CONCUSSION. Amanda Weiss Kelly, MD Rainbow Babies and Children s Hospital

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1 CONCUSSION Amanda Weiss Kelly, MD Rainbow Babies and Children s Hospital

2 Disclosure In the past 12 months I have NO relevant financial relationships with the manufacturers of any commercial products and/or provider(s) of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation Will discuss off-label use of medications

3 Objectives Describe: NEW info Epidemiology Office Exam and Management Screening Long term management Return to play criteria and protocol

4 WHAT S NEW Complete rest NOT recommended >24-48 hr Adolescents seem to take longer to recover than: Younger children &College age New SCAT5 (Standardized Assessment of Concussion) NO orientation? s on Child SCAT5 REMOVE any player suspected of concussion Physiologic recovery may be longer than clinical

5 Concussion Incidence Lystedt s Law Rosenthal JA, Foraker RE, Collins CL, Comstock RD 2014 AJSM

6 Lystedt s Law School districts must develop guidelines and educational programs Youth athlete/parent sign information sheet Immediate removal for suspected concussion Written clearance for RTP

7 Concussion Incidence: Boys boys Rosenthal JA, Foraker RE, Collins CL, Comstock RD 2014 AJSM

8 Concussion Incidence: Girls Rosenthal JA, Foraker RE, Collins CL, Comstock RD 2014 AJSM

9 Sex Differences? Females > Males concussion rate? reporting differences When girls get concussions: Higher sx score Cognitive impairment 1.7x more likely than in men greater decline reaction time neurocog performance Broshek 2005 J Neurosurg, Sandel 2016 AJSM

Typical Child Recovery Course 5 21 days: median 17d 16% < 1 week 26% > 4 weeks 1.

10 Typical Child Recovery Course 5 21 days: median 17d 16% < 1 week 26% > 4 weeks % have sx > 1 mo- 3 mo 2.3 % have sx at 1y Meehan 2010 AJSM, Guskiewicz 2010 AMSSM, Thomas 2017 CJSM, Davis 2018 BJSM)

11 Recovery time Adolescents may take longer than younger children / college Adolescent 14 d Younger 12 d

12 Slower Recovery Females Prior concussions >2 Ask about each prior concussion Length of recovery : worse if sx > 1 week 2 nd hit prior to recovery from 1 st injury Migraine Hx: personal (Family?) Mood disorder Learning disability / cognitive issues? Need more school interventions Lau 2011 AJSM, Thomas 2017 CJSM, Davis 2017, BJSM, McCrory 2017 BJSM

13 Office Evaluation History Exam Treatment

14 History Mechanism of Injury Post-Concussion Scale (PCS) Blossoming of symptoms Up to 72 hours Assess: Headache quality, location, severity School participation Activity level Sleep habits

15 History PMH (high risk groups): Migraine Depression/anxiety ADHD LD Prior concussions Concussion can worsen sx of mood disorder

17 Child Checklist: Parent & Child

18 Most Common Symptoms In Kids Headache Usually pressure Migraine hx: unilat, throbbing, pulsing Fatigue Dizziness

19 Other Common Symptoms Photo / Noise sensitivity Balance problems Difficulty concentrating Behavior changes Vision changes

20 Symptom Score in Kids Average totals: At injury: 40 Initial visit: 20 Ave score rapid recovery (sx < 1 week): At injury: 26 Initial visit: 4 Ave score sx > 1 mo: At injury: 48 Initial visit: 32 Thomas 2017 CJSM

21 Prognostic Indicators: Symptoms Greater # of symptoms at 2 days Noise/light sensitivity Fatigue Fogginess/concentrating: answer? s slowly Balance problems/dizziness Headache > 60 hours Migraine type Lau 2011 AJSM; Makdissi 2010 AJSM, Thomas 2017 CJSM

22 Prognostic Indicators: Symptoms Better prognosis Headache < 24 hr Lower PCS at initial Eval

23 Physical Exam Eyes: fundoscopic, EOEM, pupils ENT: TMs, bruising / swelling, dental trauma, smell Neck exam Neuro exam CN 2-12 Strength Reflexes Sensation Coordination Romberg Gait, tandem gait

24 BESS Count errors in each position for 20 s

25 BESS Average Errors: 8 in college age Low value if: Done within 15 min of exercise Performed > 3 weeks out from concussion No normative data for younger ages Flat footed/recent ankle injury I DO repeat before RTP so I can establish baseline BESS performance

26 Standardized Assessment Of Concussion (SAC) SAC5 introduced 5/2017 Helpful in diagnosis / tracking recovery Not very useful in RTP decisions Utility less after 3-5 d

27 Cognitive Assessment Sideline version In office

28 Physical Exam Cognitive Orientation Immediate Memory Concentration Delayed Memory BESS Stop watch! Firm surface

29 Physical Exam NEW SAC 5 More word lists

30 Physical Exam New SCAT5 LONGER word lists

31 Physical Exam MORE number lists

33 Child SCAT5 Use if 5-12 years old Differences Both parent AND child assess symptoms NO orientation questions (NEW) Days of the week backwards (instead of months) ANOTHER change All 3 stances for BESS

34 Prognostic Indicators: Exam Deficits on cognitive tests at 7d 17% signif cog deficits at 7d 35% still have cog deficits after sx resolved More prominent on computerized tests vs paper pencil Worse performance on BESS > 4 errors Worse if > 20 Greater length of time before 1 st visit Collins 2003 CJSM, Thomas 2017 CJSM

35 NEW Consensus Statement Download SCAT5/new consensus statement /28/bjsports childscat5.full.pdf ports

36 Indications for Imaging CT Repeated vomiting Headache worst of life, unable to function FOCAL neuro exam Weakness, increased tone, abnormal reflexes MRI Prolonged symptoms (>1 month) Considering Neuro referral for medication Eval for underlying issues: mass, Chiari, hydrocephalus

37 Management Immediate Management Physical Rest Cognitive Rest Electronic Rest

38 Immediate Management: Day 1 Myth: never let a concussed person sleep! Sleep is good Awaken once in night: check orientation Avoid stimulation Visual / Auditory/Electronic Cognitive: stay home from school- 1-2d Headache/neck pain control Ibuprofen / Naprosyn / Tylenol Follow-up 1 2 days

39 Management: Education Provide information regarding: Typical recovery time: 1-3 wk Typical sx Controlled study Intervention gp receiving this special education & follow up with PMD or neurologist Intervention group had fewer sx at 3mo Ponsford 2001 Peds

Management: REST Physical Rest No sports /heavy exercise / weights NOT complete bed rest Inc sx in healthy people, chronic fatigue syndrome Pts in highest &

40 Management: REST Physical Rest No sports /heavy exercise / weights NOT complete bed rest Inc sx in healthy people, chronic fatigue syndrome Pts in highest & lowest levels of activity do the worst Light/moderate activity: Below symptom threshold DOES NOT prolong sx MAY SHORTEN sx duration Majerske 2008 JAT, Davis 2018 BJSM

41 Rest Majerske 2008 JAT

42 Management: Rest Electronic Rest No / limited computer, tablet ( brightness) Limited TV (30 min / low key) No headphones / Ipod Limit smart phone (return texts 1x / hr)

43 Management: REST Cognitive Rest: NOT prolonged Prolonged sx assoc w strenuous cognitive activity 1st 7d may be most important Mild/Mod cog activity doesn t sx duration Limited / No homework (initially) No testing +/- School participation Brown Pediatrics 2014

44 Cognitive Restriction Guidance Emerging data No school initially x hr Part-time 1-2 days, then full time. If PCS score low (<20) I send them back fast Don t let them fall too far behind Increase stress makes S/S worse

45 Cognitive Rest Metabolic activity with math in PCS before treatment Increased efficiency after treatment

46 Management: Physical Therapy Physical therapy cervical spine Vestibular therapy dizziness / eye symptoms After 2-3 weeks: sub-threshold exercise: Leddy Protocol Baker, Freitas, Leddy 2012 Rhabil Res Pract

47 Improvement in sx with exercise Athletes recover faster Leddy, CJSM 2010

48 Attention and Balance Training PCS w dizziness, visual disturb, postural instab Guskiewica 2010 AMSSM

49 Management: Sleep issues Sleep hygiene Melatonin Zolpidem (off label) Trazadone (off label) Amitryptiline (off label) Black box warning Screening ECG Avoid: Benzodiazepines: worsen cog fxn, fatigue Diphenhydramine: alters sleep architecture

50 Management: Headache NSAIDs OK in the short term Rebound effect Amitriptyline (off label) 90% improvement in one study Also used in primary migraine/tension HA Occasionally used: (off label) Beta-blockers, CCBD, valproic acid, topiramate, triptans, dihydroergotamine, gabapentin Meehan 2011 ClinSportMed

51 Analgesic Overuse 104, yr old concussion patients 54 with probable medication overuse HA more common: Female Nausea Throbbing & daily HA Pre-concussion migraine Ibuprofen most common: Some w/ daily use for > 3 mo 68% had HA improvement in 8wk with cessation 13% no better or worse Heyer, Idris 2014 Ped Neurolo

52 Management: Emotional Sx Depression Counseling/Psychotherapy: Coping strategies, stress management Pharmaceutical: Sertraline (SSRI) (off-label) Sml trial: 87% pt w improvement sx May also improve cognitive deficits memory, cognitive efficiency, psychomotor speed Amitriptyline (off label) May also help sleep & headache disturbances Fann 2000 J NeuropsychClinNeurosci

53 Return to Learn

54 When to Return to School Headache tolerable (1 or 2 / 6) Nausea / dizziness tolerable PCS score 20 s or lower Able to read/do homework min Start with ½ days if needed Restrictions outlined for school

55 Return to School Strategy Stage Aim Activity Examples Goal 1 ADLs that do not Sx 2 School Activity at home 5-15 min Reading, TV, Chores Homework, reading 3 Part-time school Classroom work Start with easier activity 4 Full School Gradually classroom participation Gradually introduce usual activity Tolerance for cognitive activity Re-introduce school Return to full academic load McCroy 2017 BJSM

57 Follow-up 1-2 week f/u Improving? Worsening? Following the rules? Return to school / sport timeline Every 1-2 wk 4-6 week f/u Neuro referral for headaches Consider MRI imaging Neuropsych for school accommodations

58 Neuropsychological Testing (NPT) NOT (current) standard of care Commonly used before clearance to RTP Computerized ImPACT, ANAM, Headminder, Cogsport, CVS, AXON Pre-season baseline Post-concussion return

59 Practical Use: NPT Baseline test prior to season Test once athlete is SYMPTOM FREE Start RTP if testing back to baseline If not back to baseline: Rest, reassess symptoms Repeat testing when REALLY symptom free

60 Neuropsychological Testing: RTP

61 Neuropsychological Testing Pen and paper Assist with school restrictions Sorting out continued symptoms - HA Assess ADHD, learning disabilities Assess for confounding anxiety / depression Broad testing for specific deficits Math, visual / verbal memory Covered by insurance

62 So WHEN Can They Go Back to Sport?

63 Management: Return to Play Must be SYMPTOM FREE Back to school full time All ADLs asymptomatic Off medications Neuropsychological testing back to baseline? Exercise stress test Summary and Agreement Statement of the First International Conference on Concussion in Sport, 2001

64 Management: Return to Play Average RTP time by age: Elementary school: 11.6 High school: 25.1 College: 23.6 > 1 month Children: % Adolescent: % College 7% Carson 2014 CFP, Purcell 2016 Clin Ped, Kerr 2016 JAMA Ped Davis 2017 BJSM

65 Return to Play GRADUATED APPROACH Studies show clinical recovery may precede physiologic recovery fmri, diffusion tensor imaging Make sure that gradually increasing exertion does not increase sx

66 Return-to-Play Step 1: symptom free Step 2: light aerobic exercise minutes light jog / bike Step 3: sport-specific exercise Throwing baseball, shooting baskets, soccer foot skills Step 4: no-contact practice Drills, no scrimmaging Step 5: full contact practice Step 6: games Summary of Agreement Statement of the First International Conference on Concussion in Sport, 2001

67 Return-to-Play Minimum 24 hours between each step Stop advance if symptoms return Prolonged recovery patients SLOW RTP May advance steps over weeks, not days ART

68 When to Consider Retiring No set number of concussions Repeat concussions Closer together in time Less severe force causing concussion More severe symptoms More prolonged symptoms (months) Permanent changes in cognitive abilities / personality / mood In conjunction with specialist / neuropsych

Resources www.healthy.ohio.gov/vipp/concussion.aspx www.cdc.

69 Resources AAP Clinical Report Sport-Related Concussion in Children and Adolescents: Pediatrics, 2010 AAP Clinical Report Returning to Learning following Concussion: Pediatrics, 2013

70 Thank you

Sports Concussion What the Clinician Needs to Know

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