Understanding Sports Concussion: Should Our Kids Play Contact - PowerPoint PPT Presentation

6/20/2018 Disclosures Understanding Sports Concussion: Should Our Kids Play Contact Sports? Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco UCSF Advances in Internal Medicine May and June 2018 UCSF Sports Concussion Program Outline 1. Epidemiology 2. Evaluation Education 3. Treatment • How much rest? Sports concussion • Return to learn / work care • Return to sports 4. How many concussions is too many? Research

6/20/2018 Concussions are common Concussions are common Concussion numbers increasing Sports Concussion 2017 Marin JR et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014 May 14;311(18):1917-9. http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

6/20/2018 Put these high school sports in order of highest Rates of sports concussion in high school sports to lowest incidence of concussion. U.S. 2011-2012 Sport Rate per 1000 athletic A. Soccer (boys) exposures B. Soccer (girls) Football (boys) 0.94 C. Basketball (girls) Soccer (girls) 0.73 D. Wrestling (boys) Wrestling (boys) 0.57 E. Football (boys) Soccer (boys) 0.41 Basketball (girls) 0.37 Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014 Jul;42(7):1710-5. Concussion definition Concussion symptoms  mTBI: mild traumatic brain injury  Blow to head, neck, body  neurological symptoms within Physical 48 hours  CT and MRI normal  May or may not include loss of consciousness Sleep Cognitive  Cannot be explained by drug, alcohol, medication use, or other injuries or comorbidities Emotional http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

6/20/2018 Concussion pathophysiology Window of vulnerability  The period between the concussion and the recovery.  Return to play during this time could cause worse, even catastrophic, brain injury Force to Ion fluxes; Need glucose brain, Energy vasocon- but less axonal crisis striction blood flow stretching May be unsafe to • return to competition until brain activity has returned to normal In rats , that time • Giza CC and Hovda DA, J of Athletic Training, 2001. period averages Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. ~10 days Giza and Hovda, JAT 2001 How severe is my concussion? Concussion recovery  Concussion severity is determined retrospectively  Does not correlate with LOC nor amnesia • Grading scales no longer used  Typical time to resolve • Adults: 10-14 days • Kids: Up to 4 weeks http://thehoopla.wpengine.netdna-cdn.com/wp- http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. content/uploads/2012/10/rage-meter-1.jpg Accessed June 26, 2017.

6/20/2018 Case #1  27 y/o software engineer presenting with concussion.  5 days ago fell while skiing, helmeted. No LOC but immediate headache.  Friends took her to local ED, no head CT needed. Advised to rest and to follow up the following week in primary care.  Has not returned to work or exercise.  Mild-moderate headache is worse with bright light and with using computer / screens. Also feels foggy and tired.  Medications: none  PMHx: none (incl no h/o concussion, HA, ADHD, psych)  SHx: work is understanding of her injury. No drug use. 1-2 alcoholic beverages/week. Which of the following is the most Higher symptom burden post concussion consistent predictor of slower recovery predicts longer recovery from sports related concussion?  The strongest and most consistent predictor of slower recovery from sport related concussion A. Higher initial symptom burden  Lower symptom burden during this time period predicts more rapid recovery B. History of migraine headache 36%  In 531 patients ages 7-26 (mean 14.6), average initial visit 29% C. History of mental health problem symptom score was 26 +/- 26. 86% of patients with initial symptom 21% score < 13 recovered within 28 days of injury. (Meehan WP et al. D. Development of post injury depression Neurology. 2014 Dec 9;83(24):2204-10.) E. Development of post injury migraine 7% 7% . . . . . . . . . . . . h . . . a j j m t n n e l i i o h a e t t t s s p e h o o n m l p p i a y a t f f r n o o s g e t t a l m i m n n i e e t f i f m m n o o i p p y y r r r o o e o l l h o e e t t g s s v v i i e e http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. H H H i D D Accessed June 26, 2017.

6/20/2018 Concussion evaluation 1. Self-reported symptom  Symptom severity score? assessment  How are symptoms 2. Neurological exam clustering? including Balance Error  Should I order a head CT Scoring System (BESS or brain MRI? or modified BESS)  Establish initial post-injury • Memory • Balance • Reaction time https://www.seata.org/resources/Pictures/Sport%20concussion%20assessment%20 tool%20-%205th%20edition%20(1).pdf. Accessed June 26, 2017. 1. Self-reported symptom assessment 2. Neurological exam with balance Balance Error Scoring System: BESS Symptom severity score = 46 Clusters: headache, emotional http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg

6/20/2018 BESS scoring BESS norms: adults  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  Also if cannot maintain for minimum 5 seconds then Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: score = 10 implications for brain injury evaluations. Brain Inj. 2008 Feb;22(2):147-52. Returning to case #1 How would you treat this patient? A. Order urgent head CT to rule out 27 y/o woman 5 days s/p fall while skiing with concussion. subtle post traumatic bleed, return to Software engineer. Has been off work since injury. clinic after CT. B. Gradually return to work now as  Symptom severity score high (46) tolerated, rest from physical activity, f/u 64%  Clustering in headache, light sensitivity, mood 1 week. C. Rest from work and from physical  Neurological exam non-focal activity until symptom free, f/u 1 week. • BESS score of 15 (10-24 th percentile for her age group) 23% D. Return to work and physical activity 14% now. 0% . . . . . . . . . . . c o k m s i t r o y T o h w r C f p d d o d n n a t e n a a h r k k u r r t t o o n e e w w r g r y m o u l t a l o r r n e u f d r d t u r a s t r e e O G R R

6/20/2018 Concussion treatment How much rest after a concussion?  Cognitive rest Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23.  Physical rest  88 patients (11-22 y/o) seen at pediatric ED randomized  Medication: acetaminophen  Strict rest x 5 days vs. “usual care” of 1-2 days rest, then or NSAIDs* prn headache stepwise return to activity  No driving  Neurocognitive and balance outcomes same at 3 and 10d  No EtOH post injury  Strict rest group had more daily post concussive symptoms and slower symptom resolution over the 10d study period *Avoid NSAIDs acutely due to theoretical risk of intracranial hemorrhage. Slide courtesy of Cindy Chang, MD Berlin Consensus 2017 on Rest Return to learn / work progression  “There is currently insufficient evidence that prescribing complete rest achieves these objectives.” (those of Return to full mitigating symptoms and/or promoting recovery by day of school. minimizing brain energy demands post concussion) Return to ½ day of school. 30 min  “After a brief period of rest …24-48 hours after injury, schoolwork at a 15 min patients can be encouraged to become gradually and time until can cognitive progressively more active while staying below their do 1-2 hours. No school / activity at a work. time. cognitive and physical symptom-exacerbation OK to do light thresholds…” reading, little bit TV, drawing,  “The exact amount and duration of rest is not yet well cooking as long as doesn’t defined in the literature and requires further study.” worsen symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.