Sport-Related Concussion

(1)

Sport-Related Concussion

Bill Meehan, MD

Micheli Center for Sports Injury Prevention

Division of Sports Medicine, Division of Emergency Medicine Boston Children’s Hospital

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

Definition

• _{Working definition} • _{Characteristics} – Trauma – Impulse – Immediate – Self-resolves – Functional

(11)

Biomechanics

• _Biomechanics – Rotational acceleration – Slaughterhouses – free to move, accelerate – Denny-Brown 1941 – medicine, acceleration – Holburn 1943 – thought experiment, rotational – Ommaya and Genarelli 1974 - definitive

(12)

(13)

(14)

(15)

(16)

Pathophysiology

• _{Biomechanical injury} • _{Ion flux, K+, Na+} • _{Excitatory neurotransmitters – NMDA} • _{Ca++ influx, further EAA release} • _{Exacerbates efflux of K+} • _{Depolarization – spreading depression} • _{Glyolysis -pump restoration} • _{Decreased flow}

(17)

Assessment

• _{Acute assessment} – ABC – Other or associated injuries – History – classic – Physical – (Imaging)

(18)

Signs and Symptoms

• _{Loss of Consciousness} • _{Amnesia, retrograde or} antegrade • _{Disorientation} • _{Appearing dazed} • _{Acting confused} • _{Forgetting game rules or play} assignments • _{Inability to recall score or} opponent • _{Inappropriate emotionality} • Physical incoordination • Imbalance • Seizure • Slow verbal responses • Personality changes • Headache • Dizziness • Nausea or vomiting • Difficulty balancing • Vision changes • Photophobia • Phonophobia • Feeling “out of it” • Difficulty concentrating • Tinnitus • Drowsiness • Sadness • Hallucinations

(19)

Specific Assessment Tools

Assessment – Symptoms - PCSS – Balance - BESS – Neurocognitive: • computerized vs. neuropsychological

(20)

Post Concussion Symptom Scale

None Mild Moderate Severe Headache 0 1 2 3 4 5 6 “Pressure in head” 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6 Balance problems or dizzy 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 Vision problems 0 1 2 3 4 5 6 Hearing problems / ringing 0 1 2 3 4 5 6 “Don’t feel right” 0 1 2 3 4 5 6 Feeling “dinged” or “dazed” 0 1 2 3 4 5 6 Confusion 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like "in a fog" 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Fatigue or low energy 0 1 2 3 4 5 6 More emotional than usual 0 1 2 3 4 5 6 Irritability 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 Nervous or Anxious 0 1 2 3 4 5 6 Trouble falling asleep 0 1 2 3 4 5 6 Sleeping more than usual 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 Other: _______________ 0 1 2 3 4 5 6

(21)

Balance Error Scoring System

1. Double Leg Stance – Feet together, hands on hips, eyes closed for 20 seconds. 2. Single Leg Stance – Non-dominant foot, 30 degrees hip flexion, 45 degrees knee flexion, hands on hips, eyes closed for 20 seconds. 3. Tandem Stance – Non-dominant foot in back, hands on hips, eyes closed for 20 seconds.

(22)

BESS Errors

1. Hands off iliac crest 2. Opening eyes 3. Step, stumble or fall 4. Moving hip into >30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of position > 5 seconds • _{Errors counted.}

(23)

Neurocognitive Testing

0 10 20 30 40 50 60 70 80 90 100 Baseline Post Injury 1 Post Injury 2 Post Injury 3 Verbal Memory Visual Memory Processing Speed Reaction Time

6 Days Post 16 Days Post 23 Days Post

(24)

Management

• _Management – Physical rest – Cognitive rest – Follow-up – J Peds 2010; Genuardi 1995 – RTP stages

(25)

Step Level of activity 1. No activity, complete rest. Once asymptomatic, proceed to level 2. 2. Light aerobic exercise such as walking or stationary cycling, no resistance training. 3. Sport specific exercise - for example, skating in hockey, running in soccer; progressive addition of resistance training at steps 3 or 4. 4. Non-contact training drills. 5. Full contact training after medical clearance. 6. Game play.

(26)

Take Home

• _Rule out • _{Physical Rest} • _{Cognitive rest} • _Follow up • _{Return to play should be in stages}

(27)

Prolonged recoveries

Weeks to months: – Ease restrictions – Insomnia – Post-traumatic headaches – Cognitive dysfunction – Balance problems / dizziness

(28)

Sports Concussion Clinic

• _{10 physicians, 1 nurse practitioners, an RN, a} neuropsychologist • _{Consultants in neurosurgery, neurology,} psychology • _{>400 patient visits/month during peak season} • _{Basic science research and clinical research}

(29)

Physicians

William Meehan, MD, Founder & Director Michael O’Brien, MD, Associate Director Pierre d’Hemecourt, MD, Co-Founder Andrea Stracciolini, MD Bridget Quinn, MD Ellen Geminiani, MD Cynthia Stein, MD Michael Beasley, MD Kate Ackerman, MD Nurses Ariana Moccia, RN Michelle Parker, NP Neuropsychologist

Alex Taylor, PsyD

Clinical Collaborators

Karameh Hawash, MD Mark Proctor, MD

Sharon Chirban, PsyD Alyssa Lebel, MD

Anna Minster, MD

Celiane Rey-Casserly, PhD Regina Laine, NP

Research Collaborators

Rebekah Mannix, MD, MPH Robert Cantu, MD Rob MacDougall, BA Michael Whalen, MD Micky Collins, PhD Anthony Kontos, PhD Dawn Comstock, PhD Peter Kriz, MD James MacDonald, MD Ross Zafonte, DO Margaret Naeser, PhD Jimmy Zhang, BA

Dody Robinson, MD Jackie Berglass, BA Danielle Ruggieri, BA Alex Rotenberg, MD Justin Eckner, BA David Mendell, BA Ellen Grant, MD Liz Carew, BA Emily Hanson, ATC Alvaro Pascual-Leone, MD, PhD Dan Martin, BA Jeffrey Colvin, MD, JD Lois Lee, MD, MPH Karen Kinnaman, MD, PhD Michael Monuteaux, PhD Chris Fischer, MD Lise Nigrovic, MD, MPH Jugta Khuman, MD

(30)

Injury Risk Profile and Prescription for Prevention Physical Assessment Prevention RX Training Historical Assessment

(31)

Other Services

• _{Running Program} • _{Concussion Preparation and Prevention} • _{ACL Injury Prevention Class} • _{Coaching and Community Clinics} • _{Activity for Sedentary Kids} • _{Dance Program} • _{Training (Independent and 1 on 1)} • _{Scholarships for Underserved Athletes}

(32)

Recent Concern

• _Risk

• _Cumulative

• _{Second Impact Syndrome}

(33)

Increased Risk

• _{Gerberich 1983}

• _Schultz 2004

(34)

Cumulative Effects

• _{Gronwall 1975}

• _Collins 1999

(35)

Second Impact Syndrome

• _{Saunders and Harbaugh 1984}

(36)

Andre Waters _Terry Long

(37)

The Role of Cis-Tau

Sh

am

Ig

(38)

(39)

Non-Professional Athletes

Methods

• _{Cross sectional study} • _{New England Small College Athletic} Conference (NESCAC) Alumni (40-70 years old) • _{Sports played, number of seasons} – Collision: football, rugby, men’s ice hockey, men’s lacrosse – Non-contact: swimming, cross country, golf, tennis, squash, Frisbee, volleyball

(40)

Methods

• _{Compared collision sport vs. non-contact sport} • _{Adjusted for potential confounders}

(41)

Effect of collision sports participation on patient reported outcomes (participants without history of concussion)

β- coefficient* Standard Error 95% CI p-value Outcome Measure General Concerns -0.497 0.505 -1.487, 0.494 0.326 Executive Function 0.204 0.563 -0.900, 1.307 0.717 Anxiety -0.056 0.551 -1.138, 1.025 0.919 Depression -0.440 0.449 -1.321, 0.442 0.328 Alcohol Use† _1.957 _0.576 _{0.827, 3.086} _0.001 Sleep Disturbance 0.378 0.542 -0.685, 1.441 0.485 Emotion/Behavior Dyscontrol 0.243 0.608 -0.949, 1.435 0.689 Fatigue 0.330 0.536 -0.721, 1.380 0.538 Positive Affect 0.442 0.449 -0.439, 1.323 0.325

(42)

Limitations

• _{Only one time, email only contact, 8%} response rate • _{Recall bias regarding concussion}

Conclusions

Most athletes exposed to collision sports have no significant increase in later life neurobehavioral symptoms when compared to non-contact sport athletes.

(43)

Conclusions

Athletes exposed to collision sports at lower levels of intensity and for a shorter duration of exposure than professional athletes have no significant increase in later life neurobehavioral symptoms when compared to non-contact sport athletes.

(44)

Sport-Related Concussion