Sports Concussion: Questions Our Patients Are Asking and the Evidence-Based Responses

Size: px

Start display at page:

Download "Sports Concussion: Questions Our Patients Are Asking and the Evidence-Based Responses"

Lorin Clarke
6 years ago
Views:

Sports Concussion: Questions Our Patients Are Asking and the Evidence-Based Responses Carlin Senter, MD Co-Director UCSF Sports Concussion Program Associate Professor Primary Care Sports Medicine

1 Sports Concussion: Questions Our Patients Are Asking and the Evidence-Based Responses Carlin Senter, MD Co-Director UCSF Sports Concussion Program Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics I have no financial disclosures. UCSF Primary Care Sports Medicine Course December 9, 2016 Questions our patients are asking about concussion 1. What is a concussion? 2. When will I recover? 3. Is there a diet or supplement that will expedite my recovery? 4. When can I return to school (work)? 5. When can I return to sports? 6. Should I wear head protection when I return to sports? 7. Should I avoid heading when I return to soccer post concussion? 8. Should I go to physical therapy to work on neck strengthening to lower my risk of concussion? 9. How many concussions is too many? 1. What is a concussion? 1

Definition Sequence of events Blow to head, neck, body force to head Rapid onset of neurologic impairment Symptoms usually resolve in weeks, spontaneously, but in some cases can be

CT and MRI studies are normal Giza CC and Hovda DA, J of Athletic Training, 2001. Vespa et al, J Cerebral Blood Flow and Metabolism, 2005.

2 Definition Sequence of events Blow to head, neck, body force to head Rapid onset of neurologic impairment Symptoms usually resolve in weeks, spontaneously, but in some cases can be prolonged. Force to brain Ion fluxes; vasoconstriction Need glucose but less blood flow Energy crisis Does not have to include loss of consciousness. CT and MRI studies are normal Giza CC and Hovda DA, J of Athletic Training, Vespa et al, J Cerebral Blood Flow and Metabolism, Window of vulnerability The period between the concussion and the recovery. Return to play during this time could cause worse, even catastrophic, brain injury 2. When will I recover from my concussion? Giza and Hovda, JAT

3 Symptom resolution 50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.) Recovery in athletes may be faster than recovery in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: ) Recovery in kids may take longer than recovery in adults Majority return to play in < 1 month in FB 15.5% of concussions required 30 days before return to play. Odds of return-to-play time of 30 days were greater in youth (odds ratio = 2.75; 95% CI, ) and high school (odds ratio = 2.89; 95% CI, ) athletes than in college athletes. No difference was found between high school and youth. Concussions, % 25% 20% 15% 10% 5% 0% Youth High School College Total Percentage of concussions in youth, high school, and college football requiring 30 days before return to play, 2012 to 2014 seasons. Kerr ZY et al. Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes. JAMA Pediatr Jul 1;170(7): Who is at risk for longer recovery? LOC > 1 minute Amnesia Convulsions History of multiple concussions Injuries close together in time Repeat injuries with less and less force Younger age Migraine headaches Depression ADHD Sleep disorders Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, Is there a certain diet or supplement that you would recommend for my child to expedite his/her recovery from concussion? 3

4 Diet Sparse literature High fat diet exacerbated behavioral problems post mtbi in rats (Mychasiuk et al. Diet, age, and prior injury status differentially alter behavioral outcomes following concussion in rats. Neurobiol Dis Jan;73:1-11.) Supplements No strong evidence for use of supplements in concussion management at this time. Promising results in animal studies and a few human studies on traumatic brain injury in recovery or prevention of concussion: Omega-3 fatty acids Curcumin Resveratrol Melatonin Creatine S. baicalensis Vitamins C, D, E Ashbaugh A, McGrew C. Curr Sports Med Rep Jan-Feb;15(1):16-9. Omega-3 fatty acids Melatonin Promising animal data (mainly rats) Mostly using docosahexaenoic acid (DHA) Protective effects before injury - role for prevention? Reduces effect of concussion post injury expedite recovery? 2 double-blind RCTs presently underway in US: NCAA D1 athletes taking 2200mg DHA x 30 days post injury to see if this affects recovery UT Southwestern supplementing kids y/o 2000mg DHA daily x 3 mo post injury to see if this affects recovery May have utility in reducing post traumatic headache after mtbi Kuczynski A et al. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Dev Med Child Neurol. 2013;55(7): Study underway: Barlow KM et al. A double-blind, placebo-controlled intervention trial of 3 and 10 mg sublingual melatonin for post-concussion syndrome in youths (PLAYGAME): study protocol for a randomized controlled trial. Trials Jul 7;15:271. Growing interest in sleep disorders that contribute to post concussion syndrome -?role for melatonin as treatment (Sullivan KA et al. Poor sleep predicts subacute postconcussion symptoms following mtbi. Appl Neuropsychol Adult Nov-Dec;23(6): ) Ashbaugh A, McGrew C. Curr Sports Med Rep Jan-Feb;15(1):

5 Acupuncture 1 case study on acupuncture + neck manipulation in concussion (Gergen DM. Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report. J Chiropr Med Sep;14(3):220-4.) Lack of high quality studies precludes ability to make conclusion regarding risk/benefit in TBI. (Wong V et al. Acupuncture for acute management and rehabilitation of traumatic brain injury. Cochrane Database Syst Rev Mar 28;(3):CD ) 4. Should I wait until I am 100% better before I return to school? How much rest after a concussion? Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics Feb;135(2): patients (11-22 y/o) seen at pediatric ED randomized Strict rest x 5 days vs. usual care of 1-2 days rest, then stepwise return to activity Neurocognitive and balance outcomes same Strict rest group had more daily post concussive symptoms and slower symptom resolution Return to learn after a concussion Halstead ME et al. Pediatrics Nov;132(5): Return to learn ASAP Ok to return to learn with symptoms Avoid disruptions to the student s life with return to school Physician should suggest academic adjustments if needed Most concussions resolve within 3 weeks so 504 plan or IEP usually not necessary Slide courtesy of Cindy Chang, MD 5

Team approach to return to learn Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

OK to do light reading, little bit TV, drawing, cooking as long as doesn t worsen

30 min schoolwork at a time until can do 1-2 hours. Return to ½ day of school.

6 Team approach to return to learn Halstead ME et al. Pediatrics Nov;132(5): Return to learn progression No school. OK to do light reading, little bit TV, drawing, cooking as long as doesn t worsen symptoms. 15 min cognitive activity at a time. 30 min schoolwork at a time until can do 1-2 hours. Return to ½ day of school. Return to full day of school. CIF: Physician letter to school 5. When can I return to sports after my concussion? 24 6

7 Concussion Legislation Concussion legislation 50 states have adopted youth concussion laws California: education code (effective 1/2012) 1. Athletes and guardians sign a concussion information form yearly 2. Athlete suspected of having concussion removed at time of injury for the rest of the day 3. Athlete can return only after cleared by healthcare professional trained in evaluation and management of concussion California Assembly Bill 2127 (in effect 1/2015) Adds to AB 25 FB full-contact practice limits: No more than 2/week during preseason and season These practices cannot exceed 90 minutes No full-contact in off-season Once clear must follow gradual return to play protocol of at least 7 days under supervision of licensed provider Return to Play Progression Return to play activity examples Step Objective Activities 1 Recovery No activity Asymptomatic Light aerobic activity Sport specific activity Clinician clearance Noncontact training Full contact practice Game play 2 Light aerobic activity: Increase heart rate 3 Sport Specific: Add movement 4 Non contact training: Add coordination and cognitive load 5 Restore confidence and assess functional skills by coaching staff Walking, swimming, or stationary bike. < 70% max heart rate. No weights. Skating drills in hockey, running drills in soccer. No head impact activities. More complex drills (passing). Can start weights. Full-contact practice 6 Normal game play Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November Br J Sports Med Apr;47(5):

CIF: Return to play handout Symptoms during return to play If symptomatic during a

Consensus statement on concussion in sport: the 4th International Conference on

2013 Apr;47(5):250-8 6. This is my daughter s 3rd concussion while playing soccer.

8 CIF: Return to play handout Symptoms during return to play If symptomatic during a step of the return to play protocol Stop activity Rest until symptoms resolve, at least 24 hours. Resume return to play protocol at the step where athlete was last asymptomatic Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November Br J Sports Med Apr;47(5): This is my daughter s 3rd concussion while playing soccer. Should she keep playing? Is Concussion Really a Mild Traumatic Brain Injury? 8

Chronic traumatic encephalopathy How Many Concussions is Too Many?

sport 158 potential CTE cases reported, 6 high school age Diagnosed at autopsy: tau protein deposition Difficult to draw causality no prospective

Chronic traumatic encephalopathy in sport: a systematic review. BJSM. 2013 Jun 26. Randolph C. Is chronic traumatic encephalopathy a real disease?

Talking with parents of high school football players about chronic traumatic encephalopathy: a concise summary. AJSM 2015.

Short term risk vs long term risk Concussion hx. Number. Less force. More frequent. Increased severity of sxs Increased duration of sxs.

9 Chronic traumatic encephalopathy How Many Concussions is Too Many? Athletes and military personnel Chronic, progressive depression, cognitive impairment, aggression Symptoms develop 8-20 years after retirement from sport 158 potential CTE cases reported, 6 high school age Diagnosed at autopsy: tau protein deposition Difficult to draw causality no prospective data yet Concerning association between professional sports participation and long term neurologic/psychological problems Gardner A et al. Chronic traumatic encephalopathy in sport: a systematic review. BJSM Jun 26. Randolph C. Is chronic traumatic encephalopathy a real disease? Current Sports Med Review, Love S and Solomon G. Talking with parents of high school football players about chronic traumatic encephalopathy: a concise summary. AJSM I think best to have this conversation once the athlete has recovered from their most recent injury. Individualized to athlete. Short term risk vs long term risk Concussion hx. Number. Less force. More frequent. Increased severity of sxs Increased duration of sxs. Age: possibly more consequences if younger at time of concussion. 7. Would you recommend we purchase head protection for my child in order to reduce the risk of repeat concussion when he/ she returns to sport? Protective gear? Benson BW et al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med

Do I lower my concussion risk in soccer if I avoid heading? Contact with another player is most common reason for concussion in soccer. Fewer concussions from impact of head with ball.

) Highest head acceleration: head-to-head impacts and unintentional head impacts by the ball (Hanlon EM, Bir CA. Realtime head acceleration measurement in girls youth soccer. Med Sci Sports Exerc.

10 Do I lower my concussion risk in soccer if I avoid heading? Contact with another player is most common reason for concussion in soccer. Fewer concussions from impact of head with ball. (Comstock RD et al. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr Sep 1;169(9):830-7.) Highest head acceleration: head-to-head impacts and unintentional head impacts by the ball (Hanlon EM, Bir CA. Realtime head acceleration measurement in girls youth soccer. Med Sci Sports Exerc. 2012;44(6):1102 8; Withnall C et al. Biomechanical investigation of head impacts in football. Br J Sports Med. 2005;39(Suppl 1):i49 57.) Purposeful heading unlikely to cause concussion but the effect of heading (chronic sub concussive blows) on brain long term is unclear (Caccese JB and Kaminski TW. Minimizing head acceleration in soccer: A review. Sports Med 2016 Nov;46(11): ) Neck strengthening to reduce risk Hypothesis: strong neck muscles may diminish the acceleration of the head on impact, lowering concussion risk Studies measure isometric neck strength in flexion + extension, sometimes with left and right-lateral flexion Increased neck strength was associated with lower risk of concussion in high school athletes (Collins CL et al. Neck strength: a protective factor reducing risk for concussion in high school sports. J Prim Prev Oct;35(5): ) Neck strengthening programs can increase neck strength in athletes (Hrysomallis C. Neck Muscular Strength, Training, Performance and Sport Injury Risk: A Review. Sports Med Aug;46(8): ) Next step = development of neck strengthening intervention to see if can reduce risk of concussion in athletes Decrease exposures Have you thought about playing sports other than soccer / football / rugby? Accessed 12/5/15. 10

Incidence of concussion Reported as events per 1000 athlete exposures (AEs) Sport Male Female Pooled incidence Rugby 4.18 NR 4.18 Hockey NR NR 1.20 American football 0.53 NR 0.53 Lacrosse 0.29 0.17 0.

11 Incidence of concussion Reported as events per 1000 athlete exposures (AEs) Sport Male Female Pooled incidence Rugby 4.18 NR 4.18 Hockey NR NR 1.20 American football 0.53 NR 0.53 Lacrosse Soccer Wrestling 0.17 NR 0.17 Basketball Softball NR Field hockey NR Cheerleading NR Baseball 0.06 NR 0.06 Volleyball NR Pfister T et al. The incidence of concussion in youth sports: a systematic review and meta-analysis. Br J Sports Med Mar;50(5): Highest risk positions by sport Water polo goalie (Blumenfeld RS et al. The Epidemiology of Sports- Related Head Injury and Concussion in Water Polo. Front Neurol Jun 24;7:98.) Baseball catcher during fielding (vs batting or running) (Green GA et al. Mild traumatic brain injury in major and Minor League Baseball players. Am J Sports Med May;43(5): ) Football 1. quarterback, 2. running back, 3. linebacker (Powell JW. Traumatic brain injury in high school athletes. JAMA Sep 8;282(10): ) Ice Hockey forwards (Hutchison MG et al. A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what? Br J Sports Med Apr;49(8): ) Soccer goalkeepers and defensive midfield players due to collision with other player (Helmich I. Game-specific characteristics of sport-related concussions. J Sports Med Phys Fitness Sep 14.) Volleyball libero position due to hits from the ball (Helmich I. Game-specific characteristics of sport-related concussions. J Sports Med Phys Fitness Sep 14.) Concussion resources California Interscholastic Federation concussions/index Consensus statement on concussion in sport, CDC concussion toolkit for physicians UCSF Sports Concussion Program Concussion@UCSF.edu 11

12 Questions our patients are asking about concussion 1. What is a concussion? 2. When will I recover? 3. Is there a diet or supplement that will expedite my recovery? 4. When can I return to school (work)? 5. When can I return to sports? 6. Should I wear head protection when I return to sports? 7. Should I avoid heading when I return to soccer post concussion? 8. Should I go to physical therapy to work on neck strengthening to lower my risk of concussion? 9. How many concussions is too many? My evidence-based responses 1. Concussion = energy crisis of the brain. 2. Majority of high school athletes recover within 1 month of injury 3. No specific diet or supplements recommended yet 4. Return to learn (work) asap 5. Return to play once asymptomatic with gradual RTP protocol 6. Risk reduction 1. Head protection data equivocal. Increases aggressive play? 2. Neck strengthening too early to know risks/benefits 3. Heading not the primary cause of concussion in soccer 4. Decrease the exposure to contact: lower risk sport/position 7. Retirement from sport is an individual decision 8. In most cases concern re: short term rather than long term consequences of concussion. 12

The Latest in Sports Concussion Management UCSF Primary Care Sports Medicine Conference

The Latest in Sports Concussion Management UCSF Primary Care Sports Medicine Conference Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University