Concussion in Youth Athletes:

Where Are We “Heading?”

Thomas L. Pommering, D.O.Division Chief, NCH Sports Medicine

Assistant Clinical Professor,

Departments of Pediatrics and Family Medicine

The Ohio State University College of Medicine

The definition didn’t change

Classification of Concussion

No unanimous consensus

Previously: Simple vs. Complex)

80-90% of concussions resolve in a short

period (7-10 d), although this recovery

time may be longer in children &

adolescents

Concussion: Why should we care?

30 million children and adolescents

participate in sports in the US each year

“Silent” epidemic

– Up to 3.8 million sports-related concussions

each yr

– 300,000 sports-related TBI’s resulting in LOC

(10%)

Over half go unreported

CONCUSSIONS ARE UNDER-

REPORTED IN HS ATHLETES(McCrea M, et al. Clin J Sport Med, 2003)

Only 47% of high school athletes reported their concussion

Most common reasons for not reporting:

– Not serious enough to warrant medical

attention (66%)

– Didn’t want to be withheld from play (41%)

– Lack of awareness of probable concussion (36%)

COMMON SIGNS OF

CONCUSSION

Vacant stare

“glassy eyed”

Poor coordination or balance

Confused

LOC (<10%)

Inappropriate behavior

Unusual emotions

Slow to answer or follow instructions

Personality change

Disoriented

Unusually quiet

Motor phenomena:

– Short lived seizure

– Tonic posturing

S/S of concussion

may be progressive

and evolving

COMMON SYMPTOMS OF

CONCUSSION

Headache

Difficulty w/ memory

Dizziness/vertigo

Generalized weakness

Numbness/tingling

Vision changes

Poor concentration

“seeing stars or lights”

“foggy” or “dazed”

Phonophobia

Photophobia

Depressed mood

Nervousness/anxiety

Insomnia/hypersomnia

Emotional lability

Nausea/vomiting

Tinnitus

Fatigue

Do Cumulative Effects Exist?

Depression (Guskiewicz KM, et al. Med Sci Sports Exec, 2007)

Memory and concentration problems

Delayed recovery with subsequent concussions

Increased susceptibility for additional concussions

Chronic Traumatic Encephalopathy (CTE)

Apolipoprotein (APOE) genotype (Tierney, et al. Clin J Sport

Med, 2010)

– all 4 alleles (rare) – 10 x more likely to report prev concussion

– Promotor allele only – 8.4 x more likely to report prev concussions

Cumulative Effects cont’d

For HS and College Athletes with > 3 concussions:

More severe on field presentation of s/s (Collins et al, J

Neurosurg, 2002)

More likely to report HA’s at baseline (Register-Mahalik et al.,

Clin J Sport Med 2007)

More vulnerable to subsequent injury than those w/no

concussion hx (Iverson et al., Brain Inj, 2004)

3 x more likely to sustain additional injury (Guskiewisz et al.,

JAMA 2003)

Had prolonged recovery (Collie et al., B J Sports Med 2006;

Couvassin et al., J Athl Train 2008; Slobounov et al., Neurosurg 2007)

Cumulative Effects cont’d

For Collegiate Athletes with > 2 concussions:

Delayed recovery of verbal memory and Rxn time (Couvassin et al., J Athl Train 2008)

Independently predicted long-term deficits in executive function, processing speed and self-reported symptom severity (Collins et

al., JAMA 1999)

What do you do when faced with

a young athlete with a possible

concussion?

NO Same Day RTP for Athletes < 18

y/o

SECOND IMPACT SYNDROME

(SIS)Sanders R, Harbaugh R. JAMA, 1984)

(McCrory, P. Neurology, 1998)

(Cantu, RC. Clin Sports Med, 1998)

Occurs when an athlete sustains a second head trauma before the original head injury or concussion has healed leading to…

Acute loss of autoregulation of cerebral blood flow Diffuse Brain swellingBrain herniation!

Mortality = 50% / Morbidity = 100%

SECOND IMPACT SYNDROME (SIS)(Bey, T West J Med, 2009)

(Mueller & Cantu; National Center for Catastrophic Injury Research

http://www.unc.edu/depts/nccsi/)

1980-1993: 35 cases

2008: 5 cases

Takes about 2-5 min for the herniation to occur (much faster than for an epidural hematoma )

S/S: – Loss of EOM

– Dilated/fixed pupils

– Respiratory distress

SIS is has almost exclusively been documented in children and teens!!!Best Tx is PREVENTION

What Current Tools are at our

Disposal?

Become educated - parents, coaches, league administrators, officials, athletic trainers, physicians

Seek advice and care from medical professionals who have expertise in concussion management

“Sideline” assessment tools (training room or office setting) – SCAT

– BESS

Neuropsychological Testing (NP)

BESS (Balance Error Scoring

System)(Iverson et al., Brain Injury, 2008)

Rapid, easy to admin and cheap

Measure postural stability (balance) – a sensitive indicator of brain injury

Requires AIREX foam pad ($60)

Confounders: ankle instability, fatigue, slight practice effect

BESS testing most useful when interpreted in conjunction with other testing ( SCAT2 and NP)

Role of Neuropsychological (NP) or

Neurocognitive Testing

Allows us to objectively measure cognitive

function as it relates to brain injury

Pen and paper tests (Trail making Test - 10

min)

Computer / web-based systems (10-25 min)

Formal NP testing with a trained and

certified Neuropsychologist (4-6 hrs)

Computerized NP Testing

COGSPORT

IMPACT

ANAM

HEADMINDER

Computerized NP Testing:Advantages Disadvantages

Relatively quick and easy

Measure verbal and visual

memory, processing speed

and reaction time

Most effective when baseline

testing can be done in

conjunction with post-injury

testing

Useful and reliable clinical

tool if administered and

interpreted properly and has

value to the athlete, coach

and parent

Cost: $10-35 per test…

….Limited Availability

“Proprietary interests do exist.” (McKeag: JAMA, 2003)

Perception that they are the “Cat’s Meow” & are the absolute Standard of Care

Baseline testing is not always feasible

Practice effect

RETURN TO PLAY (RTP)

Cornerstone of management is physical

and cognitive rest

Athletes must be asymptomatic for at

least 24 hrs before they’re permitted to

start a supervised progression

RTP Guidelines

Modifying Factors in the Mgmt of

Concussion

Note: “Gender” was left

off of this list at the time

of publication, though

evidence points toward

increased risk in females

d/t:

- Smaller head mass

- Weaker neck mm

- More likely to report

symptoms than males

What’s on the Horizon in Terms of

Future Concussion Management(Davis et al., BJSM, 2009)

Structural Imaging– CT, MRI, diffusion tensor imaging

Functional Imaging– fMRI, PET, brain SPECT

Spectroscopy– MR spectroscopy (MRS), Near infrared spectroscopy (NIRS)

Balance testing– BESS, Sensory Organizational Test (SOT), gait testing, virtual reality)

Electrophysiological tests– EEG, evoked potentials (EK), event related potentials (ERP’s),

magneticoencephalography (MEG), HR variability

Genetics– APoE4, channelopathies

Blood markers– S100, neuron-specific enolase, cleaved Tau protein, glutamate

Prevention – Can Protective

Equipment Make a Difference?(Benson et al., BJSM, 2009)

1. Helmets: reduces injury risk in cycling, skiing

and snowboarding; but effect on concussion

was nonconclusive!?

2. Mouthguards: No strong evidence to reduce

concussion risk, but they’re good for the teeth!

3. Face shields: No strong evidence to reduce

concussion risk

4. Full face protection in hockey can reduce

concussion severity (time loss from

competition)

Football helmets – FRIEND OR

FOE:!

designed to prevent head bleeds and skull

fx’s, PERIOD

THE END –THANKS!