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Head Injury in Sport

Head Injury in Sport. James R. Borchers, MD The Ohio State University Assistant Clinical Professor Team Physician Dept of Family Medicine Division of Sports Medicine. Objectives. Define and discuss various types of head injuries in sport

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Head Injury in Sport

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  1. Head Injury in Sport James R. Borchers, MD The Ohio State University Assistant Clinical Professor Team Physician Dept of Family Medicine Division of Sports Medicine

  2. Objectives • Define and discuss various types of head injuries in sport • Review initial evaluation of an athlete with a head injury • Review concussion evaluation and treatment • Discuss return to play guidelines for an athlete with a head injury

  3. Head Injuries in Sport • Actual number of injuries unknown because many are not reported by the athlete • Most head injuries in sport are minor: • Sports are third behind MVA and falls as cause of minor head injuries • Most common head injury in sports is a concussion

  4. Head Injuries in Sport • NCAA Injury Surveillance System developed in 1982 and has guided the NCAA regarding head injury in sport: • 1984-1991 the highest # of head injuries were in ice hockey, followed by football,field hockey, women’s lacrosse and men’s soccer. • Football had the highest concussion rate

  5. Head Injuries in Sport • 1995-1996 data showed an increase in the number of head injuries • More aggressive play and increased contact • Better reporting and diagnosis of head injuries

  6. Focal Blunt trauma Usually associated with LOC and focal neuro deficits Subdural hematoma, epidural hematoma,cerebral contusions and intra cerebral hemorrhage Diffuse Not associated with focal intracranial injuries Severity depends on the amount of anatomic disruption that occurs Concussion is the most common type Types of Head Injuries

  7. Subdural Hematoma • Often LOC, focal deficits and slow deterioration in mental status • Low pressure disruption of venous blood supply • Two types: simple and complex • Depends on the presence of underlying cerebral contusion or edema

  8. Subdural Hematoma

  9. Epidural Hematoma • LOC at time of injury, lucid interval and then CNS deterioration • Associated with disruption of the middle or other meningeal arteries • Must have a high suspicion for injury based on mechanism and exam • Neurosurgical emergency

  10. Epidural Hematoma

  11. Concussion

  12. Concussion • Most common head injury in sports • Term has been used since the 10th century AD, first described as an abnormal physiologic state without gross traumatic lesions of the brain • Pathophysiology of concussion is still not well understood

  13. Concussion In 2004, the Concussion in Sport Group (CSIG) Prague statement defined concussion: • Concussion is defined as a complex physiological process affecting the brain, induced by traumatic biomechanical forces. • Caused by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head

  14. Concussion • Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously • May result in neuropathological changes reflecting a functional disturbance rather than a structural injury • Graded set of clinical syndromes that may or may not involve LOC • Associated with grossly normal neuroimaging studies

  15. Early Headache Dizziness Confusion Tinnitus Nausea Vomiting Loss of balance Late Memory Disturbances Poor Concentration Irritability Sleep disturbances Fatigue Personality changes Concussion Symptoms

  16. Concussion Types • Simple • Symptoms resolve over 7 – 10 days • Limit physical activity • No neuropsychiatric testing required • Rest until all symptoms resolve and then graded program of exertion before return to sport

  17. Concussion Type • Complex • Persistent symptoms even with exertion, specific sequelae, LOC> 1 min, prolonged cognitive deficit • Neuropsychiatric testing indicated • Multidisciplinary approach

  18. Concussion Evaluation • Begins with basic life support: • Airway, Breathing and Circulation • Determine if there is any loss of consciousness: • If LOC exists the athlete must be suspected to have a cervical spine injury and treated appropriately

  19. Concussion Evaluation • If the athlete can be moved to the sideline a neurologic exam should be performed • Evaluate long and short term memory • Assess memory using sport specific questions; orientation questions have poor yield for assessing memory • Assess for retrograde and antegrade amnesia • Monitor frequently

  20. Concussion Evaluation • Preparticipation Exam • Baseline evaluation for cognitive screen and symptom score • Sport Concussion Evaluation Tool (SCAT) • ImPact

  21. Concussion Grading • No consensus exists regarding the grading of concussions • There is very little evidence to support any specific grading scheme • Most have been based on expert opinion and limited data • Glasgow Coma Scale is the only validated scale for use in head injury

  22. Concussion Grading Scales

  23. Concussion Grading • In 2004, the CISG recommended that no specific system be used to grade concussions but that a clinical construct evaluating individual signs and symptoms be used to determine concussion severity and guide management and return to play

  24. Concussion Evaluation • Neuropsychological testing has been shown to be of value when evaluating concussion • Baseline testing is needed for accurate results and periodic baseline updates are recommended • Players may return to baseline testing while still symptomatic • Aid to clinical decision making

  25. Concussion Evaluation • Neuroimaging is not usually necessary and is usually normal with a concussion injury • CT scan initial study of choice if concurrent focal injury is present • MRI better for anatomy and if imaging is needed 48 hours or more post injury • Newer modalities (PET scan, structural MR modalities) promising but not established for use in concussion

  26. Concussion Management • Dependent on individual guidelines • Consensus that any athlete that has signs or symptoms of concussion should be removed from the event immediately and should not return if signs or symptoms persist at rest or with exercise

  27. Concussion Management • CSIG 2004 states when any player shows any signs or symptoms of concussion • No RTP in game or practice • Regular monitoring • Player medically evaluated • RTP must follow medically supervised stepwise process

  28. Concussion Management

  29. Concussion Management

  30. Concussion Management • Should follow a stepwise approach • At each level the athlete should be asymptomatic before progressing to the next stage • 24 hours between stages • If an athlete is symptomatic at any stage, the athlete should drop back to the previous level and try to progress again in 24 hours

  31. Concussion Management • Step wise progression • No activity, complete rest • Light aerobic exercise • Sport specific exercise • Non-contact drills • Full contact training • Game play • Should be followed for any concussion occurrence

  32. Concussion Guidelines • NATA • Allows RTP same day • Symptoms < 20 min • No symptoms with exertion • No LOC • No amnesia • Team Physician Consensus Statement • No evidence based data for RTP same day

  33. Post Concussion Risks

  34. Second Impact Syndrome • Most serious risk of premature return to play following a concussion • Any insult to the head following premature return to play causes instantaneous collapse and death • Thought to be due to loss of autoregulation of the brain’s blood supply • Researchers have questioned its existence

  35. Postconcussive Syndrome • Constellation of symptoms that persist following minor head injury • Criteria defined in DSM-IV are viewed as too strict and often clinical judgment is needed to evaluate on an individual basis • Multidisciplinary approach to treatment • Beta-blockers , SSRIs and TCAs can be used

  36. Chronic Traumatic Encephalopathy • Premature loss of normal CNS function due to multiple blows to the head • May occur in athletes with no LOC and it is difficult to predict which athletes are at risk for developing this syndrome • “Punch drunk syndrome” • Syndrome occurs in 9-25% of professional boxers, depends on # of fights and length of their career

  37. Pediatric Concussion • Physical and cognitive rest • Neuropsychiatric testing difficult • Stepwise progression suggested • Stay conservative

  38. Prevention • Multiple factors can help with head injury prevention in sport: • Equipment modification • Rule enforcement and changes as necessary • Education of proper sport specific techniques • No clinical evidence that concussion in sport can be prevented

  39. Conclusion • Most head injuries in sport are mild but there is no such thing as a minor head injury • Appropriate evaluation will help to avoid complications of an athletic head injury • When in doubt, sit them out • Clinical judgment and experience are important when dealing with head injuries in sport

  40. Thank You

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