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Concussions in Sports

Dr. Juan Ronderos, M.D.

Financial Disclosure
Consultant for Orthofix Spine receive consulting fees and royalties Investigator Zimmer Spine receive consulting fees Investigator Globus Medical Receive consulting fees Investigator Integra Medical receive consulting fees Owner NMS medical solutions receive profits Own JNJ and Medtronic stock on open market

This is what a concussion looks like...

Long term effects
Dementia Pugilistica

I object to violence because when it appears to do good, the good is only temporary; the evil it does is permanent. Mahatma Gandhi

Concussion
• Recently described as the “Silent Epidemic”

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Concussion
• A stunning, damaging, or shattering effect from a hard blow; especially: a jarring injury of the brain resulting in disturbance of cerebral function • Synonyms: bump, collision, impact, crash, jar, jolt, slam, smash, strike, wallop Merriam-Webster

Silent
• Making no mention: unspoken <history is silent about this person>(condition)

Merriam-Webster

Prevalence
• Until very recently Concussion or Mild Traumatic Brain Injury (MTBI) has been a silent epidemic • Synonyms or MTBI have helped to disguise the overall incidence and effect on our society • Lack of definitive testing has helped disguise the impact as well

Prevalence - Synonyms
• Name • Shaken Baby Syndrome • Concussion • Sports Concussion • Dementia Pugilistica • Alzheimer's disease • Senile Dementia • Age Group • Infants to age 4 • • • • • Ages 5 and above Limited to sports Limited to Boxing? Early Dementia Elderly

Epidemic
• Affecting or tending to affect a disproportionately large number of individuals within a population, community, or region

Merriam-Webster

Prevalence
• 38 million children and adolescents participate in organized sports • 170 million adults participate in physical activity not related to work • 1.1 million persons are treated and released from ED following treatment for TBI • 235,000 are hospitalized
Source: MMWR, July 27, 2007

Sports TBI 2001-05
• 5.1% of all SR ED visits were for TBI
– 70.5% male – Highest rate age 10 – 14 – 2nd highest age 15 – 19

• Most common activities
– – – – – Bicycling Football Playground Basketball Riding ATVs

Source: MMWR, July 27, 2007

Diagnosis
• • • • Symptoms reported by injured Based on Observation Observed Signs Initial Physicians role is to rule out more serious injury (Hematomas and Contusions) • Secondary Physicians role is to monitor and control back to activity decisions • Future – Functional MRI and/or PET

Diagnosis
• Observed
• • Vacant stare/befuddled expression Delayed verbal/motor responses


• • •

Easy distractibility
Difficulty focusing attention Inability to perform normal functions Disorientation


• • • • • •

Walking in wrong direction
Unaware of date, time, place Slurred/incoherent speech Incomprehensible statements LOC (Rare <10%) Nausea or vomiting “Fencing Response”

• • • • • • • • • •

Reported by Injured Headache Nausea Balance issues or Dizziness Double vision or blurred Light and/or noise sensitivity “sluggish” “foggy” Change in sleep patterns Concentration or memory problems

Common Findings
• Vacant stare/befuddled expression • Delayed verbal/motor responses • Easy distractibility • Difficulty focusing attention • Inability to perform normal functions • Disorientation • Walking in wrong direction • Unaware of date, time, place • Lack of coordination

• Inability to tandem walk
• • • • • • Exaggerated emotionality Inappropriate crying Distraught appearance Memory deficits Cannot name 3 out of 3 objects after 5 minutes Repeatedly asking same question which has been answered already Any period of LOC Paralytic coma Unresponsive to stimuli

• Slurred/incoherent speech
• Incomprehensible statements

• • •

Diagnosis
• CT and MRI are usually negative • Metabolic rather than structural disruption • Accurate diagnosis aimed at preventing cumulative effects of concussion • Preventing SIS (second impact syndrome)

Initial Treatment
• Removal from current game or activity • No return to play that day until evaluation
• Preventing SIS (second impact syndrome)

SCAT-2

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SECOND IMPACT SYNDROME
Occurs in athletes with prior concussion following relatively minor second impact
- Second impact has been shown to occur up to 14 days post-injury - Athlete returns to competition before resolution of symptoms

Catastrophic increase in intracranial pressure

- Vasomotor paralysis, edema, massive swelling, herniation, death

Most often occurs in athletes <21 years old
- Neuro-chemical processes appear to differ in developing brain

Treatment
• Widely used in athletes • Baseline normative data • Used as a adjuvant to clinical observation and reporting

ImPACT: A TOOL FOR EVALUATING CONCUSSION
(Immediate Post-Concussion Assessment and Cognitive Testing)

 Computerized test developed by clinical researchers at the University of Pittsburgh Medical Center (UPMC)  Developed to allow for a more objective assessment of concussion and recovery  Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing  Provides a common metric which allows for effective collaboration between athletic trainers, coaches, physicians, and neuropsychologists in concussion management  Utilized throughout professional and amateur sports across the country and internationally

Treatment
• Throughout all phases look for signs of deterioration • Look for signs of post concussion syndrome • Neurocognitive testing

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
Graduated return to play protocol Rehabilitation stage Functional exercise at each stage of rehabilitation
Objective of each stage 1. No activity Symptom limited physical and cognitive rest Recovery 2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rate No resistance training Increase HR 3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer. No head impact activities Add movement 4. Non-contact training drills Progression to more complex training drills, eg, passing drills in football and ice hockey May start progressive resistance training Exercise, coordination and cognitive load 5. Full-contact practice Following medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff 6. Return to play Normal game play Br J Sports Med 2013;47:250-258 doi:10.1136/bjsports-2013-092313

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Study 1
How Long Does It Take The Athlete To Recover from Concussion?

Lovell MR, Collins MW, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

STUDY 2
Do Athletes Underreport Symptoms?

Lovell MR, Collins MW, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

Long Term Effects
• Mostly studied in athletes • Boxers and more recently football injuries have brought issue to the forefront • A few high profile cases • Recently Football players have become high profile

Famous boxers known to have (or had) Dementia Pugilistica
• • • • • • • • Muhammad Ali (1942 - ) Joe Louis (1914 – 1981) Jack Dempsey (1895 – 1983) Floyd Patterson (1935 – 2006) Sugar Ray Robinson (1921 – 1989) Jerry Quarry (1943 – 1999) Mike Quarry (1951 – 2006) Leon Spinks (1953 - )

NFL prominent TBI
• Jim McMahon battling early dementia, wishes he'd played baseball

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NFL prominent TBI
• Junior Seau’s family sues NFL claiming star linebacker’s suicide a result of brain disease caused by violent hits

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NFL
• (Reuters) - The National Football League and General Electric Co are teaming up to improve the diagnosis and treatment of brain injuries amid growing concerns about sports-related concussions in youth and professional sports.

On Monday they announced a effort with leading neurologists to speed up research into brain injuries and the development of new technologies to help protect the brain from traumatic injury to benefit athletes, the military and the broader public. The initiative includes a

$60 million

$40 million research program into imaging technologies to improve diagnoses and an additional $20 million pool of funds open to researchers and
businesses trying to improve the prevention, identification and management of brain injuries.

Mon Mar 11, 2013

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Awareness
• Recent push by professional athletes to treat and prevent injury • Manufacturers have responded by having better testing of equipment and certification of equipment • Trainers and all personnel are more aware of the signs, symptoms, and treatment of MTBI

Awareness
• Main stream media has reported issues and problems • Health care providers are obtaining certification to provide better care • Governmental agencies are requiring safety initiatives at the manufacturing, public, and private sectors • Foundations are promoting awareness • Education is becoming ubiquitous

National Geographic
• February 2011 • “New Brain Science on Football Concussions”

New York Times
• October 10, 2010 • Front page • “As Concussions Rise, Scant Oversight for Football Helmet Safety”

Resources
• • • • • CDC NIH Impact concussion testing Think First Foundation The Watson Neuroscience Foundation

www.watsonresearch.org