Transcript Pediatric Grand Rounds: Management Issues in Sports

The CDC in Sports:
Sports Related Concussion–
A New Epidemic and its Management
Jeffrey B. Kreher, MD, FAAP
Pediatric Musculoskeletal & Sports Medicine
Specialist
Assistant, Department of Orthopedics—
Division of Pediatric Orthopedics
Assistant Professor, Department of Pediatrics
Massachusetts General Hospital for Children
AAP CME Disclosure


I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial
services discussed in this CME activity.
I do not intend to discuss an
unapproved/investigative use of a
commercial product/device in my
presentation.
Disclaimers
No financial interests
 There is a paucity of EBM in everything discussed
 There are no FDA approved therapies for SRC
(signs or symptoms) or
post-concussion syndrome.
 Generic non FDA medications will be
discussed.

OBJECTIVES



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1)
Understand
Massachusetts’ state
concussion legislation
2)
Integrate knowledge of
sports related concussion into
diagnosis and patient education
3) Recognize frequently used
tools in the evaluation of sportsrelated concussion
4) Describe the components
of sports related concussion
management and issues with
return to school and return to
play
CASE

15y/o wide receiver is hit hard during a punt return. He arises
to his knees and hands before placing his head between his
hands. He gets up and starts to run to the opposing bench
before a teammate guides him back to their bench. You see
him on the sidelines and he is complaining of a headache. It
does not appear there was any LOC.
–
–
–
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Does he have a concussion?
What do you do with him on the sidelines?
Where is the scar, cast, visible sign of injury?
Is this a legitimate injury?
Why can’t this athlete return back to the same game like Erin
Rogers
Epidemic or Not??
Federal Legislation

As of April 2012, 35 states (plus the District of Columbia and
the city of Chicago) have adopted youth concussion laws. The
NFL supports and recognizes the laws as they represent the
main principles of the Lystedt Law model legislation including:
–
–
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Inform and educate youth athletes, their parents and guardians
and require them to sign a concussion information form;
Removal of a youth athlete who appears to have suffered a
concussion from play or practice at the time of the suspected
concussion; and
Requiring a youth athlete to be cleared by a licensed health care
professional trained the evaluation and management of
concussions before returning to play or practice
Massachusetts State Legislation



SB 2469: An Act relating to safety regulations
for school athletic programs
Contains three tenets of model legislation
Status: Legislation passed; Governor Deval
Patrick signed youth concussion bill into law
on 7/8/10; Law went into effect on 7/19/10

Section 222 (a): training program must be
offered annually by all public schools and
those subject to MIAA:
–
–
To coaches, trainers, school-employed physicians
& nurses, volunteers, athletic directors, and
parent/legal guardians
Containing training in recognition of concussion
along with department rules/regulations on
recognition of concussion symptoms and the
consequences of concussion

Section 222 (b):
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Required form documenting head injury history at
the start of each season
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Signed by athlete and legal guardian
Provided to coach
Section 222 (c):
–
With all LOC episodes, concussion diagnoses, or
suspected concussion in practice or competition,
no further participation till written authorization by
licensed Physician, Neuropsychologist, certified
Athletic Trainer or “other appropriately trained or
licensed Health Care Provider”

Section 222 (d):
–
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Section 222 (e):
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School must maintain accurate records of compliance
Section 222 (f):
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Coach will not encourage or permit “unreasonably
dangerous athletic techniques”
Compliance does not equal a waiver of liability to school or
employees
Section 222 (g):
–
Volunteers assisting are not liable for civil damages if
noncompliance documented
DEFINITION
 CDC
& CIS
– Complex pathophysiological
process affecting the brain
induced by traumatic
biomechanical forces
http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html Accessed February 1, 2011
McCrory P, Meeuwise W, Johnston K et al. Br J Sports Med 2009;43(Suppl I):i76–i84.
DEFINITION

Complex pathophysiological process affecting
the brain, induced by traumatic biomechanical
forces
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Direct blow to head/neck or body
Rapid onset of short lived neurologic dysfunction that resolves
spontaneously
Functional disturbance
Graded set of symptoms that may or may not have LOC with
resolution following a sequential course
–

Occasionally with postconcussive syndrome
No structural abnormality on standard neuroimaging
Sports-Related Concussion (SRC)

Trauma-induced alteration in mental
status that may or may not involve a loss
of consciousness in sport
–
–
Results in physical, cognitive, emotional, and/or
sleep-related symptoms
Duration of symptoms is highly variable

Several minutes to days, weeks, months, or longer in
some cases
Pediatric/Adolescent SRC:
Epidemiology
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~9% HS injuries are SRC
~20% TBI are SRC
~33% recognize symptoms as SRC
<50% HS FB players reported SRC
3/10 not evaluated by anybody
2/10 evaluated byMcCrea
medical
personnel
M, Hanneke T, Olsen G et al. Clin J Sport Med 2004;14:13-17.
Gerberich SG, Priest JD, Boen JR. Am J Public Health 1983;73:1370-1375.
Pediatric/Adolescent SRC:
Epidemiology

Highest incidence = football and ice hockey
–

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Followed by soccer, wrestling, basketball, field
hockey, baseball, softball, volleyball
More common in games
More common in HS than college athletes
Pediatric/Adolescent SRC:
VULNERABILITY


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Less developed neck/shoulder musculature
Lifelong skills not as well developed
Continually expected to acquire new
information
–

Testing, permanent record of grades
Less likely to have easy access to Team
Physician or ATC trained in concussion
management
Pediatric/Adolescent SRC:
AGE ISSUES

Smaller pediatric brain
–
–
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Higher forces to injure
Recovers less quickly
It is NOT more plastic
Pediatric/Adolescent SRC:
GENDER ISSUES

Females have . . .
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Higher concussion rates

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Highest in soccer and basketball
Significantly more postconcussive symptoms as
well as poorer performance on computerized
neuropsychological testing
Higher incidence of migraine
SRC PATHOPHYSIOLOGY
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Rotational acceleration and/or deceleration
‘‘Metabolic mismatch’’ between energy
demand and supply, which may create
cellular vulnerability and predispose to
further injury
–
Hypermetabolic state followed by hypometabolic
state
Giza CC, Hovda DA. J Athl Train. 2001 Sep;36(3):228-235.
GRADING SYSTEMS . . .
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Colorado Medical Society
Cantu (or Modified Cantu)
American Academy of Neurology
–

trauma-induced alteration in mental status that may or may
not involve a loss of consciousness
All replaced by Concussion in Sport workgroup
–
No grading system because no system validated
McCrory P, Meeuwise W, Johnston K et al. Br J Sports Med 2009;43(Suppl I):i76–i84.
. . . CIAO!!
Signs
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LOC (<10%)
Amnesia, retrograde or
antegrade
Disorientation
Appearing dazed
Acting confused
Forgetting rules or
assignments
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Inability to recall
score/opponent
Inappropriate
emotionality
Poor physical
coordination
Imbalance
Seizure
Slow verbal responses
Personality changes
Symptoms
SOMATIC
(10)
COGNITIVE
(8)
EMOTIONAL
(4)
SLEEP
(4)
Headache *
Feeling mentally “foggy” *
Irritability *
Drowsiness *
Nausea *
Felling slowed down *
Sadness *
Sleeping more than usual
Vomiting *
Difficulty concentrating *
More emotional *
Sleeping less than usual
Balance problems *
Difficulty remembering *
Nervousness *
Difficulty falling asleep *
Visual problems *
Forgetful of recent
information
Fatigue *
Confused about recent
events *
Sensitivity to light *
Answer questions slowly
Sensitivity to sound *
Repeat questions
Dazed
Stunned
SRC Symptoms:
HS athletes
Meehan WP, d’Hemecourt P, Comstock RD. Am
J Sports Med. 2010;38:2405-2409
HA
93%
Dizziness/unsteady
Difficulty concentrating
Confusion/disorientation
Vision changes/sensitivity to
light
Nausea
Drowsiness
75%
57%
46%
38%
Amnesia
Sensitivity to noise
Tinnitus
Irritability
LOC
Hyperexcitability
Other
24%
19%
11%
9%
5%
2%
8%
29%
27%
SRC DIAGNOSIS

CLINICAL DIAGNOSIS
–
Altered mental status with signs, or symptoms of
concussion in the proper setting of trauma to
body/head
EVALUATION:
CLINIC SETTING

History
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Event
Concussion history
Pre-concussion symptoms
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ADHD, LD, mood, sleep
SCAT2
PE
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Head and Neck
Neuro including cerebellar
Fundoscopic
*
*
Available at: http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf+html

Symptom scale is not
validated in grade
school athlete

SCAT2 not validated
Available at: http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf+html
MANAGEMENT:
CLINIC SETTING
EDUCATION
EDUCATION
EDUCATION
COGNITIVE REST
PHYSICAL REST
MANAGEMENT:
CLINIC SETTING—EDUCATION

Natural History/Prognosis In HS Athlete
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80-90% asymptomatic by 10 days

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BUT, >50% take longer than 10 days to completely
recover (symptoms and NCT)
In 80%, symptoms and impairments on
neurocognitive testing will resolve by 3 weeks
In 20%, symptoms can last a month or longer
Yang CC et al. J. Trauma. 2007; 62:657-663.
MANAGEMENT:
CLINIC SETTING—EDUCATION

Prognosis – predictors of outcome
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Total symptom load
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Amnesia
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Most predictive
Longer duration
More impairments on neurocognitive testing
Self reported cognitive decline/confusion/mental fogginess
Posttraumatic migraine
LOC (not as predictive till > 1 minute)
Makdissi M, Darby D, Maruff P et al. Am J Sports Med 2010;38:464-471
Lau B, Lovell MR, Collins MW et al. Clin J Sport Med 2009;19:216–221
Lovell MR, Collins MW, Iverson GL, et al. J Neurosurg 2003;98:296–301
McCrory PR, Ariens T, Berkovic SF. Clin J Sport Med 2000;10:235–8
Cantu RC. J Athl Train 2001 Sep;36(3):244-248
Erlanger D, Kaushik T, Cantu R, et al. J Neurosurg 2003;98:477-484
MANAGEMENT:
CLINIC SETTING—EDUCATION
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Prevention
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No good clinical evidence that currently available
protective equipment prevents concussion
Education of athletes, colleagues, and the general
public is a mainstay of progress
Preparticipation Examination
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Remind all that LOC not needed
Educate about importance of subject
Obtain SRC history
Benson BW, Hamilton GM, Meeuwisse WH et al. Br J Sports Med 2009 43:i56-i67
MANAGEMENT:
CLINIC SETTING—EDUCATION

Second Impact Syndrome
(SIS)
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Fatal & rapid brain swelling felt
to occur in an adolescent
athlete, who sustains a mild
head injury when symptoms
from a prior concussion are still
present
McCrory P. Clin J Sport Med 2001;11:144–149
Cantu RC. Clin Sports Med 1998;17:37-44
MANAGEMENT:
CLINIC SETTING—EDUCATION

Chronic Traumatic Encephalopathy (CTE)
–
Neurodegenerative disease, tau pathology, that
occurs years or decades after recovery from the
acute or postacute effects of head trauma
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Selection bias
No prospective studies
Confounding EtOH, steroid use
Gavett BE, Stern RA, McKee AC. Clin Sports Med 2011;30:179–188
MANAGEMENT AFTER EDUCTION . . .
MANAGEMENT AFTER EDUCTION . . .
REST = Physical and Cognitive
Physical rest = No
activity that increase
heart rate
Cognitive rest = Limit
brain activity
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No sports
No dance
No physical
education class
No lifting weight
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No TV
No texting
No computer
No video games
No music
No reading
No test taking
MANAGEMENT:
SYMPTOMS—SOMATIC DOMAIN
HEADACHES

Analgesics,
acetaminophen
–
–
–
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Benefit short term
May lead to rebound
No return while analgesics
needed
If sleep disturbances,
consideration of
amitriptyline
Meehan WP. Clin Sports Med 2011;30:115–124
MANAGEMENT:
SYMPTOMS—SOMATIC DOMAIN
DIZZINESS

Vestibular function is
often altered
–
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Symptoms and BESS
Consideration of
vestibular rehabilitation
MANAGEMENT:
SYMPTOMS—SLEEP DOMAIN
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Avoid or minimize:
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Caffeine, nicotine, and alcohol
use, as well as daytime naps
Quiet, dark room
–
Turning stimuli off does not
suffice

Presence of a computer, to-do list,
date book, or planner can often
trigger stress and anxiety
Meehan WP. Clin Sports Med 2011;30:115–124
MANAGEMENT:
SYMPTOMS—COGNITIVE DOMAIN
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MPH is a consideration but
studied in mTBI and no
evidence in pediatric studies
Amantadine to improve
executive function and glucose
metabolism
Consideration for
neuropsychologic testing and
cognitive rehabilitation
Meehan WP. Clin Sports Med 2011;30:115–124
MANAGEMENT:
SYMPTOMS—EMOTIONAL DOMAIN
MOOD SYMPTOMS
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Symptoms tend to be short lived
–
Conservative management
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Coping strategies
Supportive environment
Counselor
SSRI studied in mTBI with favorable results
Meehan WP. Clin Sports Med 2011;30:115–124
MANAGEMENT:
RETURN TO SCHOOL
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Accommodations
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Temporary leave of school
Shortened day
Reduced workload
Increased time for assignments/tests
3 routes:
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Informal accommodations
Section 504 plans (civil rights entitlement to avoid
discrimination against those with disabilities)
IEP
MANAGEMENT:
RETURN TO SCHOOL
Academic work demands focus, memory,
and concentration – all brain processes
that are affected by a concussion.

Allow for excused absences until symptoms have decreased some

Half days – early dismissal – late to school

Excuse homework assignments for a few days

Limit or excuse from test taking

Allow for rest periods/ visits to school nurse

Avoid re-injury – no physical education
A (NOT SO) SHORT LIST OF SCHOOL
ACCOMODATIONS
1.
2.
3.
4.
5.
6.
7.
8.
Excused Absence from Classes
Rest Periods During the School Day
Extension of Assignment Deadlines
Postponement or Staggering of Tests
Excuse From Specific Tests and Assignments
Extended Testing Time
Accommodation for Oversensitivity to Light,
Noise, or Both
Excuse From Team Sport Practice and Gym
Activities
A (NOT SO) SHORT LIST OF SCHOOL
ACCOMODATIONS [continued]
9.
10.
11.
12.
14.
Avoidance of Other Physical Exertion
Use of a Reader for Assignments and Testing
Use of a Note Taker or Scribe
Use of a Smaller, Quieter Examination Room
to Reduce Stimulation and Distraction13.
Preferential Classroom Seating to Lessen
Distraction
Temporary Assistance of a Tutor to Assist
With Organizing and Prioritizing Homework
Assignments
MANAGEMENT:
RETURN TO PLAY

Stepwise exertion protocol
(medically supervised)
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1) No activity
2) Light aerobic activity (walking, stationary bike)
3) High aerobic activity (running, skating)
4) Non-contact training drills
5) Full-contact practice
6) Game play
McCrory P, Meeuwise W, Johnston K et al. Br J Sports Med 2009;43(Suppl I):i76–i84.
Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615
MANAGEMENT:
NEUROPSYCHOLOGICAL TESTING

Pen & Paper vs. Computerized
–
–
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Not diagnostic tools
Computerized tests measure:
attention, working memory, visual motor speed,
reaction time
Research tool vs. Management tool

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Much has been learned about SRC from testing
Helpful in management in some situations
MANAGEMENT:
COMPUTERIZED NEUROPSYCHOLOGICAL
TESTING

Advantages
–
–
–
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Increased validity of identifying subtle changes or
deficits in cognitive speed
Reduces administrator error and inter-rater
reliability issues
Data is easily stored and accessed
May be used to assist planning for school and
home management while the patient is still
symptomatic
MANAGEMENT:
COMPUTERIZED NEUROPSYCHOLOGICAL
TESTING

Disadvantages
–
–
–
Athlete can not be observed during testing
Access and cost
Baseline testing can be invalid

Distracting environment, not taking the test seriously,
lack of full effort, confusion with instructions, LD, ADHD,
need for more frequent baseline testing
Advances in understanding of SRC:
Computerized Neuropsychologic
Testing


Symptoms resolve prior to resolution of
neurocognitive deficits
Post-traumatic migraine athletes
–
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HS athletes
–
–
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Greater symptoms and prolonged recovery
Demonstrated longer overall recovery
With “ding” ≥ 7 days for full recovery
Pediatric athletes
–
May show a delayed onset in symptoms
Field M, Collins MW, Lovell MR et al. J Pediatr 2003;142;546-553.
Lovell MR, Collins MW, Iverson GL et al. Am J Sports Med 2004;32:47-54 & J
Neurosurg 2003;98:296-301.
What is missing?


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Evidence based RTP guidelines
Quick assessment for concussion in 5-11 y/o
Natural history of concussion in < 12 y/o
CONSIDERATIONS FOR REFERRAL

Postconcussive Syndrome
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Athlete with ADHD and/or LD
Desire for Neuropsychological Testing
–
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Computerized or pen & paper
Medical management
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Consideration of physical activity
Anecdotal evidence
Ending season
Retirement from sport
–
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(1) lingering symptoms many weeks or months following the
injury despite proper management and
(2) if minimal biomechanical force is causing a reoccurrence
of concussion-related symptoms
Concluding Remarks
Pediatric SRC
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SRC  immediate removal and no same day RTC
NO RTP until asymptomatic
Treated with physical and cognitive rest until asymptomatic
RTP after asymptomatic for several days and with exertion
RTP decisions must be individualized
RTP follows a medically supervised stepwise exertion protocol
–
If symptoms recur, an athlete should rest for 24–48 hr and try
again

More research is required in pediatric athletes to determine how
they respond and recover from concussions and to determine
evidence-based RTP guidelines

“WHEN IN DOUBT, SIT THEM OUT!!!”
??? QUESTIONS ???
Thank you for your time
and attention!
Toolbox
Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615
REASONS FOR NEUROIMAGING
Prolonged LOC (> 30 seconds)
Mental status deterioration
Worsening of headache
Focal neurologic deficit
Seizure activity
Persistence or worsening of
postconcussive symptoms
Suspected skull fracture
Toolbox
Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615.
REASONS FOR ED EVALUATION
Repeated vomiting
Severe or progressive headache
Seizure
Abnormal gait
Slurred speech
Weakness or numbness in extremities
Unusual behavior
Signs of basilar skull fracture
GCS < 15/altered mental status
Toolbox
RESOURCES:
PATIENT
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http://www.thinkfirst.ca/concussion_education.asp
http://www.cps.ca/english/statements/HAL/HAL06-01.htm
http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm
http://www.casmacsm.org/documents/PragueGuidelines.pdf
http://www.hockeycanada.ca/index.cfm/ci_id/7699/la_id/1
.htm