Concussions in Youth Sports: 2012 Update Marla S. Kaufman, MD Clinical Associate Professor UW Medicine Sports and Spine Physicians Seattle Sports Concussion Program Department of Rehabilitation Medicine Department of Orthopaedics and Sports Medicine University of Washington Medical Center Seattle, WA
Disclosures: 1. AAMPR Alternate delegate to AMA, delegate to YPS 2. NASS Membership committee
Disclosures: RESOLVED, That our American Medical Association promote awareness that even mild cases of traumatic brain injury may have serious and prolonged consequences. Directive to take action.
A Ding Is Not Always Just A Ding
3.8 million Centers for Disease Control
Epidemiology High School Sports Concussion rate per 1000 athleteexposures Football 0.47 Girls soccer 0.36 Boys soccer 0.22 Girls basketball 0.21 Boys basketball 0.07 60% higher 300% higher Gessel, 2007
Epidemiology US High School Sports 2008-2010 20 sports (girls and boys) 7,780,064 athlete-exposures (AE) 1936 concussions Concussion injury rate of 2.5/1000 AE Injury rate higher in competition than practice (6.4 vs 1.1) Marar, et al. AJSM 2012 12
Epidemiology US High school sports Football 47.1% (N=912) Girls soccer 8.2% (N=159) Boys wrestling 5.8% (N=112) Girls basketball 5.5% (N=107) In gender comparable sports, girls had higher concussion rate (1.7:1.0) Marar, et al. AJSM 2012 13
Epidemiology US High School Sports 100 nationally representative US high schools 2005-2010 Compare new vs recurrent concussions Estimated 732,805 concussions 13.2% recurrent Castile, et al. BMJ 2011 14
Epidemiology US High School Sports NEW RECURRENT LOC 4.4% 7.7% Sx > 1month to resolve 0.6% 6.5% RTP > 3 weeks 3.8% 7.5% Medical disqualification 2.9% 16.2% Castile, 15 2011
Epidemiology of Severe Injuries Among United States High School Athletes Sport Concussion (% >21 days) Boys football 5.9% Boys soccer 11.8% Girls soccer 7.7% Girls volleyball 8.9% Boys basketball 1.2% Girls basketball 6.6% Boys wrestling 3.3% Boys baseball 1.4% Girls softball 1.2%
Effective Sports Concussion Program Education & Awareness (Pre-Injury) On Field Observation, Signs & Symptoms Recognition When in Doubt, Sit Them Out Post Game-Day Evaluation & Management by Healthcare Professionals Activity Treatment/ Management Medical Physical, Cognitive (Academics) Activity Gradual Return-To-Play Protocol Return to Play Needs Medical OK Coach, Parent, Student-athlete Medical/ Healthcare Professional
Recognizing a Concussion Signs and Symptoms Signs observed by coach, parent, teammates include: Is confused about assignment Appears dazed or stunned Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness Shows behavior or personality changes Can t recall events prior to hit Can t recall events after hit Symptoms reported by athlete include: Headache Nausea Balance problems or dizziness Double or fuzzy vision Sensitivity to light or noise Feeling sluggish Feeling foggy or sluggish Concentration or memory problems Confusion
Key Elements in Recognizing a Possible Concussion 1. Blow to the head or other part of body with force of the impact transferred to the head 2. You recognize a change in player s function 3. Refer to your Signs & Symptoms card cdc.org/concussion
Physical/cognitive Rest Activity can: Exacerbate symptoms Prolong sx duration
Return-To-Play Same-Day It is essential to understand: Younger athletes recover more slowly It takes time for all signs & symptoms to develop Safest course of action is to hold an athlete out When in doubt, sit them out
Return-To-Play Same-Day It is essential to understand A player with suspected/diagnosed concussion should NOT be allowed to return to play on the same day as the injury McCory P, et al. Clin J Sport Med 2009
Premature Return to Play Subdural hematoma Second Impact Syndrome Prolong recovery
Catastrophic Head Injuries in High School and College Football National Center for Catastrophic Sports Injury Research data from 1989-2002 94 cases 92 cases were in high school players 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
Return-To-Play Post-Game Day Concerns Prolonging recovery from the current concussion 2-4X increased risk for recurrent concussion Post-concussive syndrome 5-8% of MTBI Cumulative brain trauma
Chronic Traumatic Encephalopathy CTE= progressive neurodegenerative disease Long-term consequence of repetitive closed head injuries No definitive pre-mortem diagnosis On autopsy of brain, histologically identified Risk factors include head trauma, presence of ApoE3 or ApoE4 allele, military service, old age 28
Chronic Traumatic Encephalopathy Insidious clinical presentation Begins with cognitive & emotional disturbances Can progress to Parkinsonian symptoms Exact mechanism not been precisely defined Suggested due to ongoing metabolic & immunologic cascade (immunoexcitotoxicity) No treatment 29
Chronic Traumatic Encephalopathy Unanswered questions: How do we identify athletes at risk at young age? How many concussions is TOO many? Prevention? How does this factor influence RTP decision? 30
Return-To-Play Post-Game Day Determine the athlete is asymptomatic at-rest before resuming any exertional activity - Amnesia may be permanent Utilize progressive aerobic and resistance exercise challenge tests prior to full RTP
Neuropsychological testing Only one component of the evaluation process Useful in identifying cognitive functioning/ impairment during recovery Useful to understand effects on school learning and performance Complex process requiring proper personnel with training Administering the tests Interpreting the tests Normal test scores alone do not indicate recovery
Neuropsychological Testing neuropsych test concussion
Prevention No convincing evidence for mouthguards or face shield Full face protection may decrease severity of concussion in hockey Helmets decrease the risk for more severe brain injury/skull fractures Benson 2009
Concussion Remove from practice or play Do not leave the player alone Healthcare provider evaluation following the injury Return to play- medically supervised stepwise progression Complete recovery before return to play
Youth Sports Concussions Student athletes
What is this game worth? The rest of the season? The rest of the athlete s career? The rest of the athlete s life?
Zackery Lystedt
Engrossed House Bill 1824 Requiring the adoption of policies for the management of concussion & 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. http://apps.leg.wa.gov/billinfo/summary.aspx?bill=1824&year=2009
Engrossed House Bill 1824 Requiring the adoption of policies for the management of concussion and head injury in youth sports. 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. http://apps.leg.wa.gov/billinfo/summary.aspx?bill=1824&year=2009
May 14 th 2009 Zackery Lystedt Law
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Why Players Don t Report Concussions The top reason athletes don t report concussions is NOT for fear of losing their position! It is LACK OF KNOWLEDGE Why Concussion Was Not Reported (McCrea 2004) Did not think it was serious enough Did not want to leave the game Did not know it was a concussion Did not want to let down teammates 66% 41% 36% 22% Delaney (2002) found that only 23.4% of concussed college football players and 19.8% of concussed soccer players realized they had suffered a concussion McCrea M et al. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004 Jan;14(1):13-7 Delaney JS et al. Concussions among university football and soccer players. Clin J Sport Med. 2002 Nov;12(6):331-8
We need to educate players Coaches, parents, and officials too
Finally 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 (in Washington); It Is The Right Thing To Do!