Jason M Matuszak, MD Primary Care Sports Medicine Excelsior

Jason M Matuszak, MD
Primary Care Sports Medicine
Excelsior Orthopaedics
No conflicts to report
Summary and agreement statement of the 3rd
International Conference on Concussion in
Sport, Zurich, 2008.
McCrory P, Johnston K, Meeuswisse W, Aubry M,
Cantu R, Dvorak J, Aubry M, Molloy M.
Illustrate current understanding of the
pathophysiology of concussion and potential
catastrophic injury
Describe the cumulative effect of concussion:
Increasing risk
Threshold effect
Timing effect
How many is too many?
Introduce new guidelines in sports concussion
management and demonstrate an
implementation process
15 year old soccer player goes up to head a ball
and collides with another player. The two
players strike heads.
T.E. slow to get up and is obviously dazed.
The referee calls out the athletic trainer and the
player is removed from the contest
You are the treating practitioner
A. sideline at the time of the game
B. office 3 days later
~300,000-1M sport concussions/year (US)
75% DO NOT involve Loss of Consciousness
(LOC)
Epidemiology
McCrea, CJSM (2004).
15.3% of 1532 High school football players reported
sustaining a concussion
NCAA Injury Surveillance System (2005) #/1000
athlete exposures
Soccer: concussion 1.24
Football: 3.91
Concussions to Force Young Into Retirement
It was the next hit, the knock to the noggin that was sure to come, that
would have certified San Francisco quarterback Steve Young as stupid.
By: T J. Simers
Published: June 09, 2000
Expert Ties Ex-Player’s Suicide to Brain Damage
Eagles safety Andre Waters making a tackle in 1988. Waters had a reputation
as one of football’s hardest-hitting defensive players.
By ALAN SCHWARZ
Published: January 18, 2007
High School Football Player Dies
Dougherty is the [second] teenager to die [because of a brain injury] in
New Jersey in the last three months after participating in football
activities. Dougherty is also at least the fourth high school player in the
United States to die this year because of a head injury.
By MICHAEL S. SCHMIDT and DAVE CALDWELL
Published: October 16, 2008
Congress of
Neurological Surgeons
(1966)
Temporary loss or
alteration of part or all
of the brain’s abilities to
function, without
apparent physical
damage to the brain
Animal models
None exist for sport
concussion
More severe brain
injuries
Abrupt neuronal depolorization
Release of excitatory neurotransmitters
Changes in glucose metabolism
Altered cerebral blood flow
“Energy Crisis”
Symptoms
• Headache or pressure in the head
• Balance problems or dizziness
• Nausea
• Feeling ‘‘dinged’’, ‘‘foggy’’, stunned
or ‘‘dazed’’
• Sensory alterations
• Irritability or emotional changes
• feeling of slowness
• fatigue
Signs
• Confusion
• Amnesia
• Loss/impairment of consciousness
• Poor coordination or balance
• Concussive convulsion
• Slow response
• distracted, poor concentration
• Displaying inappropriate emotions
• Vomiting
• Vacant stare/glassy eyed
• Slurred speech
• Personality changes
• Inappropriate playing behavior or
decreased playing ability
Mortality
Significant intracranial injury
Second Impact
Morbidity
Increased risk of injury
Cognitive impairment
Post-concussive syndrome
Cumulative effects of concussion
Unnecessary visits to the emergency department
with unnecessary CT scans
National catastrophic injury research center
Subdural hematoma
Skull fracture
History of helmet safety
Helmets are designed to prevent skull fracture…. Not
to prevent concussion!
“Second Impact Syndrome”
loss of autoregulation of cerebral
blood flow→ cerebral vascular
engorgement→increased intracranial
pressure→herniation.
Mori, Acta Neuro (2006)
Subdural hematoma
Cause of death for Daugherty (New
Jersey HS FB player) listed as “brain
hemorrhage” not herniation
18 cases described in medical literautre
Decreased reaction time → increased risk of injury
Maddocks (1996) ----- reduced reaction times and reduced
speed of information processing
Maruff (2002) ---- effect of concussive injury on reaction time
20 hours no sleep
50 mg/dl blood alcohol level
Lovell (MSSE 2002)
*Higher
score indicates poorer performance
6x risk of recurrence after the first
3x risk multiplier thereafter
“Threshold effect”
more trivial injuries
longer lasting symptoms
How many is too many?
Collins, Neurosurg (2002)
Guskiewicz , JAMA (2003)
30% had symptoms > 1 week
Iverson, Brn Inj (2004)
9x more likely amnesia, confusion
7x more likely to experience LOC
more preseason symptoms
8x more likely memory problems 2 days after injury
Covassin, J Ath Train (2008)
significantly slower recovery of verbal memory and
reaction time
“Recency” - Sustaining second injury while not
fully recovered from first.
Prolonged symptoms and ↑ likelihood of post-concussive
syndrome
≤ 92% of second concussions during the same
season occur in the first 7-10 days after first
(Guskiewicz, JAMA 2003)
Athlete reports to ER
unnecessary CT scan
Prolonged absence from sport
Poorly timed follow up with primary physician
OR… incorrect diagnosis and premature return to
sport
Educate kids at preparticipation evaluation for
close follow up
Psychosocial issues
Hines Ward [on Ben Roethlisberger]
Players lie. Their parents often do, too
Concern about being removed from play
Attitudes about concussion – ability to “take a hit”
…Well, it's just a concussion. You know I've played with
concussions before - I would go out there and play.'
Lack of knowledge issues
•
Delaney, 2001:
• 16% of college athletes with concussion knew what it was
•
McCrea, CJSM 2004:
• > 1/3 of high school athletes that did not report concussion
was because of ignorance
Concussed athletes must be evaluated and treated
INDIVIDUALLY
Grading / severity
Grading scales abandoned in favor of combined measures of
recovery
Elimination of Prague group categorization
Simple
Complex
Return to play
Concussion severity
can only be determined in
retrospect
symptoms have cleared
neuro exam normal
cognitive function
returned to baseline.
Some evidence that
severity correlates
with:
number and duration of
actual signs and
symptoms
degree of impairment on
neuropsychological
testing.
Significance of loss
of consciousness
Significance of
amnesia
•Loss of consciousness is
associated with early
deficits but does not
necessarily imply
severity
•Retrograde amnesia
varies after injury
•mildly reflective of
injury severity
•Post-traumatic amnesia
•better predictor of
severity than LOC
Multi symptom
evaluation more
reflective of
severity than
presence of
amnesia alone
Vast majority progressively resolve over 7-10 days
Athlete typically resumes sport without complication
Aside from limiting activity, no further intervention
needed
Kids<18 may take up to 30 days normally to recover.
Adults (Pro athletes) may take only 3 days
No indication for formal neuropsychological evaluation
No indication for neuroimaging
All concussed athletes should be evaluated by a
physician
May be managed by AT-C under medical care
Symptom “burden” – number, duration, severity
Prolonged (> 1 minute) LOC
Concussive convulsions
Temporal concerns – frequency, timing, recency
Prolonged cognitive impairment after injury
Threshold – concussion with progressively less impact force
Pediatric
Co-/Pre- morbidities: migraine, depression or other mental health
disorders, ADHD/LD
Medication – psychoactive or anticoagulant
Dangerous style of play or sport, i.e. extreme sports
Elite Level
Additional management beyond return to play
Formal neuropsychological testing and/or
other formal testing or investigations
Ideally managed in multidisciplinary manner
by doctors with specific expertise in
management of concussive injury.
Pre-participation evaluation
Attempt to identify athletes with modifying factors
that require further evaluation
Improve surveillance
Symptom based questions
questions about previous head, face, or neck injuries
perceived number of concussions
Baseline cognitive assessment and symptom score
SCAT2 tool
Symptoms
Self reported
Cognitive deficits
Physical/neurologic signs
Balance testing
SCAT2 tool
(1) Sideline evaluation for concussion.
(2) Management of concussion sports palm card; American
Academy of Neurology and the Brain Injury Association.
(3) Standardized assessment of concussion.
(4) Sideline concussion check; UPMC, Thinksafe, Sports Medicine
New Zealand Inc and the Brain Injury Association.
(5) McGill abbreviated concussion evaluation (ACE)
(6) National Hockey League physician evaluation form
(7) The UK Jockey Club assessment of concussion.
(8) Maddocks questions.
Snapshot of cognitive performance at a given moment in
time
Cognitive recovery
Lasting deficits/permanent changes
Paper and Pencil Battery
Computerized abbreviated neuropsych testing
Minimize underreporting of symptoms
Van Kampan (2006)
Cognitive recovery often trails symptomatic
improvement.
Many athletes returned prematurely
Assessment measured against self-norms
Best interpreted by neuropsychologists
In lieu of a trained neuropsychologist, by someone with
experience in managing sport concussion
Not indicated and generally normal in
concussion evaluation
CT scan in the acute phase
structural lesions suspected
prolonged diminished consciousness
worsening symptoms
focal deficit
≥ 3 weeks, must use MRI to evaluate for
chronic subdural hematoma
Individualized and not according to rigid
timetable
Stepwise approach
Should be at each step minimum of 24 hours
If no symptoms may advance
If symptoms recur, reduce step and reevaluate
No activity,
complete rest
until
asymptomatic
Light aerobic
exercise
Sport specific
exercise
Non-contact
training drills.
Full contact
training after
medical
clearance.
Game play
Okay to be more conservative in the
developing brain
Neuropsych testing may be unpredictable
Some evidence demonstrates more prolonged
symptoms in younger individuals
Consensus recommendations for individuals
aged 10 and older
Concussion management is an area of scrutiny
at present
Like other areas of primary care – if you do not
feel comfortable treating it, it’s okay to obtain
consultation
Too conservative? Too Aggressive?
Being unnecessarily aggressive leads to increased
risk
Being unnecessarily conservative leads to fear of
reporting and damaged patient-physician
relationship
Concussion subtypes??
Differences in clinical manifestations
Confusion, memory impairment, loss of cons.
Anatomical localization
Cerebral vs brainstem
Biomechanical impact
Rotational vs linear force
Genetic phenotype
ApoE4 + vs –
Imaging
fMRI
PET
SPECT
Sports concussion is defined as a complex
pathophysiological process affecting the brain,
induced by traumatic biomechanical forces
(1) Concussion may be caused by a direct blow to the
head, face, neck, or elsewhere on the body with an
‘‘impulsive’’ force transmitted to the head.
(2) Concussion typically results in the rapid onset of
short lived impairment of neurological function
that resolves spontaneously.
(3) Concussion may result in neuropathological changes, but the
acute clinical symptoms largely reflect a functional disturbance
rather than structural injury.
(4) Concussion results in a graded set of clinical syndromes that
may or may not involve loss of consciousness. Resolution of
the clinical and cognitive symptoms typically follows a
sequential course. however, it is important to note that, in a
small percentage of cases, post-concussive symptoms may be
prolonged.
(5) No abnormality on standard structural neuroimaging studies is
seen in concussion.
Pre-season
PPE – identify at risk athletes, discuss early evaluation
and proper ER utilization
Baseline cognitive assessment: SCAT2 / computer
neuropsych testing
Fieldside
Remove from play, NO same day return
SCAT2
After the game
No NSAIDS or aspirin first 72 hours
Warning signs to report to ER
No driving
Observation
In the office
Initial evaluation and follow ups
Assess for modifying factors
Imaging/neuropsych testing/referral if indicated
School issues (neurologic accommodations)
Mental/physical rest
Push fluids/encourage adequate nutrition
No sports/gym until symptom free
Gradual return to play
Know your resources – continued monitoring
Persistent symptoms
Symptoms greater than 3-4 weeks
MRI
Multiple concussion
2nd in same season
Complete vs incomplete recovery from first
3rd
Same season = end season
Career – paper and pencil neuropsychological testing
with interpretation by neuropsychologist