1. Concussion and Traumatic BrainConcussion and Traumatic Brain
Injury in SportsInjury in Sports
Thomas A. Waters MD FACEPThomas A. Waters MD FACEP
Cleveland Browns Medical Team PhysicianCleveland Browns Medical Team Physician
Department of Emergency MedicineDepartment of Emergency Medicine
The Cleveland ClinicThe Cleveland Clinic
3. Introduction
Estimated number of
Head Injuries
(concussions, skull
fractures and intracranial
injuries) presenting to the
Emergency Department
per year per sport:
Hockey 9,883
Soccer 50,035
Football
128,968
4. Introduction
Other high risk sports include:
MMA
Rugby
Basketball
Wrestling
Soccer
A study done in the year 2000 looked at >1000 retired NFL
players and found that around 60% of those players sustained at
least one concussion during their career.
AmJSportsMed201240:747
5. Introduction
Head injuries occur commonly during sports
participation.
There are three important steps when dealing with
head injury in sports.
Detecting Injury
Assessing severity
Making appropriate return to play (RTP)
recommendation.
19. History of the football
helmet
1893-First helmet was worn in the Army-Navy game
Made by Annapolis shoemaker for Admiral Joseph
Mason Reeves
Advised by Navy Doctor that he would be risking death
or “instant insanity” if he took another kick to the head.
1896
Halfback George Barclay (Lafayette College) fearing
cauliflower ear had “playing hat” made by a harness
maker-”Head Harness”
20. History of the football
helmet 1930s-Helmets became mandatory
1948-first logo(rams horns) painted on pro leather
helmet
21. History of the football
helmet 1939-first plastic helmet
invented by John
Riddell
1940-first chin strap
1955-Paul Brown put
the first face mask on a
professional helmet.
22. History of the football
helmet 1971 Riddell-”microfit” air helmets with valves on the
crown to allow air to be pumped into vinyl cushions.
1976-four point chin straps
2002 Riddell Revolution helmet
23. Head Injury in Sports
In general, head injuries that occur in the athletic
setting are mild in comparison to those that occur in
other settings such as MVAs and other high velocity
impacts.
Most common injury is the Concussion
Most common serious injuries include
Cervical Spine spine injuries
Vascular intracranial injuries
Vascular catastrophes can present immediately or be
delayed by several hours
24. Mechanism of Head
Injury Any blow to the head can cause brain injury
Injury is due to sudden head movement or cessation
of movement and shifting of the brain within the skull.
Acceleration/Deceleration forces
Head vs ground
Rotational forces
Left hook
Impact forces
Bean Ball
25.
26. Direct Injuries
Object impacts the head
Boxing, baseball, field hockey, ice hockey
or
Head impacts another object:
Ground, another player-shoulder, helmet, goalpost
27. Indirect injuries
Forces can be transferred to the cranium
Rotational forces or compressive forces
Fall off balance beam onto coccyx
Rotational hit in football or hockey
28. Biomechanics
The location and degree of head injury depends upon
the position of the head at the moment of impact, the
direction of the forces being applied to the head
combined with the structural features and integrity of
the skull
30. Subdural Hematoma
Disruption of venous blood vessels causing low
pressure accumulation of blood
Most common focal head injury in sports
Often associated with
LOC
Slow deterioration of neurologic status
Focal neurologic deficits
32. Epidural Hematoma
Not as common as subdural
High pressure vascular injuries
Middle meningeal artery
Presentation
LOC
Recovery (lucid interval)
Rapid deterioration of neurologic status
35. Definition of Concussion
Concussion
Latin
concutere-meaning to shake violently or agitate
concussus-action of striking together.
Definition in 1966 by the Committee on Head Injury
Nomenclature: “a clinical syndrome characterized by the
immediate and transient post-traumatic impairment of neural
function such as alteration of consciousness, disturbance of
vision or equilibrium due to mechanical forces.”
36. Definition of Concussion
Zurich Consensus Statement on Concussion from
2008:
“Concussion is defined as a complex pathophysiological
process affecting the brain, induced by traumatic
biomechanical forces.”
37. Concussion-Why do we
care? 44 million children/adolescents participate in
organized sports per year.
2009 in the US there were about 1.8 million
participants in football
Estimated 3.8 million concussions per year in US.
Long term effects of concussions are becoming better
understood and more heavily scrutinized
38. Concussion-Presentation
May be obvious but often subtle.
May not have witnessed the hit
Within the pile
Blow was not directly to head
Symptoms may be delayed
Player may not recognize symptoms
Teammates may notice “not acting right”
42. Sideline Assessment
Maddock’s Questions
What venue are we at
today? (Where are we?)
What quarter/half is it?
Who scored last?
Who did we play last
week?
Who won the game last
week?
What was the play?
43. “Sideline” Assessement
1)Sport Concussion
Assessment
Tool(SCAT2) is the
standard for “sideline”
assessment of
concussion
2)Balance Assessment-
Balance Error Scoring
System(BESS)
46. Sideline Assessment
NFL Sideline Concussion Assessement Tool:
Developed by the NFL Physicians Society(NFLPS)
Head Neck and Spine Committee and implemented for
the 2011-2012 season-modified for the 2012-2013
season.
Combination of the SCAT2, BESS.
Takes 4-8 mins
6 Go/No Go criteria
47. 6 Go/No Go Criteria
LOC
Confusion
Amnesia
*When in doubt-sit
them out
New/persistent Sxs
Abnl Neuro findings
Progressive symptoms
48. Removal from play
Player should be observed
for progression/development
of concerning symptoms-do
not leave them alone.
Player may NOT return to
the field of play (Madden
Rule)
Cognitive and physical rest
and insure appropriate
follow up with caregiver
experienced in concussion
follow up and parameters for
return to play.
49. Imaging?
The two most commonly used evidence based clinical
decision rules for head CT in adults are:
New Orleans Criteria
Canadian CT head rule
50.
51.
52. ACEP Summary of Indications
for CT Scanning in Adults with
mTBI
No loss of consciousness and one or more of the
following:
GCS <15
Focal Neuro findings
Vomiting more than twice
Mod to severe HA
Age> 65
Signs of basilar skull fx
Coagulopathy
Dangerous mechanism
53. ACEP Summary of Indications
for CT Scanning in Adults with
mTBI
With loss of consciousness
Finding from the previous slide plus:
If one or more of the following is present:
Drug or ETOH intox
Persistent amnesia
Post traumatic Sz
54. Bottom line
Who needs to be transported from the field for head
imaging
Prolonged LOC(>1min)
Seizures
Progressive neuro symptoms
Other concerning symptoms/conditions such as
multiple episodes of vomiting.
55. Post Concussion Care
Cognitive rest, physical rest and sleep
Eliminate
TV/Computer
Video games
Texting
Reading
School work
Bright lights and sounds
56. Follow up
It is essential that the
athlete/patient follow
up with a caregiver who
is up to date on the
latest concussion
recommendations.
57. Old Myths
When the headache is gone, you can return to play
Sit out 3 days then return to play
A player who is knocked unconscious has a worse
concussion than if they were not.
58. Return to play
Each and every individual and each and every
concussion is unique and predicting patterns of
recovery is very difficult if not impossible
What seems to be a minor concussion may linger for
weeks
What seems to be major at the outset may clear quickly
What is important is that the athlete progress through
each and every step without skipping or hurrying
through any step in the process
59. Return to play
Asymptomatic
Normal cognitive function/balance
Graded return to play with 24 hours between stages
Progression in younger athletes should occur at a
slower pace than adults
RTP decision should be more conservative in athletes
with previous history of concussion (especially if
recent)
63. Return to play
1)Asymptomatic at rest
2)Asymptomatic with cognitive activity
3)Asymptomatic with light aerobic activity
4)Asymptomatic with heavy aerobic activity
5)Asymptomatic with sport specific activity
Baseline on any cognitive/balance testing
65. Second Impact Syndrome
Occurrence of a second head injury before an
individual has fully recovered from a first insult.
First described and called SIS in 1984 by Saunders and
Harbaugh.
19yo FB player had concussion, allowed to RTP died
suddenly with no major second trauma
Autopsy showed diffuse cerebral edema but no focal
lesion or bleeding
66. Second Impact Syndrom
The second impact can cause
Brain swelling
Persistent deficits
Death
After second impact the patient deteriorates quickly
within seconds to minutes
SIS is rare and has only been reported in minors
67. Chronic Traumatic
Encephalopathy(CTE)
Complication of recurrent head injury
Premature loss of normal central nervous system function
“punch drunk” in boxers in 1928
Abnormalities in the cerebellar, pyramidal and
extrapyramidal systems and as well cognitive and
personality deficits
Diagnosis made on autopsy
68. Future directions
Genetic testing
Apolipoprotein E
Blood/Saliva testing
glutamate
New imaging techniques
fMRI
Post injury there is an increase need for glycolysis along
with decreased cerebral blood flow which may be able to
be detected
69. Future Directions
Neuroprotective medications;
Magnesium, progesterone, erythropoietin, calcium
channel blockers
Accelerometers
In helmets and mouth guards measure amount of g-
force sustained in an individual and cumulative hits.
70. Summary
Early detection and recognition is a priority
Approach in each case must be individualized
Proper follow up is the key
Must be baseline before returning to play