Concussion: Recognizing, Managing and Assisting Athletes to Return to Play Safely Todd Barron, MD Medical Director, WellSpan Neurosciences Medical Director, WellSpan Pediatric Neurology
Agenda Safety in Youth Sports Act AAN position statement Concussion: Definitions Symptoms and signs Assessment Treatment/ management strategies Outcomes Take home points
Safety in Youth Sport Act Signed by Governor Corbett 11/11 Designed to establish standards for managing concussions and traumatic brain injuries to student athletes Implemented as of 7/1/12 Establishes the following: Educational materials for coaches, students and parents Mandatory training for coaches Mandatory informational meeting for students and parents before the start of each season Removal from and Return to Play guidelines Penalities Appropriate medical professional
AAN Position Statement on Concussion: 2010 Recommendations 1. Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions. 2. No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion. 3. Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation. 4. A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion. 5. Education efforts should be maximized to improve the understanding of concussion by all athletes, parents, and coaches.
Concussion Sports concussion A temporary loss of brain function due to a head injury Features: Confusion Headache Amnesia Loss of consciousness
Epidemiology Center for Disease Control: 1990 s - ~300,000 sports related concussions Recent estimates: 1.6 to 3.8 million/year What accounts for the increase?
Most Common Activities Football Ice Hockey Basketball Playground activities (bicycles and others) Girls: cheerleading Soccer Lacrosse
U.S. Emergency Room Visits Young Athletes Bakhos, L et al, Pediatrics 2010
How It Happens* Direct blow to the Head, face, neck Elsewhere on the body with an impulsive force transmitted to the head Symptoms may be immediate or delayed *Summary and agreement statement of the 3rd International symposium on concussion in sport, Zurich, 2008
Concussion: A Brain Injury Release of potassium Release of glutamate Brain uses more energy to restore balance Increased demands for glucose, Build up of lactate
Why Important? Return to play safely Not victory at all costs! Avoid persistent symptoms Post-concussion syndrome Avoid Second Impact syndrome Reported in athletes less than 18 years Prevalence unknown Why? Impaired brain auto regulation of blood flow after head injury With second injury: possible catecholamine surge leads to increased ICP Increased ICP can result in rapid (within minutes), potentially fatal brain swelling
Second Impact Syndrome: What happens Athlete is struck Either on head, or body part and head snaps in sudden movement Appears stunned, with or without loss of consciousness Sudden collapse, coma, pupils dilate with loss of eye movement, respiratory failure How is this best prevented?
Assessment
Concussion: Symptom Clusters Cognitive Sleep Emotional Physical
Symptoms Athlete: Headache Nausea Balance problems/ dizziness Blurry vision Light/noise sensitivity Feeling sluggish Foggy Decreased concentration Memory problems Confusion Observers: Appears dazed/stunned Confused Forgets plays Moves clumsily Unsure of game, score, opponent Slow to answer questions More emotional Irritable Unable to recall information before or after injury
Clinical Assessment: On Field and After Mental status testing Orientation Concentration Digits backwards Months in reverse Memory Team names Recall of 3 words/ objects at 0 and 5 minutes Contest details Recent news External provocative tests Appearance of any symptoms is abnormal Push-ups, sit-ups, 40 yd sprint etc Neurologic assessment Pupils symmetry, reaction Coordination/balance: tandem gait, finger to nose Sensory: finger to nose with eyes closes, Romberg
Clinical: Grading AAN grading: Grade I: symptoms <15min Grade II: symptoms >15min Grade III: loss of consciousness Problems: Not evidenced based LOC not prognostic; presence of other on-field symptoms more prognostic (headache, amnesia, confusion) Gender/age differences Symptoms often resolve before cognitive function improves
Assessment On-field standardized tools Sport Concussion Assessment Tool 2 (SCAT2) Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS) Most useful if baseline completed
Assessment Radiological CT MRI MRS SPECT, PET Standard radiological studies are normal in individuals with concussion Blood work: No specific studies Always consider tox screen
Functional/Cognitive Neurocognitive thinking, memory and attention Paper and Pencil tests Not practical Time consuming, expensive, not readily available Computer based assessment ImPACT, Concussion Sentinel, Headminder Concussion Resolution Index, ANAM, CogState Inexpensive, fast, reliable Student compared to baseline or normative data
ImPACT Immediate post-concussive assessment and cognitive testing Two components Post-concussion symptom scale (0-6) Neuro-cognitive test modules that assess Attention span Working memory Sustained and selective attention time Response variability Non-verbal problem solving Reaction time Composite scores for memory, reaction time and processing speed
Reliability May be impacted upon by other factors: Amount of sleep Medication use Physical exertion Test conditions Acute medical condition Illicit drug use
Concussion: Acute Management On-field: Immediate evaluation (check symptoms, balance testing) Findings suggestive of concussion Remove from game or practice Notify parent/guardian Evaluation by appropriate professional If testing available: test within 24-72 hrs Clinical decision making based on results If not, remove from game/practice and no return to sport until symptom free at rest and after exercise utilizing AAN or CDC recommendations Return to sport must be in a step-wise fashion
Treatment & Management Strategies
GOAL: SAFE RETURN TO PLAY! Want to avoid Persistent symptoms (Post-concussive syndrome) Second Impact Syndrome
Basic Theme
Cognitive Symptoms may include: Decreased attention and concentration Mental fatigue Diminished executive function Difficulty with memory Foggy/slowed down feeling Strategies: Physical rest Cognitive rest Reduction in academic work More time to complete assignments Time off Home bound May require: Formal testing Symptom specific medications
Physical Symptoms may include: Headache, phono/photophobia Nausea, vomiting Balance problems Dizziness Visual problems Fatigue Numbness, tingling Strategies Physical rest Appropriate hydration, diet Analgesics Physical therapy if deconditioned Headache treatment
Emotional/Psychological Symptoms may include: Irritability Sadness More emotional Nervousness Strategies: Physical rest Encouragement Reassurance Referral for counseling (? grief reaction) Psychiatric intervention
Sleep Disruption may include: Drowsiness Insomnia Hypo or hypersomnia Strategies: Demand good sleep hygiene Treat other symptoms Explore sleep history Medication
Recovery About 50% recover by 7 days >90% by ~3-4 weeks Slower recovery: Non-compliance Lifestyle issues (Alcohol, drug abuse) Untreated persistent symptoms Headache Mood 7-9% will have persistent symptoms at 3 months
If a Player Doesn t Improve: Non-compliance with treatment plan Complicating factors: Substance abuse Psychosocial issues Pre-existing conditions Migraine headache Concomitant auto immune disorders: arthritis, enthesopathy Diabetes mellitus ADD/ADHD/ learning disability
Return To Play: Ideally Consensus statement on Concussion in Sport, Zurich 2008
Summary: Concussion Ideal Management On-field evaluation with standardized assessment Athlete observed Medical evaluation ImPACT or similar at 24 72 hours Clinical recommendation If changes on ImPACT or continued symptoms: no return to physical activity, assess need for cognitive rest Re-assess at 7 days, if changes persist, continue as above, consider cognitive rest if not already implemented and reassess 7-14 days Treat co-morbidities At any time, if symptomatic at rest and/or with exercise, no return to play Observe/treat for Post-concussion syndrome if symptoms persist beyond 4-6 weeks
Symptoms/Evidence of concussion On-field evaluation (ATC, Team physician) 48-72 hr f/u eval with: No RTP for 7 days ImPACT Balance testing Medical professional eval Consider referral to Concussion program (Neurology) Not at baseline No RTP X 7days Repeat eval 7 days, 14 days Consider referral to Neurology Not at baseline No RTP Concussion program referral F/U 7-21 days as indicated 14 day evaluation Baseline Stepwise RTP at 7days Baseline: stepwise RTP At 30 days: Still symptomatic/impact not at baseline/abnormal balance Referral for Post-concussion rehab for sub-symptom threshold Exercise Training Continued f/u with rehab until cleared for RTP Repeat ImPACT and final eval by Neurology Stepwise RTP
Remaining Issues Do you excuse from academics/work (cognitive rest) immediately and how long? How many concussions are too many? What is the impact of age? Does gender play a role? Can some RTP immediately? When is a concussion career ending? Do genetics play a role why do some athletes seem more susceptible?
Take Home Points Concussion is a brain injury Cannot predict outcome / recovery based on initial symptoms Treatment principles: Rest, Rest, Rest Goals of therapy: Avoid persistent symptoms if possible Reduce risk of second impact syndrome Standardize protocol to yield better outcomes Identify co-existing problems Assessment: multimodal Clinical evaluation + physical and neurological exam, cognitive evaluation, symptom tracking Return to play: standard protocol Symptoms resolved Normal physical + neuro exam Baseline neurocognitive testing Graduated return to play
Websites: Heads-up Concussion Management www.cdc.gov/ncipc/tbi Impact.wellspan.org
To learn more visit: www.wellspan.org/sportsmedicine or call (877) 482-5420 (Hotline) WellSpan Pediatric Neurology 717-851-5503