Dr. David Carfagno is the principal at Scottsdale Sports Medicine Institute, and a frequent presenter on sports medicine topics around the country. Concussions and neck injuries are a chronic issue among athletes, particularly in both collegiate and professional football. While their severity is getting more attention today, there are still unique factors that physicians and medical personnel should be aware of.

1. A SPORTS MEDICINE PHYSICIAN’S
PERSPECTIVE
DAVID CARFAGNO, D.O., CAQSM
SCOTTSDALE SPORTS MEDICINE

3. Team Doc/Fan
Team Doc

4. INJURY
RTP

5. PT HISTORY, RTP , COMMUNICATION

6. 


Sports injuries rank 2nd highest in terms of
cause of injury, after home and leisure accidents;
and rank third in terms of severity, after traffic
accidents and violence.
Approximately 11,000 persons/day receive
treatment in U.S. EDs for injuries sustained
during sports, recreation, and exercise activities.
One of every six ED visits for an injury results
from participation in sports or recreation.
Clin Rehabil. 2000 Dec;14(6):651-6.
CDC Injury Research Agenda, 2011

7. 1.
2.
3.
4.
Course set up
Resources
Staff
Yourself
PREPARATION

8. 


DAY OF WEEK, ‘FRI
NIGHT GAMES’
AWARENESS OF
CLINICAL SETTINGS
IMPACT ON TEMPORAL
DECISIONS, FOLLOW UP,
ETC.

9. 
ADMIT vs. DISCHARGE vs. TRANSFER TO HIGHER LEVEL
OF CARE or SPECIALIZED CARE

IMPORTANCE OF TIMELY DIAGNOSIS

RESOURCES
 LEVEL 1
 CONSULTANTS
 ANCILLARY TESTING

CASE BASED

10. Q. The current consensus on concussion in sport
recommends neurologic imaging only in
situations of prolonged alteration of
consciousness, focal neurological deficits, or
worsening symptoms.
A. True
B. False

11. 

Importance of effective communication between
members of healthcare team, from on-field  ED
 Level 1 Trauma Center/Specialist.
Importance of Expeditious Diagnosis
Risk of death (immediate or later)
 Malpractice/Lawsuits


Disposition


Clinical suspicion
Ongoing assessment

12. 

18 year old Junior College Football Player
sustained a head injury today while playing
football.
Seen by ATC, Team Physician, recommended to
go to ED for further management.

13. 



Concussions are an important and common injury for
athletes.
Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening
intracranial lesions and/or increased risk for sequelae
while minimizing cost, unnecessary testing, radiation
exposure and admissions*
Evaluation, management and RTP decision very
challenging
Take home message: must individualize management
and RTP decision
Emerg Med Pract. 2012;14(9):1-24.

14. 

Zurich Guidelines
2012
Complex
pathophysiological
process affecting
brain due to
traumatic
biomechanical forces.
Consensus statement, 4th International Conference, Zurich, 2012.

19. 


Direct blow to head, face, neck or elsewhere with
an “impulsive” force transmitted to head
Rapid onset of short-lived neurological
functional impairment
May/may not LOC

LOC occurs in fewer than 10% with sports-related
concussion.*
Consensus Statement on Concussion, Vienna, 2001
Emergency Emerg Med Pract. 2012;14(9):1-24.
Consensus statement, 4th International Conference, Zurich, 2012

20. 





Neurochemical and neurometabolic changes
Increase in glucose and oxidative metabolism
Increase in demand for cerebral blood flow,
which is reduced
Activation of immune inflammatory response*
Possible shear injury to vessels and neurons
May create immediate neuronal depolarization
followed by refractory period of no neural
transmission
J. Athl Train. 2001 Jul-Sep; 36(3): 228-235
*Phys Sportsmed. 2012 Nov;40(4):73-87

21. 

Jordan et al found Apolipoprotein E (ApoE) E4
assoc w/ increased severity of chronic TBI (cTBI)
in high-exposure boxers.*
College athletes w/ ApoE promoter G-219T TT
genotype may be at increased risk for having h/o
concussions.**
*JAMA. 1997;278(2):136-140.
**Clin J Sport Med. 2008 Jan;18(1):10-7.

22. 


National High School Federation Data, 20082010: 2.50 injuries/10,000 athlete exposures.
CDC: During 2001-2005, an estimated 207,830
ED visits annually for concussions and other TBIs
related to sports and recreational activities, with
65% of TBIs among children aged 5-18 years
Increase in incidence

CDC: From 2001 to 2009, annual TBI-related ED visits
increased significantly, from 153,375 to 248,418, with
highest rates among males aged 10-19 years
MMWR Morb Mortal Wkly Rep. 2011;60(39):1337-42.
AJSM January 27, 2012 as doi:10

23. 


Somatic: headache, nausea, vomiting, motor
problems, fatigue, dizziness, visual disturbance,
photophobia, phonophobia
Affective: Irritability, depression, emotional
lability, sleep disturbance, personality
disturbances
Cognitive: Confusion, disorientation, RTA, PTA,
LOC, feeling “in a fog”, “zoned out”, vacant stare,
inability to focus, decreased processing speed,
drowsiness
Modified from Herring et al, TPCC ’06

24. 


ABCD, sideline tests (e.g., SCAT 2), rule out
structural intracranial lesions
Monitor for initial few hours following injury, or
send emergently if change in behavior,
worsening headache, vomiting, seizure, double
vision, excessive drowsiness, or worsening
symptoms
No RTP on day of injury

25. 




Glasgow Coma Scale (GCS)
King-Devick Test
Bess Test
SCAT 2
Maddocks Questions
King-Devick
Test

26. 



Basic neurological scale that quantifies level of
consciousness
Score ranges from 3 (unconscious) to 15 (alert
and oriented)
Most EMS protocols: GCS score < 14 should be
transported to Level I or II trauma center
Inverse relationship between GCS score and
positive findings on CT

27. 



Tests for eye saccade
(quick, simultaneous
movements of eyes in
same direction)
Uses charts of numbers
Charts become
increasingly difficult to
read as space between
numbers increases
Patient’s speed and
fluidity of reading used
to derive score
K-D Test

28. 


Postural stability testing,
assesses cognitive motor
function
Quantifiable, modified
Romberg test – three 20second balance tests
performed on firm and
foam surfaces
Postural instability:
communication between
three sensory systems
either at central or
peripheral level is lost
Clinical J. Sports Med. 2001;11:182-190.

29. 



Calculated for athlete>10 y/o
Preseason baseline testing can be helpful.
Calculated based on symptoms, physical signs,
GCS, balance examination, coordination,
orientation, immediate memory, concentration,
delayed recall scores
No cut-off value on SCAT 2 score
Clin J Sport Med. 2005;15(2):48-55.

30. 




At what venue are we today?
Which half is it now?
Who scored last in this match?
What did you play last week?
Did your team win the last game?

31. 




Comprehensive history, physical assessment (e.g., cspine, obvious skull depressions, CSF
rhinorrhea/otorrhea)
Detailed neurological exam including Glasgow Coma
Scale (GCS), mental status, cognitive functioning, gait
and balance, pupillary reflex, cranial nerve testing
Progression since time of injury (improvement or
deterioration?)
Is emergent neuroimaging indicated?
Rule out/treat hypoxia, hypercarbia and
hypotension (associated with poorer outcomes in
TBI)

32. 


1) Avoid CT scans in low risk patients based on
validated decision rules
2) Avoid placing indwelling catheters in stable
pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to
moderately dehydrated unless oral rehydration
fails first
Choosing Wisely”® campaign during the ACEP13 annual meeting, Oct. 14-17

33. 


Related to the burden, nature and duration of
symptoms
Modifiers (Zurich ’09)
1. Age
2. Prior h/o concussion
3. Learning disability
4. Headache/migraine history
Other risk factors, h/o: neurosurgery,
drug/alcohol use, anticoagulant/antiplatelet use,
hemophilia

34. 





Acute or subacute subdural hematoma
Epidural hematoma (rapid deterioration after a
“lucid” interval)
Intraparenchymal hemorrhage
Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits)
Second Impact Syndrome (SIS)
Trauma-induced migraine
Arch Intern Med. 1998;158(15):1617-1624.

35. 







Cervical spine injury
Skull fracture
Intracranial hemorrhage
Seizures
Post-concussion Syndrome (PCS)
Second Impact Syndrome (SIS)
Cognitive decline
Dementia pugilistica*
*Neurosurg Focus. 2012. 33(6):E5: 1-9.

36. 



Evoked response potential (ERP)
Cortical magnetic stimulation
Electroencephalography
Biochemical and CSF markers of brain injury
J. Neurotrauma, 2006; 23:1201-1210.

37. CT/MRI




Whenever suspicion of intracerebral
structural lesion exists
1. Prolonged disturbance of conscious state
2. Focal neurological deficit
3. Worsening symptoms
CT/MRI typically interpreted as normal; symptoms more
often reflect functional rather than structural disturbance
Role of fMRI/PET

38. 





Evaluate brain-behavior relationships
Sensitive in assessment of brain injury
Unique contribution in RTP
Newer computerized test batteries
Validated testing
Protocols for using NP as part of “concussion
plan” evolving
Neurosurgery. 2004; 54:1073-1078; discussion, 8-80.

39. 



Endorsed as a "cornerstone" of concussion
management by Vienna and Prague Consensuses.
imPACT (Immediate Post-concussion
Assessment and Cognitive Testing)
Computer-based
Compare baseline and post-injury scores

40. 

Physical and cognitive
rest until symptoms
resolve, then graded
program of exertion
prior to medical
clearance and RTP.
Activities that require
concentration and
attention may delay
recovery.
Curr Sports Med Rep. 2004; 3:316-323
Consensus statement, 4th International Conference, Zurich, 2012

41. 

All but one U.S. states have active or pending
laws on RTP for youth sports and full elimination
of same-day RTP after concussive events.
Refer to specialist for follow-up care and
graduated RTP plan.

42. Rehabilitation Stage
1.
Functional Exercise
No activity
Complete rest
•imPACT testing
2.
Light aerobic exercise
No resistance
3.
Sport-specific exercise
No head impact
4.
Non-contact
Progressive resistance
5.
Full contact
Normal training
6.
RTP
Normal game play
Consensus statement, 4th International Conference, Zurich, 2012.

43. 


Management of sleep disturbance, anxiety,
depression
Management of headache, vomiting, dizziness
Before RTP, the concussed athlete should not
only be symptom free but avoiding any
medications that may mask or modify the
symptoms of concussion.

44. 
May need additional management considerations

Symptoms, signs, sequelae, temporal, threshold

Age, co- and premorbidities, medication,
behavior, type of sports
Consensus statement 4th International Conference, Zurich, Nov. 2012.

45. 
Internet based neurocognitive assessment tool
for use by professionals who manage and
monitor sports related concussions

Monitors sports related cognitive sequelae

Takes 25 minutes to administer

Consists of six subtests measuring reaction time,
object recognition, recall

46. 


College football players showed mild cognitive
impairment on the CRI after commonly looked at
symptoms subsided
436 Columbia U football players over 11 seasons
(2000-2011)
148 had at least one concussion prior to entering
college
Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013

47. 
All 436 received baseline CRI’s before football
started

Total of 647 CRI obtained

70 of the 436 athletes had a concussion
Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013

48. 
Median time between concussions and RTP was 10
days.

28 of the 70 concussed cleared to RTP had a decline
in their CRI assessment by 0.5 units

This is clinically significant impairment identified by
cognitive testing

Key Point- DON’T RUSH your players back, learn how
to test for concussions appropriately, and follow the
guidelines
Medpage: Post-Concussion Cognitive Deficit Lingers, Oct 16, 2013

50. 





Designed to incorporate and expand principles in
previous consensuses (Vienna and Prague)
Simple vs. complex eliminated
Individualized RTP
Differentiation of elite vs. non-elite RTP
Modifiers
Same-day RTP only in very specific situations for
adult athlete
Consensus statement, 4th International Conference, Zurich, 2012.

51. 


Symptomatic athlete should not return to play,
same-day RTP controversial, safest course of
action: hold an athlete
Care of concussed athletes ideally should be
managed by healthcare professionals with
specific training and experience.
Additional considerations in RTP:
1. Severity of injury
2. Previous injury (no, severity, proximity)
3. Significant injury to minor blow
4. Age, sport, learning disabilities
*Collaboration of ACSM, AMSSM, AOSSM, AAOS, AAFP, AOASM.

52. 
Helmets and mouth guards
1. Injury rates similar between helmeted and nonhelmeted sports.
2. No helmet in any sports prevents concussion.
3. Mouth guards do not prevent concussion but prevent
dental injury.
BMJ. 2005; 330:281-283

53. 









How many is too many?
Influence of gender and genetics on injury risk,
severity and outcome
Pediatric injury and management paradigms
Novel technique: testing for biochemical serum
and CSF markers of brain injury
Rehabilitation strategies (e.g., exercise therapy)
Novel imaging modality: role of fMRI/DTI
Long term outcomes (e.g., depression/suicide)
On-field injury severity outcomes
Concussion surveillance
Protective factors

54. Source CSHB 15(JUD)

55. 

Definition, epidemiology, causation, risks, and
RTP guidelines
All covered earlier

56. 
Guidelines established by ASAA along with
governing body of each school district to educate



Coaches
Athletes
Parents
Guidelines include risks and standards of RTP

57. 

School provides this information to
parent/guardian of athletes under 18
Athletes under 18 can not participate in sports
without signed verification stating they received
the guidelines

58. 

Athlete removed from sporting event
May not return to play w/o being cleared in
writing by qualified person (QP) with certified
training

59. 


Health care provider licensed in the state or
exempt from licensure
Person acting under supervision who is licensed
in the state
Unpaid QP may not be held liable for civil
damages resulting from act or emission of eval.
unless found negligent or reckless in care

60. 
School district not liable for injury or death
caused by concussion by actions of QP if
Action/inaction occurred during delivery of service by
district or organization in compliance with AS
14.30.142
 The organization is under contract to provide services
 Before services the organization provided written
verification of

 a valid insurance policy
 Compliance with protocol o prevention and reporting of
concussions required in AS 14.30.142

61. 

Previous slide can not be construed to impair or
modify ability of a person to recover damages
Youth organization means public/private
organization that provides service to youth 18
years of age or younger

62. 62

63. 

Roughly 12,000 new cases of SCI a year
Sports-related events causing approximately
7.6%
Semin Spine Surg 22:173-180
63

64. 
Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture

Classification



Fatal
Serious
Complete and incomplete neurological recovery
National Center for Catastrophic Sport
Injury Research

65. 65

66. 66

67. 67

68. 



Buffalo Bills TE
Fractured C3 and C4 on Sept. 9th 2007
Everett could fill nothing below his neck
following impact
He was told he would never walk again
68

69. 
He started walking again on December 7th, 2007

70. 70

71. 71

72. Recall the hit by Jadeveon Clowney
 How much time do you thinkCoaches spennt preparing and teaching him
 He spent practicing basic fundamentals and situational
football
 Scouting teams spent studying their upcoming
opponent and their style of play

ITS ALL ABOUT PREPAREDNESS

73. 


Same principles apply to sports medicine
Situational preparedness is critical to outcome
Our stake are higher, more is on the line then just
sporting events
The will to win is important, but the will
to prepare is vital.
Joe Paterno

74. 74

75. J Athl Train. 2005;40(3):155–161
75

76. 




Burners/Stringers
Strains and Sprains
Cervical Spine Fractures
Spear Tacklers Spine
Herniation and Cervical Disk Disease
76

77. 


Transient sensory and/or motor loss involving
arms and/or legs
2 mechanisms of injury
Traction and compression
Severity determined by amount of time that
passes between loss of function and restoration
of function
Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7
77

78. Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
78

80. 
Physical Exam





Test for muscle weakness: C4-C5 deltoids, C5-C6
triceps, C6-C7 triceps.
Test for sensory loss: over biceps (C5), thumb (C 6),
and long fingers (C7).
Check reflexs and Spurling’s sign
Tx- Rest until strength and sensation returns
RTP: Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med, copyright 2010

81. 

The most common cervical injury seen in sports
are stingers and burners.
True or False
81

82. 



Most common injury
No neurological or osseous injury
Cervical xray needed to r/o possible fracture
Pts return to play when pain is gone, ROM is full,
and strength is normal
Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7
82

84. 
C1-Jefferson fracture
Traumatic burst fracture from axial load
 Presents with neck pain and likely neurologic injury
 Palpate for tendeness, check ROM
 Plain films/CT are diagnostic
 Tx: unstable injury, see spine surgeon
 RTP: not likely

Netters Sports Med, copyright 2010
84

85. 
C2: Hangman’s Fracture
Traumatic spondy from axial load and extension
 Presents with neck pain, instability
 Palpate for tendeness, check ROM
 Lateral films/CT are diagnostic
 Tx: immobilize head, see spine specialists
 RTP: not likely

Netters Sports Med, copyright 2010

86. 
Burst fractures
Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord
 Presentation is similar
 Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be
discussed
 Tx: immobilize head, ABC’s, spine board, transport to
nearest ER
 RTP: to be discussed

Netters Sports Med, copyright 2010

87. 




Loss of Lordosis
Cervical Stenosis
Narrowing of disc
space
Preexisting bony or
ligamentous injury
seen on studies
Player should not be
allowed to RTP
Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29

88. 

Measuring canal width accurately and taken in all
factors that may change canal width is difficult
Torg Ratio: midsagittal diameter to the AP
diameter of corresponding vertebral body
-1.0 is normal, 0.8 consider stenotic, most use 0.7

General consensus is that normal width from C3C7 be above 15mm and anything below 13mm
AP dimension is stenotic
Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7
88

89. X-ray
MRI

90. 

Herzog* found that many athletes had larger
than normal vertebral body width
Blackley** demonstrated that measurement of
the spinal canal by plain film radiographs is not
reliable bc radiographs do not take into account:




the size and shape of the spinal cord,
the functional reserve of the spinal canal
thepresence of a disc herniation
if stenosis results from ligamentous hypertrophy
Spine. 1991 Jun;16(6 Suppl):S178-86.*
Spine. 2003 Jun;28(12):1263-8. **

91. NFL football players with
stenosis
 Jermichael Finley
 Jarvis Jones
 David Wilson
 Chris Berman
 Archie Manning

92. 

Defined as the loss of the cerebral spinal fluid
(CSF) around the cord or actual cord
deformation
Best determined with CT, MRI, or myelography
Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7
92

94. 


Far less common than lumbar herniation
Usually only affects older athletes
Two types: hard and soft
Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
94

95. 


Tx: nonoperative unless myelopathy or
progressive neurolgic deficit present
Nonoperative tx includes rest, ice, NSAIDS,
immobilization, cervical traction, and therapeutic
injections as needed
RTP: when pt regains full function without signs
of neurologic complications
Bull NYU Hosp Jt Dis. 2006;64(3-4):119-29
95

96. 96

97. 97

98. 


Every patient suspected of cervical spine injury
needs complete physical examination
Immobilize head and neck
Assess ABC’s
Semin Spine Surg 22:173-180
98

99. 
Careful attention should be directed towards
-neurological complaints
-head trauma
-headaches
-mental status changes
-midline spinal pain/tenderness
Semin Spine Surg 22:173-180
99

100. 
Following head and neck examination, careful
motor and sensory exam of extremities should be
performed
Semin Spine Surg 22:173-180
100

101. Semin Spine Surg 22:173-180
101

102. 


Lift and slide
maneuver used
Causes less motion of
C-spine then rolling
pt
DOCTOR should be
head of injured
athlete
Journal of Athletic Training 2009;44(3):306–331

103. 103

104. 




Team physician should use
multiple assistants to position
pt
DOC at head
Minimum of 4 with doc
controlling CS, one the torso,
one the hips, and one the legs
Log rolling is initiated by
team doc controlling head and
cervical spine
Pt should be rolled directly
onto spine board
Journal of Athletic Training 2009;44(3):306–331

105. 

Key to successfully maneuvering the injured pt….
Practice, practice, practice. Don’t let the injury be
the first time you try to attempt this

106. 



Only remove equipment that may obstruct
breathing
Tools and techniques that cause least amount of
torque should be used
Screwdrivers are preferred over cutting tools
Only cut away what can not be
removed manually
Journal of Athletic Training 2009;44(3):306–331

107. 


Helmeted pts are difficult to collar
Once on spine board, pt can have sandbags or
foam blocks taped to board for immobilization of
c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 2009;44(3):306–331
107

108. 



Team physician should accompany the injured
athlete
Provides Continuity of care
Provides ED doc accurate clinical information
regarding pt and injury
Allows the sports medicine professional to assist
emergency department personnel during
equipment removal
Journal of Athletic Training 2009;44(3):306–331

109. 
Once pt is stable and transferred to the hospital,
standard diagnostic evaluation of the C-spine
should be performed

AP, lateral, and odontoid radiographs of entire cervical
spine including occiput/C1 and C7/T1 junctions
should be obtained
Semin Spine Surg 22:173-180
109

110. 

CT use continues to expand with cervical neck
injuries
A diagnostic study showed that CT had higher
sensitivity, higher specificity, and higher positive
predictive value over plain films in viewing
injury
Semin Spine Surg 22:173-180
110

111. 
MRI studies are warranted when suspected
ligamentous injury or cervical disc herniation is
present
Semin Spine Surg 22:173-180
111

112. EBMedicine.net • April 2009

113. 




Dependent of context of injury
Known risk factors
Number of previous injuries
Pressure from player, coaches, and family
members
Dependent on each individual pt
Curr Sports Med Rep. 2013 Jan-Feb;12(1):14-7
113

114. 
Generally speaking, athletes can RTP when they
are:
asymptomatic,
 have full ROM,
 regain preinjury strength,
 imaging shows no evidence of functional stenosis of
spinal column
 Normal lordotic curve with no evidence of instability

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114

115. 




Neurological findings of cervical myelopathy
Continued discomfort, decreased ROM
Following C1-C2 fusion, cervical laminectomy, or
three level anterior or posterior cervical fusion
Increased ligamentous laxiety (>11degrees)
Spear Tackler’s spine
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115

116. 




RTP following injury is complicated and pt
specific
No universally accepted RTP criteria
Communication is essential from time of injury to
recovery
Begins with staff who have educated themselves
on what to do when they encounter these types
of injuries
Rehearse correct protocol
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116

117. 




USA football was established in 2002 by the NFL
and the NFL Players Association
It’s a nonprofit program
The program was developed to change the
culture of the sport and the way it has been
played with an emphasis on safety
There is a direct correlation between proper
technique and decreased injury (this goes for all
sports)
Millions of dollars have been donated
Headsupfootball.com
117

118. 118

119. David Carfagno, D.O., C.A.Q.S.M.



Board Certifications: Internal Medicine, Sports Medicine
(CAQ), Ringside Medicine (ABRM)
Medical Director, Ironman Arizona
Team physician, USA Boxing and ATP/WTA professional
tennis
10133 N. 92nd Street, Suite 102
Scottsdale, AZ 85258
Office – 480.664.4615
Email – david.carfagno@gmail.com