Trouble Ahead: Concussions and Soccer

TROUBLE AHEAD: SOCCER’S CONCUSSION PROBLEM Raymond Rocco Monto, MD Nantucket Cottage Hospital Partners Healthcare

SOCCER AND CONCUSSIONS

• Soccer is the most popular world sport • 265 million players (FIFA) • Over 24 million players in the US alone • 45% growth in women’s youth soccer • 2015 FIFA Women’s World Cup Final drew 26.7 million viewers • More than 2010 Men’s World Cup, 2014 World Series, and the 2015 NBA Finals

• MLS third highest attendance of any US professional sport league

SOCCER AND CONCUSSIONS

• Growing concern in American football regarding possible linkage between concussion and repetitive head injuries and brain injury • Chronic Traumatic Brain Encephalopathy (CTE) found in 90/94 NFL players • 750 million dollar NFL class action suit settlement • Similar concerns in soccer led to a 2014 class action lawsuit against US Soccer/USYSA/FIFA • The lawsuit was settled in 2015 • Bans heading <10 (limited 11-13) • Rule changes and public education campaign

SOCCER AND CONCUSSIONS

• Concussions • Sub-concussive injuries • Heading • Head-to-head trauma

• Short-term effects • Long-term effects • CTE • Prevention

SOCCER AND CONCUSSIONS

• Concussions (TBI) • Incidence • 330,000 sports related / year • 50,000 HS players per year • Under-reported • Less than 10% LOC • Wide spectrum of symptoms • Traumatic brain injury is leading cause of sports deaths • Fair game on ABOS board exams

SOCCER AND CONCUSSIONS

• Mechanism • Direct impact • Coup contrecoup (rebound effect) • Symptoms • Visual acuity changes • Headache • Dizziness / balance loss • Nausea • Memory loss • Late: Depression / Suicide rate 3X normal

SOCCER AND CONCUSSIONS • Clinical assessment • SAC Test • ImPACT • Memory testing • Balance error scoring system (BESS) • Pre-season baseline scores helpful

SOCCER AND CONCUSSIONS

• Treatment • Concussion protocol • No same-day return after concussion • Staged, graduated return to play schedule takes 7-10 days • More severe or recurrent cases can take several weeks to be cleared and require repeated testing and imaging studies • Burns (2016) mouse study • REST-helps synpases regenerate 7days • Inflammation persists > 1 year after impact

SOCCER AND CONCUSSIONS

• Complications • Epidural bleeding • Lucid at first, then rapid decline • Post-concussive syndrome • Headache, confusion, sleep disturbance • Second impact syndrome • Repeat TBI before symptoms resolve • 50% mortality rate • Loss of blood flow autoregulation • Adolescent males at highest risk

SOCCER AND CONCUSSIONS

• Concussions • Comstock (2015) • Soccer #1 cause of concussion in females • 4.5 per 10,000 HS girls soccer • 2.8 per 10,000 HS boys soccer • Head-to-head contact 78% m / 62% f • Remainder of injuries from heading • Banning heading not enough • UEFA (2014) • Concussion led to 50% injury risk x 1 year

SOCCER AND CONCUSSIONS • Heading • Ball sizes vary (3/4/5) (#5>U12) • Average #5 ball weight 14-16 oz • Ball pressure (non-Brady) 8.5-15.6 psi • Ball velocity 35mph to 70mph • G-Force impact heading 100g (=American football hit) (Nauman 2015) • PAA College>HS (McCuen 2015) • 6-12 heads per game • 900-1500 head balls per season • Heading banned in US youth soccer

SOCCER AND CONCUSSIONS

• Mandelbaum (1996) • No linkage between heading and neurocognitive / MRI changes

• Lipton (2011) • 37 subjects / DTI MRI • >1800 headers season • White matter atrophy and neurocognitive decline

SOCCER AND CONCUSSIONS

• Zhang (2013) • 48 subjects • Delayed motor response times lasting several hours after heading

• Tierney (2016) • 20 subjects • 10 headers at average speed • Abnormal visual focus (NPC) scores for 24+ hours

SOCCER AND CONCUSSIONS

• Koerte (2014) • HR MRI in retired players (59 yo) • No concussion history • Diffuse cortical thinning frontal lobe • Neurocognitive decline

• Koerte (2015) • HR DTI MRI in 40 young players (20 yo) • No concussion history • Increase in radial diffusivity (demyelination) • Pattern c/w mild traumatic brain injury

SOCCER AND CONCUSSIONS

• Chronic Traumatic Encephalopathy (CTE) • Linkage is controversial (“Third rail”) • 150 cases at autopsy • 90/94 NFL players positive @ autopsy (Seau) • Several documented cases in soccer (WBA legend Astle /Bellini-1958 Brazilian WC captain/US semi-pro Patrick Grange) • Suspicions of early onset dementia • 21/24 dementia in one team alone

SOCCER AND CONCUSSIONS • Prevention • Headgear remain controversial • FIFA rule changes 2007 • Slow adoption • Little research

SOCCER AND CONCUSSIONS • Bayly (2003) • Early HG failed impact testing • Delaney (2008) • 50% reduction in concussions • Decrease more evident in head-to-head • UW (2016) • $ 300,000 grant to study 3,000 HS players • US Soccer • Allows, but does not endorse HG • FIFA • Similar approach

SOCCER AND CONCUSSIONS

• Are women really at higher risk (and why)?

• Will banning heading have any effect?

• Can headgear diminish concussive risk?

• Is there a causal link between CTE and soccer concussions or repetitive sub-concussive injuries?

• If there is a link, is there a critical threshold?

• Do technique or strength really matter?

SOCCER AND CONCUSSIONS

• To contact Dr. Monto • www.drmonto.com

• Photo credits • Sam Maller @storelli.com

• For more information concussion awareness and prevention • http:// www.ussoccer.com/about/recognize-to-recov er/concussion-guidelines

• Boston University

• http://www.storelli.com/intrepido/concussi onawareness /

• goalnation.com

• http://www.pinkconcussions.com/

• US Soccer