Ricardo E. Colberg, M.D., RMSKAndrews Sports Medicine & Orthopedic Center

American Sports Medicine Institute

Update on Concussions

in Soccer

How many here have had a concussion?

Overview

• Definitions• Signs & symptoms• Management• Complications• Prevention

Epidemiology

What is a Concussion?

• Definitiono Brain irritation secondary to ao Direct blow or indirect force transmitted to the heado Manifesting with neurologic signs or symptoms.o Loss of consciousness may not happen.o Usually heals within two weeks of the injury.

Assessment of the injured athlete

Injured athlete

Loss of consciousness

Immobilize the neck

Consider CPR

Call EMS

No loss of consciousness

Sideline evaluation

Refer to a physician

Sideline evaluation

• Anyone with symptoms of a concussion needs to be removed from play and seek medical evaluation.o If in doubt, sit them out. No ‘return to play’ on same day.

• Symptoms could arise over the first 48 hours. o The athlete may sleep but should not be left alone.

• The athlete must go to the E.R. at once if they:-- Have signs or symptoms of a stroke-- Have persistent loss of consciousness-- Have seizures (arms and legs jerk uncontrollably)-- Have weakness of arms and legs

Remember, it is always better to be safe than sorry.

How many here have had a concussion?

Signs and symptoms

Grading Scales are no longer used

• Scales do not predict severity of the injury• American Academy of Neurology, Colorado Medical Society, etc.

• ANY NEUROLOGIC DEFICIT AFTER A HEAD INJURY IS A CONCUSSION• “I got my bells rung”• “Dizzy”• “Headache”• “I am seeing stars”• Confusion • Etc.

Coaches’ 4-step action plan

The CDC recommends a 4-step action plan to manage sports-related concussion:

1. Remove the athlete from play.2. Refer the athlete to a physician experienced in evaluating

concussions.3. Inform the parents about the possible concussion and give them

the CDC fact sheet on concussion.4. Keep the athlete out of play until a physician gives a written

clearance.

Radiographic imaging

• Conventional imaging is typically normal in concussion• MRI or CT scan is not routinely ordered for the average concussion

• Who do we image with CT scan or MRI?o Athletes with: o Suspicion of skull fracture, brain bleed, or spinal cord injuryo Seizureso Persistent unconsciousness

Cognitive Testing Tools• SCAT 3

o The GOLD STANDARD for an acute concussion evaluation

• Computerized TestingImPACT, CRI, CogSport, ANAMo Valid only if tested prior to start of season so there is a baseline to

compare too It measure multiple aspects of cognitive function and concentration

• Neuropsychlogic Testingo Formal pencil/paper testing

Best reserved for patients with prolonged cognitive symptoms that need reasonable accommodation at school

Management

• REST, Rest, rest...o Cognitive

Limited school activity No TV, movies, texting, computer use May not attend or watch practices/games No driving

o Physical No sports or exercise until symptom-free for 24 hours and

have physician clearance Headache or neck pain Offer only Acetaminophen (e.g. Tylenol). Do not use aspirin

or anti-inflammatory medication.

Return to Play Guidelines

They must be symptom-free for 24 hours to start this Protocol

Complications

• Post-concussion syndromeo Persistent symptoms lasting >3 months

• Second impact syndromeo Catastrophic cerebral swelling that may lead to

deatho Usually occurs when there is still residual

inflammation in the brain and the athlete returns to play and sustains a second head injury.

Complications• Chronic Traumatic Encephalopathy

o Progressive degenerative brain disease from repetitive impacto Atrophy of the braino Psychiatric disorders (i.e. depression, suicidal thoughts)

o Diagnosis is done with cadaver biopsy Initial signs and symptoms may not manifest for decades

Patrick Grange was the first soccer player to be diagnosed with CTE.

Legislation

• Alabamao HB 108- 6/9/2011

o "Any player who shows signs, symptoms or behaviors associated with a concussion must be removed from the game and shall not return to play until a medical release is issued by a medical doctor.“

o Coaches, parents, and student athletes must attend annual training programs on concussions

Additional Resources

• CDC- "Heads Up"o Videos, guides and online training for coaches,

posters, fact sheets for parents and athletes -www.cdc.gov/concussion/HeadsUp/youth.html

Common questions• Are there more concussions now than before?

o Yes. A study reviewed hundreds of hours of videotape and found that Referees have, over time, allowed more rough play. This has led to more aggressive style of play, more collisions, and more concussions.

• Are girls more likely to suffer concussions?o Maybe. A 2013 Institute of Medicine study points to boys’ stronger

necks, yet another study showed that neck strengthening exercises in female athletes have not decreased the rate of concussions. Another study showed that girls are more honest and likely to report an injury than boys.

• Are children more likely to get a concussion?o Yes. The neck muscles are smaller in relationship to the head and

cannot absorb the impact appropriately (ex. Bobbleheads) In addition, they are more likely to head the ball with the wrong technique. Finally, the child’s brain swells more easily after an injury than in adults.

• Do helmets/head gear prevent concussions?o No. Studies have shown that head gear decrease lacerations but do not

decrease the force transmitted to the brain and do not decrease the rate of concussions.

o In fact, head gear give a false sense of protection that leads to more aggressive play and an increase risk of concussions.

• As a coach, can I prevent a concussion?o YES! Teach athletes proper heading technique, foster good

sportsmanship, do not tolerate and permit aggressive behavior from players, and encourage athletes to be honest and open about reporting symptoms of a concussion.

Common questions

Questions?

It is always betterto miss one game

than a lifetime of seasons…