Transcript Concussion signs and symptoms - University of Calgary Family

Concussion: Symptoms, Signs,
Measurement, Forces in
Concussion, and Management
Roger E. Thomas, MD, Ph.D, CCFP, FCFP,
MRCGP
Professor of Family Medicine, Faculty of
Medicine, University of Calgary, Canada
OUTLINE
1. Definition of concussion
2. Symptoms and signs of concussion
3. Incidence
4. Initial assessment
5. Measurement: SCAT2/3 (Sports
Concussion Assessment Tool)
6. Numbers and force of impacts in sports
7. Therapy for concussion
Definition: A form of head injury characterized by any
alteration in cerebral function and caused by a direct or
indirect (rotation) force transmitted to the head
Acute signs or symptoms:
• Brief loss of consciousness
• Light-headedness
• Vertigo, tinnitus, blurred vision,
photophobia
• Cognitive and memory dysfunction,
difficulty concentrating, amnesia
• Headache, nausea, vomiting
• Balance disturbance
Canadian Academy of Sport and exercise Medicine. 2010
Delaney J, Frankovich R. Discussion Paper. Head Injuries and Concussions in soccer.
Canadian Academy of Sport and Exercise Medicine. 2010.
Delayed signs and symptoms:
•Sleep irregularities
•Fatigue
•Personality changes
•Inability to perform usual daily
activities
•Depression or lethargy
Canadian Academy of Sport and exercise
Medicine. 2010
Incidence
•1/3 of all mild head injuries in US
occur in 5-19 year olds
•For children > 1 year trauma is
main cause of death, and head
trauma is leading cause of disability
and death
•In high schoolers 9% of athletic
injuries involve mild head injury
Improvement in symptoms
• Symptoms of 80% to 90% of cases appear to
improve in 7 to 10 days but the long-term
effects of cumulative concussions become
apparent
• 24.5% of 13 to 21 year olds still having disabling
symptoms at one month
• 5.9% remain symptomatic after six months
• Symptoms can persist > one year
• Symptoms of repeated concussions can last a
lifetime
Comprehensive initial assessment
•Symptoms
•Details of the mechanism of
injury
•The time line of symptoms
•Aggravating factors
•Rule out child abuse
Full Physical exam, focused on Head
• Signs of trauma
• Lacerations and abrasions
• Skull fractures (depression,
discontinuity)
• Basilar skull fracture
Hemotympanum
drainage of fluid or blood from the nose or ears
Battle’s sign (bleeding behind the ear)
Physical Exam
MEASURING CONCUSSION
Systematic review of all SCAT2 and 3 tests by
Thomas, Alves, Magalhães and Vaska
•Searched 18 databases, 9 grey literature
resources searched for SCAT2/3 data; 9,150
articles identified
•21 studies with data
16 SCAT2 studies with partial/complete
data (4,087 athletes)
5 SCAT3 studies (891 athletes)
•1,067 females; 3,831 males; 80 gender not
stated
Systematic review of all SCAT2 and 3 tests
by Thomas, Alves, Magalhães and Vaska
• Only 1 study reported SCAT data for a professional league
(Finnish ice hockey players)
• Minimal data on elementary students
• No data on adult non-collegiate athletes
• Concussion: Only 2 studies report both baseline and postconcussion scores and 9 report partial scores but data are
too limited to provide weighted average scores
• Unwitnessed concussions: A study of rugby players during
62 games noted 52 concussions (44/1000match hours) with
8 witnessed concussions but 44 unwitnessed concussions
identified post-match by the King-Devick test
Weighted mean SCAT2 scores by age group (21
studies)
Age group
High school
students
Collegiate/Uni
versity/Adult
non-university
Symptom
Score (SD)
(perfect
score = no
symptoms
= 22 points)
18.46
BESS
(Balance)
total (SD)
(perfect
score = 30
points)
26.14
20.09
25.54
26.00
SCAT2
scores
(SD)
(perfect
score =
100)
88.63
27.51
91.20
SAC total
(SD)
(perfect
score = 30
points)
Perfect scores may not be attained because of age
differences in ability to repeat digits and months of the year
backwards
Study, date Age (years),
gender
Repeat 4
digits (%)
Repeat 5
digits (%)
Repeat 6
digits (%)
Repeat
months of
year
backwards
(%)
Glaviano
2015
Males, 12
85
65
31
65
Jinguji,
2012
Males, 1315
69
37
12
57
Jinguji,
2012
Males, 1619
79
37
21
70
Glaviano,
2015
Males, 18
100
82
72
82
Shehata,
2009
Males, 20
51
92
Preseason baseline SCAT2 scores 1134 High School
Arizona athletes
Instructions for the Balance Error Exam
(also printed at end of the SCAT3)
3 stance tests timed over 20 seconds:
• all without shoes, socks and trousers rolled
above ankle so you can observe balance
• all hands on hips, eyes closed
1. Double leg stance. Feet together.
2. Single leg stance. Stand on non-dominant
foot, with dominant leg 30 degrees hip
flexion, 45 degrees knee flexion
3. Tandem stance: heel-to-toe, non-dominant
foot behind
SCAT3 Balance exam: scoring errors
Take off one point for each error during each 20
second test (max errors = 10 for each test)
1. Lifted hands off iliac crest
2. Opened eyes
3. Step, stumble or fall
4. Moved hip into > 30 degrees abduction
5. Lifted forefoot or heel
6. Remained out of test position > 5 seconds
SCAT3 balance tests:
Tandem gait
• Walk heel-toe along 38 mm wide tape for 3 meters
then return
• 4 trials and choose best time (should complete in
14 seconds)
• Fail test if step off the line, or separate heel and
toe, or grab an object for support
Finger-Nose
• Starting position: sit on chair, shoulder flexed to 90
degrees, elbow and fingers extended
• Now touch nose and return to starting position 5 x
• Score 1 point for 5 correct repetitions in < 4
seconds
Systematic review of all SCAT2 and 3 tests
by Thomas, Alves, Magalhães and Vaska
• Only 1 study reported SCAT data for a professional
league (Finnish ice hockey players)
• Minimal data on elementary students
• No data on adult non-collegiate athletes
• Concussion: Only 2 studies report both baseline and
post-concussion scores and 9 report partial scores but
data are too limited to provide weighted average scores
• Unwitnessed concussions: A study of rugby players
during 62 games noted 52 concussions (44/1000 match
hours) with 8 witnessed concussions but 44
unwitnessed concussions identified post-match by the
King-Devick test
Summary: Amount of data
• Generalisability of results highest for a study of
Finnish professional male ice hockey which
assessed most players in the league
• Generalisability lowest for studies of individual
schools or studies including many sports.
• SCAT component average scores were
homogeneous between samples
• Considerable heterogeneity within samples.
• No strong differences between genders.
Summary: problems collecting data on
concussions
No uniformity across sports:
• In pre-season SCAT testing to obtain baseline scores
• Numbers of observers to increase the likelihood of
detecting concussions during play
• Using King-Devick tests to detect unwitnessed
concussions.
Urgently need:
• Systematic adoption of continuous follow-up
assessments including complete SCAT and KingDevick testing in all age ranges of amateur and
professional sports
• Follow them if concussed until fully recovered.
Summary: Comprehensive use of SCAT
3 with medical examinations and
neuropsychological testing
Minimum Clinically Important Differences in SCAT
scores:
• have not been defined
• would need to be based on careful assessments by
several assessors with minimal intra- and interobserver variability
• detailed follow-up of athletes to determine full recovery
and appropriate return to play.
Until these problems have been solved the SCAT
should be used cautiously for clinical and return-toplay decision processes and also need:
• extensive medical examination
• quantitative neuropsychological testing
Initial Management
• Allow player/child to sleep, checked regularly for clinical
deterioration
• Avoid medications that affect evaluation of cognition
(e.g. meclizine, benzodiazepines), mask symptoms (e.g.
anti-emetics) or facilitate bleeding (e.g. ASA, NSAIDs)
• Avoid participation in sports/physical activities. Make
this clear to parents, coaches, trainers and teachers
• Gradual return to mental and physical activities
• Regular assessments
Initial Management: Rest and no
intense mental activities:
•
•
•
•
•
•
Reading
Computers
Videogame
Puzzles, Sudokus
Texting, TV
Schoolwork
HOW MANY SPORTS INJURIES
ARE THERE?
• US National Electronic Injury Surveillance
System 2001-12
• 3.42 million emergency department visits for
sports- and recreation-related trumatic brain
injury
• 70% ages 0-19
• Males: bicycling, American football, basketball
• Females: bicycling, playgound, horseback
riding
Boxing: US National Electronic Injury
Surveillance System (NEISS) from a sample of
100 hospitals 1990-2008
• Extrapolated to US population: 165,502 injuries
• Rate of boxing participation computed using Superstudy of Sports
Participation database.
• Injuries: fractures (27.5%), soft tissue (26%), sprains/strains (22%),
lacerations (8.8%), concussion (5.1%), dislocations (3.7%)
• Injury rate males 13.3/1000, females 8.9/1000;
• 12-17 years 14/1000, 18-24 years 16.4/1000, 25-34 years
13.6/1000
• Concussions as % of injuries: age 12-17 8.9%, 18-24 8.1%, 25-34
8.5%
• 36.8% of all injuries occurred hitting or missing punching bag
Measuring impacts in soccer
Collegiate athletes head the ball 2.8-8.5 times/game and > 500
times/season
Summary of 18 studies of heading soccer balls:
• higher accelerations of head if low head/neck mass
• lower accelerations if align head and torso and follow
through with head
• Heading a ball:
 28.7g head acceleration if ball 6psi (pounds/square inch
pressure) and 15m/s speed
 50.7g if ball at 8 psi and 22.4 m/s (Caccese 2016)
Number of impacts: American Football
• 22 high school football players wore helmets with 6
accelerometers
• Head impacts: median 9/practice (range 2-22),
12/game (range 6-18), 252/season (306 for those who
participated in ≥ 66% of sessions)
• Maximum for an individual player was 54 for a practice,
50 for a game and 880 for a season.
• Team head impacts: 6183/season (61% in the 27
practices, 33% in the 9 games and 6% in pre-game
warm-ups)
• Average linear acceleration: 25.5g (range 10,175.9g)
• Average rotational acceleration: 1691.8 rad/s2 (range
7.1, 12,322.5)
Number of impacts: American
Football
Total head accelerations received by 20 University of
Virginia American football players/player/season
• Average number of head impacts (> 10g) = 974
(maximum 2277)
• Average cumulative Peak Linear Acceleration =
29,233g (maximum 76,296g)
• Average cumulative Peak Rotational Acceleration =
5,857,749 rad/s2 (maximum 16,174,965 rad/s2)
(Reynolds 2015)
Mixed Martial Arts
Author, date,
competitors
Setting; method of defining
injury and concussion
Injury rate
Hutchison 2016,
USA.
 508 competitors,
males, avg age
30 years
 3 rounds, each 5
minutes
 All KOs and TKOs
from 844 numbered
Ultimate Fighting
Championship MMA
events 2006-2012;
 Video, scorecards,
fighters’ histories on
www.UFC.com
 KO rate 64/1000 AE (12.7% of matches)
 TKO due to repetitive strikes 95/1000 AE (19.1%
of matches)
 average time KO-strike to match stoppage 3.5
secs (range, 0-20 seconds), losers received
average 2.6 additional strikes (range, 0-20
strikes) to head;
 for TKOs during 30 seconds interval immediately
preceding match stoppage, losers received
average 18.5 strikes (range, 5-46), 92.3% to head
McClain 2014, USA
 657 males, 54
females
 556 amateurs,
155
professionals
 3 - 5 rounds, 3-5
minutes/round
MMA competitions,
Kansas, Missouri, 20082012
 physician exam after
bouts
 Altered mental state:
fighter’s inability to
orient themselves to
person, place, or
time
 121 injuries (85/1000AEs); 5.6% of 2178 rounds
 KO/TKO 29%; submission 55.3%, decision
14.9%;
 Injury type: males lacerations/abrasions 38%,
altered mental state 22%, fractures 17%
 females: lacerations/abrasions 27%, fractures
27%; altered mental state 9%
How many concussions are there?
The more detailed the data collection the
higher the rate
1% of high school athletes, Minneapolis/St Paul, Minnesota.
[trainers entered concussion details in Reporting Information
Online system of the Nationwide Children’s Hospital of
Columbus, Ohio]
• 3% of athletes at two Canadian universities (2.58%
females, 3.39% males)
Boxing: post-fight medical examinations of all 550 boxers
and 1181 mixed martial artists (MMA) in Edmonton, Canada,
2000-2013
• 10.4% of boxers and 8.3% of MMA had concussions
• 7.1% of boxers and 4.2% MMA loss of consciousness
• Boxers average 26 and MMA 20 days post-bout medical
suspensions
How many concussions? The more detailed
the data collection the higher the rate
Motocross motor bike racers:
48% of 139 motocross under 18 concussed/
racing season (range 1-5 concussions)
(average age 12 years)
• 61% continued racing the same day and 24%
the entire season
• 33% had concussions from multiple sources
other than motocross
Specific activities within sports
cause the highest percentage of
concussions in that sport:
• Soccer: heading ball (40.5%), goaltending
(20.5%), receiving a pass (10.5%)
• American Football: running play
offense/defence (55.4%), passing play
offence/defence (16.3%)
• Wrestling: takedown (42.8%) and sparring
(21.9%)
• Basketball: rebounding (30.5%) and chasing a
loose ball (26%); and
• Baseball/softball: batting (50.6%)
Multiple cellular changes occur during a
concussion
 efflux of potassium and influx of sodium
increase in intra-axonal calcium which triggers calpain-mediated
proteolysis of the cytoskeletal proteins
glutamate release leading to increased glucose consumption
acidosis and cerebral edema
microtubule disassembly impairing axonal transport
swelling of axons and disconnection at the site of injury (usually deep
gyri at the white and grey matter interfaces)
biomarker research incudes:
NFL (found in large calibre myelinated axons which project to the
spinal cord and deep brain regions
tau proteins (found in non-myelinated axons of cortical
interneurons)
Second Impact Syndrome
Can occur after a concussion if further blows to
the head result in:
 loss of autoregulation of the cerebral
circulation
 massive brain edema
What forces are received during
daily activities?
Head accelerations from 7 impacts in daily life
• Each tested by 10-20 subjects who wore triaxial head
accelerometers and 2 bite block accelerometers
 soccer ball impact to forehead (5-11.5 cms/sec)
self-imposed hand strike to forehead
vigorous head shaking
plopping down in chair
jumping off step (30-90 cms)
seated drop onto buttocks 5-10cm drop)
vertical drop while seated supine in chair 5-10cms
Head accelerations from daily activities
Linear acceleration (g) ± one
standard deviation
Rotational acceleration
(radians/sec2) ± one standard
deviation
121 ± 4.9
2217 ± 356
Headstrike:
11 ± 4.1
277 ± 88
Headshake:
3.8 ± 1.2
214 ± 94
Chair plop:
3.7 ± 2.1
169 ± 151
Chair tip:
6.0 ± 2.1
496 ±116
Jump from 90 cms:
6.4 ± 1.9
138 ± 67
Seated drop of
10cms
4.8 ± 0.9
170 ± 71
Activity
Soccer ball at
11.5m/s:
Head accelerations received by
soccer players
• 16 Collegiate soccer players headed wearing
mouthpiece with three accelerometers, soccer machine
accelerated balls (8 pounds/square inch pressure): to
30, 40 or 60 mph
Ball speed m/sec-2
13.4
Linear acceleration
(g)
39.7
17.9
49.2
22.4
50.7
Head accelerations received by
American Football players
• Reconstruction in laboratory of 31 of the 182
concussions in US National Football league 19962001
Activity
Linear acceleration (g) ± one
standard deviation
Rotational acceleration
(radians/sec2) ± one
standard deviation
25 concussed players
who were hit
6 non-concussed hit
players
27 con-concussed
striking players
107.6(26.1)
6730(1854)
57.5(4.1)
4446 (1059)
48.3(21.8)
3470(1113)
At what forces do concussions occur?
• Concussions tend to occur above linear accelerations ≥ 50 g
• Rotational accelerations are more important in the combination of
rotational and linear accelerations in causing concussions
Rotational acceleration
radians/sec2)
6383
6945
7482
Risk of concussion
50%
75%
90%
• Concussions occur all the way down to rotational accelerations
< 1000 radians/sec2
Effects of concussions?
66 US Major League Baseball players who
sustained a concussion 2007- 2013 were
identified through league disabled-list records
Compared to 68 players on paternity or
bereavement leave same period
Concussed players 2 weeks after return
lower performance (p<.05):
batting average
.235 vs .266
on-base percentage .294 vs .326
slugging percentage .361 vs .423
onbase plus slugging .650 vs .749
Methods of reducing head injuries
1. Training to avoid contact (Taekwondo)
2. Rules to outlaw dangerous manoevres (Mixed Martial
Arts)
3. Training to avoid dangerous manoevres
4. Training to block dangerous manoevres
5. In pair sports, pair opponents of similar weight,
training and match success (Boxing)
6. Shorter matches (Taekwondo 3 bouts of 3-5 minutes
vs. boxing 14 bouts)
7. Train coaches and referees to enforce rules
8. Remove dangerous players
9. Better protective gear
Athletes still receive major impacts wearing
boxing and Taekwondo helmets
(Hybrid III Crash Test Dummy head and neck hit at 8±0.3 m/s)
Adidas boxing helmet
Front: 217 ±22g
Side: 320 ±70g
Rotational head
acceleration (rad/s2)
with standard
deviation
Front: 5197 ±1600
Side: 7997 ±552
Greenhills boxing
helmet
Front: 293 ±36g
Side: 268 ±60g
Front: 14,065 ±8502
Side: 4427 ±590
Adidas taekwondo
helmet
Front: 281 ±8g
Side: 294 ±15g
Front: 14,010 ±5021
Side: 3554 ±468
Nike taekwondo
helmet
Front: 327 ±38g
Side: 386 ±25g
Front: 20,519 ±5037
Side: 8703 ±3287
O’Sullivan 2016
Linear head
acceleration (g) with
standard deviation
2 layers of foam on helmets reduce head
accelerations
• Helmets with HIT system accelerometers
• In laboratory 10 hits on each of 9 helmets from 0 layers
polyolefin foam to 2 layers of foam on both helmet and
impacting helmet
Amount of foam
padding on helmets
No foam:
2 layers foam on both
helmet and impacting
helmet
Linear acceleration (g) ±
one standard deviation
Rotational acceleration
(radians/sec2) ± one
standard deviation
38.14( 1.4)
3418 (13)
26.2 (1.2)
2416 (102)
Conclusions: numbers of concussions
•There are large numbers of impacts in
contact sports per player and season
•American football, ice hockey, soccer,
boxing, martial arts, wrestling
motocross have the highest concussion
rates
•There are far more unobserved and
undocumented than observed and
documented impacts and concussions in
sports
Conclusions: effects of concussions
on tissues
• Shearing of interneuronal connections is an important
cause in concussions and occurs more by rotational than
linear head accelerations
• Forces sufficient to cause concussions also show
damage to animal, cadaver and operation specimens
• Cumulative effect of subclinical impacts is not
known
• Rules to avoid injuries and enforcement of rules
reduces injuries and concussions
• 2 layers of padding on helmets reduces linear and
rotational impacts by 30%
What therapy can we offer?
Systematic review of therapy for mild brain injury/concussion.
Thomas RE, Alves J, Magalhães R, Vaska M
Problem
Attention and Information
Processing Speed
Executive Function and SelfAwareness
Cognition and cognitive therapy
Memory
TOTALS
No of
RCTs
Patients
randomised
6
345
11
526
11
7
1245
321
35
2437
Attention and Information Processing Speed
• 2 methylphenidate trials found attention and
processing speed improved (at the .03 level or higher)
• 4 psychological cognitive intervention trials: 2
showed significant effects on attention and cognition at
the .05 level or higher:
Tiersky used CBT and cognitive remediation during
55 hours of intervention
Fasotti used 6 to 9 hours of Time Pressure and
Management Strategy training and found both training
groups improved equally.
Executive Function and Self-Awareness
• 11/12 RCTs significant positive effects:
• 6 RCTs metacognitive strategy instruction for difficulty
problem solving, planning and organization, focused on
everyday problems and functional outcomes, with selfmonitoring and incorporating feedback into future
performance
• 2 RCTs for impaired reasoning skills use strategies to
improve the capacity to analyze and synthesize
information
• 1 RCT corrective feedback to improve self-awareness
to treat awareness deficits
• 2 RCTs group-based interventions to remediate
executive and problem-solving deficits
Cognition and cognitive therapy
10/11 RCTs significant positive results:
rehearse communication skills in situations
appropriate to the context in which person lives, works,
studies and socializes
use interventions to address patient-identified goals
for social communication deficits, and measure
outcomes and participation in everyday social life
CBT usually included psychotherapy and stress
management, and specific concussion problems of
memory, cognition, concentration, problem solving, selfmonitoring for improvement, and generalizing skills to
work and social environments
Only 1 RCT provided supervised work: 50% of
former soldiers obtained work
Memory
5/7 RCTs significant positive results:
3 RCTs instructional and/or metacognitive
strategies
• visualization
• repeated and retrieval practice
• PQRST (preview, question, read, self-recitation, test),
• self-cueing
• self-generation
• self-talk)
2 RCTs environmental supports, prompts and
reminders (e.g., NeuroPage, paging, mobile/
smartphones).
How families and friends can help
“Communication partners” could help:
• individual identify problems due to the concussion or
made worse by the concussion
• test ways to help individual improve deficits of
attention, communication, executive skills and memory
• help reintegration in home and work environments
Family members and work colleagues:
• know individual well
• are ideally placed to identify deficits, how individual
is responding to interventions to reintegrate into home
and work life and return to a competitive employment
environment.
3 ways families and friends can help
(1) Refresh work skills
• Bring key manual from work, help read and simplify
manual
• plan usual activities at work based on the manual
• solve problems together
• rehearse skills in short sessions before fatigue
begins
• suggest strategies appropriate to the person to
improve comprehension, memory and planning
and execution
3 ways families and friends can help
(2) Plan daily activities at home
•If memory is a problem then list the
steps in common tasks, e.g.:
•getting ready in the morning
•planning and preparing shopping
and meals
•laundry
3 ways families and friends can help
(3) Diarize tasks
• Modern society runs on coordinating
activities and information
• “communication partner” can show the patient
how to use the cell phone to plan activities
and link them to key persons who need
contacting for each activity
• A common diary would be even more helpful
so that the communication partner can follow
the patient’s progress and make suggestions
and reminders
Conclusions
1. High rates of injuries
There are high rates of injuries among all age groups in contact
sports
2. Marked underreporting and major effort needed to collect
complete data on all athletes
There is marked under-reporting and under-detection of
concussions
There needs to be uniform measurement by SCAT of all athletes in
contact or high risk sports before game seasons, after any
concussion, and until recovery is complete
3. It is known at what level forces cause concussion
The risk of concussions is 50% at linear accelerations > 50 g and
rotational accelerations > 6000radians/sec2
The cumulative effects of concussions are best known in ice
hockey and American Football
There is limited research at low risk of bias on the effects of
cumulative concussive and sub-concussive impacts
Conclusions
4. Sporting organisations need huge change
Sports need to change to non-contact formats
Major efforts to improve adherence to rules and
training to avoid contact in sports are required
5. Intensive therapy is required to replace neuronal
interconnections damaged by the concussion
 There are 35 RCTs of therapy for concussion. Most
are small, at medium risk of bias, and only one was
designed directly to lead back to employment
The concussed individual has lost many
interconnections built up over a lifetime between
neurons
A family member can be very helpful as a
communication partner identifying problems and
helping with therapy