Concussion Update The State of Play

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Concussion UpdateThe State of Play

• Terry Coyne
• BrizBrain Spine
• Sunshine Coast Brain Spine

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Aims

• Identify concussion
• Appropriately advise players/other stakeholders
  re management, return to play
• Access resources

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NFL, RETIRED PLAYERS RESOLVE CONCUSSION LITIGATION
COURT-APPOINTED MEDIATOR HAILS HISTORIC
AGREEMENT Thousands of Retirees and Families to
Benefit Medical Testing Research Compensation
and Promotion of Safety All Part of
Agreement Former United States District Judge
Layn Phillips, the court-appointed mediator in
the consolidated concussion-related lawsuits
brought by more than 4,500 retired football
players against the National Football League and
others, announced today that .
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• NFL would pay 765 million plus legal costs, but
  admits no wrongdoing.
• Individual awards would be capped at 5 million
  for players suffering from Alzheimers disease.
• Individual awards would be capped at 4 million
  for deaths from chronic traumatic encephalopathy
  (CTE).

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• Greg Williams has said that multiple concussions
  in his career resulted in permanent damage.
• The Age, September 2013

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NRL legend Mark Geyer set to have a brain
examination and wants to other players who
suffered concussion to be tested for potential
trauma James Hooper The Sunday TelegraphMarch
15, 2014
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What is concussion?

• Subset of mechanical brain injury
• Can be direct or transmitted force to head
• Typically rapid onset of neurological impairment
  which resolves spontaneously, but may evolve over
  minutes/hours
• Acute symptoms usually due to functional
  disturbance rather than structural
• May or may not involve LOC
• Occasionally symptoms may be prolonged

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• AFL 5-6/1000 player hours
• Equals 6-7/season per team on average

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Symptoms Signs

• Symptoms - somatic (eg headache)
• - cognitive (eg feeling
  foggy)
• - emotional (eg lability)
• Signs eg loss of consciousness, amnesia
• Behavioural change (eg irritability)
• Cognitive impairment (eg slowed reaction times)
• Sleep disturbance (eg insomnia)

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On field/Sideline evaluation

• If ANY features of concussion
• Player requires evaluation if none available,
  remove from play and arrange assessment
• Standard emergency evaluation (ABCs), Cx spine
  assessment
• Assessment using appropriate tool (eg SCAT 3)
• Player not left alone
• If concussion no return to play that day

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• Diagnosis is a medical decision based on clinical
  judgement
• Traditional questions to assess orientation (T,P,
  P) unreliable
• Can be delayed

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In Emergency Room/Surgery

• Good history, detailed neuro exam (including
  mental status, cognition, gait, balance)
• Improving or deteriorating?
• Assess need for neuroimaging if need to exclude
  structural injury (prolonged disturbed LOC, focal
  deficit, deteriorating)
• (SCAT 3)

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Other Investigations

• Balance Error Scoring System (BESS) postural
  stability correlates well with overall
  neurological motor function
• Biomarkers genetic (eg Apo 4)
• - cytokines (eg IGF-1,
  S-100), in
• serum, CSF
• Electrophysiological EEG, evoked responses) -
  interesting, but significance
• unknown

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Neuropsychological Assessment

• Useful, but not practical except in professional
  setting
• Symptoms usually resolve first, so when used
  usually after player asymptomatic
• No evidence to support baseline neuropsych testing

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Concussion
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Management

• Key Points physical and cognitive rest until
• acute symptoms
  resolve
• - then graduated
  exertion to
• normal play
• No return to play on day of a concussion, esp
  school age, where cognitive deficits may not be
  present on the sideline, but may be delayed, more
  so than in adults

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Graduated RTP

• Usually 24 hrs for each level, so 1 week to
  progress to RTP from when asymptomatic at rest
• If symptoms recur, rest 24 hrs, and restart one
  level back, where was asymptomatic
• Elite v non-elite elite may have more
  resources, but their brains are the same, so
  management no different

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Persisting symptoms (gt10 days)

• 10-15 of concussions
• Consider other pathologies (imaging)
• Maybe multi-disciplinary approach physio,
  psychologist, neuropsychologist, vestibular rehab
  etc
• Pharmacology specific symptoms (eg sleep
  disturbance, anxiety)
• - modify
  pathophysiology to shorten symptoms -
  methylphenidate (Ritalin), amantadine. But.

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Children (lt13 yrs)

• Ist step is successful return to school, prior to
  physical activity, even physical ADLs
• Increased risk of cerebral swelling
• Need to be entirely symptom free before return to
  sport
• May take longer to recover than adults
• Child SCAT neuropsych more difficult as brain
  not mature, so hard to standardise tests
• Generally be more cautious

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Risks of too soon RTP

• Impaired performance, re-injury due to slower
  reaction times, for example
• 2nd impact acute severe cerebral swelling
• - ? disturbed auto
  regulation
• - case report level
• ?CTE seems to be greater risk of cognitive
  impairment, depression/other mental health issues
  amongst NFL players with multiple concussions
  but we dont know the type, number or severity of
  concussions required, and why a small only get
  CTE. So, err on the side of caution

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Chronic traumatic encephalopathy (CTE)

• Distinct tau-opathy
• Incidence in athletes unknown
• Cause and effect unknown
• ?Genetic disposition
• Other factors age, mental health, alcohol/drug
  use, medical co-morbidities largely not
  accounted for in studies to date

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Prevention

• Unfortunately, little evidence for protective
  gear. Mouthguards, football helmets good for
  dental, facial protection, but no evidence they
  decrease concussion. Also risk compensation,
  esp children, adolescents
• Skiing, snowboarding evidence, so recommended
• Cycling, equestrian, motor sports - prob protect
  against falls against hard surfaces, less skull
  s

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Thank you

• Visit BBS Website to download
• Pocket Concussion Recognition Tool
• SCAT 3
• Child SCAT 3
• Consensus statement on concussion in sport the
  4th International Conference on Concussion in
  Sport, held in Zurich, November 2012