Concussions:Should Richie play football?

Christina Smith Paul MD, FAQSMPrimary Care & Sports Medicine

Student Health ServiceUniversity of Pennsylvania

Concussions are not a new phenomenon, but they certainly have been getting a lot of attention in the news in the past few years. High profile professional athletes and former athletes have started to come forward and speak about their experiences with this injury and its (sometimes) prolonged and profound effect on their respective futures. The heightened awareness about this important injury has led to a boom in marketing efforts: both from an injury prevention standpoint and a diagnosis standpoint, with inconsistent evidence that these efforts are successful. Education about the injury remains the most important tool in preventing bad outcomes. Come learn a bit more about concussion, help clarify some myths, and hear how we take care of our concussed students here at Penn

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”

Overview

• Definitions• Diagnosis • Cognitive tests • Treatment• Prevention• Return to school, return to athletics/clearance• Ongoing research • Systems at Penn

Headgames

• http://vimeo.com/headgames/trailer

Concussion

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

predictive)• Causes: blow to head or body

http://www.youtube.com/watch?feature=player_detailpage&v=fY7J7bccNoU

• Symptoms vary • Grading systems obsolete – Simple vs Complex (Prague, abandoned Zurich)– Avoid slang terms as well (“bell rung” etc.)

• Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008

What we know

• Numbers are increasing– More so in females

• Each subsequent concussion seems to require less force

• Balance testing is an objective measure (BESS: Balance Error Scoring System)

• Is a functional, not structural issue

What we know

• Equipment does not PREVENT concussion

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

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

• How to predict duration of recovery• Why some people are more susceptible• http://www.youtube.com/watch?v=O8R1x6Co

6OY&feature=player_detailpage• How many is “too many”• How to speed recovery– Supplements– Medications– Physical therapy

Concussion Symptoms

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

Concussion Facts

• High risk activities: Bicycling, Football, Playground Activities, Basketball, Soccer– Numbers and rates are highest in:• football (55,007; 0.47 per 1000 athlete exposures) • girl’s soccer (29,167; 0.36 per 1000 athlete exposures)

• ED visits:– 1.37 million per year (790k male/575k female)

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• http://www.nfl.com/videos/nfl-network-arou

nd-the-league/09000d5d814d2543/Concussion-safety

Concussion Treatment

• Initial Treatment: – Do I need to take Richie to the ED?– Should Richie get a head CT?

• COGNITIVE AND PHYSICAL REST

Treatment, continued

• Ongoing: – Do I need to wake Richie up at night?– Can Richie go to school?– Can Richie do homework, watch TV, email?– Can Richie play in his game tomorrow?– Can Richie take ibuprofen?– Role of meds or physical therapy?

Concussion Investigations

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

• Objective balance assessment (BESS)• 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

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?

• Gear– Head gear

• Helmet• Other head gear

– Mouth guards– Softer balls (soccer)

• Exercises:– Strengthen neck– Learn proper techniques

• Tackle techniques• Heading techniques

Prevention

• Rule Changes:– NFL and College Football

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

– 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)• All varsity and club athletes must be evaluated and

cleared by SHS physician• Baseline ImPACT testing done on all Varsity athletes

involved in contact sport• Referral resources:– Neurology and Neuropsychiatry– Weingarten– CAPS– Physical Therapy (Vestibular Rehabilitation)

SHS visits for concussions

sports fall MVC hit object assault work0

10

20

30

40

50

60

52

129 9

41

Mechanisms of Injury,All Concussions 2010

n=87

2010 SHS Data

male54%

female46%

By Gendern=87

Undergrads78%

Grad-uate Stu-

dents22%

Concussions by Degreen=87

2010 SHS Data

competition50%

practice35%

missing or n/a15%

Competition or practice?n=52

NCAA65%

non-NCAA35%

Pct of sports concussions in NCAA athletes

n=52

2010 SHS Data

no alcoholor not documented

84%

alcohol16%

Pct of concussions related to alcohol

n=87assault

14%

fall57%

hit object29%

Injury mechanism in alcohol-related concussions

n=14

summary

• http://www.youtube.com/watch?v=yyRBlSAfb_k&feature=player_detailpage

Should Richie play football?Should Finley play Soccer??

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.)

More video, if time…

• Sudden Impact Syndromehttp://www.youtube.com/watch?v=dqlDOH45xWM&feature=relmfu