Concussions: What’s the big deal? Carla Bystricky, MD Pediatrician at Parkview Whitley

Some facts about concussions: Football has the highest number of concussions per year BUT girls have a higher concussion rate in similar sports (example girl soccer players get more concussions than boy soccer players) There are an estimated 3.8 MILLION recreation and sport related concussions in the US each year 8.9% of all high-school related sports injuries are concussions

What is a Concussion? A brain injury A complex pathologic process that affects the brain due to traumatic biomechanical forces secondary to direct or indirect forces to the head An alteration to mental status with or without loss or consciousness due to trauma Medical Term- also known as a mild Traumatic Brain Injury Often no STRUCTURAL damage (normal MRI, CT) but FUNCTIONAL damage is present

Pathophysiology of Concussion Release of Excitatory Neurotransmitters Altered Cerebral Blood Flow Changes in Glucose metabolism Production of Lactic Acid and Free Radicals Mitochondrial dysfunction Axonal injury

Concussions cause an “Energy crisis” in the brain

Signs and Symptoms 4 categories: Physical Cognitive Emotional Sleep Headache is the MOST common reported symptom Loss of Consciousness occurs in less than 10% of concussions but may be clue that further imaging and testing should be done Amnesia (before or after event) and vomiting are also concerning signs Assess for bruising of mastoid (battle sign) and raccoon eyes (blood around eyes)-signs of skull fractures

Physical Signs and Symptoms Headache Nausea Vomiting Balance Problems Visual Problems Fatigue Sensitivity to light Sensitivity to Noise Dazed Stunned

Cognitive Signs and Symptoms Feeling “foggy” Feeling “slowed down” Trouble concentrating Trouble remembering Forgetful of recent information Confused about recent events Answers questions slowly Repeats questions

Emotional Signs and Symptoms Irritability Sadness More Emotional Nervousness May appear similar to depression, anxiety or ADHD Kids with pre-existing ADHD, mental health issues or migraines are likely to have a more difficult to control course

Sleep Signs and Symptoms Drowsiness Sleeps more than usual Sleeps less than usual Difficulty falling asleep

Short Term Effects The signs and symptoms for each child can be very different Most kids recover within 2-4 weeks if treated appropriately 85-95% fully recover by 3 months Home life, school life and academic performance, peer relationships all can be affected.

Diagnosis and Management: What to Do Grading and severity are no longer recommended for use by several medical organizations, as much of the symptom checklists and symptoms by the individual are subjective and/or related to prior existing medical conditions. Thus, severity would be difficult to predict

Sideline Assessment Tools Many different Versions Sports Medicine and Pediatric professional organizations lean towards: SCAT 2 (Sports Concussion Assessment Tool 2) The American College of Sports Medicine Assessment Tool Concussion Recognition and Response App (free!) The American Academy of Neurology recommend: GSC (Graded Symptom Checklist) SAC (Standardized Assessment of Concussion) BESS (Balance Error Scoring System Concussion Quick Check App (free!)

Portable Technology…

Immediately After: Remove from the Game!!! (As discussed) No NSAIDS (Motrin, Ibuprofen, Advil, Aleve, Naproxyn) or Aspirin until at least 24 hours after injury After the initial 24 hours, may wish to take for some symptom relief but will not necessarily speed recovery For the most part, the child does NOT need to be awoken during the night Rest/sleep is a chance to let the brain heal

If assessment is suspicious for concussion: Do not return to game if concussion is suspected If no loss of consciousness, no amnesia, no vomiting the child should not need any brain imaging and may not need to see a doctor until the next day or 2. The child should see a doctor and be placed on an INDIVIDUALIZED return to learn and return to play protocol

Other Assessment and Diagnostic Tools New Research in 2014 JAMA Neurology T-tau biomarker peaks within 12 hours of concussion and remains elevated up to 6 days. T-tau decreases as the patients signs and symptoms improve

ImPACT Testing Immediate Post-Concussion Assessment and Cognitive Testing Used by many schools and Universities for athletes A Neuropsychiatric test, performed on athletes at “baseline” then after concussion to monitor cognitive effects of the concussion Developed in early 1990s by a neuropsychiatrist (Dr Lovell) and Neurosurgeon (Dr Maroon) Should only be used as an adjunct, not the sole diagnostic eval to guide return to play

ImPACT- Maybe not as good as we thought Some “risks”: Recent review of data showed a 30-40 % false + AND false negative rate (missing some and over-including others) Company claims “Reliable and Valid” based on many studies but many of these studies done by developers and did not report conflict of interest 2007 Journal of Athletic Training- study on athletes concussion free for at least 6 months, study at “baseline”, repeated 45 days later, 38% identified as having concussion

Beware of “Sandbagging” Athlete deliberately performs poorly on baseline testing, so that if there is a concussion that occurs, it will not keep them out of play Several professional athletes are now admitting to this

Return to Learn? Start with “Cognitive Rest”- minimal activities that activate the brain, like TV, video games, computer games, homework Once good symptom control at rest and can concentrate at least 30-45 minutes, may start back to school but may need extra time for tests, lower homework load Recent studies show prolonged (>48 hours) “strict rest” delays recovery NO STANDARDIZED TESTS (ex ACT, SAT) should be taken while the child is recovering as this can cause lower than expected score that are not truly representative of abilities.

Return to Learn Some other school adjustments: Shortened days Work 30-45 min then 15 min break Provide class notes Tutoring Decrease course expectations Limit hours of homework Sunglasses Quiet environments Decrease particular subjects that exacerbate symptoms Extra time for tests If special school adjustments needed longer than 3 weeks, athlete may require 504 or IEP (longer & more extensive)

Consequences The graduated returning to learning can be hard in several aspects Teachers may not understand why child needs special treatment because child looks “normal” Friends may not understand or talk to child as much when can cause stress Can get behind in school work which makes more stress for child

Return to Play (RTP) American Academy of Pediatrics has a 6 Phase program for RTP May progress to next phase every 24 hours if SYMPTOM FREE If has symptoms, return to the PREVIOUS phase for another 24 hours

RTP Phases 1. Baseline 2. Increase Heart Rate 3. Moderate Exercise No physical or cognitive symptoms for 24 hours 2. Increase Heart Rate Increase HR for 5-10 minutes with mild activity (walking, light jog, exercise bike) 3. Moderate Exercise Limit body and head movement (brief running, moderate weight lifting

RTP Phases (continued) 4. Noncontact Exercise Increase intensity but no contact (intense running and non-contact sport specific drills) 5. Practice With full contact 6. Play/Game Return to competition

Long Term Risks After 1st concussion, it take less impact/injury to cause a 2nd concussion that may take an even longer time to heal than the 1st. 3 months after, studies show some kids have persistent processing issues Athletes with 2 or more concussions show on average to have lower grade point averages

Long Term Risks: Postconcussion Syndrome If the child takes longer than normal for the concussion symptoms to resolve, this is known as post concussive syndrome. Most kids heal in 2-4 weeks The definition of the length of time is not agreed on but is usually greater than 6 weeks Early postconcussive syndrome and cognitive impairments are longer lasting in younger athletes compared to older athletes Most concussion assessments have not been validates on pre-teens or younger AAN recommends more conservative management regarding RTP in athletes high school age and younger

Long Term Risks: Second Impact Syndrome A rare problem in which someone with a concussion returns to play before symptoms resolved and gets a second injury that causes vascular “congestion” in the brain (bad blood flow in the brain) This can cause brain swelling and death Kids and Teens at highest risk for this (compared to college age kids and adults)

Long Term Risks: Chronic Traumatic Encephalopathy Basically, long term brain damage Highest risk in those that have had 3 or more concussions This is the ongoing debate in the NFL now

When to see a Concussion Specialist Parental Concern Worsening symptoms despite appropriate accommodations and management Symptoms longer than 6 weeks Multiple concussions Risk factors for prolonged recovery These specialists would make decisions about “Retirement from Play”

Prevention? Recognition and Education are KEY!!! Kids, Parents, Teachers, Coaches, Trainers, even Doctors!!! Proper Equipment with appropriate fit Good Sports technique Adherence to Rules of the Sport

Resources for PT/ATC and parents/families/coaches Kidshealth.org Healthychildren.org Cdc.gov Heads Up program American Academy of Neurology American Academy of Pediatrics www.evanshealthlab.com (search concussion 101)

Questions?