Sports-Related Concussion

Keith Eggleston, AT/L, ATC
Sports Medicine Coordinator – Rockwood Clinic
Sports Medicine Instructor – Spokane Valley Tech
Athletic Trainer – Central Valley High School
Assuming you know the basics about
concussion, so taking different approach:
 Discuss trends and directions
 Research areas re: diagnosis and
assessment
 Touch on a lot of different aspects of
sports-related concussion
 16yo male football player
 No relevant health issues; no hx of concussion
 3rd quarter, head first into group tackle in V game
 Immediately:
 Grasped head in obvious pain & goes to ground
 HA; Several other typical concussive S/S
 Delayed responsiveness but alert and oriented x3
 Brief (seconds) spasmodic episode, ended before AT got
to him
 Transported to hospital via EMS
 Was stable, no findings on imaging, released to home
that night
 Uneventful recovery, passed neurocognitive
assessment and went thru gradual RTP program
 Returned to play and participated in last 2 games of
the season, no other sports for senior year
 “Case closed” – just the way we want them all to end!
 Direct/indirect blow to the head + some form of
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change in cognitive function = CONCUSSION
They aren’t on the decline
They aren’t getting any easier to treat
We are still learning about how to fully assess them
Still learning about ST & LT implications
They are prevalent in all sports
 Do not need to exhibit significant symptoms
 Even just having a headache, if not explained by other
reason, is consistent w/concussion
 Athletes must get written clearance for RTP
 Schools should have policy and plan for these injuries
 Talking about concussion, not subdural hematomas
and bleed/fracture injuries
 APOE4 (apolipoprotein epsilon4 allele) is the current
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target
Hockey siblings: Eric/Brett Lindros; Sidney/Taylor
Crosby
Testing is cheap and it is not predictive
What does it test? Repeat concussion vs initial
concussion vs healing issue, etc?
Clearance if you have it? Liability and insurance?
 Everything goes through neural system or vessels,
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likely we will find indicators
Military research work
Concussion markers in blood concussion
Tau Proteins found post-bout in boxers
Goal: define active/ongoing concussion
Long ways to go (thresholds)
 Expensive pictures but diagnosis, prognosis
 fMRI interesting but not established clinically
 DTI-MRI available but not established clinically
 CT and MRI not effective for concussion
 Goal: images direct treatment, care, or prognosis.
MRI
fMRI
MRI
DTI-MRI
 Q: how do we know what is going on?
 Professional, college, and HS (ROI) tracking
 Establishing data for further evaluation
 Findings:
 Concussions “on the rise”
 Who has them, where, and when
 Frequency
 Duration of S/S
 Seeking an A + B = C predictive modeling
 Seattle Children’s (n=1412):
 Risk factors for concussion S/S 1 week
 4+ symptoms = double risk 1 week
 Hx of prior concussion =double risk in FB only 1 week
 Drowsiness, nausea, difficulty concentrating = increased
risk 1 week
 Amnesia 1 week in males only
 Used to think brain didn’t heal
 Now we know lifelong changes occur
 Peds = changes found in white matter 1 month after
symptoms “resolved”
 Will there be residual tissue changes similar to scar
tissue after an ankle sprain, or will brain heal/adapt
around that area?
 Need to ID methods to encourage healing & know
when/how to do so
 Ongoing research
 Repetitive blows to the head are bad
 How many? Unknown
 How often? Unknown
 Time between contact? Unknown
 What is the threshold for trauma & timeline for
healing?
 150N hit to head 1 time
 3 x 50N hits to head in 1 day =/worse?
 6 x 50N hits to head in 3 days =/worse?
 Concussion is a metabolic issue
 Exertion = controlled ↑ to HR, BP, etc
 Evaluation:
 Used as progressive assessment in RTP
 If S/S return during progression, not healed
 Potential FUTURE treatment?
 Threshold below S/S to encourage healing
 Research needs to ID ‘Goldilocks’ guidelines
 Avoid contact to head while symptomatic
 Avoid cognitive stressors that increase S/S
 Avoid emotional stressors that increase S/S
 Avoid alcohol, tobacco, caffeine
 Avoid any meds not recommended by provider
 Some medications used via skilled provider direction
 ‘ST’ injuries: sports-related concussion
 ‘Lifelong’ injuries: MVA, significant head
trauma and disability
 Opposite ends of the spectrum
 Recent decades experts bridging gaps between
opposite ends.
 Sharing research/care paradigms shows
promise in sports-related TBI/concussion
 Lots of research, lots of promotions
 Sales more marketing driven than proof-driven
 Additional equipment may encourage more contact
 No data defining prevention of concussion via
equipment
 Tissue damage more extensive than previously
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understood.
We underappreciated both effects and FQ
We underappreciated LT implications
We don’t know how much brain can heal
We don’t know how to influence healing
 No RTP while symptomatic
 When in doubt – they are out
 Graduated RTP is the standard (S/S clear)
 Coaches are eyes/ears, but should only be decision-
makers in a conservative direction
 Imaging is largely un-useful for concussion
 No mild/moderate/severe classifications
 They are STUDENT-athletes
 Athlete presents to UCC, girlfriend reports seizure
 No family hx, no hx of seizure prior to brief seizure
episode in fall football
 Dx: epilepsy
 Tx: probable LT (lifelong?) care & meds
 Did initial focal injury to area of brain never heal,
leading to electrical issue/epilepsy?
 Did symptoms manifest weeks/months later?
 Is there any treatment that would have altered
outcome?
Why Odd & Unpredictable Symptoms?
Keith Eggleston, AT/L, ATC
Cell: (509) 868-2608
Email: [email protected]