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Concussion Awareness and Safety: 2015J. Peter Zopfi, DO, FACOS
Trauma Medical DirectorCal North Chairman
USSF “A” LicenseUSSF “Goalkeeping” License
Definitions
Traumatic Brain Injury (TBI): General term that includes concussions, contusions, subdural hematomas, cerebral hemorrhages and penetrating injuries.
Concussion: A disturbance in brain function caused by a direct or indirect force to the head.
What is a Concussion?
Usually from a direct blow to the head
Variable loss of consciousness (usually not!)
Rapid onset of “Neurologic Impairment”
“Injury” not seen on CT or MRI scans
“Neurologic Impairment”
Variable consciousness (“in a fog”)
Amnesia
Headache
Irritability / Emotional
Slowed Reaction Times
Insomnia
Sports with Highest Frequency of Concussions(<19 years)
Bicycling
Football
Basketball
Soccer
0 5,000 10,000 15,000 20,000 25,000 30,000
Concussions Reported Annually (2001-09)
Concussions
Source: Centers for Disease Control and Prevention
Concussions: By the Numbers
Fewer than 10% of sport related concussions involve a loss of consciousness
78% of concussions occur during games (as opposed to practices)
Headache (85%) and Dizziness (70-80%) are the most commonly immediate symptoms following concussions for injured athletes
47% of athletes do not report feeling any symptoms after a concussive blow
Soccer is the most common sport with concussion risk for females (50% chance for concussion)
Soccer Head Trauma
“What should I do?”
“What should I do?”
4th Consensus conference on concussion management, Zurich. September 2012
American Academy of Pediatrics. 2010
CDC – Center for Disease Control. July 2013
http://www.cdc.gov/concussion/HeadsUp/youth.html
April 2013
“Zurich”Recommendations
Recommended: Screen with SCAT3 evaluation tool Clinical Neurologic exam for all with
a positive screen Formal Neuropsychological testing or
MRI for some
April 2013
SCAT3(Sport Concussion Assessment Tool)
Designed for use by medical professionals
SCAT3 (13-19 years old) & Child-SCAT3 (5-12 years old)
8 Parts: Glasgow Coma Scale (GCS), Maddocks Score, Symptom Evaluation, Cognitive Assessment, Neck Examination, Balance Examination, Coordination Examination and SAC Delayed Recall
Pediatric version: SCAT3
(Age 5-12)
Pediatric version: SCAT3
(Page 2)
Glasgow Coma Scale
“Okay, but what should I do?”
The New York TimesNovember 5, 2013
“Time to Remove Coaches From Concussion Decisions”
InitialSideline Assessment
Indications for Emergency Management
Glasgow Coma Score less than 15
Deteriorating mental status
Potential spinal injury
Worsening symptoms or new neurologic signs
Concussion Recognition Tool
1. Visible clues of suspected concussion
2. Signs and symptoms of suspected concussion
3. Memory function
Visible clues of suspected concussion
Lying motionless on the ground / Slow to get up
Unsteady on feet / Balance problems
Grabbing / Clutching of the head
Dazed, blank or vacant look
Signs and symptoms of suspected concussion
Nausea or vomiting
Drowsiness or fatigue
“In a fog” / “Don’t feel right”
Blurred vision / sensitivity to light
Memory function
“What field are we playing at today?”
“What is the score of the game?”
“What team did we play last game?”
“Did we win our last game?”
Concussion Recognition Tool“Practice”
1. Visible clues of suspected concussion
2. Signs and symptoms of suspected concussion
3. Memory function
“When in doubt, take them out”
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be returned to activity until they are assessed medically.
Athletes with a suspected concussion should NOT BE LEFT ALONE and should not drive a motor vehicle.
Treatment
It’s a Concussion: Now what?
SCAT3 or Child-SCAT3: Screen
Medical evaluation and Neurologic exam if +LOC, then same day urgent evaluation
No school or sports until medically cleared.
Rest for at least 24 hours.
Avoid any computer, internet or electronic gaming activity.
No medications unless prescribed by a doctor
“Zurich” Recommendations
Treat with physical and cognitive rest until asymptomatic without meds
Initial 24-48 hour period of strict rest.
Recommend gradual return to school and social activities prior to sports.
April 2013
“Zurich”Recommendations
When to Return to sports Graduated return program
Begins after asymptomatic off meds Usually at least 7 days
Program“modifiers” Number and frequency LOC >1min Symptoms >10 days Seizures Female
April 2013
Multiple Concussions
“Time Interval Between Concussions and Symptom Duration”- Journal of Pediatrics, June 2013.
Duration of symptoms longer for more than one concussion (28 days) vs. a single concussion (12 days)
2 concussions in a year: symptom duration is even longer (35 days)
“U.S. Soccer and MLS to hold First-of-Its-Kind Medical Symposium at NSCAA Convention”
Philadelphia, PA January 16, 2015
Coach Education
Incidence & Mechanisms associated with concussion injuries in soccer “Coaches awareness of the injury”Dr. Ruben Echemendia, U.S. Soccer and MLS Neuropsychologist
“Best Practice” for recognizing, evaluating and management of concussion injuries “From the sideline to return to participation”Dr. Margot Putukian, U.S. Soccer and MLS Primary Care Sports Medicine
Return to participation process post-concussion injuryJohn Gallucci Jr., MLS Medical Coordinator
Panel Discussion – Coaches, players and experts share their experiences and looking to the future
TOPICS
Coach Education
Player Education
Tips for Counseling Parents
Do NOT give a specific time for a return Must be symptom free first. Graduated program that includes cognitive activity.
Repetitive concussions within a short time span Potential lasting deficits. Potential for longer restrictions.
Need for further testing is variable Follow up MRI Neuropsychology testing
Imaging in Concussions
CT Scan (primary modality)
MRI (magnetic resonance imaging)
DTI (diffusion tensor imaging)
MRI with DTI
MFC (magnetic field correlation)
fMRI (functional MRI)
CT vs MRI
Diffusion Tensor Imaging
Heading and Brain Injury
Albert Einstein College of Medicine (Gruss Magnetic Resonance Research Center) in New York (reported November 2013)
Diffusion Tensor Imaging (DTI) used
37 soccer players (29 men); median age 31; played 22 years
> 1,000 headers in a year: injury in regions of the brain responsible for cognitive functions such as attention, memory, planning, organizing, physical mobility and high-level visual functions
Heading and Brain Injury
Evidence linking brain injury and heading has been inconsistent
American Academy of Pediatrics
“There is not sufficient data to recommend that young players abstain from heading, but suggest that players minimize contact between head and ball.”
Protective Headgear
Studies have shown peak force of impact and peak acceleration at impact are diminished wearing headgear which theoretically translates into concussion prevention or reduction.
This applies more to player-to-player and player-to-hard object contact (high force and speed) rather than to purposeful heading of a ball (lower force and speed)
Protective Headgear
No studies have sufficiently supported the protective effect of wearing headgear
The rules of the National Federation of State High School Associations, the United States Soccer Federation (USSF), and the Federation Internationale de Football Association (FIFA) do not require players to wear headgear during games but do permit players to wear headgear if they so choose
Impact Testing
Pre and post concussive Neuropsychologic function testing Need an initial baseline exam
May be really useful for: High risk kids History of prior concussions (fit to play??) Prolonged symptoms Vague or poorly defined symptoms
Does not alter recommendations: rest until asymptomatic and then gradual return.
Summary
Concussions are serious injuries that result in significant “Neurologic Impairment”
Concussions are common in youth soccer and require initial sideline assessment followed by evaluation and treatment by a medical professional if a concussion is suspected
Education of players, parents, coaches and referees is essential for the successful treatment of this epidemic
Specific diagnostic tests are not available at this time and clinical suspicion and evaluation are the keystones to the management of traumatic brain injuries
Questions?
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