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Concussion in soccer

Concussion in soccer. Thomas Martinelli, MD Commonwealth Orthopaedics and Rehabilitation. Presented to. Virginia Youth Soccer Association January 22, 2011. Historical Example of what not to do. 1973 13 year old CYO football punter in first half – bad snap – runs for it

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Concussion in soccer

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  1. Concussion in soccer Thomas Martinelli, MD Commonwealth Orthopaedics and Rehabilitation

  2. Presented to Virginia Youth Soccer Association January 22, 2011

  3. Historical Example of what not to do 1973 • 13 year old CYO football punter in first half – bad snap – runs for it • Knocked unconscious on field – ambulance called – woke up before they arrived • Went back in second half, played entire half, tackles QB for safety, team wins

  4. Definition of Concussion “A trauma induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are the hallmarks of concussion.” (American Academy of Neurology Summary Statement – The Management of Concussion in Sports)

  5. Simply put – It is a Brain injury !

  6. Synonyms • Dinged • Bell rung • Knocked out • Fell out • Saw stars • MTBI (Mild Traumatic Brain Injury)

  7. How frequent are they ? • 1.4 to 3.6 million sports and recreation related concussions per year • The majority occur at high school level ! (2006 CDC estimate)

  8. Who gets them? • Sport • Age • Male vs Female • Position on field • How they happen • Prior concussions

  9. Sport • Intentional brain injury sports – boxing, mixed martial arts, extreme fighting • 100 % even with protective headgear • Persistent brain/neuro damage • Some with serious long term effects (Muhammad Ali) (AAN)

  10. Sport • Non-Intentional brain injury sports: • High school level • Ice hockey • Football • Soccer • Wrestling • Basketball • Field hockey (Wilson Pediatrics 2006)

  11. Sport – Soccer/Age • 50,000 high school concussions/year in 2006 data (J Athletic Training) • Various studies 2 % to 62.7% (Delaney, McGill University)

  12. Sports - Soccer • Almost all of the studies done since 2004 show minimal difference in incidence of concussion in football and soccer players at the high school level or at the university level

  13. Male vs Female in Soccer • 40% higher rate in women at high school level (J Athletic Training 2007) • 2.6 times more likely for women in University level soccer (McGill university 1999 study) ■ Several reasons postulated for this: 1. reporting differences 2. game differences 3. musculature differences

  14. Position on field • Of players with at least 1 concussion: • Goalie 79% incidence • Defense 70.2% • Mid/Forward both 57% (Delaney, McGill University) • Other studies not as clear a difference

  15. How Do These Occur?

  16. How do these occur ? • Head to head (ACC 1996-1998, US Olympic data 1993) • Hand/Arm/elbow to head (J Athletic Training) • Ball to head • Head to ground • Other body part to head

  17. It is possible to get a concussion without head impact! Rapid acceleration/deceleration from impact to shoulders/torso transmitted to the brain

  18. Does heading the Ball cause concussions?

  19. Heading the ball ?“Footballers Migraines” • Yes but only reports and not on ImPact testing (Kaminski Delaware, Putukian Princeton) • Yes and measurable long term (Tysvaer 1989 AJSM) • No (Fuller, Dick, Anderson) Overall felt to be inconclusive but AYSO recommends against heading until age 10.

  20. Heading the ball – however… • Several studies have demonstrated worse performance on physical (balance) and/or cognitive tests in recent concussion patients who repeatedly head the ball (ACSM meeting 2009) ■ So caution is needed in return to head impact sports with recent concussion

  21. Best predictor of concussion ? • Prior concussion !!! • 3 to 10 times more likely to get another concussion if you have had one before • 92% occur within 10 days of first one • Thoughts range from style of play to genetic or anatomic factors • No current recommendations for prevention, other than teaching proper technique and using proper equipment

  22. Initial Complaints • Dizziness • Double vision • Drowsiness • Foggy • Headache • Nausea • Nervousness • Ringing in ears • Vomiting

  23. Later complaints • Depression/Sadness • Excessive sleep/fatigue • Irritability • Sensitivity to light • Sensitivity to noise • Vomiting • Poor concentration/memory issues

  24. Worrisome physical findings • Worsening neurologic exam • Worsening headache • Seizure • Stiff neck • Fluid leaking from nose • Bleeding from ears • Unequal pupil size • Weakness/tingling in arms or legs • All of these mean an immediate trip to the emergency room

  25. Physical exam • Standard field management if unconscious • Airway • Breathing • Circulation • Ambulance if needed • Sideline management • Overall exam • Cognitive testing • Motor testing • Serial repeats

  26. Overall exam • Rule out other pathology • Neck, Back, extremities • Rule out bad things • Eye tracking, pupil reaction and size • Fluid leaking from places it should not leak from • Swelling/deformity • specifically around the head and face

  27. Tests • Sideline exam • Mental • Physical • ImPact • MRI,CT Scan • Functional MRI • Blood tests

  28. Multiple tests exist • Cognitive • SAC, U of Pitt for sideline/initial evaluation • ImPact, CogSport, Headminder Concussion Resolution Index, ANAM-SMB for later eval • Graded Symptom Checklist for both • Physical • Smart Balance Master, Chattecx Balance System, Balance Error Scoring System

  29. Cognitive – U of P sideline test • Orientation • What stadium is this • What city is this • Who is the opposing team • Month, day, year • Posttraumatic amnesia • Repeat 3 words • Retrograde amnesia • What happened last quarter • What do you remember before the hit • What was the score of the game before the hit • Do you remember the hit • Concentration • Days of the week backwards • Repeat numbers backward – 2 digit, 3 digit,… • Word list repeat • What were the 3 words given earlier

  30. Sports Concussion Assessment Tool (SCAT2) • 4 page cognitive and physical assessment • Lots of sections with scores in each • No current normative data so no cutoff scores are established • Best in comparison to pre-injury score • Available for free download at http://www.sportalliance.com/Images/Sport%20Safety/SCAT2.pdf

  31. ImPact test • Immediate Post-concussion Assessment and Cognitive Testing • Developed in 1990’s by Mark Lovell, PhD and Joseph Maroun, MD, who run the U of P concussion program • 20 minute online test - 5 sections with 6 modules in the actual test section • Given before season begins then after concussion • Return to baseline indicates return to contact time • Purely neurocognitive • Used in Fairfax County Schools, MLS, US Olympic Soccer, NFL, NHL, MBL, NBA (8 teams), Rugby, auto racing • Validated

  32. Physical tests Double leg stance with eyes closed, hands on hips • Single leg stance, same • Heel to toe walking in line • Finger to nose - rapid alternating • 40 yard sprint • Balance Error Scoring System • UNC Chapel Hill • Supposed to take 10 minutes http://www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

  33. MRI, CT Scan • Consensus – no role in the management of concussion ! • Concussion is a microscopic brain injury with no MRI or CT findings • However, can rule out other worse pathologies and is useful if symptoms deteriorate over time

  34. Functional MRI, PET scans • Look at brain activity in the course of cognitive activity • Can demonstrate abnormal patterns • Have correlated with ImPact score improvement • Not widely available and expensive

  35. Blood Tests/Genetic Markers • Blood tests • Myelin Basic Protein • Tau • GFAP • S100 • Neuron specific enolase • SOD1 • Genetic markers • APO E4 • APO E promotor • Tau polymerase

  36. Classification schemes • Over 40 known classifications • Most do not agree with each other • 3 are widely used: • Cantu • Colorado Medical Society • American Academy of Neurology

  37. Classification - Cantu • First published in 1986 • based on amnesia and loss of consciousness • Updated in 2001 to include secondary symptoms • Grade 1 no loss of consciousness less than 30 minutes post traumatic amnesia • Grade 2 LT 1 minute loc amnesia 30 minutes to 24 hrs • Grade 3 GT 1 minute loc any symptoms lasting over 1 week

  38. Classification – Colorado Medical Society • Published 1991 • in response to high school athletes death • Grade 1 confusion only • Grade 2 confusion and post traumatic amnesia • Grade 3a unconscious for seconds • Grade 3b unconscious for minutes

  39. Colorado Medical Society Classification • First to add specific guidelines for return to sport Timing based on first or repeat concussions

  40. Classification- American Academy of Neurologists • Introduced 1997 – based on Colorado guidelines • Grade 1 no loss of consciousness confusion lasts less than 15 minutes • Grade 2 same but more than 15 minutes • Grade 3a brief loss of consciousness (seconds) • Grade 3b prolonged loss of consciousness (minutes)

  41. AAN return to play guidelines • Same as Colorado except grade 1 • Do neuro exam every 5 minutes • Return to play if normal within 15 minutes • However, policy was stated in 1997 and is slated for a late 2011 update. Expect much more stringent guidelines

  42. International Conference on Concussion in Sport • First Vienna 2001 • Second Prague 2004 • Third Zurich 2008 • Consensus panels of international experts • Each built on the prior panels’ work • Latest guidelines for return to sport, work- up and follow-up • Wide range of recommendations, some controversial

  43. ICCS recommendations • Pre-participation concussion history is very important • Sideline evaluation medically then cognitive using SCAT2 • Attention to cervical spine as additional concern • No return to sport day of concussion except in rare adult instances • Should not be left alone for several hours post injury • Imaging, genetic studies not helpful in most cases • Graduated return to sports

  44. ICCS Controversies • Guidelines can apply to as young as 10 year olds • Treat elite/non-elite athletes the same • Helmet/mouthguard use does not lessen concussions • Do not agree that loss of consciousness under 1 minute is a measure of severity • No consensus about chronic effects • No defined guidelines based on grading – in fact no grading system • Modifying factors may lengthen recovery • ADD/ADHD • LD • Depression • Sleep disorders

  45. Do Mouthguards/Helmets help? • Mouthguards – a resounding no! • But important for oral/dental injury prevention • Helmets • In American Football, yes for skull fractures, facial injuries, eye injuries • Uncertain for concussions • Different game now vs pre-helmet days • Different reporting of injuries • Different awareness of concussion risks

  46. Soccer helmets • Allstar, Headblast • Full90 • 25 to 45 dollars online • Complies with FIFA and US Soccer regulations • 2008 study: use cut risk in half and 19% decrease in recurrent concussions (Delaney BJSM) • May not be as beneficial for women as men in lab study (Tierney J Ath Train 2008)

  47. Soccer Helmets • Not currently widely used • Relatively new • Not cool yet since not highly endorsed by professional players • 2006 attempted law in Mass did not pass • Worries exist that it will cause more head impact injuries due to American football spearing effect • So far however no changes in the game where it has been used are noted • Did shin guards change the game?

  48. Old myths • Don’t go to sleep after a concussion • Current recommendation is to periodically wake for assessment every 3 hours but sleep itself is ok • Don’t take medications for a headache after a concussion • No indications against any medication except alcohol • Weak recommendations against aspirin/Motrin for bleeding • Better helmets will lessen the risk in football players • Risk has gone up with bigger and faster players who use their helmets to lead in tackles

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