Sports Concussion Update: 2012 Michael C. Koester, MD, ATC May 14 - - PowerPoint PPT Presentation

Sports Concussion Update: 2012

Michael C. Koester, MD, ATC May 14th, 2012

Director, Slocum Sports Concussion Program

Slocum Center for Orthopedics and Sports Medicine Eugene, OR

Disclosures

 I am a paid consultant for the Oregon Center

for Applied Science, Inc. (ORCAS). They have developed two on-line concussion education programs- ACTive and Brain 101: The Concussion Playbook.

 I am the Chair of the NFHS Sports Medicine

Advisory Committee and the OSAA Medical Aspects of Sports Committee. Both are unpaid positions.

Concussions and Politics

 The flying wedge, football's

major offense in 1905, spurred the formation of the NCAA

 Large numbers of players

injured and killed

 President Roosevelt

summoned college athletic leaders to the White House

 Reform game or have it

banned

Concussions in Popular Entertainment

1939

Concussions in Popular Entertainment

2012

What is a Concussion?

 A concussion is a mild

traumatic brain injury that interferes with normal function of the brain

 Evolving knowledge-

“dings” and “bell ringers” are serious brain injuries

 LOC not required-

 Far less than 5%

What happens to the brain?

 A complex physiological process induced by

traumatic biomechanical forces:

 sudden chemical changes- neurotransmitters

and glucose utilization disrupted

 stretching and tearing of brain cells

• Structural brain imaging (CT or MRI) is almost

always normal Concussions are physiologic, not anatomic injuries

• Still many unanswered questions . . .

Pediatric and Adolescent Brain

 Increased risk for injury

 Water content  Cerebral blood volume  Level of myelination  Skull geometry  More vulnerable to

diffuse injury

 More difficult to

assess and monitor recovery the younger the patient!!!

Concussion Effects

 Impacts 4 areas of

function

 Cognitive 

Concentration, memory

 Somatic 

HA, fatigue

 Emotions 

Irritability

 Sleep 

Insomnia

Extent of the Problem

 Professional athletes get

a great deal of attention

 Much more common in

high school than any

• ther level- due to large

number of participants

 Oregon HS Sports

Participants



Football- 15,000



Boys Soccer- 6,000



Girls Soccer- 5,000



Boys Hoops- 7,000



Girls Hoops- 7,000

Extent of the Problem

 Estimated 250,000

sports-related concussions in high school athletes yearly

 20% of all HS sports

injuries

 47.1% of all injuries

• ccurred in FB

 Likely more than 2000

concussions in Oregon HS athletes every year

 Planned 3 year injury

data collection in HS FB to begin Fall 2012

Not Just a Football Problem

Injury rate per 100,000 player exposures

 Football

69

 Ice Hockey

61

 Boys’ Lacrosse

42

 Girls’ soccer

38

 Girls’ Lacrosse

34

 Wrestling

28

 Girls basketball

28

 Boys’ soccer

23

 Boys basketball

18

 Softball

15

 Cheerleading

14

 High School RIO 08-11

Chronic Traumatic Encephalopathy

 CTE- progressive

degenerative disease

• f the brain found in

athletes (and others) with a history of repetitive brain trauma

 Tau protein

 Examples-

 Normal brain  45 year old former

NFL player

 73 year old boxer

“Max’s Law” 2009

 Mandatory coach education  Player must be removed

from play if “exhibits signs, symptoms, or behaviors consistent with a concussion”

 Cannot return to play that

day

 Cannot return to play until

asymptomatic and cleared to return by a “health care professional”

Concussion management made easy!

 When in doubt, sit

‘em out!!

 No return to

activity on the same day of a concussion

 No return to activity

if having symptoms

• f a concussion

Concussion Management: Zurich Guidelines, 2008

 Notion of grading systems

has been abandoned

 Over 20 classifications  Can only be applied

retrospectively

 No same day return to play  Modifying Factors

 Persistent symptoms, age,

prolonged LOC, multiple concussions

 Graded Return to Activity  Management continues to

evolve!!!

Return to Activity Protocol

7 Steps to a Safe Return

Step 1. Complete cognitive rest. This may include staying home from school or limited school hours for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.

 Step 2. Return to school

full-time.

Return to Activity Protocol

7 Steps to a Safe Return (cont)

 Step 3. Light exercise. This

step cannot begin until you are cleared by your physician for further activity.

 Step 4. Running in the gym

• r on the field. No helmet or
• ther equipment.

 Step 5. Non-contact training

drills in full equipment. Weight-training can begin.

Return to Activity Protocol

7 Steps to a Safe Return (cont)



Step 6. Full contact practice or training.



Step 7. Game play. Must be cleared by your physician before returning to play.

 Cannot advance to next

level if symptomatic

 Progression usually takes

about 1 week

The Biggest Problem

How do you know who has recovered from a concussion?

Return to Play Determination

 No symptoms

 Rest and Exertion

 Normal Exam  “Normal” academic

performance

 “Pass”

Neuropsychologic testing

Computerized Neuropsychological Testing

 Computerized testing

has role in RTP

 Never stands alone

 ImPACT most widely

used and known

 40+ Oregon high schools

 Current data shows

similar efficacy among all 3 tests

Coach Education

On-line training for coaches:

 CDC Heads Up  USA Football  NATA/NHL Collaboration  NFHS/CDC Heads Up

collaboration

 www.nfhslearn.com 

Additional resources



400,000+ courses delivered

Brain 101: The Concussion Playbook

 School-wide Concussion Management

 Targets everyone- coaches, athletes, teachers,

and parents!!

 Research projects ongoing

 http://brain101.orcasinc.com/#

OCAMP Oregon Concussion Awareness and Management Program

 Max’s Law: Concussion Management

Implementation Guide for School Administrators

 Can be used as a companion document to Brain 101  Sample Policies and Procedures  Sample school forms 

http://www.ode.state.or.us/teachlearn/subjects/pe/ocampguide.pdf

 CBIRT Contact:

Melissa Nowatzke nowatzkm@cbirt.org

REAP Concussion Management Program

 R = Reduce – physical and cognitive demands  E = Educate – everyone on symptoms:

Physical (How one “feels physically”) Cognitive (How one “thinks”) Emotional (How one “feels”) Maintenance (Energy and Sleep)

 A = Accommodate academics – teach the teachers  P = Pace – Graduated Return-to-Play

 http://www.rockymountainhospitalforchildren.com/sports-

medicine/concussion-management/reap-guidelines.htm

Principles of Concussion Management

 No cure for concussion, but treatment can

help the athlete feel better and function better while symptomatic

 Medication?

 Early diagnosis and education is critical,

especially to avoid re-injury

 Rest early (7-10 days?) and then gradually

increase activity

 Cognitive rest

Concussion in the Classroom

 Fatigue - tire easily in class

and over the course of the day

 Headache and other

symptoms worsen with reading or concentration

 Trouble doing more than

• ne thing at a time (e.g.,

looking at PowerPoint and taking notes)

 Frequent visits to the

nurse’s office

 Biggest Issue- NO ONE

TAKES THEM SERIOUSLY!!!

Management- Academic Accommodations

 School

 Stay home!!!  Transition to half-days  Naps/rest time  Extended time to

complete assignments

 Limit homework  Skip assignments,

modify, or reduce

 Extended time to take

tests

 Open note/book  Allow time to visit school

nurse for treatment of headaches, if needed

 Written instructions for

homework

 Repeat and present new

information slowly

 No standardized testing  Share progress and

difficulties



Someone to talk to

 Need “point person” 

Don’t leave them adrift!!

Management- Cognitive Rest

 Home

 Sleep!!!  Limit “stimulation”:  Phone  Computer  Music  TV  Texting  Gaming

Management Challenges

 Very little EBM  Variation in initial

management by providers

 School setting  RTP when

“Asymptomatic”

 Role of neuropscyh

testing

 Academic performance

 Prolonged symptoms

Athletes with Prolonged Symptoms

 Variation in services

 Where do you live?

 Typical problems

 Headache  Insomnia  Irritability

 Medications

 OTC Analgesics  Headache

 Exercise Protocols

 Aerobic protocol 

Stationary bike

Concussion Prevention

 “Concussion prevention”

has become the “holy grail” for sports equipment marketers

 Soccer head gear  Football helmets with “new

technology”

 Helmets were designed to

prevent skull fractures- NOT concussions!!

 NO PROVEN

PROTECTION FROM CONCUSSION!!

Concussion Prevention

 Everyone has

something to sell to “prevent concussion” or monitor for “possible” concussion

 Shockstrips  Chin straps  Mouthpieces  Various helmet paddings

Concussion Prevention

 Many interventions

sound good, but have little or no evidence to support efficacy

 Concept of

unintentional consequences

 What are best steps

forward?

 Girls’ Lacrosse

Prevention- National, State and Local

 Football Rules POE

 No helmet to helmet contact  Almost 70% of concussions

 Limit contact in off-season

 Regulate camps and “spring

football”

 7 on 7 football

 Lengthen preseason

 Looking to add a week in

2013

 Tackling progression- USA

Football

 Kidsports

Local Efforts

 Kidsports, Eugene Metro FC, and Pop

Warner have all mandated coach education and return to play policies.

 Athletic Trainers @ South Eugene, North

Eugene, Sheldon, Willamette, Churchill and Marist have been leaders in community and state.

 Continued research efforts at UO Motion

Analysis Lab and ORCAS, Inc.

Conclusions

 Everyone dealing with

young athletes must be aware of the signs and symptoms of concussions

 Early recognition and

management are essential to good

• utcome

 Schools and

• rganizations must have

a concussion management plan in place

THANK YOU!!!!!!

 Thad Stanford, MD, JD- Salem  Bill Bowers- Executive Director, OADA  Tom Welter- Executive Director, OSAA  Mickey Collins, PhD- Pittsburgh  Ron Savage, EdD- New Jersey  Brian Rieger, PhD- New York  Ann Glang, PhD- Eugene  Stan Herring, MD- Seattle

Thank you all very much!!!!!

michael.koester@slocumcenter.com Cell 541-359-5936