Sports Concussion:
Injury
Signs & Symptoms
Return to Play
Samuel R. Browd, M.D., Ph.D.
UW Assistant Professor Neurological Surgery
Attending Neurosurgeon, Seattle Children's Hospital
Richard G. Ellenbogen, M.D.
Chairman, UW Department of Neurological Surgery
Co-Chairman NFL Head, Neck and Spine Committee
OBJECTIVES
1. A REVIEW OF HEAD
INJURY IN THE ATHLETE
2. A REVIEW OF THE
SYMPTOMS AND SIGNS
OF CONCUSSION
3. A REVIEW OF THE TOOLS
AND GUIDES IN RETURN
TO PLAY DECISIONS
THE CONCUSSION CONTROVERSY IN SPORTS TODAY
Any Given Sunday
• 17+ ARTICLES IN 2009 ALONE
• Forum for Football Brain Injuries Set for Houston
– 01/07/10
• Lawmakers Grill Doctor for His Views on Concussions
– 01/04/10
• Silence on Concussions Raises Risks of Injury
– Alan Schwarz 09/15/07
Richard Ellenbogen, M.D.
Zackery Lystedt
Concussion
International Conference on
Concussion in Sport
– Vienna 2001, Prague 2004, Zurich 2008
– “THIS IS A WORLDWIDE PROBLEM
AFFECTING BOTH SEXES,
STUDENT/ATHLETES, PROFESSIONALS
AND THE MILITARY“
• (Ellenbogen, NFL Committee)
– CONCUSSION:
• “Complex pathophysiologic process
affecting the brain, induced by
traumatic biomechanical forces.”
Concussion Definition
– COMPLEX
• no “easy” concussions!
– PATHOPHYSIOLOGY
• RARELY structural!
– TRAUMA INDUCED
• an impact to the head or body that is transmitted to the head
– LOSS OF CONSCIOUSNESS
• < 10% of players
Concussion Definition
Common features include:
• Rapid onset of usually short-lived neurological impairment
which typically resolves spontaneously.
• A range of clinical symptoms that may or may not involve
loss of consciousness (LOC).
 Less than 10% of sports concussions involve loss of consciousness
Epidemiology of Severe Injuries Among
United States High School Athletes
•
National High School Sports-Related Injury
Surveillance System 2005-2007
•
Nationally representative sample of 100 US
high schools
•
9 sports (football, wrestling, baseball,
softball, girls’ volleyball, and boys’ and girls’
soccer and basketball)
•
Loss of >21 days of sports participation
Darrow, CJ et al. Am J Sports Medicine Vol 7, #9 2009
Sport
Concussion (% >21 days)
Boy’s football
Boy’s soccer
Girl’s soccer
Girl’s volleyball
Boy’s basketball
Girl’s basketball
Boy’s wrestling
Boy’s baseball
Girl’s softball
5.9%
11.8%
7.7%
8.9%
1.2%
6.6%
3.3%
1.4%
1.2%
World-Wide:
Australia
Epidemiology of Concussions
in High School and Collegiate Sports
• Data from the High School Reporting Information Online
System and the NCAA Injury Surveillance System
– 5.9% of all collegiate athletic injuries
– 8.9% of all high school athletic injuries
– Concussion rates were higher in college, but concussions
were a higher proportion of all high school athletic injuries
Gessel LM et al. “Concussions Among United States High School and
Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503
High School Sports
• Concussion rate per 1000 athlete-exposures
•
•
•
•
•
Football
0.47
Girl’s soccer
0.36
Boy’s soccer
0.22
Girl’s basketball 0.21
Boy’s basketball 0.07
Gessel LM et al. “Concussions Among United States High School and Collegiate
Athletes” Journal of Athletic Training 2007; 42:495-503
High School Sports
• 16.8 % of concussed athletes had suffered a previous
concussion in that season or in a prior season
– Greater than 20% of concussions in boys’ and girls’
basketball were recurrent concussions
• Girls took longer than boys to recover
Gessel LM et al. “Concussions Among United States High School and
Collegiate Athletes” Journal of Athletic Training 2007; 42:495-503
Recurrent Injuries:
High School Athletes
• 11.6% of the recurrent injuries were concussions
• Swenson, DM et al. Am J Sports Medicine 2009;37(4)
Brain Injury-Related Fatalities
American Football Players
Different Levels of Play (1945-1999)
400
350
300
374
High school
Sandlot
College
Professional
250
200
150
100
50
0
76
33
fatalities
14
Cantu and Mueller. Neurosurgery 2003;52:846-853
Brain Injury-Related Fatalities
American Football Players
Injury Type (1945-1999)
450
400
429
350
300
Subdural
Unknown
Fracture
Aneurysm
Edema
250
200
150
100
50
0
40
18
6
4
Fatalities
Cantu and Mueller. Neurosurgery 2003;52:846-853
Catastrophic Head Injuries
High School and College Football
• National Center for Catastrophic Sports Injury Research data
from 1989-2002
– 94 cases
• 75 subdural hematomas
• 10 subdural with diffuse brain swelling
• 5 diffuse brain swelling
• 4 AVM or aneurysm
– 92 cases were in high school players
» Boden et al. AJSM 2007; 35: 1075 - 1081
Catastrophic Head Injuries
High School and College Football
• 59% of athletes had a previous history of concussion(s)
• 71% of those injuries occurred in the same season as the
catastrophic injury
• 39% of athletes at time of catastrophic injury were playing
with residual symptoms from a previous concussion
» Boden et al. AJSM 2007; 35: 1075 - 1081
Classification/Grading Guides
Conflicting and do NOT guide therapy!!!
Guideline
Grade 1
Grade 2
Cantu
1. No LOC
2. Posttraumatic amnesia <30
min
1. LOC > 5 min
2. Posttraumatic amnesia
> 30 min
2. Posttraumatic
amnesia >24˚
Colorado
1. Confusion w/out amnesia
2. No LOC
1. Confusion w/ amnesia
2. No LOC
1. LOC
(of any duration)
AAN
1. Transient confusion
2. No LOC
3. Concussion syx, ms change
resolve w/in 5 min
1. Transient confusion
2. No LOC
3. Concussion syx, ms
change >15 min
1. LOC
(brief or prolonged)
Cantu
(Revised)
1. No LOC
1. LOC < 1 min
1. LOC > 1min
OR
2. Posttraumatic amnesia
signs/syx < 30 min
Grade 3
OR
OR
2. Posttraumatic amnesia
>30 min, <24˚
1. LOC > 5 min
OR
OR
2. Posttraumatic
amnesia >24˚
OR
3. Post concussion
signs/syx > 7d
A Ding Is Not Always Just A Ding
1.6 to 2.3 million sports concussions per year
Center for Disease Control 2006
Acute Signs and Symptoms:
Suggestive of Concussion
COGNITIVE
SOMATIC
•Confusion
•Post-traumatic amnesia
•Retrograde amnesia Loss
of consciousness
•Disorientation
•Feeling “in a fog,” “zoned
out”
•Vacant stare
•Inability to focus
•Delayed verbal and motor
responses
•Slurred/incoherent speech
•Excessive drowsiness
•Headache
•Fatigue
•Disequilibrium, dizziness
•Nausea/vomiting
•Visual disturbances
(photophobia, blurry/double
vision)
•Phonophobia
AFFECTIVE
•Emotional lability
•Irritability
Pathophysiology
• In a concussion, certain chemical levels are altered at the
cellular level
• Blood supply to the brain decreases
• The brain’s demand for glucose increases
• Mismatch in fuel supply and demand
– Neuronal tissue vulnerability
• Brain needs time to recover
Game-Day:
Evaluation & Treatment
Pre-Game
It is essential to:
– Implement a game-day medical plan specific to
concussion.
– Understand the indications for cervical spine
immobilization and emergency transport.
Game-Day:
Evaluation & Treatment
On-Field
It is essential to:
• Evaluate the injured athlete on-the-field in a systematic
fashion
• Determine initial disposition
– emergency transport vs. sideline evaluation
Recognizing a Concussion
Signs and Symptoms
Signs observed by trainer preferably,
coach, parent, teammates include:
Symptoms reported by athlete include:
•
Headache
Is confused about assignment

Nausea

Forgets plays

Balance problems or dizziness

Is unsure of game, score, or opponent

Double or fuzzy vision

Moves clumsily

Sensitivity to light or noise

Answers questions slowly

Feeling sluggish

Loses consciousness

Feeling foggy or sluggish

Shows behavior or personality changes

Concentration or memory problems

Confusion
•
Appears dazed or stunned


Can’t recall events prior to hit

Can’t recall events after hit.
Game-Day:
Evaluation & Treatment
Sideline
It is essential to:
– Not leave the player unsupervised
– Determine disposition
• home with observation
• transport to hospital
– Provide post-event instructions to the athlete and others
• e.g., regarding alcohol, medications, physical exertion and
medical follow-up
THE EVIDENCE FOR RETURN TO PLAY
THERE IS NONE
IT IS:
JUDGEMENT
EXPERIENCE
Return to Play
Same Day
It is essential to understand:
– A (youth) player with diagnosed (or suspected) concussion should
not be allowed to return to play on the same day as the injury.
• McCory P, et al. Consensus Statement on Concussion in Sport
3rd International Conference on Concussion in Sport
– Held in Zurich, November 2008.
» Clin J Sport Med 2009;19:185-200
Post-Game
Management by Healthcare Provider: Return to Play
• Obtain a comprehensive history
• current concussion
• any previous concussion
• Determine the need for further evaluation and consultation.
• Determine return-to-play status
– ***CONCUSSION FOLLOWED BY SYMPTOMS AFTER 20
MINUTES OF REST…
• DISQUALIFIED FROM PLAYING ON THE DAY OF INJURY
– COGNITIVE REST AS WELL (NO SCHOOL!)
• HIGH SCHOOL IS EASY: “WHEN IN DOUBT, SIT THEM OUT”
– COLLEGE/PROS IF AFTER 20 MINUTES OF REST AND THEY HAVE NO
EXERTIONAL SYMPTOMS THEY MAY RETURN
Post-Game
Management by Healthcare Provider: Return to Play
– LOC or Amnesia
• Disqualified from immediate RTP
– no tool is sufficient to determine
RTP
» SCATII, SAC or BESS
• Athletes under 18 years old and
Females
– longer period of neurocognitive
recovery after concussion
Symptom, Cognitive, and Postural Stability Recovery in
Concussion and Control Participants
McCrea, M. et al. JAMA 2003;290:2556-2563.
Copyright restrictions may apply.
PRINCIPALS OF RTP
•
3 or more CONCUSSIONS in a SEASON
– 3 MONTH SYMPTOM FREE PERIOD BEFORE THEY RETURN TO A COLLISION SPORT
•
3 or more CONCUSSIONS in a SEASON with SLOWED RECOVERY
– THEY SIT OUT FOR THE SEASON OR MAYBE PERMANENTLY
•
DISQUALIFY:
– NEURO EXAM IS NOT RETURNED TO NORMAL
– NEUROPSYCH BATTERY IS ABNORMAL
– SYMPTOMS
•
Take into account the SEVERITY OF THE BLOW AND PROLOGNATION OF THE
AMNESIA
•
ABNORMAL MRI: 1 YEAR OF REST
PRINCIPALS OF RTP
• Understand:
– Brief LOC (seconds, not minutes)
– Amnesia, as well as the number and duration of additional
signs and symptoms (and neuropsychological data) are
more accurate in predicting severity and outcome.
– The treatment of and the RTP decision for the athlete with
concussion must be individualized
– Manage by symptoms, not by grades
• Many return to play guidelines are weighed to LOC
– NOT A GOOD IDEA!
PRINCIPALS OF RTP
• Consider factors which may affect RTP, including:
–
–
–
–
–
–
–
–
Severity of the current injury
Previous concussions (number, severity, proximity)
Significant injury in response to a minor blow
Age (developing brain may react differently to trauma than mature
brain)
Sport
Learning disabilities
Depression, anxiety
Migraine headaches
PRINCIPALS OF RTP
• Neuropsychological testing
– Post-injury neuropsychological test data are more
useful if compared to the athlete’s pre-injury baseline.
– It is unclear what type and content of test data are
most valuable.
– It is only one component of the evaluation process.
Graduated Return to Play in 1 Slide
Rehab Stages (1-6)
Functional Exercise
Objective
1. No activity
Complete physical & cognitive Recovery of cognitive
rest (No school, if indicated!)
function
2. Light aerobic exercise
Walking, swimming or
stationary bike; no resistance
training
 HR
3. Sport-specific exercise
Running drills; no head
impact activity
Add movement
4. Non-contact training
drills
Progression to more complex
training drills; start
progressive resistance
training
Exercise, coordination,
cognitive load
5. Full contact practice
After Medical Clearance Only; Restores confidence &
Normal activity
assess functional skills
6. Return to play
Normal game/competition
Prevent Next Injury
PRINCIPALS OF RTP
• Physical and cognitive rest may be necessary including
cognitive rest from school
•
Determine the athlete is asymptomatic at rest before
resuming any exertional activity.
• Utilize progressive aerobic and resistance exercise
challenge tests prior to full return to play.
Sport Concussion Assessment Tool
• SCAT 2
• Developed from International
Conference on Concussion in Sport
– Zurich 2009
• Used during and after game time
for RTP
Sport Concussion Assessment Tool
• Update of the 2005 SCAT1
• Used by medical and health professionals
• 4 pages
• 20 minutes to administer
• Athletes 10 years old and above
• Preseason baseline
• Evaluates for one or more of the
following:
– Symptoms
– Signs
– Impaired brain function
– Abnormal behavior
– Impaired Neuro Function
22 questions
None
Mild
Moderate
Severe
Headache
0
1
2
3
4
5
6
“Pressure
in head”
0
1
2
3
4
5
6
Neck pain
0
1
2
3
4
5
6
Nausea/vo
miting
0
1
2
3
4
5
6
Do the symptoms get worse with physical activity? ☐Yes☐No
Do the symptoms get worse with mental activity? ☐Yes☐No
At what venue are we today?
0
1
Which half is it now?
0
1
Who scored last?
0
1
What team did we play last week?
0
1
Did we win last week?
0
1
Scoring: 1 point for each correct answer (maximum of 5)
Validated for sideline diagnosis
1.
Orientation
2.
Immediate Memory
3.
Concentration
•
•
•
•
•
What month is it?
What is the date today?
What is the day of the week?
What year is it?
What time is it right now?
(within 1 hour)
0
1
0
1
0
1
0
1
0
1
Scoring: 1 point for each correct answer (maximum of 5)
List
Trial
1
Trial
2
Trial
3
Alternative Word List
elbow
apple
0 1 0 1 0 1
0 1 0 1 0 1
candle
paper
baby
monkey
carpet
saddle
0 1 0 1 0 1
0 1 0 1 0 1
sugar
sandwich
perfume
sunset
bubble
0 1 0 1 0 1
wagon
iron
Scoring: 1 point for each correct answer (maximum of 15)
Digits Backward
List
4-9-3
3-8-1-4
0 1
0 1
6-2-9-7-1
7-1-8-4-6-2
0 1
0 1
Alternative Digit List
6-2-9
5-2-6
3-2-7-9
1-7-9-5
1-5-2-8-6
5-3-9-1-4-8
3-8-5-2-7
8-3-1-9-6-4
Scoring: 1 point for each correct answer (maximum of 4)
• Months in reverse order
Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan
Scoring: 1 point for entire sequence correct
Instructions:
• “Which foot do you kick with?” (i.e. dominant
foot)
• 20 seconds per stance
• Shoes off
• Remove ankle taping
• Place hands on hips
• Close eyes
A. Double leg stance
Feet shoulder-width apart
B. Single leg stance
Lift the dominant foot (30° hip flexion, 45° knee
flexion)
C. Tandem stance
Dominant foot in the front
Scoring: 1 point for each error (max. of 10 per stance)
Final score is 30 minus total errors
Finger-to-nose task:
• Athlete is to touch their nose and then your
finger
• Athletes fail if they don’t touch their nose,
don’t fully extend the elbow, or don’t perform
5 repetitions
Scoring: 1 point for five repetitions in < 4 seconds (maximum of 1)
• Delayed recall
List
elbow
apple
carpet
saddle
bubble
Scoring: 1 point for each recalled word (maximum of 5)
SCAT 2: Scoring
• Symptom score (22)
• Physical signs score (2)
• GCS (15)
• Maddocks’ score (5)
• Orientation (5)
• Immediate memory (5)
• Concentration (5)
• Balance examination (30)
• Coordination exam (1)
• Delayed recall (5)
Max is 100/100
Lowest is 3/100
Goals
• Recognition of a potential concussion
• Initial screening (SCAT2, SAC, Maddocks) to obtain post-injury
baseline
• Avoid leaving the athlete unsupervised
• Serial neurologic exams
• Determine disposition
• Post-game instructions and follow-up screening
• SCAT2 is just a screening tool
• It won’t catch every concussion
– Use your judgment
• Only gives you one moment in time
– Things change and they change quickly
–“When in doubt, sit them
out"
SECOND IMPACT SYNDROME
• Rare
• Limited to teenagers or under 18 in
all cases
• No cases in NFL/NHL/MLB
• Medical review after witnessed 1st
impact
• Documented ongoing symptoms
until 2nd impact
• Witnessed 2nd impact followed by
rapid deterioration
• Evidence of cerebral swelling
without other cause
Recurrent Concussion: Who Cares?
• 2- 4X increased risk for
recurrent concussion
– More symptoms
– Last longer
– Small but repetitive
hits
• Cumulative brain trauma:
– CHRONIC TRAUMATIC
ENCEPHALOPTHY
Sports Concussions:
Education, Awareness, Action
Washington State Heads Up:
Concussion in Youth Sports Campaign
Washington State Road Show
Stan Herring, M.D.
Richard Adler, J.D.
Educate or Legislate?
wsata
Engrossed House Bill 1824
Requiring the adoption of policies for the management of
concussion and head injury in youth sports.
• All student athletes and parents/guardians sign an information sheet
regarding concussion prior to each season
• School districts to work with the Washington Interscholastic Activities
Association (WIAA) to develop information and policies on educating
coaches, youth athletes, and parents about the nature and risk of
concussion including the dangers of premature return to practice or play
after a concussion
• Any athlete suspected of suffering a concussion is removed from play
until they receive written clearance for return to practice and play by a
licensed health care provider trained in the evaluation and management
of concussions
Zackery Lystedt Law
May 14th, 2009
Is This Practice/Game More Important Than:
• The rest of the season?
• The rest of the athlete’s career?
• The rest of the athlete’s life?
CONCLUSION
Do not let a injured athlete back into practice
or games until they have been evaluated and cleared
in writing by a licensed healthcare provider trained in
the evaluation and management of concussions.
That is not only the LAW;
It Is The Right Thing To Do!