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Traumatic brain injuries in equestrian athletes

Traumatic brain injuries in equestrian athletes. Lola B. Chambless, MD Department of Neurosurgery Vanderbilt University. Overview. Definitions Incidence data Mechanisms of Injury Symptoms Diagnostic tools Outcome Prevention. Definitions. TBI = traumatic brain injury

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Traumatic brain injuries in equestrian athletes

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  1. Traumatic brain injuries in equestrian athletes Lola B. Chambless, MD Department of Neurosurgery Vanderbilt University

  2. Overview • Definitions • Incidence data • Mechanisms of Injury • Symptoms • Diagnostic tools • Outcome • Prevention

  3. Definitions • TBI = traumatic brain injury • Any injury to the brain which produces structural or functional alterations • May be “mild” – concussion • Severe cases cause coma and death • Concussion = transient trauma-induced alteration in brain function • Does NOT require loss of consciousness • CTE = chronic traumatic encephalopathy • Slowly progressive loss of global neurologic function in athletes with history of multiple concussions

  4. Scope of the problem • Between 2 and 3.8 million cases of TBI reported annually in the US • 500,000 – 760,000 are sports-related • 50,000 deaths/year • 70,000 – 90,000 permanently disabled/year • Highest incidence: ages 15-24

  5. Scope of the problem • Concussion in athletes: • Duration of symptoms is highly variable • 15% of these patients will continue to have symptoms one year after the injury • An athlete who sustains a concussion is 4-6 times more likely to sustain a second concussion

  6. Scope of the problem • Horseback riding causes 11.7% of all TBIs among recreational sports • Highest percentage of any recreational sport • In 2009 there were over 14000 ER visits for brain injuries among riders

  7. Major traumatic brain injury • REMEMBER: in the unconscious patient ALWAYS assume an associated spine injury • ABC’s • Emergency airway • Hyperventilation

  8. Types of TBI • Skull fractures • Intracranial hematomas • Concussions

  9. Skull fractures

  10. Skull fractures – diagnosis and management • CANNOT reliably diagnose these lesions by palpation • Significant individual variability in baseline contours of skull • Does not always have an associated scalp laceration • May occur even with mild brain injury • If suspected – refer for CT • X-ray useless

  11. Basilar skull fracture • Can present in delayed fashion • Symptoms: • Hearing loss, severe dysequilibrium • CSF rhinorrhea or otorrhea • Loss of smell or taste • Signs: • “racoon eyes” • Battle sign (bruising over mastoid)

  12. Intracranial hematomas in sports • Suspected from symptoms and course • Severe headache with vomiting • Lethargy • Pupil asymmetry (with above) • Lateralizing neuro signs • Beware the “lucid interval” • Initial mild symptoms, then rapid deterioration • Usually occurs within 6 hours Valadka AB (2004). "Injury to the cranium". in Moore EJ, Feliciano DV, Mattox KL. Trauma. New York: McGraw-Hill, Medical Pub. Division. pp. 385–406.

  13. Basic Science Studies • Current knowledge limited due to available models • There is no existing animal or experimental model that accurately reflects a sporting concussive injury

  14. How do we diagnose a concussion? • Mostly a clinical diagnosis based on reported symptoms, observation of the athlete’s behavior and function and examination of specific brain function • Inherent problem of truthful symptom reporting • Requires on site assessment by personnel trained to identify brain injury

  15. Symptoms Headache    Nausea    Balance problems or dizziness   Double vision    Sensitivity to light or noise    Feeling sluggish    Feeling “foggy”     Concentration or memory problems    Change in sleep pattern (appears later)    Feeling fatigued Signs and Symptoms of Concussion Signs • Appears dazed or stunned • Confused about assignment • Forgets plays • Is unsure of game, score, or opponent • Moves clumsily • Answers questions slowly • Loses consciousness • Shows behavior or personality change • Forgets events prior to play (retrograde amnesia) • Forgets events after hit (anterograde amnesia)

  16. From Powell et al. Neurosurg 54(1) 2004 • Three most common symptoms: • Headaches (55%) • Dizziness (42%) • Blurred vision (16.3) • 45.9% experienced either cognitive or memory problems • 9.3% had loss of consciousness

  17. Maddocks’ Questions • Which field are we at? • Which team are we playing? • Who is your opponent at present? • Which quarter (period) is it? • Which side scored the last point? • Which team did we play last week? • Did we win last week? Clinical Journal of Sports Medicine, 1995

  18. Concussion grading scales • Several grading scales have been used as an attempt to classify severity of concussions based on presenting symptoms (grade1, 2, and 3) • No standardized definitions • No correlation with outcome • Arbitrary return to play guidelines • Becoming obsolete

  19. Concussion classification – modern thoughts • Each concussion is assessed independently based upon: • Nature and duration of symptoms and signs • Patient’s age • Patient’s previous concussion history

  20. Note: in the overwhelming majority of cases both CT and MRI imaging modalities will be normal. This does NOT rule out a very serious brain injury, since CT and MRI are tests of structure and not brain function

  21. Treatment • BY FAR THE MOST EFFECTIVE STRATEGY FOR PREVENTING SEVERE BRAIN INJURY IS TO AVOID RETURNING TO EXPOSURE BEFORE A PREVIOUS INJURY HAS FULLY HEALED

  22. Time course of recoveryGuskiewicz et al. JAMA 2003 • Average duration of symptoms is 3.5 days • 88% of athletes have full recovery at 1 week

  23. Second Impact Syndrome • Initially described by Schneider 1973 • 3 cases moderate impact caused almost immediate death • Coined by Saunders and Harbaugh 1984 • Described college FB player who was in a fight week before then sustained minor trauma and died • “….an athlete who has sustained an initial head injury, most often a concussion, sustains a second head injury before symptoms associated with the first have fully cleared.”

  24. Second Impact Syndrome • Pathophysiology • Loss of autoregulation of brain’s blood supply • Leads to vascular engorgement with resultant cerebral edema • Increasing ICP and herniation • 50% mortality • 100% morbidity Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998.

  25. Delayed worsening of symptoms • Delayed Symptoms: • Division 1 College Football: • 33% of players who returned to play prior to resolution of symptoms experienced delayed onset of additional symptoms vs 12.6% that did not return • Guskiewicz. JAMA. 2003

  26. Why are individual neurocognitive baselines useful in assessment of sports-related concussions?

  27. What is computerized cognitive testing? • Concussion will produce transient alterations in objective measures of visual attention, concentration, visual, verbal and spatial memory, and reaction time • Measurement of these functions has historically required a paper and pencil battery of tests administered by a neuropsychologist • Expensive, time-consuming, and subject to the limited availability of qualified practitioners who understand the unique time sensitivity of athletic team schedules • A computerized test can provide a quick, reproducible assessment of these parameters • Eliminates reliance on honesty of athlete’s reporting of symptoms

  28. WHAT DOES ImPACT MEASURE? •  Demographic/Concussion History Questionnaire •  Concussion Symptom Scale • - 21 Item Likert scale (e.g. headache, dizziness, nausea, etc) •  Eight Neurocognitive Measures • - Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores •  Detailed Clinical Report • - Automatically computer scored • - Outlines demographic, symptom, neurocognitive data

  29. ImPACT MEMORY COMPOSITEControl vs. Concussed Athletes Significant difference between groups out to at least 8 days post-injury N.S. p.<.00001 p.<.0001 p.<.03 N=410 . *Lower score indicates poorer performance Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

  30. Current ImPACT test users • All NFL teams • All NHL teams • 31 Major League baseball teams • 7 NBA teams • All MLS teams • Formula One and IRL auto racing • USA Olympic teams – soccer, hockey, skiing, boxing • Over 100 major US universities

  31. The Bottom Line: • Policies in place within the NCAA, NFL, NHL and all published practice parameters for medical professionals support neurocognitive testing as the standard of care for athletes with sports-related concussion.

  32. RTP same game – 2010 NCAA guidelines • “Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan.”

  33. Step-wise return to play • No activity until asymptomatic • Light aerobic exercise • Sport specific training • Non-contact drills • Full-contact drills • Game action

  34. What is the maximum number of “safe” concussions?

  35. ? (but probably zero)

  36. Strategies for concussion prevention • HELMETS! • Reduce risk of severe brain injury in all sports where used (including non-contact) • Multiple examples worldwide where mandatory helmet laws have reduced severe brain injuries and neurologic deaths from sports and leisure activities

  37. 2010 NFL/NFLPA study • The results of an independent study commissioned by the NFL and the players’ union show modern helmets meet all national safety standards, though it stressed that no helmet can prevent concussions and more studies are necessary.

  38. Rule changes and technique

  39. Rule changes • NFL • No helmet–to–helmet hits • “defenseless quarterback” • MLB • Automatic ejection for pitch aimed at head • NHL • More frequent penalties for high sticks or checks above shoulders

  40. Recent Equestrian Developments • US Eventing Assoc. required that paticipants wear ASTM-approved helmets at all times when mounted • US Dressage Assoc. adopts similar rule for non-FEI levels • US Polo Assoc. to require that participants in sanctioned events wear NOCSAE-approved helmets (Jan 2012?)

  41. 1997 NAYRC CCI**

  42. Summary • Management of sports concussions is under ever increasing scrutiny from regulatory bodies, media, and others • RTP decisions should be based on standard assessment tools which include self-reported symptoms, standardized scales, balance testing, and neurocognitive testing of some form • Data from each of these components must not be considered in isolation

  43. Summary • Long term effects of multiple sports concussions remain to be elucidated • Lifetime number of “safe” concussions remains unknown, though repeated traumatic brain injuries can clearly produce delayed cognitive deficits • Proper equipment, technique, and avoidance of exposure to another head impact while recuperating from previous concussion are all important prevention strategies

  44. Opportunities for Improvement • Get professionals behind the use of proper helmets whenever mounted • Institute a formal system of sideline evaluation of injured players • Create formal return-to-play guidelines • Use a Comprehensive Concussion Center to evaluate high-risk athletes • EDUCATION

  45. Thank You! • US Polo Association • Allen Sills, MD • Craig Ferrell, MD

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