Dr. Joseph Rempson Co-Medical Director of the Atlantic HealthConcussion Center at Overlook Hospital Director of he Department of Rehabilitation at

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Atlantic Neurosurgical 310 Madison Avenue Morristown, New Jersey 07960

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 Appointment: Office: Tel Cell:

2 1) 1.6 to 3.8 million sports and recreational mild traumatic brain injuries/year 2) Closed head injury (Acceleration/Deceleration Injury)

8 Severity of traumatic brain injury Mild Moderate 9 12 GCS PTA LOC <1 day >1 to <7 days Severe 3 8 >7 days 0-30 minutes >30 min to <24 hours >24 hours

9 GCS scores don t predict outcomes!!!

11 High school sports participation has grown from an estimated 4 million participants during the school year to an estimated 7.2 million in million played high school football in 2008 and 2009 and 43,000 to 67,000 were diagnosed with concussion

12 TABLE 1 Concussion Rates in High School Football a,b Girls soccer 0.36a Boys lacrosse c,d Boys soccer 0.22a Girls basketball 0.21a Wrestling 0.18a Girls lacrosse c,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): 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): 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): 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):

13 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 National Athletic Trainers' Association 2004 Position Statement: Management of Sport-Related Concussion

14 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)

15 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.

17 SCAT 2 SAC Maddock s Questionnaire Balance Error Scoring System (BESS) 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. On field/sideline evaluation Don t forget

18 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)

19 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.

20 Grading Scales are not used!!!!!!!!!! Individualized care of each patient is now the standard of care!!!!!!

22 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) 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) Basic Management Consideration

23 Neurocognitive testing recommended

24 Cog Sport Headminder Impact (NJISSA): Verbal Memory, Visual Memory, Processing Speed, Reaction Time

25 PRO s Objective Inexpensive Takes 20 minutes Educational Can check reaction time unlike pencil and paper Con s A test A mistake to use as a sole criteria to return to play Need someone who can interpret the test

28 DAY 7 DAY 4 DAY 2 Baseline 5-15 min < 5 min P<.02 P<.01 P<03 NS 70 P<.003 P< N = 64 High School Athletes 60 ImPACT Memory-Percent Correct Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98: ,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004

29 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:

30 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.

31 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?

33 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.

34 Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Somatic Symptoms Emotionality More emotional Sadness Nervousness Irritability Cognitive Symptoms Sleep Disturbance Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing Sleeping less than usual Difficulty falling asleep

35 Headaches (Magnesium, Riboflavin, Elavil, Topamax) Vestibular Symptoms: Vestibular Rehabilitation Somatic Symptoms Emotionality Antidepressants Sports Psychologists Psychiatry Cognitive Symptoms Sleep Disturbance Neuropsychologists Learning Disability Specialists Cognitive Therapists Medications Melatonin

36 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.

37 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.

38 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.

41 Case 1: ( 1 st or 2 nd week) youngster mildly symptomatic, but able to get through the day comfortably Case 2: (1 st or 2 nd week) youngster able to get through the day, but difficult Case 3: (1 st or 2 nd week) youngster spends most of the day in the nurses office Case 4: youngster after 3 months has persistent cognitive issues with severe headaches with studying

43 CTE Depression Alzheimer's Zurich 2008 (3 rd 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.

44 Cognitive Symptoms Short attention span Poor working memory Poor short term memory Difficulty in planning & reasoning Environmental dependence syndrome Behavioural Symptoms Utilization behaviour Perseveration behaviour Inappropriate aggression Inappropriate sexual behaviour Inappropriate humour & telling of pointless & boring stories (Witzelsucht) Emotional Symptoms Difficulty in inhibiting emotions, anger, excitement, sadness etc... Depression, possibly due to above. Occasionally, difficulty in understanding others' points of view, leading to anger & frustration

45 Language Memory Behavior Learning

48 18 yo HS athlete - 2 documented concussions in football - Multi-sport athlete - Early CTE changes on autopsy

50 With the use of the HIT system, Impact testing, and fmri they tested 11 high school football players ages 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.

51 1) 90% of people who have concussions don t lose consciousness. 2) In the United States there is no medical treatment for concussion that has been approved by the FDA. No evidence based pharmacological treatment. 3) Symptoms may take up to 3 days to declare themselves. 4) Best treatment of concussion is early recognition and cognitive rest. 5) Individuals with a history of migraines and ADHD are at increased risk.

53 1) 90% of people who have concussions don t lose consciousness. 2) In the United States there is no medical treatment for concussion that has been approved by the FDA. No evidence based pharmacological treatment. 3) Symptoms may take up to 3 days to declare themselves. 4) Best treatment of concussion is early recognition and cognitive rest. 5) Individuals with a history of migraines and ADHD are at increased risk.

54 6) Concussions most likely to occur during a game than practice (10 fold greater risk) 7) Athletes who have had at least 1 concussion are at increased risk for another concussion 8) A repeat concussion that occurs before the brain fully recovers from the initial insult can result a more severe concussion than the insult may have induced in a normal brain 9) Age matters 10) Sex matters 11) Highly individualized presentation

55 1) That mouth guards prevent concussions. 2) Xenith vs. Schutt, Revolution, vs other helment

56 Halsted M, Walter K. Clinical Report: Sports Related Concussions in Children and Adolescents. Pediatrics 2010; 3: McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Concensus statement on concussion in sport The 3 rd 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): 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:

Concussion Management and Update. Objectives

Concussion Management and Update Ricardo Guirola MD M Ed Pediatric Rheumatology Primary Care Sports Medicine Objectives Review definition, signs and symptoms Discuss the initial evaluation of a patient