12/12/2015 Sports Concussion Update 2015 Carlin Senter, MD Co-Director UCSF Sports Concussion Program UCSF Departments of Medicine and Orthopaedics December 11, 2015 I have no disclosures. Who are you? Who are we? A. Primary care provider, involved in sports coverage. 75% B. Primary care provider, not involved in sports coverage. C. Physical therapist. D. Chiropractor. 13% 7% E. Athletic trainer. 5% 0% 0% • UCSF Playsafe and UCSF Sports Concussion Program F. Other Other Physical therapist. Chiropractor. Athletic trainer. Primary care provider, no... Primary care provider, in... – Athletic trainer at high school – M.D. on sideline and in clinic – Preparticipation exams 1
12/12/2015 How many sports concussion cases do Concussion update 2015 you see in your practice? A. A few patients/week 55% B. A few patients/month C. A few patients/year D. None 21% 20% 4% k h r e a n e t n e o e w o y N / m / s s t / t s n n t e e n i t i e a t a i p p t a w w p w e e f f e A A f A Keys to managing Sports concussion updates 2015 sports concussion in 2015 1. Concussion legislation • 3-pronged evaluation 2. CIF handouts and guidelines • Treatment is rest 3. US Soccer and heading • Gradual return to learn then play • No available gear that definitively reduces risk of injury • When to refer 2
12/12/2015 Rates of sports concussion in high Put these high school sports in order of highest to lowest incidence of school sports U.S. 2011-2012 Sport Rate per 1000 athletic concussion. exposures A. Soccer (boys) Football (boys) 0.94 B. Soccer (girls) Soccer (girls) 0.73 C. Basketball (girls) Wrestling (boys) 0.57 D. Wrestling (boys) Soccer (boys) 0.41 E. Football (boys) 0% 0% 0% 0% 0% Basketball (girls) 0.37 ) ) ) ) ) s s s s s y l l y y r r o i i o o Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete g g b b b ( ( ( r ( ( r l l l e a g l e n a c c b c i b Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014 Jul;42(7):1710-5. c o t l o e t t S s o S k e o s r a W F B Concussion definition Concussion Symptoms • Type of mild traumatic brain injury Physical • Blow to head, neck, body � force to head. • Neurologic impairment within 48 hours of trauma. • Symptoms usually resolve in 1-2 weeks Sleep Cognitive spontaneously but in some cases can be prolonged. • May or may not include loss of consciousness. Emotional http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008. 3
12/12/2015 How Severe is my Concussion? Symptom Resolution • Concussion grading is retrospective • 50% recovered and returned to play in 1 week; – Historically concussions were graded on the 90% in 3 weeks (Collins et al. Neurosurgery, 2006.) sideline based on amnesia and LOC at time of • Recovery in athletes may be faster than recovery injury. – American Academy of Neurology, 1997 in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: – Cantu, 2001 506-17.) – Studies have shown these factors not to be predictive • Recovery in kids may take longer than recovery in of recovery. adults • Only when the athlete recovers can you tell how severe the concussion was Who is at risk for delayed RTP? Case 1 • LOC > 1 minute • Younger age 17 y/o high school lacrosse player presents to • Amnesia • Migraine headaches your clinic with symptoms concerning for • Convulsions • Depression concussion. How would you evaluate her? • History of multiple • ADHD 1. Neck exam • Sleep disorders concussions Rule out 2. Head exam • Injuries close together emergency 3. Neurologic exam in time • Repeat injuries with less 4. Concussion evaluation and less force Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014. 4
12/12/2015 Concussion evaluation: 3-pronged concussion evaluation physical exam • Normal neck exam 1. Self-reported symptom assessment • Normal neurologic exam 2. Mental status: Standardized Assessment of Concussion (SAC) 3. Balance. Balance Error Scoring System (BESS or modified BESS) Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014. Consensus statement on concussion in sport: the 4th International Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8 Sports Med. 2013 Apr;47(5):250-8 5
12/12/2015 Symptom and SAC norms BESS 9 th grade 10 th grade 11 th grade Symptom score 17 +/- 5 16 +/- 5 17 +/- 6 SAC 26 +/- 3 27 +/- 2 27 +/- 3 Valovich McLeod TC et al. Representative baseline values on the sport concussion assessment tool 2 (SCAT2) in adolescent athletes vary by gender, grade and concussion history. AJSM 2012. http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg BESS scoring BESS norms: ages 10-17 • Each error is counted as one point • Score = the sum of the error points for all six trials • Errors – Eyes opening – Hands coming off the hips – Hip flexion or abduction of greater than 30 – Changing foot placement from the stance – Remaining out of the test position for > 5 seconds • Max score 10 errors Khanna NK, Baumgartner K, LaBella CR. Balance Error Scoring System Performance in • Also if cannot maintain for minimum 5 seconds then Children and Adolescents With No History of Concussion. Sports Health. 2015 Jul;7(4):341-5. score = 10 6
12/12/2015 BESS norms: adults Case 2 16 y/o high school student presents to your office with concussion sustained 3 days ago during football. He reports headache, fogginess, and dizziness that is mild to moderate intensity at home but moderately severe at school. He is resting from sports. Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: implications for brain injury evaluations. Brain Inj. 2008 Feb;22(2):147-52. What do you recommend he do with Concussion treatment respect to school? • Cognitive rest A. Continue school without 73% • Physical rest adjustments. B. Continue school but no test-taking. • Medication C. Rest from school until can tolerate – Tylenol 1-2 hours of work at home. – Ibuprofen after first 72 10% 10% 8% hours D. Rest completely from school until • No driving all concussion symptoms have . . . . . . . . . . . . t a h t u o c c • No Etoh resolved. o n l s t i h m t n t u i u o w b r l o f o l o l o y o l o h e h h c t c s e c s m l s p e e u o m u n r n f o i c i t t t n n s t o e s o e C R C R 7
12/12/2015 New in 2015 CIF: Physician letter to school 31 32 Return to learn progression Case 3A 16 y/o high school student presents to your Return to full office with concussion sustained playing soccer day of school. Return to ½ 2 weeks ago. She initially had headache, day of school. 30 min dizziness, and fogginess, but those symptoms schoolwork at 15 min a time until cognitive resolved 2 days ago. She is now asymptomatic can do 1-2 No school. activity at a hours. time. OK to do light with a normal neurologic exam. She has no reading, little bit TV, drawing, deficits on balance testing. She has no deficits cooking as long as doesn’t on memory testing. worsen symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html 8
12/12/2015 Assuming she remains asymptomatic, Concussion Legislation when would you clear her to return to • 50 states have adopted youth concussion laws full contact soccer games? • California: education code 49475 (effective 1/2012) 49% A. Today 1. Athletes and guardians sign a concussion information B. Tomorrow form yearly 25% C. In 2 days 2. Athlete suspected of having concussion removed at 18% time of injury for the rest of the day D. In 1 week 6% 2% 3. Athlete can return only after cleared by healthcare E. 1 month after symptoms professional trained in evaluation and management of Today In 2 days Tomorrow In 1 week 1 month after symptoms ... resolved concussion Concussion legislation Return to Play Progression • California Assembly Bill 2127 (in effect Clinician clearance 1/2015) Game play – Adds to AB 25 Full contact practice • FB full-contact practice limits: Non- Asymptomatic contact – No more than 2/week during preseason and season Sport training specific – These practices cannot exceed 90 minutes Light activity aerobic – No full-contact in off-season activity • Once clear must follow gradual return to play protocol of at least 7 days under supervision of licensed provider 9
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