the cdc in sports: sports related concussion– a new epidemic and its management jeffrey b. kreher,...

The CDC in Sports: Sports Related Concussion–

A New Epidemic and its Management

Jeffrey B. Kreher, MD, FAAPJeffrey B. Kreher, MD, FAAPPediatric Musculoskeletal & Sports Medicine Pediatric Musculoskeletal & Sports Medicine SpecialistSpecialistAssistant, Department of Orthopedics—Assistant, Department of Orthopedics—Division of Pediatric OrthopedicsDivision of Pediatric OrthopedicsAssistant Professor, Department of PediatricsAssistant Professor, Department of PediatricsMassachusetts General Hospital Massachusetts General Hospital forfor Children Children

AAP CME Disclosure

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) 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.

Disclaimers

No financial interests There is a paucity of EBM in everything discussed There are no FDA approved therapies for SRC (signs

or symptoms) orpost-concussion syndrome.

Generic non FDA medications will be

discussed.

OBJECTIVES

1) Understand Massachusetts’ state concussion legislation

2) Integrate knowledge of sports related concussion into diagnosis and patient education

3) Recognize frequently used tools in the evaluation of sports-related concussion

4) Describe the components of sports related concussion management and issues with return to school and return to play

CASE

15y/o wide receiver is hit hard during a punt return. He arises to his knees and hands before placing his head between his hands. He gets up and starts to run to the opposing bench before a teammate guides him back to their bench. You see him on the sidelines and he is complaining of a headache. It does not appear there was any LOC.

– Does he have a concussion? – What do you do with him on the sidelines?– Where is the scar, cast, visible sign of injury?– Is this a legitimate injury?– Why can’t this athlete return back to the same game like Erin

Rogers

Epidemic or Not??

Federal Legislation

As of April 2012, 35 states (plus the District of Columbia and the city of Chicago) have adopted youth concussion laws. The NFL supports and recognizes the laws as they represent the main principles of the Lystedt Law model legislation including:

– Inform and educate youth athletes, their parents and guardians and require them to sign a concussion information form;

– Removal of a youth athlete who appears to have suffered a concussion from play or practice at the time of the suspected concussion; and

– Requiring a youth athlete to be cleared by a licensed health care professional trained the evaluation and management of concussions before returning to play or practice

Massachusetts State Legislation

SB 2469: An Act relating to safety regulations for school athletic programs

Contains three tenets of model legislation Status: Legislation passed; Governor Deval

Patrick signed youth concussion bill into law on 7/8/10; Law went into effect on 7/19/10

Section 222 (a): training program must be offered annually by all public schools and those subject to MIAA:– To coaches, trainers, school-employed physicians

& nurses, volunteers, athletic directors, and parent/legal guardians

– Containing training in recognition of concussion along with department rules/regulations on recognition of concussion symptoms and the consequences of concussion

Section 222 (b):– Required form documenting head injury history at

the start of each season Signed by athlete and legal guardian Provided to coach

Section 222 (c):– With all LOC episodes, concussion diagnoses, or

suspected concussion in practice or competition, no further participation till written authorization by licensed Physician, Neuropsychologist, certified Athletic Trainer or “other appropriately trained or licensed Health Care Provider”

Section 222 (d):– Coach will not encourage or permit “unreasonably

dangerous athletic techniques”

Section 222 (e): – School must maintain accurate records of compliance

Section 222 (f): – Compliance does not equal a waiver of liability to school or

employees

Section 222 (g):– Volunteers assisting are not liable for civil damages if

noncompliance documented

DEFINITION

CDC & CIS– Complex pathophysiological

process affecting the brain induced by traumatic biomechanical forces

McCrory P, Meeuwise W, Johnston K et al. Br J Sports Med 2009;43(Suppl I):i76–i84.

http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html Accessed February 1, 2011

DEFINITION

Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces

Direct blow to head/neck or body Rapid onset of short lived neurologic dysfunction that resolves

spontaneously Functional disturbance Graded set of symptoms that may or may not have LOC with

resolution following a sequential course– Occasionally with postconcussive syndrome

No structural abnormality on standard neuroimaging

Sports-Related Concussion (SRC)

Trauma-induced alteration in mental status that may or may not involve a loss of consciousness in sport– Results in physical, cognitive, emotional, and/or Results in physical, cognitive, emotional, and/or

sleep-related symptoms sleep-related symptoms – Duration of symptoms is highly variable Duration of symptoms is highly variable

Several minutes to days, weeks, months, or longer in Several minutes to days, weeks, months, or longer in some casessome cases

Pediatric/Adolescent SRC:Epidemiology

~9% HS injuries are SRC ~20% TBI are SRC

~33% recognize symptoms as SRC <50% HS FB players reported SRC

3/10 not evaluated by anybody 2/10 evaluated by medical personnel

McCrea M, Hanneke T, Olsen G et al. Clin J Sport Med 2004;14:13-17.

Gerberich SG, Priest JD, Boen JR. Am J Public Health 1983;73:1370-1375.

Pediatric/Adolescent SRC:Epidemiology

Highest incidence = football and ice hockey– Followed by soccer, wrestling, basketball, field

hockey, baseball, softball, volleyball

More common in games More common in HS than college athletes

Pediatric/Adolescent SRC:VULNERABILITY

Less developed neck/shoulder musculature Lifelong skills not as well developed Continually expected to acquire new

information– Testing, permanent record of grades

Less likely to have easy access to Team Physician or ATC trained in concussion management

Pediatric/Adolescent SRC: AGE ISSUES

Smaller pediatric brain – Higher forces to injure – Recovers less quickly– It is NOT more plastic

Pediatric/Adolescent SRC: GENDER ISSUES

Females have . . .– Higher concussion rates

Highest in soccer and basketball

– Significantly more postconcussive symptoms as well as poorer performance on computerized neuropsychological testing

– Higher incidence of migraine

SRC PATHOPHYSIOLOGY

Rotational acceleration and/or deceleration ‘‘Metabolic mismatch’’ between energy

demand and supply, which may create cellular vulnerability and predispose to further injury– Hypermetabolic state followed by hypometabolic

state

Giza CC, Hovda DA. J Athl Train. 2001 Sep;36(3):228-235.

GRADING SYSTEMS . . .

Colorado Medical Society Cantu (or Modified Cantu) American Academy of Neurology

– trauma-induced alteration in mental status that may or may not involve a loss of consciousness

All replaced by Concussion in Sport workgroup– No grading system because no system validated

. . . CIAO!!


Signs

LOC (<10%) Amnesia, retrograde or

antegrade Disorientation Appearing dazed Acting confused Forgetting rules or

assignments

Inability to recall score/opponent

Inappropriate emotionality Poor physical coordination Imbalance Seizure Slow verbal responses Personality changes

Symptoms

SOMATIC (10)

COGNITIVE (8)

EMOTIONAL (4)

SLEEP (4)

Headache * Feeling mentally “foggy” * Irritability * Drowsiness *

Nausea * Felling slowed down * Sadness * Sleeping more than usual

Vomiting * Difficulty concentrating * More emotional * Sleeping less than usual

Balance problems * Difficulty remembering * Nervousness * Difficulty falling asleep *

Visual problems * Forgetful of recent information

Fatigue * Confused about recent events *

Sensitivity to light * Answer questions slowly

Sensitivity to sound * Repeat questions

Dazed

Stunned

SRC Symptoms:HS athletes

HA 93%

Dizziness/unsteady 75%

Difficulty concentrating 57%

Confusion/disorientation 46%

Vision changes/sensitivity to light

38%

Nausea 29%

Drowsiness 27%

Amnesia 24%

Sensitivity to noise 19%

Tinnitus 11%

Irritability 9%

LOC 5%

Hyperexcitability 2%

Other 8%Meehan WP, d’Hemecourt P, Comstock RD. Am J Sports Med. 2010;38:2405-2409

SRC DIAGNOSIS

CLINICAL DIAGNOSIS– Altered mental status with signs, or symptoms of

concussion in the proper setting of trauma to body/head

EVALUATION:CLINIC SETTING

History– Event– Concussion history– Pre-concussion symptoms

ADHD, LD, mood, sleep

SCAT2 PE

– Head and Neck– Neuro including cerebellar– Fundoscopic

*

*

Available at: http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf+html

Symptom scale is not validated in grade school athlete

SCAT2 not validated

Available at: http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf+html

MANAGEMENT:CLINIC SETTING

EDUCATION

EDUCATION

EDUCATION

COGNITIVE REST

PHYSICAL REST

MANAGEMENT:CLINIC SETTING—EDUCATION

Natural History/Prognosis In HS Athlete– 80-90% asymptomatic by 10 days

BUT, >50% take longer than 10 days to completely recover (symptoms and NCT)

– In 80%, symptoms and impairments on neurocognitive testing will resolve by 3 weeks

– In 20%, symptoms can last a month or longer

Yang CC et al. J. Trauma. 2007; 62:657-663.


Prognosis – predictors of outcome– Total symptom load

Most predictive

– Amnesia Longer duration More impairments on neurocognitive testing

– Self reported cognitive decline/confusion/mental fogginess– Posttraumatic migraine– LOC (not as predictive till > 1 minute)

Makdissi M, Darby D, Maruff P et al. Am J Sports Med 2010;38:464-471Lau B, Lovell MR, Collins MW et al. Clin J Sport Med 2009;19:216–221Lovell MR, Collins MW, Iverson GL, et al. J Neurosurg 2003;98:296–301McCrory PR, Ariens T, Berkovic SF. Clin J Sport Med 2000;10:235–8Cantu RC. J Athl Train 2001 Sep;36(3):244-248Erlanger D, Kaushik T, Cantu R, et al. J Neurosurg 2003;98:477-484


Prevention– No good clinical evidence that currently available

protective equipment prevents concussion– Education of athletes, colleagues, and the general

public is a mainstay of progress Preparticipation Examination

– Remind all that LOC not needed – Educate about importance of subject– Obtain SRC history

Benson BW, Hamilton GM, Meeuwisse WH et al. Br J Sports Med 2009 43:i56-i67


Second Impact Syndrome (SIS)– Fatal & rapid brain swelling felt

to occur in an adolescent athlete, who sustains a mild head injury when symptoms from a prior concussion are still present

McCrory P. Clin J Sport Med 2001;11:144–149

Cantu RC. Clin Sports Med 1998;17:37-44


Chronic Traumatic Encephalopathy (CTE)– Neurodegenerative disease, tau pathology, that

occurs years or decades after recovery from the acute or postacute effects of head trauma

Selection bias No prospective studies Confounding EtOH, steroid use

Gavett BE, Stern RA, McKee AC. Clin Sports Med 2011;30:179–188

MANAGEMENT AFTER EDUCTION . . .

MANAGEMENT AFTER EDUCTION . . .

Physical rest Physical rest = No = No activity that increase activity that increase heart rateheart rate

No sportsNo sports No danceNo dance No physical No physical

education classeducation class No lifting weightNo lifting weight

Cognitive rest Cognitive rest = Limit = Limit brain activitybrain activity

No TVNo TV No textingNo texting No computerNo computer No video gamesNo video games No musicNo music No readingNo reading No test takingNo test taking

REST = Physical and CognitiveREST = Physical and Cognitive

MANAGEMENT:SYMPTOMS—SOMATIC DOMAIN HEADACHES

Analgesics, acetaminophen– Benefit short term– May lead to rebound– No return while analgesics

needed If sleep disturbances,

consideration of amitriptyline

Meehan WP. Clin Sports Med 2011;30:115–124

MANAGEMENT:SYMPTOMS—SOMATIC DOMAIN DIZZINESS

Vestibular function is often altered

– Symptoms and BESS

Consideration of vestibular rehabilitation

MANAGEMENT:SYMPTOMS—SLEEP DOMAIN

Avoid or minimize:– Caffeine, nicotine, and alcohol

use, as well as daytime naps

Quiet, dark room– Turning stimuli off does not

suffice Presence of a computer, to-do list,

date book, or planner can often trigger stress and anxiety


MANAGEMENT:SYMPTOMS—COGNITIVE DOMAIN

MPH is a consideration but studied in mTBI and no evidence in pediatric studies

Amantadine to improve executive function and glucose metabolism

Consideration for neuropsychologic testing and cognitive rehabilitation


MANAGEMENT:SYMPTOMS—EMOTIONAL DOMAINMOOD SYMPTOMS

Symptoms tend to be short lived– Conservative management

Coping strategies Supportive environment Counselor

SSRI studied in mTBI with favorable results


MANAGEMENT:RETURN TO SCHOOL

Accommodations– Temporary leave of school– Shortened day– Reduced workload– Increased time for assignments/tests

3 routes:– Informal accommodations– Section 504 plans (civil rights entitlement to avoid

discrimination against those with disabilities)– IEP

MANAGEMENT:RETURN TO SCHOOL

Allow for excused absences until symptoms have decreased someAllow for excused absences until symptoms have decreased some

Half days – early dismissal – late to schoolHalf days – early dismissal – late to school

Excuse homework assignments for a few daysExcuse homework assignments for a few days

Limit or excuse from test takingLimit or excuse from test taking

Allow for rest periods/ visits to school nurseAllow for rest periods/ visits to school nurse

Avoid re-injury – no physical educationAvoid re-injury – no physical education

Academic work demands focus, memory, and concentration – all brain processes that are affected by a concussion.

A (NOT SO) SHORT LIST OF SCHOOL ACCOMODATIONS

1. 1. Excused Absence from ClassesExcused Absence from Classes2. 2. Rest Periods During the School DayRest Periods During the School Day3. 3. Extension of Assignment DeadlinesExtension of Assignment Deadlines4. 4. Postponement or Staggering of TestsPostponement or Staggering of Tests5. 5. Excuse From Specific Tests and Excuse From Specific Tests and

AssignmentsAssignments6. 6. Extended Testing TimeExtended Testing Time7. 7. Accommodation for Oversensitivity to Light, Accommodation for Oversensitivity to Light,

Noise, or BothNoise, or Both8. 8. Excuse From Team Sport Practice and Gym Excuse From Team Sport Practice and Gym

ActivitiesActivities

A (NOT SO) SHORT LIST OF SCHOOL ACCOMODATIONS [continued]

9. 9. Avoidance of Other Physical ExertionAvoidance of Other Physical Exertion

10. 10. Use of a Reader for Assignments and TestingUse of a Reader for Assignments and Testing

11. 11. Use of a Note Taker or ScribeUse of a Note Taker or Scribe

12. 12. Use of a Smaller, Quieter Examination Room Use of a Smaller, Quieter Examination Room to Reduce Stimulation and Distraction13. to Reduce Stimulation and Distraction13. Preferential Classroom Seating to Lessen Preferential Classroom Seating to Lessen

DistractionDistraction

14. 14. Temporary Assistance of a Tutor to Assist Temporary Assistance of a Tutor to Assist With Organizing and Prioritizing Homework With Organizing and Prioritizing Homework AssignmentsAssignments

MANAGEMENT:RETURN TO PLAY

Stepwise exertion protocol (medically supervised)– 1) No activity– 2) Light aerobic activity (walking, stationary bike)– 3) High aerobic activity (running, skating)– 4) Non-contact training drills– 5) Full-contact practice– 6) Game play


Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615

MANAGEMENT:NEUROPSYCHOLOGICAL TESTING

Pen & Paper vs. Computerized– Not diagnostic tools– Computerized tests measure:

attention, working memory, visual motor speed, reaction time

– Research tool vs. Management tool Much has been learned about SRC from testing Helpful in management in some situations

MANAGEMENT:COMPUTERIZED NEUROPSYCHOLOGICAL TESTING

Advantages– Increased validity of identifying subtle changes or

deficits in cognitive speed– Reduces administrator error and inter-rater

reliability issues– Data is easily stored and accessed– May be used to assist planning for school and

home management while the patient is still symptomatic

MANAGEMENT:COMPUTERIZED NEUROPSYCHOLOGICAL TESTING

Disadvantages– Athlete can not be observed during testing– Access and cost– Baseline testing can be invalid

Distracting environment, not taking the test seriously, lack of full effort, confusion with instructions, LD, ADHD, need for more frequent baseline testing

Advances in understanding of SRC: Computerized Neuropsychologic Testing

Symptoms resolve prior to resolution of neurocognitive deficits

Post-traumatic migraine athletes – Greater symptoms and prolonged recovery

HS athletes – Demonstrated longer overall recovery – With “ding” ≥ 7 days for full recovery

Pediatric athletes – May show a delayed onset in symptoms

Field M, Collins MW, Lovell MR et al. J Pediatr 2003;142;546-553.

Lovell MR, Collins MW, Iverson GL et al. Am J Sports Med 2004;32:47-54 & J Neurosurg 2003;98:296-301.

What is missing?

Evidence based RTP guidelines Quick assessment for concussion in 5-11 y/o Natural history of concussion in < 12 y/o

CONSIDERATIONS FOR REFERRAL

Postconcussive Syndrome– Consideration of physical activity

Athlete with ADHD and/or LD Desire for Neuropsychological Testing

– Computerized or pen & paper Medical management

– Anecdotal evidence Ending season Retirement from sport

– (1) lingering symptoms many weeks or months following the injury despite proper management and

– (2) if minimal biomechanical force is causing a reoccurrence of concussion-related symptoms

Concluding RemarksPediatric SRC

SRC immediate removal and no same day RTC NO RTP until asymptomatic Treated with physical and cognitive rest until asymptomatic RTP after asymptomatic for several days and with exertion RTP decisions must be individualized RTP follows a medically supervised stepwise exertion protocol

– If symptoms recur, an athlete should rest for 24–48 hr and try again

More research is required in pediatric athletes to determine how they respond and recover from concussions and to determine evidence-based RTP guidelines

“WHEN IN DOUBT, SIT THEM OUT!!!”

??? QUESTIONS ???

Thank you for your time and attention!

Toolbox

REASONS FOR NEUROIMAGING

Prolonged LOC (> 30 seconds)

Mental status deterioration

Worsening of headache

Focal neurologic deficit

Seizure activity

Persistence or worsening of postconcussive symptoms

Suspected skull fracture

Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615

Toolbox

REASONS FOR ED EVALUATION

Repeated vomiting

Severe or progressive headache

Seizure

Abnormal gait

Slurred speech

Weakness or numbness in extremities

Unusual behavior

Signs of basilar skull fracture

GCS < 15/altered mental status

Halstead ME, Walter KD et al. Pediatrics. 2010;126:597-615.

Toolbox

RESOURCES:PATIENT

http://www.thinkfirst.ca/concussion_education.asp http://www.cps.ca/english/statements/HAL/HAL06-01.htm http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm http://www.casm-acsm.org/documents/

PragueGuidelines.pdf http://www.hockeycanada.ca/index.cfm/ci_id/7699/la_id/

1.htm

the cdc in sports: sports related concussion– a new epidemic and its management jeffrey b. kreher,...

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