnitude of Forces
 254 college football players (3 teams)
 184,358 head impacts
 330 practices, 82 games
 4.8-7.5 impacts per player per practice
 12.1 – 16.3 impacts per player per game
 Peak linear acceleration and peak rotational
acceleration measured
 Data heavily skewed to lower values
 50%ile LA =20G, 95%ile = 62G
 50%ile RA =1392 Rad/s, 95%ile = 4289 rad/s
Crisco JJ et al. J Appl Biomech,
2012
Magnitude of Forces: Youth
 50 players, age 11 years, 3 teams
 1 team had fewer practices and limited
contact in those practices, skewing data
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11,978 head impacts over 1 season
240 +/- 147 impacts /player/year
95%ile peak LA = 43G
95%ile peak RA = 2034 rad/s
Cobb BR, et al, Annals of Biomed
Eng, 2013
Pathophysiology
 Complex ion shifts and metabolic
changes result in increased
glycolysis and altered cerebral blood
flow
 The combination of metabolic
changes and altered cerebral blood
flow may not induce cell death, but
may produce a period of cell
vulnerability to re-injury
Neurometabolic Cascade
Following Cerebral Concussion
500
Calcium
% of normal
400
K+
300
Glucose
200
Glutamate
100
50
0
2
6
12
20
minutes
Cerebral Blood Flow
30
6
24
hours
3
6
days
(Giza & Hovda, 2001)
UCLA Brain Injury Research Center
10
Concussion
Clinical Presentation
Sideline Evaluation
Detection
Common Symptoms
Common Physical Findings
 Cognitive changes
Disorientation or confusion
Amnesia
Slow response time
Poor concentration
Disturbance of new learning and short-term
memory
 Reduced attention and information processing
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 Balance impairment / gait alteration
 Brief LOC, seizures – rare
Vestibulo-Ocular Reflex (VOR)
 Reflex eye movement triggered by the
vestibular system
 Stabilizes visual images during head
movement by producing eye movement in
the opposite direction of head movement
 Following concussion VOR can be
compromised, resulting in altered VOR
function.
Concussion Eval/Management:
Overview
 Multi-disciplinary multi-modal
evaluation
 Sideline evaluation by AT or MD
 Possible ED evaluation and/or hospital
admission with serial evaluations
 Neuroimaging
 Follow up care
 Monitoring/treatment for long term
effects
Evaluation: ED
 Emergency Room Evaluation for:
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Prolonged loss of consciousness
Seizure like activity
Focal findings on detailed neuro exam
Progressively worsening symptoms
Decline in mental status over time
Evaluation: Imaging
 Usually not necessary
 CT Scan – used acutely (1st 48 hours)
to rule out intracranial hemorrhage
 MRI Scan:
 Not used acutely
 Used to evaluate prolonged symptoms
 Usually done 10-30 days after injury
Evaluation: Sideline Assessment
 Sideline eval with AT-C / Physician:
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ABC’s, C-spine eval.
Neuro exam
*SCAT-3
Maddocks questions
Balance Errors Scoring System (BESS)
Standard Assessment of Concussion
King-Devick test
 Suspected concussion = remove from play
 Serial exams on sideline
McCrory P, et al. BJSM, 2013
Sport Concussion Assessment Tool
 Symptom checklist
 Mental status exam –
 GCS, Orientation, Maddocks questions
 Reverse digit span, MOY reverse order
 Immediate and 5 min recall
 Physical Exam
 Neuro
 Neck
 Balance / postural stability
McCrory P, et al, BJSM 2013
Balance Errors Scoring System
Guskiewicz K, et al, J Ath Training,
2001
BESS
 Errors:
Hands lifted off iliac crests
Opening eyes
Step/stumble/fall
Hip flexion >30 degrees of
flexion/abduction
 Lifting forefoot or heel
 Out of test position for > 5 seconds
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Guskiewicz K, et al, J Ath Training,
2001
BESS
Guskiewicz K, et al, J Ath Training,
2001
King Devick Test
 Test of rapid saccadic eye movements
 May be used on the sideline to
identify concussed athletes
 Slowing >1 s more than baseline
correlates with concussion
Galetta KM et al, J Neurol Sci 2011
King Devick Test
VOMS Test
Vestibular/Ocular Motor Screen
 Brief test of eye movements which
triggers symptoms in concussed
athletes
 VOMS screen positive if exacerbates
or elicits concussion symptoms
Mucha A et al, Am J Sports Med,
2014
VOMS
Concussion Diagnosed:
NOW WHAT???
Management
Neuropsychological Evaluation
Return to Play
Return to Learn
Concussion Management:
Overview
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Remove from play
Cognitive rest
Abstinence from Physical Exertion
Neuropsychological evaluation
Serial symptom checklist
Gradual return to physical activity
Cognitive Rest: Key to recovery
Brown NJ et al, Pediatrics 2014
Cognitive Rest
 NJ Brown et al, Pediatrics 2014
 Cohort of 335 teenagers with concussion
 High levels of cognitive activity
correlated with prolonged symptom
recovery
 Also found that high symptom score at
initial visit correlates with longer
recovery
Cognitive rest: Dose?
 Thomas DG et al, Pediatrics, 2015
 Strict rest (5d) vs. Usual Care (2d)
 Strict rest = no school, no physical activity
 UC = no school x 2d, then graded increase
 Results Higher total symptom scores, longer
duration of symptoms in SR group
 No difference on cognitive testing (Impact)
 Conclude that SR for 5 days less
beneficial than UC recommendations
Physical Rest
 Majerske et al, J Ath Training, 2008
 High levels of physical activity correlate
with prolonged recovery on neuropsych
test battery
 Moderate levels of physical activity had
quickest time to recovery
Neuropsychological Testing
Neuropsychological Evaluation
 Neuropsychological testing of the
athlete via computerized screening
test = one tool in the tool box
 Assesses verbal memory, visual
memory, processing speed, reaction
time
 Not a stand alone test to diagnose
concussion, nor to deem recovery
Timeline for Neuropsych Tests
 Common use of NP test:
 Preseason baseline testing
 Retesting at 24-48 hours after injury
 Once asymptomatic and progressing
physical activity, retest
 If athlete has not returned to baseline,
repeat evaluations weekly until at
baseline
Results of Neuropsych Testing
 Among college athletes, significant
decline in function 48 hours after
injury
 Majority return to baseline by 7 days
post-injury
Echemendia RJ, Clin J. of Sports
Med., 2001, 11:23-31.
Neuropsych Impairment of High
School Athletes
 Injured HS athletes had prolonged
memory dysfunction when compared
to college athletes with similar or
more severe injury
 Injured HS athletes still had memory
impairment at 7 days post-injury
Field M, Journal of Pediatrics,
2003, pp546-553
Neuropsych Impairment of High
School Athletes
 2003 study by Lovell and Collins
 HS athletes had resolution of symptoms
by an average of 4 days post-injury
 However, HS athletes had abnormal tests
of memory that persisted beyond 7 days
 This subgroup of athletes may require
more cautious return to play advice
Lovell MR, Journal of
Neurosurgery, 2003, 98:296-301.
Summary of Neuropsych
Testing
 Short computerized batteries of tests are now
available
 Most useful if each player has both preseason and
post-injury testing
 Deficits on neuropsych testing for college athletes
correspond with symptom resolution
 Neuropsych deficits for HS athletes persist after
symptom resolution
 Neuropsych testing is useful tool to help guide safe
return-to-play when combined with other measures of
recovery
 Only one tool in the toolbox; prudent to use MULTIPLE
measures of recovery
Physical Activity Advance
 24 hours at each level
 If symptoms recur, rest x 24 hrs,
restart at last successfully completed
level
McCrory P, BJSM, 2013
Concussion Management:
Return to Learn
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Recent attention in medical literature
Programmatic opportunity
School staff / family / physician roles
Halstead ME et al, Pediatrics, 2013
McGrath N, J Ath Training, 2010
Again, “dose” and effect of classroom
accommodations unknown
REAP Program
 http://rockymountainhospitalforchildr
en.com/service/concussionmanagement-reap-guidelines
Classroom Accommodations
McGrath N, J Ath Training, 2010
Concussion Management
Models for Management of
Concussion
Concussion Management Model:
Bowdoin College
 Athlete identified with concussion by
AT-C or Physician (SCAT card)
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Removed from play / physical activity
Brain Rest x 48 hours
Complete Physical Rest
Within 48 hours of injury:
 Health center eval
 Impact, BESS, KD
 Daily symptom score with AT-C
Concussion Management Model:
Bowdoin College
 Once asymptomatic x 24 hours
 Gradual activity advance
 Repeat BESS, Impact, KD prior to full
clearance
 Only necessary to repeat tests that were
abnormal at post-injury visit
 If BESS/Impact/KD are at baseline and if
athlete has remained asymptomatic during
activity advance, return to full sport
participation
Concussion Management Model:
Bowdoin College
 Academic affairs
 Work with Dean’s office to:
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Adjust schedules
Create classroom accommodations
Incomplete classes / make up work
Potentially coordinate medical leave
Concussion Management Model:
Boston Children’s Hospital
Concussion Management Model:
Boston Children’s Hospital
Concussion Management Model:
Boston Children’s Hospital
Post-Concussion
Management
Medications
Physical Therapy
Neuropsychological testing
Medications
 Target medical therapy based on
symptom cluster
 All medications used in management
of concussion are off-label
Amantadine
 Amantadine 100 mg BID x 30 days
 Cognitive symptom cluster, symptoms
lasting >21 days
Reddy CC et al, J Head Trauma
Rehab, 2012
Other commonly used medications
 Cognitive Cluster:
 Mood Cluster:
 Amantadine 100 mg
BID
 Methylphenidate
 Donepezil 5 mg QHS
 Physical Cluster:
 Nortriptyline 25 mg
QHS
 Gabapentin 300 mg
TID
 Nortriptyline 25 mg
QHS
 Sertraline 25-50 mg
QD
 Counseling!
 Sleep Cluster:
 Nortriptyline 25 mg
QHS
 Zolpidem 10 mg QHS
 Trazodone 50 mg
QHS
Meehan W, CJSM 2012
Physical Therapy
 Evolving treatment adjunct for
prolonged Post-Concussion Symptoms
 Vestibular therapy
 Graded sub-symptom threshold
exercise
Vestibular therapy
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VOR Habituation
Balance retraining
Dix-Hallpike and Epley’s Maneuver
https://www.youtube.com/watch?v=v
XTsf_Zv5i4
Graded Subsymptom Threshold
Exercise
 Balke Protocol
 1 min, 3.3 mph, 0% incline
 1 min, 3.3 mph, 2% incline
 Each min thereafter, 3.3 mph +1% incline
 Protocol stops at 1st sign of symptom
exacerbation
 Monitor RPE and HR
 Exercise prescribed at 80% of threshold HR
 Bike, walk, row, 20 min 1-2x/day at
80%HR
Exercise Therapy: Safety and
Efficacy
 Leddy JJ et al, CJSM 2010;20:21-27
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Balke protocol exercise assessment
Exercise prescription, 5-6 days/week
Improvement in PCS over time
No adverse events
 Gagnon I et al, Brain Inj, 2009
 Case series of PT / exercise in
peds pts with PCS
 Exercise associated with hastened
recovery, reduction in symptoms
Other Adjunct Treatments
 Osteopathic / Chiropractic evaluation and
treatment
 Cervicogenic headaches
 Neuro-optometric rehabilitation
 Convergence disorders
 Counseling
 Mood disorders
 Prolonged recovery, retirement from sport
 Sleep hygiene (self hypnosis)
Neuropsychological Testing
 Full Battery traditional NP testing for
patients w/ refractory cognitive sx
 3 mo of cognitive dysfunction
 Guides IEP/504 plan
 Targeted neuropsychological / cognitive
rehabilitation (unproven)
 VERY limited resource in Maine,
insurance coverage variable
Additional Issues
Detection
Prevention
Policy
Detection
 Helmets
 Impact sensors (Shockbox, ShokSpotR, Heads-up Stabilizer™)
Detection
 Impact monitoring system on
chin strap
 Light flashes above
~70g impact
 Not a proven technology
 Not 100% accurate
 Flashing lights are NOT a sign
or symptom of concussion
and will not diagnose a
concussion.
Prevention
 Mouth guards
 No proven benefit in reducing
concussion risk
 Prevents peri-oral and dental injury
 Helmets
 Designed to prevent skull fractures
– not concussions.
 PROPER FIT most important aspect
 Virginia Tech STAR study helmet
ranking
 Should not be considered accurate –
too many limitations
Prevention
 Soccer “Full 90”
 Ineffective at reducing risk of concussion
 Reduces rate of scalp lacs / facial trauma
 Rugby headgear
 Does not reduce rate of concussion
 Reduces rate of scalp lacs / facial trauma
Prevention
 Cumulative effect of subconcussive
blows
 Interest in limited contact practices
 “Hit Counts”
 Rugby tackling technique, helmetless
practices at UNH
 http://usafootball.com/headsup
Policy: Concussion Laws
 Since 2009, every state in US has enacted
legislation regarding concussion
 Most call for education of coaches, mandate
evaluation for suspected concussion, etc
 None are particularly enforceable
 http://www.mainelegislature.org/legis/bills/
bills_124th/billpdfs/HP090301.pdf
Summary
 Concussion is a complex disorder
requiring skillful management by a
coordinated group of diverse
caregivers
 Multiple tools aid in diagnosis of
concussion
 Multiple measures of recovery should
be used to determine readiness for
return to play
Summary
 Medications and adjunct therapies
can be useful in management of
prolonged PCS
 Reduction in risk in future will likely
be accomplished by technique
changes and exposure reduction
rather than protective equipment
Thanks!