On the Sidelines of a Soccer Match

1. Concussion in SportsStephen V. Cantrill, MD, FACEPAssociate DirectorDepartment of Emergency MedicineDenver Health Medical CenterDenver, Colorado

2. On the Sidelines of a Soccer Match • Soccer forward collides with opposing player while trying to head the ball. Both players tumble to the ground. • Opposing player immediately jumps to his feet • Other player arises slowly and starts walking towards the goal, appearing dazed. Is brought to sidelines by teammates • Complains of a headache and dizziness but denies any tinnitus, nausea or vision changes. • Is oriented to person, place and time, but is unable to recall what period they are playing in or the current score. • Symptoms abate after 30 minutes. He denies any other symptoms and desperately wants to continue in the game.

3. The Questions • What is the appropriate decision about return to play for this player? • Return to this game? • Able to practice tomorrow? • What type of sideline evaluation is appropriate? • Is any follow-up needed?

4. Background • Estimated 200,000-300,000 concussions per year in sports in US alone • 75% of concussions in sports DO NOT involve Loss of Consciousness (LOC) • May be under-recognized • Concussion with LOC is obvious • 75% that do not have LOC may be much less obvious

5. Reasons for Under Reporting • Player lack of knowledge as to what compromises a concussion • Delaney, 2001: Only 16% of university football players who suffered a concussion knew what it was • Concern about being removed from play

6. Concussion - What is It? • Defined in 1966 by the Congress of Neurological Surgeons: • “A clinical syndrome characterized by immediate and transient post traumatic impairment of neural function due to brainstem involvement” • Broadened to include any posttraumatic alteration in mental status that may or may not involve loss of consciousness

7. And Now, the Updated Version • A complex patholophysiological process affecting the brain, induced by traumatic biomechanical forces…. • Causes: direct or indirect force • Rapid onset of short lived impairment that resolves spontaneously • Reflects functional disturbance, not structural • Usually grossly normal structural imaging studies First International Conference on Concussion in Sport, Vienna 2001

8. Football Soccer Wrestling Basketball Baseball Softball Field Hockey Ice Hockey Lacrosse Volleyball Multiple others Sports at Risk: Incidence versus Concussions per 1000 player hours

9. The Controversy over Heading: Does it contribute to brain injury? • Much sensation in the lay press • Some poorly designed studies state emphatically: YES • Other studies are much less clear • May be a factor in players who sustain multiple concussions

10. Other Epidemiologic Factors • Concussed football players have a six fold increase in suffering yet another concussion • Cumulative effect of multiple insults • Apolipoprotein E epsilon-4: May imply increased brain susceptibility to damage (Rabadi, 2001)

11. Cerebral Forces Causing Injury • Compresssive/Direct Pressure • Tensile/Negative Pressure • Rotational/Shearing Forces • Cause of most devastating injuries

12. Cellular Effects • Metabolic dysfunction resulting in increased cellular vulnerability • Large potassium ionic flux • Increased cellular glucose demand • Decreased cerebral blood flow • Lactate accumulation • Intracellular acidosis

13. Concussion Presentation • Confusion and amnesia are cardinal features • Multiple manifestations

14. Concussion Presentation:Neurobehavioral Features • Vacant stare • Delayed verbal and motor responses • Inability to focus attention • Disorientation • Slurred or incoherent speech • Gross observable incoordination • Excessive emotionality • Memory deficits • Any period of loss of consciousness

15. Commonly Seen Early (min to hours) Headache Dizziness or vertigo Lack of awareness of surroundings Nausea and vomiting Commonly Reported Symptoms

16. Persistent low-grade headache Lightheadedness Poor attention and concentration Memory dysfunction Easy fatigability Irritability and low frustration tolerance Intolerance of bright lights or difficulty focusing vision Intolerance of loud noises, sometimes ringing in ears Anxiety and depressed mood Sleep disturbance Commonly Reported Symptoms: Seen Late (days to weeks)

17. Concussion Grading andReturn-to-Play Guidelines: Why Worry? • Return to play with altered cognition and physical capability • Risk of additional injury • Risk of “Second Impact Syndrome” • Blow to head of individual still symptomatic from previous mild brain injury • Rapid, diffuse brain swelling resulting most often in death • Controversial entity

18. Concussion Grading and Return to Play Guidelines • As many as 25 different sets of criteria • Little evidence-based support • Expert opinion • Consensus • Three most often referenced: • Cantu • Colorado Medical Society • American Academy of Neurology

19. Concussion Grade Cantu – 1998 CMS - 1991 AAN – 1997 Grade 1 – Mild No LOC and Post-traumatic amnesia < 30 min No LOC Post-traumatic confusion No post-traumatic amnesia No LOC Post-concussive sx last < 15 min Grade 2 – Moderate LOC < 5 min or Post-traumatic amnesia > 30 min, < 24 hrs No LOC Post-traumatic amnesia No LOC Post-concussive sx last > 15 min Grade 3 - Severe LOC > 5 min or Post-traumatic amnesia > 24 hrs Any LOC Any LOC Classification of Severity of Concussion

20. First Concussion Second Concussion Third Concussion Grade 1 May RTP if asymptomatic for 1 week RTP in 2 weeks if asymptomatic for 1 week Terminate season; may RTP next season if asymptomatic Grade 2 May RTP if asymptomatic for 1 week Minimum of 1 month; may then RTP if asymptomatic for 1 week; consider terminating the season Terminate season; may RTP next season if asymptomatic Grade 3 Minimum of 1 month; may then RTP if asymptomatic for 1 week Terminate season; may RTP next season if asymptomatic Return to Play - Cantu, 1998 Return to play recommendations: Cantu, 1998

21. First Concussion Second Concussion Third Concussion Grade 1 May RTP if asymptomatic for > 20 min RTP if asymptomatic for 1 week Terminate season; may RTP in 3 months if asymptomatic Grade 2 May RTP if asymptomatic for 1 week Consider terminating season. May RTP after asymptomatic for 1 month Terminate season; may RTP next season if asymptomatic Grade 3 Minimum of 1 month; may then RTP if asymptomatic for 2 weeks Terminate season; discourage any return to contact sports Return to Play - CMS, 1991 Return to play recommendations: CMS, 1991

22. First Concussion Multiple Concussions Grade 1 May RTP if asymptomatic in < 15 min at rest and with exertion RTP in 1 week if asymptomatic at rest and with exercise Grade 2 May RTP if asymptomatic for 1 week at rest and with exercise May RTP if asymptomatic for 2 weeks at rest and with exercise Grade 3 Transport to ED if appropriate; Brief (seconds) LOC: RTP if asymptomatic for 1 week at rest and with exercise; Prolonged (minutes) LOC: RTP if asymptomatic for 2 weeks at rest and with exercise Transport to ED if appropriate; RTP for a minimum of 1 asymptomatic month or longer based on physician evaluation Return to Play - AAN, 1997 Return to play recommendations: AAN, 1997

23. Points of Commonality in Most RTP Guidelines: • Any concussed athlete should be removed from competition, examined and observed • Serial assessment of the athlete after the concussion • Any evidence of deterioration, no matter how mild the injury: transport to hospital for appropriate evaluation • Athlete with LOC, even momentary, or post-event amnesia should not be allowed to immediately return to play • Post-concussed athlete cannot return to play until completely asymptomatic, both at rest and after exertion • Multiple concussions may have a cumulative effect on the athlete

24. Sideline Assessment of Neurological Function • Glasgow Coma Scale • Lacks sensitivity • Standard orientation (X3) • Lacks sensitivity

25. Sideline Assessment of Neurological Function • Maddocks Questions • Which field are we at? • Which team are we playing today? • Who is your opponent at present? • Which quarter (period) is it? • Which side scored the last goal? • Which team did we play last week? • Did we win last week? • More sensitive: concussed vs nonconcussed

26. “Standardized Assessment of Concussion” - SAC - McCrea 1997 • Orientation (Month, Date, Day of Week, Year, Time) • Immediate Memory (3 trials of 5 words) • Concentration (3, 4, 5 and 6 digit strings backwards) • Delayed Recall (1 trial of 5 words, used above) • Maximum of 30 points • Brief neurological screen • LOC - Amnesia - Strength - Sensation - Coordination • Exertional evocative component: • 5 jumping jacks - 5 sit-ups - 5 push-ups - 5 knee-bends

27. “Standardized Assessment of Concussion” • Useable in the field • Best if individual baseline established before season starts • Decrease in 1 point or more from baseline: 96% sensitivity, 76% specificity in detecting symptomatic concussed players using AAN criteria (McCrea, 2001)

28. Neuropsychological Testing • Much development in past decades • Additional tool to evaluate recovery • But: • Best tests yet to be demonstrated • Baseline testing should be done • Time and dollar costs are high • Computer and web-based testing may help

29. Neuropsychological Testing • May be helpful in situations of: • Severe concussion • Prolonged post-concussive symptoms • Multiple concussions • Questions of athlete truthfulness • Concept endorsed by Concussion in Sport Group

30. Problems with Hospital Care • Lack of awareness of RTP guidelines by clinicians • Discharge instructions don’t address adequate follow-up and return-to-play criteria nor limitations in activities of daily living

31. Concussion in Sports Summary • Most concussions in sports do not involve LOC, but rather confusion/amnesia • Concussion grading criteria RTP criteria have limited scientific grounding but serve as useful tools for guidance • To avoid further injury and possibly the potentially lethal “second impact syndrome”, concussed athletes should not return to play until completely asymptomatic, sometimes requiring a prolonged period of time

32. Concussion in Sports Summary • The sideline use of detailed mental status screening tools allows for more sensitivity and standardization in the evaluation of the concussed athlete • Neuropsychological testing may be helpful with ongoing post-concussive symptoms, multiple concussions or severe concussions • Ongoing education of athletes is necessary to emphasize a concussion does not require loss of consciousness

33. Concussion in Sports Summary • Ongoing education of providers about guidelines for concussion in sports to insure appropriate and thorough evaluation of concussed athletes on the field, in the office and in the emergency department. • These guidelines should be utilized as part of the decision-making process of when the athlete should be allowed to return to play and to insure the adequacy of patient post-injury education.

34. Back on the Soccer Field… • Due to duration of his symptoms, the athlete sat out the rest of the game • He was administered Standardized Assessment of Concussion (SAC) instrument, scoring 23 out of 30. His preseason baseline score was 27. • The athlete was instructed by the trainer about symptoms to be aware of that could represent a worsening of his traumatic brain injury or could indicate a post-concussive syndrome.

35. And Finally... • He did have recurrence of his headache that evening, but it had abated by the next morning and he remained symptom free. • Re-administration of the SAC instrument 48 hours post-injury revealed return to his normal baseline of 27. • The athlete was counseled to not engage in contact sports for an additional week. • By the way, his team won the league title, 2-1.