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DRSteve OlveyFIA Institute Fellow - USA
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CONCUSSION RECOGNITION AND MANAGEMENT
FIA MEDICINE IN MOTOR SPORT SUMMIT 2010
Stephen E. Olvey, M.D.Associate Professor Clinical Neurology/Neurosurgery
Director Neuroscience Intensive Care UnitUniversity of Miami/Miller School of MedicineFellow FIA Institute for Motor Sports Safety
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WHY THIS IS A HOT TOPIC? There are 250,000 - 300,000 sports related TBIs
reported annually in the U.S alone. Thousands more worldwide.
Sports concussion is unique in that it is generally mild, but carries a high risk of recurrent concussion and subsequent illness due to early return to competition.
Long term dysfunction often follows repeated concussions. (Mohamed Ali, Steve Young, Troy Aikman, and more than a few racing drivers)
Annual cost in the United States exceeds 1 billion dollars.
>98% of sports related head injuries are concussions.
Misunderstanding of concussion still permeates the medical profession
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CLINICAL DILEMMA
Major health problem No proven acute treatment. Injury must
run its course. Severity of the concussion not known until
it has resolved. The final outcome may take years.
Uncertainty about when it is safe to return to competition.
Multiple criteria and guidelines exist; but these are based primarily on subjective clinical factors and the duration of impairment, they do not, unfortunately correlate with outcome.
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WHAT IS A CONCUSSION?
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OLD DEFINITION
“A reversible injury to the brain due to traumatic forces, resulting in amnesia and/or loss of consciousness.”
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NEW DEFINITION
Don’t need to have been unconscious Don’t need to have directly hit your head Don’t need to have been amnesic Must have some concussion related
symptoms Normal routine CT or MRI May or may not have post concussion
symptoms Repeated sub-clinical head accelerations
will likely become part of the definition in the near future.
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PATHOPHYSIOLOGY
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METABOLIC ABNORMALITIES
Potassium, glutamate, and glucose are
immediately released from affected brain cells… Calcium enters these disturbed cells in exchange
for the K+… Neurotransmitter release occurs with loss of
autoregulation in the area of the brain affected… Concomitant decrease in regional cerebral blood
flow with a resultant energy crisis…
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INJURY AFTERMATH
Brain is vulnerable to further injury during this period due to altered cerebral glucose metabolism. (20 minutes to a few days?)
The hyperglycolysis that results, depletes cellular ATP resulting in an energy crisis as decreased blood flow limits body’s ability to supply enough glucose to satisfy the supply/demand relationship for brain function.
Results in seriously altered brain function It has been shown that if there is too much
calcium influx, actual cell death may occur; seen in the most severe forms of concussion
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NOT JUST A BUMP ON THE HEAD
SUMMARY: There is a Triphasic metabolic response in mild TBI:
Hyperglycolysis (hours-days) Metabolic depression (days-weeks) Metabolic recovery (days-weeks-mos.)
None of the above is directly related to the initial
clinical presentation.
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WHAT HAPPENS IF CONCUSSED ANIMAL IS CONFINED POST INJURY?WHAT HAPPENS IF AN ANIMAL IS CONFINED POST INJURY?
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THE DICOTOMY OF RETURN TO COMPETITION
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THERAPEUTIC DELIMMA
How much rest before how much activity?
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There is a period of energy crisis and vulnerability during which secondary insults must be avoided---return to play issues
Post-traumatic physiological brain abnormalities in humans can last days to months.
Clinical assessment is inadequate to quantify post traumatic dysfunction.
Excessive activation or forced disuse of injured brain can worsen the outcome---therapeutic implications
The developing brain is uniquely vulnerable to trauma.--- It is different in kids!
PATHOPHYSIOLOGY SUMMARIZED
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BIOMECHANICS
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THE TWO TYPES OF ACCELERATION
Translational acceleration- Total applied force passes through the center of gravity of the head (walking into a flag pole, hitting steering wheel head on)
Angular acceleration- Force generates motion around an axis (Whiplash, or left hook in boxing)
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TWO TYPES OF ACCELERATION APPLICATION
Impulsive loading (whiplash, shaking baby, most open wheel crashes) and Impact loading (skull vs. a rigid surface as happens in rally cars, stock cars)
Impact loading in general produces much higher forces than does impulsive loading.
Mild TBI may result from both.
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DIAGNOSIS
Physical Signs of Mild TBI
Any loss of consciousness Retrograde or anterograde amnesia Seizure at time of impact (so-called impact seizure) Vacant stare Inability to focus, easily distracted Slurred speech, slow to answer questions Disoriented, unsteady gait Memory deficits, personality change Emotionally unstable, inappropriate behavior Delayed verbal and motor responses
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DIAGNOSIS, CONT.
Symptomatology
Headache ( nearly always present) Dizziness, vertigo Lack of awareness Nausea, vomiting Loss of balance Feeling dazed, “dinghy” Ringing in the ears (tinnitus) Blurred or double vision (diplopia) “Just not feeling right”
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BOTTOM LINE
Examiner must have high index of suspicion based on mechanism of injury, velocity, in- car damage, helmet damage, damage to surrounding area, etc.
Athletes themselves will under report symptoms and out right lie to stay in the event.
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MANAGEMENT
ANY Symptoms or Signs: NO RETURN TO ANY SPORTS ACTIVITY; whether competition, or training
Driver or athlete should be medically evaluated and monitored every 5 min. for symptom/sign resolution or deterioration for at least 1 hr.
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WHEN IN DOUBT, SIT THEM OUT!
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STATE OF THE ART
Neuro-psyche testing: ImPACT: Immediate Post-Concussion Assessment and Cognitive Testing
One of several available: Now used in Indy Car, Formula 1, NASCAR, NFL, NHL, World Cup Soccer, USSA, FISA, and FIFA.
Most extensively tested (Initially over 18,000 subjects)
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WHY USE NEUROPSYCH TESTING
Athletes with a mild TBI will often deny symptoms
Athletes may lack awareness of symptoms
Testing provides unique informationTrusting an athlete’s self-assessment
is very dangerous!Eliminates bias, favoritism, and
revenge
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ImPACT ADVANTAGES
Minimizes practice effects (can’t out smart the test)
Measures reaction time to 1/100 th Sec. Can be administered in a group setting Can be administered by a Nurse or Athletic
Trainer, even a PhD or MD Now available for I-PHONE and other
wireless use < 30 Minutes to administer 24/7 World wide reporting of the results
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HOW TO USE ImPACT
Initial preseason baseline testing on all athletes
(now enough tests so not absolutely necessary)
Administer test as soon as practical following incident (readings returned in matter of minutes)
Diagnosis confirmed if test determined to be abnormal (more than 2 SD from baseline)
Repeat test at 48 hrs. and again at 7 days and every 7 days until normal.
Provides a definitive guide for return to competition
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EFFECT OF REPEATED MILD TBI ON THE ATHLETE
An athlete with more than three previous concussions is 9 x more likely to have associated amnesia either anterograde or retrograde as well as post concussion symptoms
Retrograde amnesia: 10 x more likely to have a poor outcome
Anterograde amnesia: 4.2 x more likely to have a poor outcome
L.O.C. not predictive of outcome!!!
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WHEN DO WE NEED CT/MRI?
Suspicion of a structural lesion: focal neurological signs, evidence of significant impact i.e. helmet, cockpit damage in racing
Seizure activity > 1 minute Prolonged disturbance of consciousness or
worsening level of consciousness while under observation
Persistent clinical or cognitive symptoms, doesn’t improve gradually over period of 2 to 3 weeks.
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RETURN TO COMPETITION Level 1. No activity, complete rest; once
asymptomatic proceed to level 2 Level 2. Light aerobic exercise such as walking or
stationary cycling Level 3: Sport-specific training (skating in hockey,
running in soccer, simulator, go-kart, family car in racing)
Level 4: Return to sport with supervised private practice with attention to consistent, competitive times or abilities
Level 5: Return to competition under observation during practice then competition
Any re-occurrence of symptoms along the line, athlete should go back to previous level!!!!
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WHAT WE STILL DON’T KNOW
How many mild TBI’s are too many? When is the brain really back to normal? Is there effective pharmacotherapy? Why some athletes are “brain injury prone”? - The exact role of age/development (kids and women are more vulnerable) - The role of genetics, seems to run in families - The role of other conditions (migraine, ADD)
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WHAT HAVE WE LEARNED
Mild TBI can have long term effects Most but not all athletes recover quickly Age may be important in recovery Neuropsychological testing is a useful tool Management should involve multiple
components Total inactivity is bad but, activity too soon
is also bad
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22
Effect of Transfer Function Correction: Case 1
-500
50100150200250300350400450
-0.001 0.000 0.001 0.002 0.003 0.004 0.005 0.006 0.007Re
sulta
nt (G
)Time (Sec)
Test 1_2Lf Ear Lf Ear Ref Computed Lf Ear Ref
• CT scan of Specimen 1 (EShock1) showing position of each ear mounted sensor.
• From C. Bass and R. Salzar, Final Report 2008.
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PREVENTION
Stay inside and don’t do anything
or
Wear an approved/well fitted helmet (FIA 8860) Head and Neck restraint SYSTEM in 4 wheel vehicles Newer devices available for motorcycles (Leatt) Something to “catch” the head. Pad everything with energy absorbing material
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THE END