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
 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
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)
Simply put – It is a Brain injury !
Synonyms
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Dinged
Bell rung
Knocked out
Fell out
Saw stars
MTBI (Mild Traumatic Brain Injury)
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)
Who gets them?
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Sport
Age
Male vs Female
Position on field
How they happen
Prior concussions
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)
Sport
 Non-Intentional brain injury sports:
 High school level
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Ice hockey
Football
Soccer
Wrestling
Basketball
Field hockey
(Wilson Pediatrics 2006)
Sport – Soccer/Age
 50,000 high school concussions/year in
2006 data
(J Athletic Training)
 Various studies 2 % to 62.7%
(Delaney, McGill University)
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
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
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
How Do These Occur?
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
It is possible to get a concussion
without head impact!
Rapid acceleration/deceleration from impact
to shoulders/torso transmitted to the brain
Does heading the Ball cause
concussions?
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.
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
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
Initial Complaints
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Dizziness
Double vision
Drowsiness
Foggy
Headache
Nausea
Nervousness
Ringing in ears
Vomiting
Later complaints
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Depression/Sadness
Excessive sleep/fatigue
Irritability
Sensitivity to light
Sensitivity to noise
Vomiting
Poor concentration/memory issues
Worrisome physical findings
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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
Physical exam
 Standard field management if unconscious
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Airway
Breathing
Circulation
Ambulance if needed
 Sideline management
– Overall exam
– Cognitive testing
– Motor testing
 Serial repeats
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
Tests
 Sideline exam
– Mental
– Physical
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ImPact
MRI,CT Scan
Functional MRI
Blood tests
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
Cognitive – U of P sideline test
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Orientation
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What stadium is this
What city is this
Who is the opposing team
Month, day, year
Posttraumatic amnesia
– Repeat 3 words
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Retrograde amnesia
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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,…
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Word list repeat
– What were the 3 words given earlier
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
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
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/BESS
ProtocolNATA09.pdf
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
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
Blood Tests/Genetic Markers
 Blood tests
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Myelin Basic Protein
Tau
GFAP
S100
Neuron specific enolase
SOD1
 Genetic markers
– APO E4
– APO E promotor
– Tau polymerase
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
Classification - Cantu
 First published in 1986
– based on amnesia and loss of consciousness
 Updated in 2001 to include secondary symptoms
 Grade 1
 Grade 2
 Grade 3
no loss of consciousness
less than 30 minutes post traumatic
amnesia
LT 1 minute loc
amnesia 30 minutes to 24 hrs
GT 1 minute loc
any symptoms lasting over 1 week
Classification – Colorado Medical
Society
 Published 1991
– in response to high school athletes death
 Grade 1
 Grade 2
 Grade 3a
 Grade 3b
confusion only
confusion and post traumatic
amnesia
unconscious for seconds
unconscious for minutes
Colorado Medical Society
Classification
 First to add specific guidelines for return to sport
Timing based on first or repeat concussions
Grade
First concussion
Second
concussion
1
15 minutes
1 week
2
1 week
2 weeks with MD
approval
3a
1 month
6 months with MD
approval
3b
6 months
1 year with MD
approval
Classification- American
Academy of Neurologists
 Introduced 1997 – based on Colorado
guidelines
 Grade 1
 Grade 2
 Grade 3a
 Grade 3b
no loss of consciousness
confusion lasts less than 15 minutes
same but more than 15 minutes
brief loss of consciousness (seconds)
prolonged loss of consciousness
(minutes)
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
International Conference on
Concussion in Sport
 First
 Second
 Third
Vienna
Prague
Zurich
2001
2004
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
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
ICCS Controversies
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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
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ADD/ADHD
LD
Depression
Sleep disorders
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
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)
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?
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
Old myths
 Don’t eat or drink after a concussion
– Only if nausea/vomiting prevent it
 Stay at bedrest after a concussion
– Physical and mental rest are good, but no study
indicated better outcomes with bedrest
Old myths
 Loss of consciousness is an indicator of
concussion severity
– At least 3 studies and the 3rd ICCS say this is
not true
 Young people do not have as severe
concussions as professionals
– At least 4 studies say younger athletes have
more severe symptoms that last longer
Long term effects
 Single injury
 Rapid repeat injury
 Multiple injuries over long term
Single injury
 Measurable learning deficits
– “Testing effect” absent in post concussion
states until back to baseline
 Frequently worsening scores over 48 hours
 Measurable cognitive and physical deficits
can persist for weeks or months
 Seldom result in long-term effects
Rapid repeat injury
 More likely to get another concussion until
brain returns to “baseline”
 Second Impact Syndrome (SIS)
– Nearly all in under 20 age group
– High incidence in American football
– All die or are severely disabled afterward
– Massive brain swelling is the reason
– CDC estimates 1.5 deaths per year due to
concussions so the incidence is low
Multiple injuries over time
 Some studies recommend 3 concussions
lifetime end a person’s career
– (NCAA Concussion study, Guskiewicz AJSM, Collins NS)
 Others not conclusive
– (Collie Br JSM, McCrory Br JSM)
Multiple injuries over time
 Retired NFL players with 3 or more concussions 2005
study
– 5x likelihood of cognitive impairment
– 3x likelihood of significant memory issues
(vs other retired NFL players without concussions)
 More recent studies link to
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Alzheimer’s dementia
Post-traumatic Encephalopathy
Parkinson’s disease
Depression
Emotional lability
Notable Soccer stars
 Taylor Twellman – MLS MVP 2005
– Played just 2 games since Aug 30, 2008
– Still can’t head the ball
 Lori Chalupny
– Former captain of US women’s team
– MD’s refuse to clear her return to national team but playing this year
in the women’s professional league
 Alecko Eskandarian – MVP of 2004 MLS Cup final
– Out since 4th concussion in 2009
 Ross Paule
– Retired age 29 with post concussion syndrome
 Josh Gros - Former all-star
– Retired at 25 in 2007 with 7 concussions that year alone
– USMC will not readmit him
Treatment
 Minimal interventions actually work
 Time seems to be the best treatment
 “Brain rest” may include avoidance of video
games
(Cantu et al 1st ICCS)
Future directions
 Army announces blood test for brain injury in
concussion
– Details are very scarce at this time but 4 markers
 SBDP145, SBDP120, UCH-L1, MAP-2
– Remains to be seen how accurate this turns out to be over time
 HITS Head Impact Telemetry System
– Instrumented helmets in football and other sports gives instant
feedback about likelihood of concussion in a given hit
– Problem is not all brains react the same to the same energy impact
Future directions
 Increased NFL vigilance against head
impact
– Trickle down effect to youth football
 Soccer mandates helmet use starting with
goalies
– MY GUESS - IT IS JUST A MATTER OF TIME !
So back to the 13 year old football
player
What should have been done?
 ImPact baseline before season
 Serial cognitive/physical monitoring using U of P,
BESS or similar guidelines
 Serial ImPact testing until return to baseline
 Grade 3 concussion (if you believe in grading)
– Minimum 1 month before return to sports per Colorado
and AAN guidelines
– Minimum 1 week after symptoms resolve per ICCS
Thank You !