Concussion:Return to Riding

Concussion:Return to Riding

Concussion: Return to Riding Kenneth Perrine, Ph.D Department of Neurological Surgery Weill-Cornell Medical College Topics

Traumatic Brain Injury Concussion ER and early treatment Natural progression of concussion Return to riding Jockeys the LAST athletes to discuss and set voluntary or mandated guidelines for concussion Junior high school soccer teams have more awareness and guidelines than jockeys My Goals Teach you about concussion Discuss how to manage concussion, return to riding I get it

Little to no health insurance Not under contract/salary paid for each race Eat what you kill 1099 income If you acknowledge concussion, you sit out races and lose money But: Make informed, rational decisions Think of your future and that of your family Concussion or Brain Injury? Not all blows to the head are concussions Are on a continuum Concussion or Mild Traumatic Brain Injury (mTBI) Moderate Traumatic Brain Injury

Severe Traumatic Brain Injury Type of injury drastically affects outcome Will discuss TBI (moderate or severe) first Definition of TBI Damage to brain tissue caused by mechanical force All of the following: Loss of consciousness Retrograde Amnesia (amnesia for events before injury) Post Traumatic Amnesia (amnesia for events after injury and after resumption of consciousness) Skull fracture, facial fracture, brain contusions, bleeding in the brain or between the brain and skull, brain swelling

Objective neurological findings (e.g., weakness, deficits in pupil response or eye movements, etc.) Objective findings on mental status examination (orientation to time, place, person; attention; memory; other cognitive skills) Mechanisms of TBI Mechanisms of brain injury: Contact injuries: object strikes the head or head strikes object (falls) Acceleration/deceleration injuries: movement of the brain within the skull. E.g., car accidents with air bag deployed Open TBI: object penetrates brain (bullet, shrapnel, etc.)

Injuries can be focal (affecting just one region of the brain) or diffuse (affecting the brain in a widespread pattern) Result can be mTBI or moderate/severe TBI Classification of TBI Severity Glasgow Coma Scale (GCS) immediately after injury Best motor response Best verbal response Best eye response Duration of true loss of consciousness Duration of post traumatic amnesia (PTA): time between resumption of consciousness and laying

down new memories (e.g., awake and talking in ER but no recollection of it later) Findings Following Moderate/Severe TBI Skull fractures Displaced Depressed into brain

Leakage of cerebral spinal fluid from nose or ears Contusions (bruising) of brain Hematoma (bleeding) in brain Subdural hematoma (slow venous bleeding) Epidural hematoma (rapid arterial bleeding) Diffuse axonal injury (DAI- tearing/shearing of the long fibers leading down from the cortical grey matter Neuron and Axon Course of Recovery from Severe TBI

Coma Vegetativ e State Minimall y Consciou s State Confused State PTA

Recovery Functional Outcomes Return to work and independent living Injury severity is predictive of functional outcomes Duration of PTA is best predictor of outcome Pre-injury factors are also predictive of functional outcomes Outcomes Following Moderate/Severe TBI Death

Vegetative state Good recovery Severe disability Moderate disability Implications for Jockeys Recovering from Moderate/Severe TBI Good Recovery (~50%) usually takes 3-4 years, and is helped by treatment in a specialized rehab facility Still a risk of greater injury with less severe impact (more

likely to sustain another skull fracture or concussion) Moderate Disability usually results in ability to function in another job but with residual cognitive deficits (especially memory) and struggles to succeed at work as well as personality problems (frustration tolerance, anger outbursts, impulsivity, etc.) Severe Disability usually means an inability to work at any job and with significant psychosocial problems Return to Riding should NOT be considered after a moderate or severe TBI: High risk of sustaining a severe TBI resulting in death or permanent disability Concussion Less severe form of TBI (mTBI) Does not result in structural brain damage on

CT/MRI Damage is neurochemical, not to brain substance Usually resolves without any lasting problems Definition of Concussion (4th Zurich Conference Direct blow to the head, face, neck or elsewhere with animpulsive force transmitted to the head. Rapid onset of short-lived neurological impairment that resolves spontaneously. Sometimes, symptoms and signs may evolve over minutes to hours. May result in neuropathological changes, but acute symptoms

reflect a functional disturbance rather than structural usually normal neuroimaging studies May or may not involve loss of consciousness. Resolution of the symptoms typically follows a sequential course. However, in some cases symptoms may be prolonged. Other Aspects of Concussion Do NOT need to have LOC most have at most brief LOC Bell rung Ding Seeing Stars may or may not be concussions Retrograde Amnesia usually brief Post-traumatic Amnesia (PTA) can be extensive (remembering only ER)

Many Post-Concussion Symptoms (PCS) Post-Concussion Symptoms Physical Cognitive Headache Feels mentally Irritability foggy Drowsiness

Nausea/ Vomiting Poor concentration Sadness Onset insomnia Balance problems

Poor memory Nervous/ Anxious Sleeping less than usual Visual problems Slow responses

More emotional Sleeping more than usual Fatigue Repeats questions Sensitivity to light/noise

Confused about recent events Looks dazed Emotional Sleep Concussion Modifiers (Zurich)

Prolonged (>1 min.) LOC, amnesia Number, severity, duration of symptoms Recent concussion(s) Concussion from less impact than prior concussion Co-morbidities of migraine or mental health disorders, ADHD, learning disabilities, sleep disorders Use of psychoactive drugs or anti-coagulants Dangerous sport, high-risk activity (falling off of a horse galloping at 40-50mph and being trampled)

Concussion in Riding Its not a matter of IF I have another concussion, its a matter of WHEN I do More concussions than in ANY other sport Not the repeated sub-concussive blows of boxing, football or hockey, but very severe when occurs Collision with ground, your own horse, other horses Better helmets alone are not the answer but do help Immediate Management: Ideal but Recognizing Realities of Riding

SPORT Remove from riding Sideline assessment with SCAT-3 by physician or other licensed healthcare provider SPORT OR NON-SPORT Follow CDC guidelines Return too quickly can result in concussion from less impact Try NOT to ride again that program if symptomatic Transport to ER

By ambulance if: Suspected spinal cord involvement Focal neurologic deficit (paralyzed/weak, sensory loss, speech) Condition worsens (subjective symptomss, nausea, vomiting, balance, fatigue, decline in mental status) Raccoon eyes, bruising behind ear Bleeding from nose or ear Seizure/convulsion If dont transport, alert caretaker and give CDC fact sheet on what to watch out for after concussion

When to DEMAND CT New Orleans Criteria: GCS = 15 Canadian Rule: GCS = 13 15 Headache GCS < 15 within 2 hr after injury Vomiting Suspected open/depressed

skull fx Age > 60 Any sign of basal skull fracture (otorrhea, rhinorrhea, raccoon eyes, Battles sign) Drug/alcohol intoxication >=2 episodes of vomiting Persistent anterograde amnesia

Age > 65 Soft-tissue or bone injury above clavicle Retrograde Amnesia >= 30 minutes Seizure Dangerous mechanism (MVA After Concussion

Not left alone, go to hospital if any of following Headache that WORSENS Drowsy and cannot be woken up Cant recognize people or places

Repeated vomiting Confusion/irritability worsens Seizures Weakness/paralysis, numbness Unsteady on feet Slurred speech First Few Days Rest & avoid strenuous activity if symptoms worsen No alcohol/recreational drugs No sleeping medication (can mask bleeding in brain) Avoid aspirin or NSAIDs for headache can mask

Avoid driving if possible until symptoms improve NO exercise or riding until symptoms improve Recovery Most uncomplicated concussions resolve in 1-2 weeks If more than a few symptoms, or some severe, consider evaluation at a concussion clinic COMPLETE cognitive and physical rest is no longer considered appropriate Tailor rest to symptoms if activity produces/exacerbates symptoms, back off As recovery progresses, increase activity

Natural Progression of Uncomplicated Concussion Gradual resolution of symptoms over 2-4 weeks, complete usually by 3 months Some football/hockey players can play in 1 week Most patients recover fully Miserable Minority take longer with persisting symptoms Longer recovery if prior concussions NFL and NHL Protocol NHL: ImPACT computerized battery at baseline After concussion:

Wait until mostly symptom free Repeat ImPACT and get brief neurocognitive testing NFL: Same as above, except baseline neurocognitive testing Both: If pass ImPACT and neurocognitive testing Gradually escalating exercise Move on only if asymptomatic at each step Exercise

Light exercise (walking, riding exercise bike) Running, interval bike sprints, vigorous exercise Non-contact drills in full equipment; lifting (riding horse, not racing) Limited, controlled return to full practice (riding: practice racing) Return to racing When to Refer for Neurocognitive Testing PCS symptoms are not getting better History of multiple prior concussions Positive findings on neuroimaging, neurologic examination Suspicion of non-sports related factors

Neuropsychological Evaluations Should be brief and targeted to concussion signs and symptoms actual testing < 1 hour Computerized testing MAY be helpful, especially if there is a VALID baseline Paper-and-Pencil, face-to-face testing more valid Recommendations should make sense, and not include snake-oil invalid tests Utilizing a Neuropsychologist Pro: Can monitor effort, reliability

Look in their eyes Non-sports related issues family, financial Flexibility to target specific symptom complexes Sensitivity/specificity of neurocognitive tests Con: Cost Availability Computerized Batteries

Reliability is very poor Confusion over instructions Wrong buttons Accidentally moving screen to screen No way to monitor effort Sandbagging at baseline (intentional poor effort) Computer glitches screen savers, backups No measure of delayed recall memory

ImPACT Battery 6 subtests and a symptom checklist Combined to form composites: Verbal Memory Visual Memory Visual Motor Reaction Time Impulse Control Norms and Reliable Change Indexes Studies by researchers not affiliated with ImPACT show very poor reliability My Paper-and-Pencil Battery: <30

$200-$300 Post-Concussion Scale (21 signs/symptoms) Verbal learning

Non-verbal learning Visuo-motor sequencing/speed Visuo-motor learning Attention/concentration Fine motor speed Frontal executive/cognitive speed Balance Errors Scoring System (BESS) Review of ImPACT computerized battery and SCAT-3 Memory: List Learning Read & Recall 3 Times, hour delay: Fork Rum

F Pan Pistol Sword Spatula Bourbon Vodka Pot Bomb Rifle Wine Case Example: NY Jet

Concussed during play, not noticed at first Continued to play (defense) Other players alerted ATCs Pulled, failed SCAT-2 Had to hide his helmet to keep him from returning to play Day after Neuropsych Assessment

at Practice (Red Jersey) Progression of Player Passed ImPACT testing with scores > 90%ile Neurologist cleared to play but I was suspicious due to paper-pencil testing and interview Referred to Cornell neurologist who found cerebellar deficits MRI/DTI showed Diffuse Axonal Injury Previous year I had returned him too early DAI on MRI

Controversies Media hype exceeds science and facts, especially: NY Times ESPN Sports Illustrated Concussions ARE problem, but writers are out for prizes and fame Front page NYT article on concussions by Alan Schwarz was full of errors (I saw the player he highlighted). I wrote a letter to the editor of NYT correcting errors, not published. Schwarz won a Pulitzer Prize for the article.

Dont believe everything you read, ANYWHERE! Conclusions Moderate to severe traumatic brain injuries usually result in inability to continue riding Concussions are different. Depends on: Number of concussions Severity of concussions Allowing proper time to recovery Try to seek expert opinion concussion specialist Get neuroimaging (MRI preferable over CT) Get brief neurocognitive testing, including postinjury ImPACT computer and paper/pencil testing

Conclusions There is a difference between concussion and TBI Do NOT try to hide concussion symptoms Money made on rest of one days racing program is not worth what could happen next One concussion makes you more likely to have a second concussion with LESS impact if you have not cleared from the first concussion There is no magic number of number of concussions that is too much Think about your family and how you will be at 65yo My Contact Information

Kenneth Perrine, Ph.D. NY Presbyterian/Weill-Cornell Medical Center [email protected] (212) 746-2197 Feel free to call with any questions about yourself Agencies/Groups: please contact me for establishing guidelines, etc.

I will distribute a list of neuropsychologists who are experienced in assessing concussion without ripping you off

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