Concussions on Campus

Christina Smith Paul MD, CAQSMPrimary Care & Sports Medicine

Student Health ServiceUniversity of Pennsylvania

Overview

• Definitions• Diagnosis & Clinical Course • Cognitive tests • Treatment• Prevention (EDUCATION, gear)• Clearance: Academics, Sports• Referrals?• Ongoing research

Concussions in the News: ESPN, NYTimes

• “SEC concerned about concussions”• “New concussion law suit filed by 100 ex-

players”• “Concussions affecting women more often

than men”• “More retired players sue NFL over

concussion effects”• “Trying to Reduce Head Injuries, Youth

Football Limits Practices”

NFL, players reach concussion dealAugust 2013

• Landmark decision• 4500 plaintiffs (former players)• $765 million dollars– $75 million - health exams– $675 million – compensation– $10 million - research

DP

• 19 yo M, plays ultimate Frisbee, collided w another player 2 d ago. – No LOC– Tried to get back in the game but “didn’t feel right”– HA, + photophobia, + difficulty concentrating ever

since.– Has a test tomorrow– Wants to play in tournament this weekend – Wants to know what he can take/do to get better

Concussion

• Concussion = Traumatic Brain Injury• Loss of consciousness = Rare (and not

predictive)• Causes: blow to head or body • Symptoms vary • Grading systems obsolete

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Evidence-Based Medicine?

Consensus Statement on Concussion in Sport: International Conference(s)• 1st (Prague) 2001• 2nd (Vienna) 2004– Produced SCAT

• 3rd (Zurich) November 2008 – Produced SCAT 2– Designed to follow US NIH consensus criteria

• And…..

British Journal of Sports Medicine April 2013; 47: 250-258

Panel included Stanley Herring and Margot Putukian from AMSSM

The Fourth Conference: Zurich 2012

Used the same format as previously:• 32 international experts• 2 full days of new research presentations• Extensive structured discussion• Drafted a consensus paper, edited until all were in

agreement• Updated version of SCAT (SCAT 3)-with 3 distinct tools• Final drafting of 12 critical review papers, co-published

in multiple journals

• To provide an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion

• To establish the level of evidence, knowledge gaps and areas requiring additional research

AMSSM Position Statement: Concussion in sport

--Purpose--

What we know

• Numbers are increasing. 3.8 million in US/yr– More so in females

• Theories on why: Anatomy– heads are smaller– necks are smaller/less muscle mass

• Theories on why: Culture– Girls more likely to self-report?– Girls get more attention?

What we know

• Equipment does not PREVENT concussion

“Absence of Proof is not Proof of Absence” www.sportsdentristy.com

What we know

• Each subsequent concussion - requires less force• Post Concussion Vulnerability– A second blow sustained before recovery results in

worsening metabolic changes within the neuron– This concept is distinct from “second impact syndrome”

• The concussed brain is less responsive to usual neuron activation

• Prolonged dysfunction may result from premature cognitive activity or vigorous physical activity

Is a functional, not structural issue

What we don’t know (but are working on)

• How to predict duration of recovery• Why some people are more susceptible– Genetic component (APOE ε4 genotype)

• How many is “too many”• How to speed recovery– Supplements– Medications– Physical therapy

DP

• 19 yo M, plays ultimate Frisbee, collided w another player 2 d ago. – No LOC– Tried to get back in the game but “didn’t feel right”

– HA, + photophobia, + difficulty concentrating ever since.

– Has a test tomorrow– Wants to play in tournament this weekend – Wants to know what he can take/do to get better

Concussion Symptoms

• Headache• Nausea• Dizziness• Blurry vision• Sensitivity to light or noise• Feeling sluggish, foggy, “out of it”• Confusion• Difficulty with concentration, memory

Emotional

• Irritability, sadness, more emotional, nervousness

• If positive, screen further (PHQ-9)

• Compounding factors:– Loss of time from sport– Falling behind in school– Lack of physical activity/release as coping skill

Concussion Diagnosis

• You can’t SEE it• Sings/symptoms usually follow the injury but

there can be a delay• Awareness/education of coaches, parents,

athletes is VITAL

Concussion Evaluation• HEENT

– Pupils– Ocular movement– Nystagmus– hemotympanum

• Neck– C-spine tenderness

• Neuro– Cranial Nerves– Short term memory– Concentration– Balance (BESS testing if baselined)

Balance Error Scoring System (BESS)

Concussion Treatment

• Initial Treatment: – Need for immediate/ED evaluation?– Imaging (ie Head CT?)

• Education (student; family; professors, etc.)• HIPPA

• COGNITIVE AND PHYSICAL REST

Treatment, continued• Ongoing: – Wake up at night?– Attendance in class?– homework, watch TV, email?– Return to athletics?– ibuprofen?– Role of other meds or physical therapy?

• Melatonin• Amantadine• Amitriptyline• Vestibular therapy

Concussion Investigations

• Neuroimaging– CT scan– MRI (structural and functional: studies emerging)

• Neuropsychological assessment

Neurocognitive Testing• Computer-based– ImPACT, CogSport, HeadMinder– Added tool for use in return-to-play decisions– Avoidance of returning an athlete too soon– Baseline testing– Timing of testing– Pros/cons of testing

• Formal “paper and pencil” testing• Several hours• Comprehensive• Reserved for chronic/difficult cases

Management in College

• Student/Family education• Health Center• Dean’s Office• Disability Services• Professors• Athletics– Coaches– ATCs

Accommodations

• Rest from class• Frequent breaks• Extra time for assignments• Postpone tests/exams• Note taking service• Quiet environment

DP

• Returns 48 hours later after complete cognitive and physical rest

• Symptom score goes from 35 to 10• Can he go to school? • Can he go for a run?• When would you expect all symptoms to

clear?

Return To School Guidelines (CHOP)

• Step 1– Complete cognitive rest: No TV, computer, text, etc.

• Step 2– Light cognitive activity, 5-15 min increments, frequent

breaks, stop if symptomatic• Step 3– Schoolwork at home, 30 min increments

• Step 4– if tolerating 1-2 hrs at home, can go half day

*advance to next step if symptom-free x 24 hrs

Graded Return to PlayRehab Stage Functional Exercises Objective at each stage

1. No activity Physical and Cognitive Rest Recovery

2. Light aerobic exercises Walking, swimming, stationary bike; intensity <70% maximum HR

Increase HR

3. Sport-specific exercises Skating drills, running drills etc. No head impact.

Add movement

4. Non-contact training drills

Progression to more complex training (passing, etc.); May start resistance training

Exercise, coordination, and cognitive load

5. Full contact practice Following medical clearance participate in normal training/practice

Restore confidence and assess functional skills

6. Return to play Normal game play

Recurrent Concussions

• Second impact syndrome:– Brain swells rapidly, death near certain– repeat injury w/o proper healing time– Young people more vulnerable– Few cases

• Post concussive syndrome• Chronic Traumatic Encephalopathy

Sports Legacy Institute

• Chris Nowinski

Concussions and mental health:In the news

Chronic Traumatic Encephalopathy (Tau Protein)

Prevention?

• EDUCATION (Coaches, parents, administrators)– Gear limitations (Head gear, Mouth guards)

• Gear Changes (Softer balls - Soccer)• Exercises:– Strengthen neck– Learn proper techniques• Tackle techniques• Heading techniques

Prevention• Rule Changes:– NFL and NCAA Football

• Kickoffs moved up to 35 yd line (from 30 yd line)– NCAA Football

• Post-game video review “targeted hits” – Impose suspension if intentional or reckless

– Pop Warner Football• No hitting in 2/3 of practice• Additional precautions (3 yards or less, etc)

– USA Hockey• Raise checking age (11 to 13)

– Education (coaches, trainers, athletes, parents)

What we are doing at Penn• Concussion policy (NCAA requires)• Baseline ImPACT testing – All Varsity contact sports

• All varsity and club athletes must be evaluated and cleared by SHS physician

• Referral resources:– Neurology & Neuropsychiatry– Weingarten Learning Resource Center– CAPS (Counseling)– Physical Therapy (Vestibular Rehabilitation)

SHS visits for concussions2012-2013

2012-13 SHS Data

2012-13 SHS Data

2012-13 SHS Data

2012-13 SHS Data

DP

• Symptom score 0• ImPact back to baseline• Tolerating full academics• 5 day graded return to sport completed• Cleared for ultimate frisbee tournament play

Summary

• Suspect concussion?

NO return to play same day, regardless of resolution of symptoms

Education – most important tool in preventing bad outcomes

• Return to academics before athletics– Stepwise approach for both

References• www.cdc.gov/concussion/sports• McCrory P, Meeuwisse W, Johnston K, et al.Consensus Statement on Concussion

in Sport: the 3rd International Conference on Concussion in Sport, Zurich 2008. Br J Sports Med 2009;43:i76-i84.

• New York Times, June 13 2012• Internet resources (ESPN, Youtube, Vimeo, google,etc.)• Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC,

Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co; 2000:80–100

Questions?