Anna Mazur, PhD PEDIATRIC SPORTS RELATED CONCUSSIONS Disclosure No financial interests or funding 1
Presentation Outline Prevalence Predicting recovery: Post Traumatic Amnesia and Loss of Consciousness in Concussion Definitions Symptoms Evaluation Recovery and Treatment Additional Consideration During Recovery Q &A Prevalence 2
Prevalence Concussion = mtbi 1.12 million report mtbi to the ER (U.S.) Heterogeneous in origin: Direct blow to the head Indirect impact on the body with an impulsive force transmitted to the head Acceleration and/or deceleration Rotational force Broad spectrum of pathophysiology affects recovery From mild neuro metabolic to permanent structural Prevalence of Pediatric Sport Concussion 8.9% of all high school athletic injuries. Data is significantly lacking about concussions in grade school and middle school athletes Girls are reported to have a higher rate of concussion than boys in similar sports The sport with highest risk in high school is football In girls sports, the rate of concussion is highest in soccer and basketball. Rugby, ice hockey, and lacrosse have high rates 3
Diagnostic Criteria Concussion Diagnostic Criteria 4
Accepted Definitions of mtbi The American Congress of Rehabilitation Medicine: 1. Loss of consciousness less than 30 minutes and GCS score of 13 to 15 after this period of loss of consciousness; OR 2. Any loss of memory of the event immediately before or after the accident, with posttraumatic amnesia of less than 24 hours; OR 3. Any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused). (Kay T, et al. Definition of mild traumatic brain injury. J Head Trauma Rehabil. 1993) The Centers for Disease Control and Prevention Any period of observed or self reported transient confusion, disorientation, or impaired consciousness Any period of observed or self reported dysfunction of memory (amnesia) around the time of injury Observed signs of other neurologic or neuropsychological dysfunction Any period of observed or self reported loss of consciousness lasting 30 minutes or less. (CDCP. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem.2003). Concussion A complex pathophysiological process affecting the brain, induced by biomechanical forces. May be caused by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. (McCrory, P. et al, (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.) 5
Concussion: Influence of LOC and PTA There is no clear association between brief LOC and short term neuropsychological outcome Presence and duration of PTA (post traumatic amnesia/confusion) is associated with: Worse immediate outcome Worse short term neuropsychological outcome Slower recovery However: 3 months post injury, this association disappears Symptoms 6
Most Common Symptoms 260 acutely concussed HS and college athletes Assessment time 5 days, mean 2.0, SD=1.2 days Most common acute symptoms: Headache (78.5%) Fatigue (69.2%) Feeling slowed down (66.8%) Drowsiness (64.2%) Difficulty concentrating (65.8%) Feeling mentally foggy (62.3%) Dizziness (61.2%) Lovell et al, 2006 Least Common Symptoms Nervousness (21.2%) Feeling more emotional (17.7%) Sadness (15%) Numbness or tingling (14.6%) Vomiting (8.8%) 7
Evaluation On Field or Sideline Evaluation When a player shows ANY features of a concussion: Physician or other licensed healthcare provider onsite evaluation using standard emergency management principles particular attention to exclude a cervical spine injury. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be removed from practice and urgent referral to a physician arranged. Once the first aid issues are addressed, an assessment should be made using the SCAT or other sideline assessment tools. The player should not be left alone and serial monitoring over the initial few hours. A player with diagnosed concussion should not be allowed to RTP on the day of injury. 8
ER or Medical Evaluation An athlete with concussion may be evaluated in the ER or doctor's office as a point of first contact following injury. This examination should have : A medical assessment including: a comprehensive history detailed neurological examination mental status cognitive functioning gait and balance. A determination of the clinical status, including whether there has been improvement or deterioration since the time of injury. This may involve information from parents, coaches, teammates and eyewitnesses to the injury. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality. In Medical Office or ER The Sport Concussion Assessment Tool (SCAT) was introduced in 2004, following the Second International Conference on Concussion in Sport in Prague, Czech Republic. The aim was to create standardized tool used for patient education and physician assessment of sports concussion Child SCAT 3/SCAT 5 is for children 5 12 For use by medical professionals Assessment of suspected concussion Contains behavioral checklist and cognitive screen Child SCAT 3 was released in 2012, Child SCAT 5 is expected in 2017 SCAT 3/SCAT 5 is for athletes 13 and older 9
Child SCAT Symptom Assessment Diverse physical, cognitive, and emotional symptoms in the initial days and weeks post injury. 10
Post Concussion Symptom Inventory Parent, Self An example of a tool that assesses before and after Gioia,GA, et al. (2008) Psychometric Properties of the Parent & Teacher Post Concussion Symptom Inventory (PCSI) for Children & Adolescents. Recovery and Return to Activities 11
Expected Cognitive Outcome The natural history of mtbi is reasonably well understood. Patients perform more poorly on neuropsychological tests in the initial days and up to the first month following the injury Full recovery is expected from a single mtbi Neuropsychological deficits typically are not seen in athletes after 1 3 weeks* In trauma patients the symptoms last 1 3 months** *e.g., Bleiberg et al. 2004; Lovell et al. 2004; Macciocchi et al. 1996; McCrea et al. 2003, 2004; Pellman et al. 2004 **e.g., Gentilini et al. 1985; Lahmeyer and Bellur 1987; Ponsford et al. 2000 Percentage of People with Prolonged Recovery 570 athletes with concussion/mtbi 90% recover in the first 10 days 10% take longer than 7 days to return to neurocognitive baseline Recovery is predicted by acute severity (LOC and PTA) No impairment on objective test relative to baseline on day 45 2.5% symptomatic on self report after 45 days 12
High Schoolers and College Athletes Younger and Older Children Age groups 5 12 must follow more conservative RTP than children 13 and above Younger group is recommended to receive a neuropsychological assessment by a trained neuropsychologist RTP only after successful return to school Consideration of school accommodations Return to activities should be extended over a longer period of time than in adults 13
Rest and Return to Activities Importance of Rest and Monitoring Cognitive and physical rest is a helpful Return to sport should use: a progressive exercise program while evaluating for any signs or symptoms (Pediatrics. 2010 Sep;126(3):597 615. doi: 10.1542/peds.2010 2005. Epub 2010 Aug 30.) Safe return to play decisions include: rest neuropsychological testing a graded program of exertion before return to sport 14
Understanding Cognitive Rest Early rest after a concussion is important to allow recovery. Activity can all worsen symptoms /delay recovery physical activity physiological stress (eg. flying) cognitive loads (eg. school work, video games, computer) Individuals should be advised to rest from these activities in the early stages after a concussive injury, especially while symptomatic The use of alcohol, sedatives or recreational drugs can exacerbate symptoms /delay recovery or mask deterioration and should also be avoided Period of Rest A brief period (24 48hours) of cognitive and physical rest is appropriate for most patients Following this, patients should be encouraged to gradually increase activity. (Schneider KJ, et al. Br J Sports Med 2017;0:1 7. doi:10.1136/bjsports 2016 097475) Psychological consequences of removal from validating life activities, combined with physical deconditioning, contribute to the development and persistence of postconcussive symptoms after mtbi in some youth. Prompt reengagement in life activities as tolerated is encouraged. (DiFazio, et al., Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes? Clinical Pediatrics, 55 (5) 15
Neuropsychology Helps identify the rate of return to activities Strongly recommended in all children with concussion screen If recovery slower or complicated full assessment of basic cognitive and emotional functioning Computerized screen does not substitute a neuropsychological assessment Should be done by a trained pediatric neuropsychologist Second Impact Syndrome Second impact syndrome occurs when an athlete who has sustained an initial head injury sustains a second head injury before the symptoms associated with the first have fully cleared. 16
Genetics and Sport Concussion The presence of genetic markers (eg, apolipoprotein E4 gene, S 100 calcium binding protein gene) have been evaluated as possible predisposing risk factors for concussion. However, the few studies conducted on younger athletes have not demonstrated significant differences in head injury characteristics or outcomes of athletes who possess these genetic markers. At this time, genetic testing is not recommended for evaluating young athletes with concussion. External and Internal Factors Affecting Recovery 17
Factors Influencing Recovery and Presentation Symptom Exaggeration Reinforced Behavior Influence of Others Financial Gain Structural Brain Damage Neuro metabolic Factors Neck Injury Pain Medication Effects Motivational Factors Injury Related Factors Social/External Factors Internal/Psychological Comorbidities Good Old Days bias Expectations and Misattributions Nocebo Effect P Personality Depression Grief Anxiety/PTSD/Stress Somatization Importance of Collaborative Care in Chronic Symptomology Greater reduction in mixed postconcussive and psychological symptoms if: CBT/therapy to address Anxiety Depression Stress management Sleep issues Psychopharmacology Care management 18
Thank You! Questions? 19