1. Sports-Related Concussion George C. Phillips, MD, FAAP, CAQSM Clinical Associate Professor of Pediatrics Sports Medicine Rounds September 16, 2010

2. Sports-Related Concussion NCAA studies estimated ~ 6% of athletes incurred a concussion each season (FB) More recent studies of high school athletes estimate a seasonal rate of 15% –CJSM 2004 McCrea et al Sports-related concussions estimated at 300,000 per year –Over 135,000 in high school sports (JAT 2007 Gessel et al) At least 55,000 to 60,000 concussions occur each year in high school football alone.

3. Simple versus Complex Concussion Simple –Resolves in 7-10 days –No complications –Formal neuropsychological evaluation unnecessary –Most common form –Rest until symptoms resolve –Graded RTP Complex –Persistent symptoms –Specific sequelae Prolonged cognitive impairment –Multiple concussions, perhaps with less force –Formal neuropsychological evaluation –Sports medicine expertise

4. Classification No proposed classification scheme Agreement that 80% to 90% of concussions have symptom resolution within 7-10 days, except… Pediatric concussions may last longer

5. Are All Athletes Equal? CJSM 2007 Iverson 114 high school football players 52% suffered complex concussions –No increased history of prior concussions –Symptoms took an average of 19 days to resolve (vs. 4.5 days for simple concussions)

6. Next Steps in Evaluation Neuroimaging – no, for clinical purposes Balance testing – can see measurable deficits in first 72 hours Neuropsych testing – valid tool; best when interpreted by an expert Genetic testing – unclear value at this time

7. Return to Play Guidelines Stepwise RTP Protocol –No activity until 24 hours without symptoms –Light aerobic exercise –Sport-specific training (skating, running) –Noncontact training drills –Full contact drills after medical clearance –Return to competition Recurrence of symptoms at any stage warrants removal from participation until symptom-free for another 24 hours. Participation then resumes one stage earlier in the protocol.

9. What about Sunday afternoons? Team physicians experienced in concussion management Sufficient resources (access to specialists) Immediate (sideline) neurocognitive assessment Note: 1 study cited for adult RTP same day, vs. 7 studies for problems in college and high school athletes

10. Return to Play Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005–2008. Brain Injury, October 2009; 23(11): 888–898. Reviewed use of RTP guidelines at 100 HS Estimated 400,000 concussions nationwide AAN guidelines – 40.5% returned early Prague guidelines – 15% returned early In football, 15.8% of concussed athletes with LOC returned in less than 24 hours

11. Other Management Issues Consider depression in the athlete Athlete should be asymptomatic, off meds, for RTP Individual consideration for athletes on anti- depressant meds and RTP –Experienced clinician judgment

12. Preparticipation Screening Not just number of concussions, but prior symptoms –How good is the concussed athlete’s recall? Head, face, neck trauma history Impact vs. symptom severity – mismatch?

13. How Well Do We Take a History? 2008 CJSM Valovich McLeod et al

14. Symptom%(+) Responses# Episodes Headache43.53.1 ± 2.1 Dazed or Confused 23.82.6 ± 1.8 Dizziness or Balance Problems 20.82.5 ± 1.8 Trouble Concentrating 18.73.4 ± 2.1

15. Duration of Symptoms Meehan WP, d’Hemecourt P, Comstock RD. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. AJSM Preview, August 17, 2010. 544 concussed high school athletes 15.1% had symptoms > 1 week but <1 month 1.5% had symptoms > 1 month

16. Post-Concussion Syndrome ICD-10 –Head trauma w/LOC precedes symptoms by  4 weeks –Three or more symptoms categories: HA, dizziness, malaise, fatigue, phonophobia Irritable, depression, anxiety, emotionally labile Subjective concentration, memory, or intellectual difficulties Insomnia Reduced alcohol intolerance Preoccupation with symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role

17. Post-Concussion Syndrome DSM-IV: –3 or more of the following occur shortly after trauma and last at least 3 months: Fatigued easily Disordered sleep Headache Vertigo or dizziness Irritable or aggressive with little/no provocation Anxiety, depression, or affective lability Personality changes Apathy or lack of spontaneity

18. Does PCS Exist? Plenty of experts say no: –Depression –PTSD –Litigation, Worker’s Compensation –Chronic Pain What are we asking? –Self-reported questionnaires –Structured Clinical Interview/Sx assessments –Neuropsychological testing When are we asking?

19. Attentional Deficits in PCS Categorization of PCS patients: –Mild sustained attentional deficits Sustained Attention to Repsonse Task Younger, better educated –Selective and divided attentional deficits Best on SART; Stroop Word-Color, PASAT, Symbol Digits Modality Test impaired –General attentional deficits Poor on everything Disproportionately female

20. Risk Factors for PCS Preexisting psychiatric condition Comorbid psychiatric diagnosis Alcohol Litigation Age Female gender Violent injury mechanism Dizziness Prior head injury or CNS disorder Education Learning disability Academic success (GPA)

21. Post-Concussion Syndrome Emotional disturbance and secondary gain are true confounders of PCS Controlled studies reveal objective findings of cognitive dysfunction in PCS Functional neuroimaging and electro- physiology studies can support diagnosis

22. Episodic Symptoms Tucker (1986) described 20 cases with episodic changes in cognition, mood, hallucinations Abnormal EEG but not epileptiform Poor response to antipsychotics, lithium, or tricyclics (lower seizure threshold) Improved with anti-epileptic medications

23. Episodic Symptoms Tinnitus Head pain Memory gaps for experiences Déjà vu Automatisms of walking and speech Staring spells Anger episodes Dizziness Vertigo Micropsia (funnel of light)

24. MIND Multiple authors describe similar cases Epilepsy Spectrum Disorder (ESD) Multiple Intermittent Neurobehavioral Disorder (MIND) No clear etiology –Hippocampal, brainstem, multifocal cortex- white matter junction lesions Differential: intermittent explosive disorder; personality disorder; mood disorder

25. MIND Typical neuropsychological profile: –Mild to moderate attentional problems –Short-term and long-term memory problems –Focal NP deficits matching gross lesions –Frontal lobe dysfunction (olfactory) –Executive dysfunction

26. Medications for MIND No randomized, controlled trials Most experience with carbamazepine and valproic acid –Both are good for partial seizure disorders –Carbamazepine used in mood control: rage –Valproic acid used in mood control: anxiety Iowa experience – 95% positive response to CBZ Second-line antiepileptics phenytoin and gabapentin with less experience

27. Post-Concussion Syndrome For athletes, multiple concussions are a significant risk factor. While many symptoms of PCS overlap with other diagnoses, subscales of symptoms specific for cognitive function may delineate true cases of PCS. Neuropsychological testing can provide objective data for diagnosis, follow-up comparisons, and information to assist in reintegrating the injured person to work, school, and/or athletics. If objective neuropsychological findings support the diagnosis of MIND, a trial of antiepileptic medications may prove useful.

28. Multiple Concussions 2002 Neurosurgery Collins et al –History of ≥3 concussions = 9.3x more likely to experience 3 of 4 “onfield markers” LOC, RG amnesia, AG amnesia, or confusion –6.7x more likely to experience LOC 2003 JAMA Guskiewicz et al –≥3 concussions = 3x more likely to have another concussion –≥3 concussions: 30% had symptoms > 1 week

29. Multiple Concussions 2004 Brain Injury Iverson et al –≥3 concussions = more preseason symptoms –≥3 concussions = 7.7x more likely to have memory problems 2 days after injury 2008 J Ath Train Covassin et al –≥3 concussions = significantly slower recovery of verbal memory and reaction time –No significant change in symptom scores 5 days after the concussion

31. Pediatric Concussion Zurich guidelines appear applicable down to age 10 For younger athletes, need different evaluation tools, teacher/parent input Longer recovery Cognitive rest “Diffuse cerebral swelling” Modifiers may apply even more

32. Second Impact Syndrome Rare, controversial diagnosis Results when a second head injury occurs before resolution of first injury Rapid progression to altered sensorium, seizures, coma, brain death Abnormal or immature autoregulation of cerebral blood flow causes swelling,  ICP and cerebellar herniation (2-5 minutes)

34. Chronic Traumatic Encephalopathy “Punch-drunk” boxers – Martland 1928 Dementia pugilistica Psychopathic deterioration of pugilists Progressive neurodegeneration clinically associated with memory disturbances, behavioral and personality changes, parkinsonism, and speech and gait abnormalities.

35. CTE 48 cases proven by microscopic evaluation reported in the literature Cerebral and medial temporal lobe atrophy, ventriculomegaly, enlarged cavum septum pellucidum, and extensive tau- immunoreactive pathology –Tau-reactive neurofibrillary tangles (NFT) very similar to Alzheimer’s disease

36. CTE Football players’ history different from boxers – –Younger at age of death (44 yo versus 60 yo) –Shorter duration of symptoms (6 versus 20.6 yrs) Head trauma linked with Alzheimer’s, suggesting a possible common pathway to chronic neuronal damage