Concussion in the High School Athlete: The Need for Education and - PowerPoint PPT Presentation

Concussion in the High School Athlete: The Need for Education and Setting Up Your Program Dennis A. Cardone, DO

Disclosure • Chief Medical Officer, New York City Public High Schools Athletics (PSAL) 2

Concussion Overview •Concussion accounts for 1 of 10 sports injuries •Likelihood of suffering a concussion while playing a contact sport estimated to be as high as 19 percent per year of play •McGill University found 60% of college soccer players reported symptoms of a concussion at least once during a season. 3

Concussion Rates Among High School Athletes in Sports Football Boys ice hockey Boys lacrosse Girls soccer Girls lacrosse Girls basketball Boys soccer Boys wrestling Girls field hockey Boys Basketball Girls softball Mallika Marar, Natalie M. McIlvain, Sarah K. Fields and R. Dawn Comstock. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med. 2012 40:747

Definition of Concussion Vienna 2001 Prague 2004 Zurich 2008, 2012 Berlin 2016

Definition of Concussion “a trauma induced alteration in mental status that may or may not be accompanied by a LOC”

Concussion: Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features: • May be caused by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to head • Typically results in rapid onset of short lived impairment of neurological function that resolves spontaneously • Functional disturbance rather than structural injury • No abnormality on standard structural neuroimaging studies • In a small percent of cases post-concussive symptoms may be prolonged.

Signs and Symptoms Recognition • Often difficult • Athletes and coaches: minimize or deny sxs • Athletes who report being symptom free may continue to exhibit neurocognitive deficits that they are either unaware of or are failing to report.

Clinical Features of Concussion Symptoms Signs Headache 70% Vacant stare Memory loss* 50% Delayed verbal / motor response Dizziness 50% Confusion Drowsiness 50% Disorientation Poor concentration 50% Slurred speech Feeling “in a fog” 50% Incoordination Nausea Emotional disproportion Sleep disturbance Memory deficit Sensitive to noise Loss of consciousness Irritability Nervousness *unaware of period, score, opposition Sadness

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Postural Instability Postural equilibrium disrupted in concussion Returns to baseline around day 3 BESS (Balance Error Scoring System) • Guskiewicz et al. (J Athl Train 2001) • Measure postural stability on-field or in office

King-Devick Test

Vision testing is additive to the sideline assessment of sports-related concussion • Examined K-D test, as a complement to components of the SCAT3 for diagnosis of concussion. • Baseline and post-concussion data for the U of Florida men's football, women's soccer, and women's lacrosse teams were collected, including the K-D test, SAC, and Balance Error Scoring System (BESS). • Among 30 athletes with first concussion during their athletic season (n = 217 total), differences from baseline to post-injury showed worsening of K-D time scores in 79%, while SAC showed a ≥2 -point worsening in 52%. • Combining K-D and SAC captured abnormalities in 89%; adding the BESS identified 100% of concussions. • Adding a vision-based test may enhance the detection of athletes with concussion. Marinides, Z, et al. Neurol Clin Pract 2014

Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Brian C. Lau,MD, Anthony P. Kontos, PhD, Michael W. Collins, PhD, Anne Mucha, PT, and Mark R. Lovell, PhD Am J Sports Med 2011 39: 2311 • DIZZINESS at time of injury

Median recovery 18 days Predicted prolonged symptoms: • Female • Continued activity participation • Loss of consciousness • Anterograde amnesia • Premorbid headaches • Emotional component (day of concussion) • Cognitive-fatigue, cephalgic, emotional components (day of clinic) 21

Decision Making in Sports Concussion Individualized approach to each athlete

Duration of Symptoms Several hours…several days…several months? Variables: • Age of athlete • Severity of injury • Gender • History of concussion, especially if currently recovering from earlier concussion • Personal and/or family history of migraine headaches • History of learning disabilities or developmental disorders • History of depression, anxiety, or mood disorders

Duration of Symptoms Professional and college football players recover faster than high school players Pellman et al. (Neurosurgery 2006) • Recovery of NFL and high school athletes after concussion • Neuropsychological testing: HS athletes had more prolonged neuropsych effects Field et al. (Am J Pediatr 2003) • Compared recovery from concussion in high school and college athletes • HS athletes had slower recovery • Prolonged memory dysfunction (7 days)

History of Recurrent Concussions HS and college athletes with history of concussion are at increased risk of future concussions and cognitive sequelae tend to be more severe and prolonged. • Prospective studies • Guskiewicz et al. (JAMA 2003) • McCrae et al (JAMA 2003) • Moser RS. (Neurosurgery 2005) History of multiple concussions related to poorer performance on baseline neuropsychologic testing (Collins et al. JAMA 1999)

History of Recurrent Concussions HS athletes with 3 or more prior concussions were at increased risk for experiencing the following after a subsequent concussion: • LOC (8x greater risk) • Post-traumatic amnesia (5.5x greater risk) • Confusion (5.1x greater risk) Collins MW, et al (Neurosurgery 2000) How many concussions before recommending ending a player’s season or career? • Number? • Recovery time? • Ease of concussion (force involved)?

Second Impact Syndrome Athlete sustains second head injury before complete recovery from 1st injury. Associated with athletes 19 years old and younger 50% mortality, 100% morbidity At risk population unknown. Incidence? • 17 of 35 probable cases confirmed between 1980 and 1993 (Cantu RC. Clin Sports Med 1998)

Return to Play Often difficult decision: No consensus No objective measures Poor knowledge of short and long term consequences Abandonment of grading scales Guidelines “Rest” until asymptomatic Step-wise return to learn Step-wise return to play

Interdisciplinary Team Medical and Rehabilitation • Athletic Trainer • Sports Medicine • Nursing • Rehab Medicine • Occupational (Vision) Therapy • Neurology • Physical Therapy • Neuro-ophthalmology • General • Neuro-optometry • Vestibular • Neurosurgery • Psychology/Neuropsychology • Neuroradiology • Neuro-otology • Social Work • Pediatrics • Speech Language Pathology • Emergency Medicine • Vocational Therapy • Otolaryngology • Psychiatry • Ophthalmology • Endocrinology 29

Concussion Management and Awareness Act • Statute’s provisions took effect July 1, 2012 • Requires the biennial completion of an approved State Education Department and Department of Health course relating to recognizing the symptoms of mild traumatic brain injuries (“concussion”) and monitoring and seeking proper medical treatment for athletes who suffer mild traumatic brain injuries. • Coaches • PE teachers • School nurses • ATCs • Deemed to be the minimum standards that must be complied with but more stringent standards may be adopted

Concussion Management and Awareness Act During school athletic activities schools are required to remove from activity any student suspected of sustaining a mild traumatic injury (“concussion”) Student not permitted to return to athletic activity until: • Symptom free for not less than 24 hours • Evaluated by and received written signed authorization from a licensed physician • Authorization is required to be kept in the student’s permanent health record • Schools required to follow any guidance from the student’s treating physician in regards to limitations on school attendance and activities