Concussion in the Young Athlete: Return-to-Learn and Return-to-Play UCSF Family and Community Medicine Annual Review Course December 10, 2015 Cindy J. Chang, M.D. Associate Clinical Professor UCSF Dept of Orthopaedics UCSF Dept of Family & Community Medicine Past President, AMSSM (2011-12) Sports Medicine Advisory Committee, California Interscholastic Federation and National Federation of State High School Associations Team Physician, UC-Berkeley and Berkeley High School
Disclosure • Neither I, Cindy J. Chang, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
Case A • 16 year old female football goalie comes into your office for follow up of a wrist injury and also mentions that… • A basketball hit her in the head during PE class yesterday. She initially felt dizzy and foggy, but cleared after 5 minutes, so she continued participating . She felt tired and took a nap after school. • When she awoke, she had a headache, which worsened as she tried to study. • In three days, she is playing against their high school rival. She denies having a headache today and school was “fine.” • Her HS soccer coach wants a letter for her wrist saying she is cleared to play. Her coach doesn’t know about her headache. • Should you clear her to play?
Case B • 9 year boy was skating at the ice rink with friends when he slipped, and hit the occipital region of his head. • His friends state that he was “ out ” for at least 5 seconds. When he came to, he “ felt fine ” but decided to stop skating because his neck was sore. • His mom brings him to see you the next day because he had a hard time at school with the noise; he also felt foggy and says it was hard to pay attention. He also got a headache. • When should you advise that he returns to school?
Objectives 1. Discuss the recommended return to learn (RTL) and return to play (RTP) guidelines 2. Review some of the evidence behind RTL and RTP guidelines for concussions in young athletes 3. Cite the current concussion legislation in California
Sometimes it can be challenging… • Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. • Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self- limited and at the less-severe end of the brain injury spectrum.
#1. You don’t have to get hit in the head to get a concussion The biomechanical force can be a bump, blow, or jolt to the head • The head does not have to be directly hit for the brain to injured – Whiplash
#2. You don’t have to lose consciousness to have had a concussion • Fewer than 10% of concussions involve a loss of consciousness (LOC)
#3. Just because you don’t have symptoms right away doesn’t mean you don’t have a concussion • Evolving injury; serial assessments • The “Monday Concussion” • Don’t underestimate adrenaline or rationalization
#4. Wearing a helmet or other protection doesn’t prevent a concussion
#5. A normal head CT scan or MRI does not mean the brain is okay A concussion causes a temporary disruption of normal neurological functioning • Disruption in functioning = symptoms Ion Need Force to fluxes; glucose Energy brain vasocon- but less crisis striction blood flow
Concussion Symptoms Physical Sleep Cognitive Emotional
Brain Changes = Signs and Symptoms Physical • Headache • Fuzzy or blurry vision • Nausea or vomiting (early on) Sleep • Dizziness • Sleeping more than • Sensitivity to noise or light usual • Balance problems • Trouble falling • Feeling tired, having no energy asleep • Sleep less than usual
Brain Changes = Signs and Symptoms Cognitive • Difficulty thinking clearly/Foggy • Dazed or feeling “out of it” • Feeling slowed down • Difficulty concentrating • Difficulty remembering new information Emotional • Irritability • Nervousness or anxiety • Sadness • More emotional
#6. Do not grade concussions • Having certain symptoms, or more or less symptoms, does not make a concussion more mild or more severe Each Concussion is Unique
Concussion Grading Author Grade I Grade II Grade III LOC<5 ’ or LOC>5 ’ or No LOC Cantu¹ PTA>30 ’ but PTA<30 ’ PTA>24 ° <24 ° No LOC No LOC LOC Colorado Confusion w/o Confusion with Medical amnesia amnesia Society² No LOC No LOC Any LOC American Transient Transient Academy confusion confusion of Sx last >15 ’ Sx last <15 ’ Neurology³ 1. Cantu RC, Sports Med 1992 LOC and Amnesia 2. CMS, 1991 3. AAN, Neurology 1997
Return to Play Criteria After 1st Concussion Author Grade I Grade II Grade III RTP if RTP in 1 wk if asymp RTP in 1 mo if Cantu¹ asymptomatic or RTP within 2 wks asymp for final 1 if asymp for wk preceding 7 days RTP if asymp at RTP in 1 wk if asymp RTP in 1 mo if Colorado rest and exertion at rest and exertion asymp at rest Medical after 20 ’ and exertion for 2 Society² wks RTP if asymp RTP after 1 wk w/o If brief LOC American within 15 ’ symptoms at rest (sec), RTP after 2 Academy of and exertion wks w/o sx; if Neurology³ prolonged (min), RTP ≥1 mo 1.Cantu RC, Sports Med 1992 2.CMS, 1991 3.AAN, Neurology 1997
So how do we know when it is okay or even safe to return to play?
Family Practice News June 1, 1997
X ’ S AND O ’ S (Working Memory) X X X X X X X X X Remember the location of the highlighted symbols
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
VISUAL MEMORY DISTRACTOR Reaction Time Task Click the left mouse button when you see this Click the right mouse button when you see this
X ’ S AND O ’ S (Working Memory) X X X X X X X X X Remember the location of the highlighted symbols
Outcome measure is Outcome measure is Speed reported as Speed reported as Working Memory Attention
Neuropsychological Testing • With baseline data and post-injury testing, data is objective • Valuable adjunct to the management of concussions; may protect those patients who minimalize their symptoms in order to be cleared • But still just a “tool in the toolbox”
“Window of Vulnerability” • The period between the concussion and recovery • Return-to-play during this time could cause more severe or even catastrophic brain injury • May be unsafe to return to competition until brain activity has returned to normal • I n rat rat s , that time period averages ~ 10 days Giza and Hovda, JAT 2001
First International Conference on Concussion in Sport, Vienna 2001 • Acknowledged that scientifically validated RTP guidelines are absent; abandon grading scales • Return to play must follow medically supervised stepwise process – athlete must first be completely asymptomatic and have normal neurological and cognitive evaluations – neuropsychological testing one of the cornerstones of concussion evaluation; baseline testing recommended • No mention of pediatric/adolescent athlete Aubrey et al, BJSM 2002
• Even athletes who said they had ‘recovered’ within minutes of a concussion still showed abnormalities on cognitive tests 36 hours later • Evidence that no youth athlete “recovers” on the same day of injury AJSM 2004
Second International Conference on Concussion in Sport, Prague 2004 • Individually guide RTP decisions based on combined measures of recovery; determine concussion severity in retrospect • Recommendations applicable to children (5-18 yoa) • Concept of “cognitive rest”--limit exertion with ADL; limit scholastic activities while symptomatic • May be appropriate to extend asymptomatic rest and/or length of the graded exertion in children and adolescents. McCrory et al, BJSM 2005
Second International Conference on Concussion in Sport, Prague 2004 • Recommended that neuropsychological testing remain one of the cornerstones of evaluation for complex concussion – should not be the sole basis of management decisions • Recommended that, in organized high risk sports, consideration be given to having cognitive evaluation regardless of the age or level of performance . McCrory et al, BJSM 2005
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