Concussion

School Age Population

Amber G. Luhn, MD, FAAP, CAQ-SM

Knoxville Orthopaedic Clinic

Certified Impact Consultant

Medical Director, KOC Sports Medicine Outreach

Assistant Team Physician, University of Tennessee

Disclosures

• I have no financial disclosures.

• I have four really cute kids and an

awesome husband.

Objectives

• Review the most recent

international, national and state

guidelines1,2,3,4,5,6

• Discuss sideline evaluation tools &

management

• Discuss clinical management

• Return to learn & return to play

guidelines1,2,3,4,5,6

Epidemiology

• Incidence US ED visits for sports-related concussions 2001-20059

• 4 in 1000 8-13 yrs

• 6 in 1000 14-19 yr

• 2.5 concussions for every 10 000 athletic exposures7

• Underestimates true number of concussions8

– CDC estimates annually up to 3.8 million recreation and sport related concussions in US

• Gender difference and sport difference8,9

Sport Injury Rate/1000 Athlete Exposures

Football 0.47–1.03

Girls’ soccer 0.36

Boys’ lacrosse 0.28–0.34

Boys’ soccer 0.22

Girls’ basketball 0.21

Wrestling 0.18

Girls’ lacrosse 0.10–0.21

Softball 0.07

Boys’ basketball 0.07

Boys’ and girls’

volleyball

0.05

Baseball 0.05

Adapted from Halstead ME, Walter KD, 2010, Figure 1.8

Concussion Statements

• Concussion Grading Systems – Many described in the literature

• American Academy of Neurology

• Colorado Medical Society

• Cantu

• 2004 Prague Statement abandoned grading systems2

– Simple vs. Complex categorization

• 2008 Zurich Statement abandoned 2004 categorization3

– Symptom-based approach (subjective)

– Postural and cognitive testing (objective)

• 2012 Zurich Statement4

– Updated information presented in last statement

2016 Berlin Statement5

• Posed a series of clinical questions

– Specific formal systematic review

published concurrently with statement

– 60 000 published articles reviewed

– Concussion in Sports Group (CISG)

set forth an updated definition of the

sports related concussion (SRC)

Definition of SRC5

• May be caused either by a direct blow to

the head, face, neck or elsewhere on the

body with an impulsive force transmitted

to the head.

• Typically results in the rapid onset of

short-lived impairment of neurological

function that resolves spontaneously.

Signs and symptoms can evolve over a

number of minutes to hours.

Definition of SRC5

• May result in neuropathological changes,

but the acute clinical signs and

symptoms largely reflect a functional

disturbance rather than a structural

injury.

• Results in a range of clinical symptoms

that may or may not involve loss of

consciousness. Resolution of clinical and

cognitive features typically follows a

sequential course. Symptoms may be

prolonged.

• Cannot be explained by another etiology

Mechanism of Injury

• Coup-Contrecoup

– Linear

– Acceleration-

Deceleration

• Rotational

– Brain rotates on

axis causing

stretching and

tearing of axons

• Acceleration,

deceleration and rotational forces8

– Threshold of injury is elusive10

– Developmental immaturity may affect

threshold

• Head impact telemetry(HIT) system10

– Avg head impact acceleration: 29.2 g

– Avg head impact acceleration resulting

in injury: 103.3 g (high school), 95 g

(collegiate)

Mechanism

Concussion = Energy Crisis

Injury disrupts brain cell membrane

Potassium leaks out

Potassium/ ATP pump works

overtime to restore electrolyte balance

Brain cell uses ATP to restore electrolyte

balance NOT to process information

Brain cell membrane cannot take up

glucose well and cannot efficiently

make ATP ENERGY

CRISIS!!!

From Halstead ME,

Walter KD, 20108

Signs and Symptoms

• Symptom clusters

– Physical (migraine), Cognitive,

Emotional, Sleep

• <10% have LOC

• Severity of amnesia (retrograde and

anterograde) may correlate with

severity

• Mental “fogginess” and symptom

clusters may predict length of

recovery14

PHYSICAL (Migraine)

EMOTIONAL(Neuropsychiatric)

COGNITIVE

SLEEP

Headache

Nausea, Vomiting

Balance problems

Visual problems

Fatigue

Sensitivity to light

Sensitivity to noise

Dazed

Stunned

Feeling mentally “foggy”

Feeling slowed down

Difficulty concentrating

Difficulty remembering

Forgetful of recent information

Confused about recent events

Answers questions slowly

Repeats questions

Drowsiness

Sleeping more than usual

Sleeping less than usual

Difficulty falling asleep

Irritability

Sadness

More emotional

Nervousness

On-Field Evaluation

• Primary survey

– “ABCs”, level of consciousness, C-spine

evaluation

– Assume C-spine injury if unconscious after

head or neck trauma

• Secondary survey

– Exam for facial & dental trauma, neuro exam

– Sideline Assessment Tools

• SAC (Standardized Assessment of Concussion)

• BESS (Balance Error Scoring System)

• Maddocks questions

• SCAT5, child SCAT5

– Incorporates elements from all three of the above

From McCrea et al.

1997

Balance Error Scoring System (BESS)

• Developed at UNC Sports Medicine

Research Laboratory

– portable, cost-effective, and objective

assessment of static postural stability

– 10-15 min to administer

• Materials

– 2 surfaces: ground and foam pad

– Stop watch (6s, 20s trials) & spotter

– BESS Testing Protocol

– BESS Score Card

From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

BESS Score Card

From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

Maddocks Questions

• At which ground are we?

• Which quarter is it?

• How far into the quarter is it- the

first, middle, or last 10 min?

• Which side kicked the last goal?

• Which team did we play last week?

• Did we win last week?

From Maddocks et al. 1995.

Sideline Management

• Athlete removed from practice/ game remainder of day– ANY TSSAA sanctioned sport athlete must be seen by

MD/DO prior to return to competition

• Monitor athlete for several hours for any deterioration

• Seizure like movement may accompany a concussion8

• ER referral– Potential C-spine injury

– Recurrent vomiting

– Severe or progressively worsening headache

– Deterioration in mental status

– Seizure activity

– Focal neurological symptoms (Unsteady gait, slurred speech, weakness or numbness in the extremities)

– Signs of a basilar skull fracture or skull fracture

– Altered mental status resulting in a GCS <15

– Unusual or very irritable behavior

Clinical Follow-up (1-5d)• History

– Post-Concussion Symptom Scale

– Previous head injuries

– Comorbid conditions

• PE– Head and C-spine examination

– Neurologic examination, including gait and cerebellar function

– Assessment of cognitive function (computerized neuropsych testing)

• Additional testing– C-spine films if neck pain, iROM

– Advanced imaging

– Other tests?

From http://impacttest.com/resources

Post-Concussion Symptom Scale

Post-Concussion Symptom Scale

• Helpful to have a baseline

• Consider pre-existing conditions

that may affect the symptom scale

– ADHD, learning disabilities, sleep

disturbances, depression, chronic

migraines, environmental allergies,

medications, etc

Caveats to Symptom Scale

• Minimize or even lie about

symptoms to avoid loss of playing

time

• Lack maturity to express symptoms

or understand symptom score

• Need cognitive function to even

know there is a deficit of cognitive

function

• Developing adaption for the 5-12yo

age group

Computerized

Neuropsychological Testing• Another tool to assess cognitive function

of a concussed athlete– Does not independently confirm diagnosis

– Does not independently determine RTP

– Does not replace need for physician evaluation

• Does not replace formal neuropsych testing– Computerized tests easily administered &

widely available

– Insurance sometimes do not cover formal neuropsychological testing

• Most useful with a baseline

Computerized Neuropsychological Testing

• ImPACT: www.impacttest.com – Has normative data for 11-14yo

• http://www.impacttest.com/pdf/ImPACTchildnorms

2003.pdf

– Pediatric ImPACT for 5-12yo

• US Army Med Dept ANAM (Automated

Neuropsychological Assessment Metrics):

www.armymedicine.army.mil/prr/anam.html

• CogState: www.cogstate.com/go/sport

– Available in several languages

• Headminder: www.headminder.com

• CNS Vital Signs: www.cnsvs.com

Computerized

Neuropsychological Testing

• No standard protocol for test

administration

– 1st post-injury test within 72hrs

– 2nd post-injury when symptom-free on

exertion

– Additional post-injury tests as indicated by

clinical course or results of 2nd post-injury test

• When interpreting take into account

comorbid diagnoses (ADHD, LD, etc),

age and baseline academic status

• NEVER return an athlete who remains

symptomatic no matter their test results!

Advanced Imaging

• CT or MRI typically normal

• Conventional imaging identifies structural pathology– cervical spine injury, skull fracture,

intracranial hemorrhage (subdural, epidural, intracerebral, or subarachnoid)

• Worrisome symptoms for structural pathology– severe headache; seizures; focal neurologic

findings; recurrent emesis; significant drowsiness or difficulty awakening; slurred speech; poor orientation; neck pain; significant irritability8

Advanced Imaging

• CT test of choice 1st 24 to 48 hrs– Intracranial hemorrhage

– Skull fracture

• MRI test of choice >48hrs – Cerebral contusion

– Petechial hemorrhage

– White matter injury

• Emerging MRI modalities better at detecting white matter alteration, esp. in younger patients– Gradient echo (GRE) sequences

– Perfusion & Diffusion tensor imaging (DTI)

– Magnetization transfer imaging (MT)

• Useful in patients with persistent cognitive complaints

Concussion Management

• EDUCATION!!

• Cognitive Rest

– Limit schoolwork, reading, playing video games, using a computer, watching television

• Physical Rest

• Restrict driving

• Sleep hygiene

• Daily activities that

don’t exacerbate sx

Concussion Management

• Medications (2-14d)

– Sleep/Rest best management of HA

• Acetaminophen 1st line, but NSAIDs are

fine if no suspicion of ICH (negative CT

and/or PE reassuring)

• Continued med use to control concussion

symptoms indicates incomplete recovery

• Before RTP athlete must remain

symptom-free off medication

• May also use sleep aids if needed

– Melatonin, Tylenol PM

Return to Learn6

• TN is the 3rd state to implement

Return to Learn Guidelines

– Follows CO and NE

• Released by TN Dept of Health

June 6, 2017

– Explains pathophysiology of

concussion in plain language

– Reviews symptoms in the “cluster”

model

Return to Learn6

• Recommends a Concussion

Management Team

– Designated Point Person

– Multidisciplinary

• Recommends “concussion action plan”

and gives an action plan template

• Consider return to school when the

student can tolerate 30min of light mental

activity

• ONLY in schools that have appropriate

accommodations in place

Return to Learn6

Symptom Specific Classroom Strategies

Return to Learn6

• Addresses when and how to make a

504

– Plans are specific to symptoms

– Includes reference to a Section 504

Decision Formula for Concussions

www.GetSchooledOnConcussions.com

• Cognitive Activity Monitoring Log

• Medical release

• School accommodations form

• Updated Return to Play Form

NASN Position Statement2012, files.eric.ed.gov

• Role of school nurse

– Provide concussion prevention

education

– Identify suspected concussions

– Guide post-concussion graduated

academic and activity re-entry process

• Advocate for student

– Support for necessary

accommodations

– Watch for emotional distress

Return to Play

• “Under no circumstances should

pediatric or adolescent athletes with

concussion return to play the same

day of their concussion.”8

• “When in doubt, sit them out!”8

• No return to play while symptomatic

• All decisions individualized

– Usually in the range of 10-14d

– The younger they are, the more

conservative you are

Concussion Rehab Protocol

Rehabilitation Stage Functional Exercise

1. No activity Complete physical and cognitive

rest

2. Light aerobic activity Walking, swimming, stationary

cycling at 70% max HR; no

resistance exercises

3. Sport-specific exercise Specific sport-related drills but

no head impact

4. Noncontact training drills More complex drills, may start

light resistance training

5. Full-contact practice After medical clearance,

participate in normal training

6. Return to play Normal game play

From Halstead ME, Walter KD, 20108, Figure 5

TN Sports Concussion LawPublic Chapters 148/948, www.tn.gov

• Requires governing authority of

each school/youth sport to:

– Adopt guidelines for concussion

education of coaches, athletes, & their

guardians

– Requires annual completion of

education that includes CDC symptom

checklist (must be on website) www.cdc.gov/concussion/pdf/TBI_schools_checklist_508-a.pdf

– Information sheet signed annually by

coach, AD & athlete’s guardians prior

to competition

TN Sports Concussion LawPublic Chapters 148/948, www.tn.gov

• Requires governing authority of

each youth sport/school to:

– Immediately remove any athlete

showing signs or symptoms of a

concussion (checklist must be utilized)

– Once removed that athlete may not

return until evaluated by a health care

provider

• MD, DO, neuropsychologist, PA

w/concussion training

Post-Concussion Syndrome

• 3 months duration of ≥ 3 of the following symptoms after head injury:– Fatigue

– Disordered sleep

– Headache

– Vertigo/dizziness

– Irritability or aggressiveness

– Anxiety or depression

– Personality changes

– Apathy

• Symptoms typically ABATE over months to years (unlike CTE)

• Accumulation of immediate symptoms from multiple concussions or subconcussive events (unlike CTE)

Post-Concussion Syndrome

Management

• Management depends on predominant lingering symptom(s)

– Cognitive• Formal neuropsychological testing

– Emotional• Sports psychologist or other behavioral

therapist

– Physical• Vestibular therapy; physical therapy for

neck pain

– Sleep• Sleep clinician

Post-Concussion Syndrome

Management

• Subsymptom threshold exercise training

– Short durations of light cardiovascular activity without inducing symptoms

• Medications

– Amantidine 100mg BID (“fogginess”)

– Stimulants (attention, concentration)

– SSRIs (depression, irritability, aggression, anxiety)

– Trazadone, melatonin (insomnia)

– Amitriptyline (headaches)

Web Resources

• Return to Learnhttp://tn.gov/health/article/tbi-concussion

• CDC Concussion Tool Kithttp://www.cdc.gov/concussion/HeadsUp/youth.html

• SCAT5 form

– Child http://bjsm.bmj.com/content/51/11/862.extract.jpg

– Regular http://bjsm.bmj.com/content/51/11/851.extract.jpg

– TSSAA concussion policy (incl RTP

form)• http://www.kocortho.com/pdfs/tssaa-concussion.pdf

Web Resources

• Get Schooled on Concussions

– http://www.GetSchooledOnConcussions.com

• Project BRAIN (TN Disability Coalition)– http://tndisability.org/coalition_programs/project_brain/co

ncussion_within_our_sports_community

– http://tndisability.org/tennessee-parent-parent

• Online course for parents and coaches

– http://www.nfhslearn.com

• Vanderbilt Sports Concussion Center– www.vanderbilthealth.com/orthopaedics/33536

Take Home Points

• Understand sideline assessment tools and follow-up clinical management.

• Students should be returned to school based on new “Return to Learn” guidelines that give practical classroom strategies and a specific 504 decision formula.

• Return to learn decisions precede return to play decisions.

• Never return an athlete to play on the day of concussion or while symptomatic.

• School nurses are the front line!

Sources

1. Aubry M, Cantu R, Dvorak J, et al; Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st International Symposium on Concussion in Sport: Vienna 2001. Clin J Sport Med. 2002;12(1):6–11

2. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39(4):196 –204

3. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185–200

Sources

4. McCrory P, Meeuwisse W, Aubrey M, et

al. Consensus Statement on

Concussion in Sport. 4th International

Conference on Concussion in Sport

held in Zurich, Nov 2012. Br J Sports

Med. 2013; 47:250-8.

5. McCrory P, Meeuwisse W, Dvorak J, et

al. Consensus Statement on

Concussion in Sport. 5th International

Conference on Concussion in Sport

held in Berlin, Oct 2016. Br J Sports

Med. 2017; 51(11):837.

Sources

6. Lee T, Diamond A, Solomon G, et al.

Return to Learn/Return to Play:

Concussion Management Guidelines.

Tennessee Dept Health. Jun 2017.

http://tn.gov/health/article/tbi-

concussion.

7. Guerriero RM, et al. Epidemiology,

trends, assessment and management of

sport-related concussion in United

States high schools. Curr Opin Pediatr.

2012 Dec; 24(6):696-701.

Sources

8. Halstead ME, Walter KD. Clinical Report—Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126:597–615

9. Bakhos LL, Lockhart GR, et al. Emergency department visits for concussion in young child athletes. Pediatrics. 2010 Sep;126(3):e550-6

10.Apps JN and Walter KD (eds), Pediatric and Adolescent Concussion, Diagnosis, Management and Outcomes, Springer 2012.

Sources

11.Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375–378

12.Gordon KE, Dooley JM, Wood EP. Descriptive epidemiology of concussion. Pediatr Neurol. 2006 May;34(5):376-8

13.Willer B, Dumas J, Hutson A, and Leddy J. A population based investigation of head injuries and symptoms of concussion of children and adolescents in schools. Inj Prev. 2004 June; 10(3): 144–148

Sources

14.Lau B, Lovell MR, Collins MW, Pardini

J. Neurocognitive and Symptom

Predictors of Recovery. Clin J Sport

Med. 2009 May;19(3):216-21

15.McLeod TCV, Bay RC, Lam KC,

Chhabra A. Representative Baseline

Values on the Sport Concussion

Assessment Tool 2 (SCAT2) in

Adolescent Athletes Vary by Gender,

Grade, and Concussion History. Am J

Sports Med. Jan 11, 2012 (online).

Sources

16. Kirkwood MW, Yeates KO, Wilson PE. Pediatric Sport-Related Concussion: A Review of the Clinical Management of an Oft-Neglected Population. Pediatrics. 2006 Apr;117(4):1359-71

17. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train. 2001 Jul-Sep; 36(3): 228–235

18. Marar M, McIlvain NM, Fields SK, Comstock RD Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012 Apr;40(4):747-55

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et al. Standardized assessment of

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Second Impact Syndrome

• Occurs when a second head injury occurs while the individual is still recovering from the first concussion

– Second injury may be very minor

• Disparity between supply and demand during hyperglycolysis leads to an energy crisis

• Dysautoregulation of cerebral blood flow

– Vascular engorgement

– Diffuse cerebral swelling

– Increased ICP

– Brain herniation

• Extremely rare, but often fatal

Chronic Traumatic

Encephalopathy (CTE)• Definition:

– Neurodegenerative disease thought to be caused by repetitive brain trauma (i.e. concussions)

• Contact sports

• Military participation

– Symptoms typically do not present until years after activity causing injury

• “Cognitive Reserve”

– 46 of 51 (90%) neuropathologicallyconfirmed cases of CTE were athletes (2009)

What happens to the brain

(Microscopically)?• Tau protein

– Found mainly in neurons of the CNS

– Major role is in the stability of axonal microtubules

– Diseased neuron results in accumulation of phosphorylated tau proteins

• Neurofibrillary tangles, neuritesand glial tangles

– Seen in CTE and Alzheimer’s Disease (AD)

What happens to the brain

(Microscopically)?

Risk Reduction

• Improved Concussion Management

– Access to Athletic Trainers

– Access to Physicians trained in

concussion management

– Physician education on concussion

management

Prevention

• Protective

Gear

– Helmets

• Proper fit

• Meet standards of NOCSAE

– Mouth guards

• Shown to protect against dental injury

• No definitive data about iconcussions

– Soccer headgear

• Seems to reduce soft-tissue injuries

• No definitive data about iconcussions

Risk Reduction

• Changes in

coaching methods

– Proper tackling

techniques

– Modified contact

drills

– Fewer full contact

practice days

• NCAA football

practice guidelines