Sport-Related Concussion

Transcription

1 Sport-Related Concussion Bill Meehan, MD Micheli Center for Sports Injury Prevention Division of Sports Medicine, Division of Emergency Medicine Boston Children s Hospital

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9 Nathan Horton sustained a concussive brain injury

10 Definition Working definition Characteristics Trauma Impulse Immediate Self-resolves Functional

11 Biomechanics Biomechanics Rotational acceleration Slaughterhouses free to move, accelerate Denny-Brown 1941 medicine, acceleration Holburn 1943 thought experiment, rotational Ommaya and Genarelli definitive

12 Normal Physiology

13 Normal Physiology

14 Normal Physiology

15 Normal Physiology

16 Pathophysiology Biomechanical injury Ion flux, K+, Na+ Excitatory neurotransmitters NMDA Ca++ influx, further EAA release Exacerbates efflux of K+ Depolarization spreading depression Glyolysis -pump restoration Decreased flow

17 Assessment Acute assessment ABC Other or associated injuries History classic Physical (Imaging)

18 Signs and Symptoms Loss of Consciousness Amnesia, retrograde or antegrade Disorientation Appearing dazed Acting confused Forgetting game rules or play assignments Inability to recall score or opponent Inappropriate emotionality Physical incoordination Imbalance Seizure Slow verbal responses Personality changes Headache Dizziness Nausea or vomiting Difficulty balancing Vision changes Photophobia Phonophobia Feeling out of it Difficulty concentrating Tinnitus Drowsiness Sadness Hallucinations

19 Specific Assessment Tools Assessment Symptoms - PCSS Balance - BESS Neurocognitive: computerized vs. neuropsychological

20 Post Concussion Symptom Scale None Mild Moderate Severe Headache Pressure in head Neck Pain Balance problems or dizzy Nausea or vomiting Vision problems Hearing problems / ringing Don t feel right Feeling dinged or dazed Confusion Feeling slowed down Feeling like "in a fog" Drowsiness Fatigue or low energy More emotional than usual Irritability Difficulty concentrating Difficulty remembering Sadness Nervous or Anxious Trouble falling asleep Sleeping more than usual Sensitivity to light Sensitivity to noise Other:

21 Balance Error Scoring System 1. Double Leg Stance Feet together, hands on hips, eyes closed for 20 seconds. 2. Single Leg Stance Non-dominant foot, 30 degrees hip flexion, 45 degrees knee flexion, hands on hips, eyes closed for 20 seconds. 3. Tandem Stance Non-dominant foot in back, hands on hips, eyes closed for 20 seconds.

22 BESS Errors 1. Hands off iliac crest 2. Opening eyes 3. Step, stumble or fall 4. Moving hip into >30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of position > 5 seconds Errors counted.

23 Neurocognitive Testing Percentile Verbal Memory Visual Memory Processing Speed Reaction Time Baseline Post Injury 1 Post Injury 2 Post Injury 3 6 Days Post 16 Days Post 23 Days Post

24 Management Management Physical rest Cognitive rest Follow-up J Peds 2010; Genuardi 1995 RTP stages

25 Step Level of activity 1. No activity, complete rest. Once asymptomatic, proceed to level Light aerobic exercise such as walking or stationary cycling, no resistance training. 3. Sport specific exercise - for example, skating in hockey, running in soccer; progressive addition of resistance training at steps 3 or Non-contact training drills. 5. Full contact training after medical clearance. 6. Game play.

26 Take Home Rule out Physical Rest Cognitive rest Follow up Return to play should be in stages

27 Weeks to months: Prolonged recoveries Ease restrictions Insomnia Post-traumatic headaches Cognitive dysfunction Balance problems / dizziness

28 Sports Concussion Clinic 10 physicians, 1 nurse practitioners, an RN, a neuropsychologist Consultants in neurosurgery, neurology, psychology >400 patient visits/month during peak season Basic science research and clinical research

29 Physicians William Meehan, MD, Founder & Director Michael O Brien, MD, Associate Director Pierre d Hemecourt, MD, Co-Founder Andrea Stracciolini, MD Bridget Quinn, MD Ellen Geminiani, MD Cynthia Stein, MD Michael Beasley, MD Kate Ackerman, MD Neuropsychologist Alex Taylor, PsyD Sports Concussion Clinic Nurses Ariana Moccia, RN Michelle Parker, NP Clinical Collaborators Karameh Hawash, MD Mark Proctor, MD Sharon Chirban, PsyD Alyssa Lebel, MD Anna Minster, MD Celiane Rey-Casserly, PhD Regina Laine, NP Research Collaborators Rebekah Mannix, MD, MPH Robert Cantu, MD Rob MacDougall, BA Michael Whalen, MD Micky Collins, PhD Anthony Kontos, PhD Dawn Comstock, PhD Peter Kriz, MD James MacDonald, MD Ross Zafonte, DO Margaret Naeser, PhD Jimmy Zhang, BA Dody Robinson, MD Jackie Berglass, BA Danielle Ruggieri, BA Alex Rotenberg, MD Justin Eckner, BA David Mendell, BA Ellen Grant, MD Liz Carew, BA Emily Hanson, ATC Alvaro Pascual-Leone, MD, PhD Dan Martin, BA Jeffrey Colvin, MD, JD Lois Lee, MD, MPH Karen Kinnaman, MD, PhD Michael Monuteaux, PhD Chris Fischer, MD Lise Nigrovic, MD, MPH Jugta Khuman, MD

30 Injury Risk Profile and Prescription for Prevention Physical Assessment Historical Assessment Training Prevention RX

31 Other Services Running Program Concussion Preparation and Prevention ACL Injury Prevention Class Coaching and Community Clinics Activity for Sedentary Kids Dance Program Training (Independent and 1 on 1) Scholarships for Underserved Athletes

32 Recent Concern Risk Cumulative Second Impact Syndrome Chronic Traumatic Encephalopathy

33 Increased Risk Gerberich 1983 Schultz 2004 Guskiewicz 2003

34 Cumulative Effects Gronwall 1975 Collins 1999 Guskiewicz 2003

35 Second Impact Syndrome Saunders and Harbaugh 1984

36 Andre Waters Terry Long Mike Webster Chris Benoit

37 The Role of Cis-Tau Sham IgG

38 Cis-Tau Antibody

39 Non-Professional Athletes Methods Cross sectional study New England Small College Athletic Conference (NESCAC) Alumni (40-70 years old) Sports played, number of seasons Collision: football, rugby, men s ice hockey, men s lacrosse Non-contact: swimming, cross country, golf, tennis, squash, Frisbee, volleyball

40 Methods Compared collision sport vs. non-contact sport Adjusted for potential confounders Removed those with a history of concussion

41 Effect of collision sports participation on patient reported outcomes (participants without history of concussion) β- coefficient* Standard Error 95% CI p-value Outcome Measure General Concerns , Executive Function , Anxiety , Depression , Alcohol Use , Sleep Disturbance , Emotion/Behavior , Dyscontrol Fatigue , Positive Affect ,

42 Limitations Only one time, only contact, 8% response rate Recall bias regarding concussion Conclusions Most athletes exposed to collision sports have no significant increase in later life neurobehavioral symptoms when compared to non-contact sport athletes.

43 Conclusions Athletes exposed to collision sports at lower levels of intensity and for a shorter duration of exposure than professional athletes have no significant increase in later life neurobehavioral symptoms when compared to non-contact sport athletes.

44 Further Reading McCrory P, Meeuwisse W, AubryM, et al. Consensus statement on concussion in sport: the 4th Int l Conference on Concussion in Sport. J Athl Train 2013;48(4): Meehan WP III, Bachur RG. Sport-related concussion. Pediatrics 2009;123: Shaw NA. The neurophysiology of concussion. Prog Neurobiol 2002;67: Meehan WP III. Kids, Sports, and Concussion: A guide for coaches and parents. Praeger Publishing

45 Questions?