Traumatic brain injuries in
equestrian athletes
Lola B. Chambless, MD
Department of Neurosurgery
Vanderbilt University
Overview
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Definitions
Incidence data
Mechanisms of Injury
Symptoms
Diagnostic tools
Outcome
Prevention
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
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
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
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
Major traumatic brain injury
• REMEMBER: in the unconscious patient
ALWAYS assume an associated spine injury
• ABC’s
– Emergency airway
– Hyperventilation
Types of TBI
• Skull fractures
• Intracranial hematomas
• Concussions
Skull fractures
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
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)
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.
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
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
Signs and Symptoms of Concussion
Signs
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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)
Symptoms
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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
From Powell et al. Neurosurg 54(1) 2004
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Three most common symptoms:
1. Headaches (55%)
2. Dizziness (42%)
3. Blurred vision (16.3)
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45.9% experienced either cognitive or
memory problems
9.3% had loss of consciousness
Maddocks’ Questions
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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
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
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
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
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
Time course of recovery
Guskiewicz et al. JAMA 2003
• Average duration of symptoms
is 3.5 days
• 88% of athletes have full
recovery at 1 week
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.”
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.
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
Why are individual neurocognitive baselines
useful in assessment of sports-related
concussions?
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
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
ImPACT MEMORY COMPOSITE
Control vs. Concussed Athletes
CONCUSSED
CONTROL
p.<.00001
p.<.0001
100
Significant
difference
between
groups out to
at least 8
days
post-injury
N=410
95
90
N.S.
85
80
p.<.03
75
70
.
Baseline
2 days
5 days
8 days
*Lower score indicates poorer
performance
Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports
Exercise, 34:5;2002
Current ImPACT test users
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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
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.
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.”
Step-wise return to play
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No activity until asymptomatic
Light aerobic exercise
Sport specific training
Non-contact drills
Full-contact drills
Game action
What is the maximum
number of “safe”
concussions?
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(but probably zero)
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
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.
Rule changes and technique
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
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?)
1997 NAYRC CCI**
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
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
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
Thank You!
• US Polo Association
• Allen Sills, MD
• Craig Ferrell, MD