Sports Concussion What the Clinician Needs to Know

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Carlin Senter, MD Associate Professor Co-Director

Medicine University of California San Francisco UCSF

Concussion 2010 UCSF Sports Concussion Program

clinical care for sports concussion patients Need

1 I have no disclosures. Sports Concussion What the Clinician Needs to Know Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco UCSF Essentials of Women s Health July 7, 2016 Sports Concussion 2010 UCSF Sports Concussion Program Concussion is serious public health issue Need clinical care for sports concussion patients Need community education Need to advance diagnostic tools Need prevention measures Education Sports concussion care Research

UCSF PlaySafe Outline: Sports Concussion 2016 Athletic

Treatment How much rest? Return to learn Return to play 4.

2 UCSF PlaySafe Outline: Sports Concussion 2016 Athletic trainer at high school M.D. on sideline and in clinic Preparticipation exams Baseline testing Education 1. Epidemiology 2. Evaluation 3. Treatment How much rest? Return to learn Return to play 4. Legislation 5. How many concussions is too many? Concussions are common Concussions are common

3 Concussion numbers increasing Put these high school sports in order of highest to lowest incidence of concussion. A. Soccer (boys) B. Soccer (girls) C. Basketball (girls) D. Wrestling (boys) E. Football (boys) Marin JR et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA May 14;311(18): Rates of sports concussion in high school sports U.S Sport Rate per 1000 athletic exposures Football (boys) 0.94 Soccer (girls) 0.73 Wrestling (boys) 0.57 Soccer (boys) 0.41 Basketball (girls) 0.37 Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From to Am J Sports Med Jul;42(7): Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From to Am J Sports Med Jul;42(7):

4 Concussion definition Concussion symptoms Type of mild traumatic brain injury 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. May or may not include loss of consciousness. CT and MRI studies are normal Sleep Physical Emotional Cognitive Symptom Resolution Who is at risk for delayed return to play? 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 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, 2014.

Case #1 3-pronged evaluation recommended 16 y/o high school soccer goalie Presents to you in urgent care with wrist pain Also, she hit

She took a nap after practice as she felt unusually tired. Now she has no headache: I feel fine. What do you do next? 1.

Balance Error Scoring System (BESS or modified BESS) 3.

SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014. 1.

5 Case #1 3-pronged evaluation recommended 16 y/o high school soccer goalie Presents to you in urgent care with wrist pain Also, she hit heads with teammate in practice earlier today and had 15 minutes of headaches and dizziness. She took a nap after practice as she felt unusually tired. Now she has no headache: I feel fine. What do you do next? 1. Self-reported symptom assessment 2. Motor control: Neurologic exam including balance. Balance Error Scoring System (BESS or modified BESS) 3. Mental status: Standardized Assessment of Concussion (SAC) Case courtesy of Cindy Chang, MD Case courtesy of Cindy Chang, MD Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, Self-reported symptom assessment 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):250-8 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):250-8.

Symptom norms 9 th grade 10 th grade 11 th grade 2. Neurological exam with balance Balance Error Scoring System: BESS Symptom score 17 +/- 5 16 +/- 5 17 +/- 6 Valovich McLeod TC et al.

jpg BESS scoring BESS norms: ages 10-17 Each error is counted as one point Score = the sum of the error points for all six trials Errors Eyes opening Hands coming off the hips Hip flexion or

6 Symptom norms 9 th grade 10 th grade 11 th grade 2. Neurological exam with balance Balance Error Scoring System: BESS Symptom score 17 +/ / /- 6 Valovich McLeod TC et al. Representative baseline values on the sport concussion assessment tool 2 (SCAT2) in adolescent athletes vary by gender, grade and concussion history. AJSM BESS scoring BESS norms: ages Each error is counted as one point Score = the sum of the error points for all six trials Errors Eyes opening Hands coming off the hips Hip flexion or abduction of greater than 30 Changing foot placement from the stance Remaining out of the test position for > 5 seconds Max score 10 errors Also if cannot maintain for minimum 5 seconds then score = 10 Khanna NK, Baumgartner K, LaBella CR. Balance Error Scoring System Performance in Children and Adolescents With No History of Concussion. Sports Health Jul;7(4):341-5.

BESS norms: adults 3. Mental status Iverson GL, Kaarto ML, Koehle MS.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med.

When he came to he felt fine but stopped practicing due to neck pain.

7 BESS norms: adults 3. Mental status Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: implications for brain injury evaluations. Brain Inj Feb;22(2): 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): Case #2 9 y/o boy playing ice hockey, slipped and hit back of his head. Friends said he was out for 5 seconds. When he came to he felt fine but stopped practicing due to neck pain. Mom brings him to see you the next day because at school he felt foggy and had headache worse with noise. He says it s hard to pay attention. What tool should one use in evaluating a child with concussion? When should he return to school? 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):250-8

Statistically significant differences between males/females (males worse) and ages 5-9/10-13 (younger worse) Tandem Gait Statistically significant differences between ages 5-9/10-13 (younger worse)

8 Can the Child SCAT3 be validated? Cognition Over 1/3 of all children didn t know the date 70% 5-7 yo, 39% 8-10 yo, 23% yo Concentration days of week 88% correct Of 56 who couldn t, 63% were 5-7 yo Can the Child SCAT3 be validated? Balance (modified BESS) Statistically significant differences between males/females (males worse) and ages 5-9/10-13 (younger worse) Tandem Gait Statistically significant differences between ages 5-9/10-13 (younger worse) Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending Concussion treatment How much rest after a concussion? Cognitive rest Physical rest Medication Tylenol Ibuprofen after first 72 hours No driving No Etoh 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 at 3 and 10d post injury Strict rest group had more daily post concussive symptoms and slower symptom resolution over the 10d study period Slide courtesy of Cindy Chang, MD

Return to learn after a concussion Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

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

9 Return to learn after a concussion Halstead ME et al. Pediatrics Nov;132(5): Team approach to return to learn 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 Return to learn progression Return to Learn BEFORE Return to Play 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 Concussion Information Sheet Acute Concussion Notification Form Graded Concussion Symptom Checklist Physician Letter to School After

Case #3 15 y/o high school girls soccer player Concussion f/u in clinic Injured 2 weeks ago Rested at home x 2 days then gradually returned to school with RTL protocol

10 CIF: Physician letter to school Concussion Information Sheet Acute Concussion Notification Form Graded Concussion Symptom Checklist Physician Letter to School After Concussion Visit Concussion Return to Learn (RTL) Protocol Physician Recommended School Accommodations Following Concussion Concussion Return to Play (RTP) Protocol Case #3 15 y/o high school girls soccer player Concussion f/u in clinic Injured 2 weeks ago Rested at home x 2 days then gradually returned to school with RTL protocol Tolerating school 100% No concussion symptoms Soccer championship game in 2 days. She requests your clearance to play. What do you recommend? Follow gradual RTP progression

Return to play progression Return to play activity examples Asymptomatic Light aerobic activity Sport specific activity Clinician clearance Noncontact training Full contact practice 2 nd

11 Return to play progression Return to play activity examples Asymptomatic Light aerobic activity Sport specific activity Clinician clearance Noncontact training Full contact practice 2 nd International Conference on Concussion in Sport (2004) Br J Sport Med 39:196. Game play Step Objective Activities 1 Recovery No activity 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 Concussion Information Sheet Acute Concussion Notification Form Graded Concussion Symptom Checklist Physician Letter to School After Concussion Visit Concussion Return to Learn (RTL) Protocol Physician Recommended School Accommodations Following Concussion Concussion Return to Play (RTP) Protocol

12 California concussion legislation Hawaii concussion legislation AB 25 Concussion Law parts (education, remove from play, written medical note to return) AB 1451 Coaches Concussion Training Law 2013 Mandatory education every 2 years AB 2127 Concussion Safety Law 2015 Limit FB full-contact practices Mandatory RTP protocol of no less than 7 days from the diagnosed date of concussion RTP under the supervision of LHCP Act 197 enacted 7/3/2012 Hawaii High School Athletic Association members must Provide annual concussion training for coaches, faculty, staff, parents and students who play sports Immediate removal from play if signs or symptoms of concussion Student must be evaluated and cleared by LHCP prior to return to learn/play Slide courtesy of Cindy Chang, MD Case #4 Post Concussion Syndrome A 15 y/o lacrosse player presents to you 3 months after her 5 th concussion sustained when she was elbowed in the head during a game. She has had a headache with light sensitivity since the injury. She and her father would like to know if and when she can return to lacrosse. What is her diagnosis? What do you do next? Frequency unclear (0-15%). Concussion symptoms persist x months, usually <1 year. Patients benefit from multidisciplinary approach to treatment.

Think about post concussion syndrome when Symptoms not improving after 2 weeks of treatment.

History of migraine, anxiety, depression, sleep disorder. History of concussion.

Many? Individualized to athlete. Concussion hx. Number. Less force. More frequent.

Age: possibly more consequences if younger at time of concussion.

13 Think about post concussion syndrome when Symptoms not improving after 2 weeks of treatment. Unable to return to school or work after 1-2 weeks of treatment. History of migraine, anxiety, depression, sleep disorder. History of concussion. Post concussion syndrome treatment: Multidisciplinary approach How Many Concussions is Too Many? Individualized to athlete. 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. Corrigan JD, Concussion webcast 10/18/2011. Outline: Sports Concussion Epidemiology 2. Evaluation 3. Treatment How much rest? Return to learn Return to play 4. Legislation 5. How many concussions is too many?

Keys to managing sports concussion in 2016 3-pronged evaluation: Symptoms, Neuro/balance exam, Cognitive Treatment is rest Gradual return to learn Return to play protocol at least 7 days since day of

14 Keys to managing sports concussion in pronged evaluation: Symptoms, Neuro/balance exam, Cognitive Treatment is rest Gradual return to learn Return to play protocol at least 7 days since day of diagnosis (in state of California) Majority recover within 3 weeks Consider referral for post concussion syndrome Repeat injuries: individual approach Concussion resources California Interscholastic Federation concussions/index Consensus statement on concussion in sport, CDC concussion toolkit for physicians Thank You! Carlin Senter, M.D. Carlin.Senter@ucsf.edu UCSF Sports Medicine

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