Transcript Slide 1

Dr. Joseph Rempson
Co-Medical Director of the Atlantic HealthConcussion Center at Overlook Hospital
Director of he Department of Rehabilitation at Overlook Hospital
Atlantic Neurosurgical 310 Madison Avenue Morristown, New Jersey 07960
Appointment: 908 522-6395
Office: Tel 973.285.7800
Cell: 973 908-1091
E-mail: [email protected]
1) 1.6 to 3.8 million sports and recreational
mild traumatic brain injuries/year
2) Closed head injury
(Acceleration/Deceleration Injury)
 Academics
 Social
Relationships
 Behavior
 Emotions
High school sports participation has grown from an
estimated 4 million participants during the 1971--72
school year to an estimated 7.2 million in 2005—06.
1.1 million played high school football in 2008 and
2009 and 43,000 to 67,000 were diagnosed with
concussion
TABLE 1 Concussion Rates in High School
Football 0.47–1.03a,b
Girls’ soccer 0.36a
Boys’ lacrosse 0.28–0.34c,d
Boys’ soccer 0.22a
Girls’ basketball 0.21a
Wrestling 0.18a
Girls’ lacrosse 0.10–0.21c,d
Softball 0.07a
Boys’ basketball 0.07a
Boys’ and girls’ volleyball 0.05a
Baseball 0.05a
a Data from Gessel LM, Fields SK, Collins CL, Dick RW,
Comstock
RD. Concussions among United States high school
and collegiate athletes. J Athl Train. 2007;42(4):495–503.
b Data from Guskiewicz KM, Weaver NL, Padua DA, Garrett
WE. Epidemiology of concussion in collegiate and high
school football players. Am J Sports Med. 2000;28(5):643–
650.
c Data from Lincoln AE, Hinton RY, Almqueist JL. Head, face,
and eye injuries in scholastic and collegiate lacrosse: a
4-year prospective study. Am J Sports Med. 2007;35(2):
207–215.
d Data from Hinton RY, Lincoln AE, Almquist JL. Epidemiology
of lacrosse injuries in high school-aged girls and boys:
a 3-year prospective study. Am J Sports Med. 2005;33(9):
1305–1314.
All of the recent consensus statements on sport-related
concussions recommend a more conservative approach
to concussion management for athletes under the age
18 than for older athletes:

Third International Conference on Concussion in Sport, Zurich
2008
The American College of Sports Medicine's 2006 Consensus
Statement on Concussion (Mild Traumatic Brain Injury) and the
Team Physician
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National Athletic Trainers' Association 2004 Position Statement:
Management of Sport-Related Concussion
Brain tolerance to biomechanical forces differ
between adults and children (2-3 fold force is
needed to create similar symptoms in children)
 Immature brain may be 60 times more sensitive
to glutamate-mediated N-methyl-D-aspartate
(NMDA): one example an increase in
intracellular calcium
 Significant neural development of the brain
through the age of 15
 Second Impact Syndrome (felt to only occur in
adolescence)

Why are girls at increased risk?
Neck musculature?
Muscle mass in boys
likely diminishes force
transmission
 Susceptibility?
Boys and girls brains are
not the same
 More likely to report?
Boys may be more likely
to hide symptoms
 Also take longer to recover.
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SCAT 2
 SAC
 Maddock’s
Questionnaire
 Balance Error Scoring
System (BESS)
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On field/sideline evaluation
ABC’s and cervical
spine (most
important)
 Basic neurologic exam
is often normal
 Asking month, year,
and day not sensitive.
 Symptoms can take
up to 48 to 72 hours
to fully manifest
themselves.

Don’t forget
Headaches (pressure)
70%
 Feeling slowed down
(58%)
 Poor concentration
(57%)
 Dizziness (55%)
 Feeling Foggy (53%)
 Fatigue (50%)
 Visual blurring or double
vision (49%)
 Irritablity

Light sensitivity (47%)
 Memory Dysfunction (43%)
 Balance problems (43%)
 Increased sensitivity to
loud noises
 Anxiety and/or
depression
 Sleep disturbances
 Nausea
 Vomiting
 Feeling sluggish
 Seizure (on field)

Neuro-imaging (CT) should be considered whenever
suspicion of an intracranial structural injury exists. Signs
and symptoms that increase the index of suspicion for
more serious injury include severe headache; seizures;
focal neurologic findings on examination; repeated
emesis; significant drowsiness or difficulty awakening;
slurred speech; poor orientation to person, place, or
time; neck pain; and significant
Irritability. Any patient with worsening symptoms
should also undergo neuroimaging. Patients with LOC for
more than 30 seconds may have a higher risk of
intracranial injury, so neuroimaging should be considered
for them.
Grading Scales are not used !!!!!!!!!! Individualized
care of each patient is now the standard of care
!!!!!!
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Baseline
Neuropsychological testing
Balance Error Scoring
System (BESS)
Cognitive Rest/Physical
Rest !!!!!!!!!!!!!!!!!!!
Symptom Free Repeat
Neuropsychological Test
when available
Exertion Protocol (if no
test available one
suggestion is 1 week
symptom free then start
exertion: NJSIAA 2010)
Basic Management
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Minimize medications (no
evidence medications
facilitate healing)
Special groups for
consideration: Migraines,
ADHD, learning disabilities,
depression, and other
underlying disorders
Remember in children
symptoms can resolve
before neuropsychological
testing returns to baseline
(different than adults)
Consideration
 School
 Television
 Video
Games
 Noise (ear plugs)
 Lights (glasses)
 Hanging out with friends
 Riding in a car
 Computers
 Going to games
_____No gym class.
_____Restricted gym class activity as
specified below:
Academic Modifications
(Not a 504) for cognitive
rest in school.
_____Full academic accommodations as
specified below:
_____untimed tests
_____preprinted class notes
_____tutoring
_____reduced workload when
possible
_____frequent breaks from class
when
experiencing symptoms
_____modified homework
assignments
_____extended time on
homework, projects
_____Other:
_____Additional recommendations below:
When returning athletes to play, they should follow a
stepwise symptom-limited program, with stages of
progression.
Step 1: rest until asymptomatic (physical and mental rest)
Step 2: light aerobic exercise (e.g. stationary cycle)
Step 3: sport specific training
Step 4: non-contact training drills (start light resistance
training)
Step 5: full contact training after medical clearance
Step 6: return to competition (game play)
There should be approximately 24 hours (or longer) for
each stage and the athlete should return to the prior stage
if symptoms recur. Resistance training should only be
added in the later stages.
 Children
shouldn’t return to play until completely
symptom free which may require a longer time
frame than for adults.
 “Cognitive rest” was highlighted with special
reference to a child’s need to limit exertion.
 It is appropriate to extend the amount of
asymptomatic rest and/or length of the graded
exertion in children and adolescence.
 Children aren’t professional athletes?
A recently proposed definition of post-concussive
syndrome is the presence of cognitive, physical, or
emotional symptoms of a concussion lasting longer
than expected, with a threshold of 1 to 6 weeks of
persistent symptoms after a concussion to make
the diagnosis.
• Headaches
• Visual Problems
• Dizziness
• Noise/Light
Sensitivity
• Nausea
•Attention
Problems
•Memory
dysfunction
•Fogginess”
•Fatigue
•Cognitive slowing
• More emotional
• Sadness
• Nervousness
• Irritability
Somatic
Symptoms
Emotionality
Cognitive
Symptoms
Sleep
Disturbance
• Sleeping less
than usual
• Difficulty falling
asleep
Headaches
(Magnesium,
Riboflavin, Elavil,
Topamax)
•Vestibular
Symptoms:
Vestibular
Rehabilitation
•Antidepressants
•Sports
Psychologists
•Psychiatry
•
•Neuropsychologists
•Learning Disability
Specialists
•Cognitive
Therapists
• Medications
Somatic
Symptoms
Emotionality
Cognitive
Symptoms
Sleep
Disturbance
• Melatonin
 Gradual
exercise may help restore brain
auto-regulation
 Helps restore sense of self
 Not exercising changes the physiology of the
body
We start this about 4 to 6 weeks into the
injury. We find this to be invaluable.
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Compared with similar students without a history of
concussion, athletes with 2 or more concussions also
demonstrate statistically significant lower grade-point
averages.
Three months after a concussion, children 8 to 16 years of
age have been found to have persistent deficits in
processing complex visual stimuli.
Headaches (which can be migraine like) can be debilitating
and difficult to treat.
Section 504 is a civil rights law that
prohibits discrimination against individuals
with disabilities. Section 504 ensures that
the child with a disability has equal access to
an education. The child may receive
accommodations and modifications.
 CTE
 Depression
 Alzheimer's
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Zurich 2008 (3rd international
conference):
Epidemiologic studies have
suggested an association
between repeated sports
concussions during a career
and late-life cognitive
impairment. A panel
discussion was held and no
consensus was reached on
the significance of such
observations at this stage.
18 yo HS athlete
- 2 documented
concussions in football
- Multi-sport athlete
- Early CTE changes on
autopsy
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With the use of the HIT system, Impact testing,
and fMRI they tested 11 high school football
players ages 15-19. They found 3 categories of
players:
1) No diagnosis of concussion and no change in clinical
behavior. (4 patients)
2) Diagnosis of concussion and a change in clinical behavior.
(3 patients)
3) No diagnosis of concussion, but a change in visual
working memory and fMRI (altered activation in the
dorsolateral prefrontal cortex). Greater number of hits to
the top of the head in this category. (4 patients)
Small sample size so must be careful how to interpret !!!
However, raises questions.
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Halsted M, Walter K. Clinical Report: Sports Related Concussions
in Children and Adolescents. Pediatrics 2010; 3: 597-615
McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu
R. Concensus statement on concussion in sport – The 3rd International
Conference of Concussion in sport, held in Zurich November 2008
McDonald JW, Johnston MV. Physiological pathophysiological roles of
excitatory amino acids during central nervous system development. Brain
Res Rev 1990; 15:41-70
Omaya AK, Goldstein W, Thibault L. Biomechanics and neuropathology of
adult and pediatric head injury. Br J Neurosurg 2002, 16 (3): 220-242
Talvage T, Nauman E, Breedlove E, Yoruk: Functionally-Detected
Cognitive Impairment in High School Football Players Without Clinically –
Diagnosed Concussion. Journal of Neurotrauma. Submitted by Author
9/27/2010. For Peer Review
Leddy J, Kozlowski K, Fung M. Regulatory and autoregulatory
physiological dysfunction as a primary characteristic of post-concussion
syndrome: Implications for treatment. NeuroRehab 2007, 22: 199-205