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
19. Meaney DF, Smith DH: Biomechanics of Concussion. Clin Sports Med 30(1): 19-32, Jan 2011
20. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011; 30 (1): 33–48, vii–viii
21. Meehan WP 3rd, Taylor AM, Proctor M. The pediatric athlete: younger athletes with sport-related concussion. Clin Sports Med. 2011 Jan; 30(1):133-44, x
Sources
22.McCrea M, Kelly JP, Randolph C,
et al. Standardized assessment of
concussion (SAC): on-site mental
status evaluation of the athlete. J
Head Trauma. 1998. 13(2):27-35
23.Maddocks DL, Dicker GD, Saling
MM. The assessment of orientation
following concussion in athletes.
Clin J Sport Med. 1995;5(1):32-5.
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