Sports Concussion Update: 2012 Michael C. Koester, MD, ATC May 14 - PowerPoint PPT Presentation

Sports Concussion Update: 2012 Michael C. Koester, MD, ATC May 14 th , 2012 Director, Slocum Sports Concussion Program Slocum Center for Orthopedics and Sports Medicine Eugene, OR

Disclosures  I am a paid consultant for the Oregon Center for Applied Science, Inc. (ORCAS). They have developed two on-line concussion education programs- ACTive and Brain 101: The Concussion Playbook.  I am the Chair of the NFHS Sports Medicine Advisory Committee and the OSAA Medical Aspects of Sports Committee. Both are unpaid positions.

Concussions and Politics  The flying wedge, football's major offense in 1905, spurred the formation of the NCAA  Large numbers of players injured and killed  President Roosevelt summoned college athletic leaders to the White House  Reform game or have it banned

Concussions in Popular Entertainment 1939

Concussions in Popular Entertainment 2012

What is a Concussion?  A concussion is a mild traumatic brain injury that interferes with normal function of the brain  Evolving knowledge- “dings” and “bell ringers” are serious brain injuries  LOC not required-  Far less than 5%

What happens to the brain?  A complex physiological process induced by traumatic biomechanical forces:  sudden chemical changes- neurotransmitters and glucose utilization disrupted  stretching and tearing of brain cells  Structural brain imaging (CT or MRI) is almost always normal Concussions are physiologic , not anatomic injuries  Still many unanswered questions . . .

Pediatric and Adolescent Brain  Increased risk for injury  Water content  Cerebral blood volume  Level of myelination  Skull geometry  More vulnerable to diffuse injury  More difficult to assess and monitor recovery the younger the patient!!!

Concussion Effects  Impacts 4 areas of function  Cognitive Concentration, memory   Somatic HA, fatigue   Emotions Irritability   Sleep Insomnia 

Extent of the Problem  Professional athletes get a great deal of attention  Much more common in high school than any other level- due to large number of participants  Oregon HS Sports Participants Football- 15,000  Boys Soccer- 6,000  Girls Soccer- 5,000  Boys Hoops- 7,000  Girls Hoops- 7,000 

Extent of the Problem  Estimated 250,000 sports-related concussions in high school athletes yearly  20% of all HS sports injuries  47.1% of all injuries occurred in FB  Likely more than 2000 concussions in Oregon HS athletes every year  Planned 3 year injury data collection in HS FB to begin Fall 2012

Not Just a Football Problem Injury rate per 100,000 player exposures  Football 69  Ice Hockey 61  Boys’ Lacrosse 42  Girls’ soccer 38  Girls’ Lacrosse 34  Wrestling 28  Girls basketball 28  Boys’ soccer 23  Boys basketball 18  Softball 15  Cheerleading 14  High School RIO 08-11

Chronic Traumatic Encephalopathy  CTE- progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma  Tau protein  Examples-  Normal brain  45 year old former NFL player  73 year old boxer

“Max’s Law” 2009  Mandatory coach education  Player must be removed from play if “exhibits signs, symptoms, or behaviors consistent with a concussion”  Cannot return to play that day  Cannot return to play until asymptomatic and cleared to return by a “health care professional”

Concussion management made easy!  When in doubt, sit ‘em out!!  No return to activity on the same day of a concussion  No return to activity if having symptoms of a concussion

Concussion Management: Zurich Guidelines, 2008  Notion of grading systems has been abandoned  Over 20 classifications  Can only be applied retrospectively  No same day return to play  Modifying Factors  Persistent symptoms, age, prolonged LOC, multiple concussions  Graded Return to Activity  Management continues to evolve!!!

Return to Activity Protocol 7 Steps to a Safe Return Step 1. Complete cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.  Step 2. Return to school full-time.

Return to Activity Protocol 7 Steps to a Safe Return (cont)  Step 3. Light exercise. This step cannot begin until you are cleared by your physician for further activity.  Step 4. Running in the gym or on the field. No helmet or other equipment.  Step 5. Non-contact training drills in full equipment. Weight-training can begin.

Return to Activity Protocol 7 Steps to a Safe Return (cont) Step 6. Full contact practice or  training. Step 7. Game play. Must be  cleared by your physician before returning to play.  Cannot advance to next level if symptomatic  Progression usually takes about 1 week

The Biggest Problem How do you know who has recovered from a concussion?

Return to Play Determination  No symptoms  Rest and Exertion  Normal Exam  “Normal” academic performance  “Pass” Neuropsychologic testing

Computerized Neuropsychological Testing  Computerized testing has role in RTP  Never stands alone  ImPACT most widely used and known  40+ Oregon high schools  Current data shows similar efficacy among all 3 tests

Coach Education On-line training for coaches:  CDC Heads Up  USA Football  NATA/NHL Collaboration  NFHS/CDC Heads Up collaboration  www.nfhslearn.com Additional resources  400,000+ courses delivered 

Brain 101: The Concussion Playbook  School-wide Concussion Management  Targets everyone- coaches, athletes, teachers, and parents!!  Research projects ongoing  http://brain101.orcasinc.com/#

OCAMP Oregon Concussion Awareness and Management Program  Max’s Law: Concussion Management Implementation Guide for School Administrators  Can be used as a companion document to Brain 101  Sample Policies and Procedures  Sample school forms http://www.ode.state.or.us/teachlearn/subjects/pe/ocampguide.pdf   CBIRT Contact: Melissa Nowatzke nowatzkm@cbirt.org

REAP Concussion Management Program  R = Reduce – physical and cognitive demands  E = Educate – everyone on symptoms: Physical (How one “feels physically”) Cognitive (How one “thinks”) Emotional (How one “feels”) Maintenance (Energy and Sleep)  A = Accommodate academics – teach the teachers  P = Pace – Graduated Return-to-Play  http://www.rockymountainhospitalforchildren.com/sports- medicine/concussion-management/reap-guidelines.htm

Principles of Concussion Management  No cure for concussion, but treatment can help the athlete feel better and function better while symptomatic  Medication?  Early diagnosis and education is critical, especially to avoid re-injury  Rest early (7-10 days?) and then gradually increase activity  Cognitive rest

Concussion in the Classroom  Fatigue - tire easily in class and over the course of the day  Headache and other symptoms worsen with reading or concentration  Trouble doing more than one thing at a time (e.g., looking at PowerPoint and taking notes)  Frequent visits to the nurse’s office  Biggest Issue- NO ONE TAKES THEM SERIOUSLY!!!

Management- Academic Accommodations  School  Allow time to visit school  Stay home!!! nurse for treatment of headaches, if needed  Transition to half-days  Written instructions for  Naps/rest time homework  Extended time to  Repeat and present new complete assignments information slowly  No standardized testing  Limit homework  Share progress and  Skip assignments, difficulties modify, or reduce Someone to talk to   Extended time to take  Need “point person” tests Don’t leave them adrift!!   Open note/book

Management- Cognitive Rest  Home  Sleep!!!  Limit “stimulation”:  Phone  Computer  Music  TV  Texting  Gaming

Management Challenges  Very little EBM  Variation in initial management by providers  School setting  RTP when “Asymptomatic”  Role of neuropscyh testing  Academic performance  Prolonged symptoms

Athletes with Prolonged Symptoms  Variation in services  Where do you live?  Typical problems  Headache  Insomnia  Irritability  Medications  OTC Analgesics  Headache  Exercise Protocols  Aerobic protocol Stationary bike 

Concussion Prevention  “Concussion prevention” has become the “holy grail” for sports equipment marketers  Soccer head gear  Football helmets with “new technology”  Helmets were designed to prevent skull fractures- NOT concussions!!  NO PROVEN PROTECTION FROM CONCUSSION!!

Concussion Prevention  Everyone has something to sell to “prevent concussion” or monitor for “possible” concussion  Shockstrips  Chin straps  Mouthpieces  Various helmet paddings