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Concussion and the Pediatric Athlete

Concussion and the Pediatric Athlete. Amber G. Luhn, MD, CAQ-SM Knoxville Orthopaedic Clinic Medical Director, KOC Sports Medicine Outreach Assistant Team Physician, University of Tennessee Team Physician, Karns High School. Disclosures. I have no financial disclosures.

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Concussion and the Pediatric Athlete

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  1. Concussion and the Pediatric Athlete Amber G. Luhn, MD, CAQ-SM Knoxville Orthopaedic Clinic Medical Director, KOC Sports Medicine Outreach Assistant Team Physician, University of Tennessee Team Physician, Karns High School

  2. Disclosures • I have no financial disclosures. • I have four really cute kids and an awesome husband.

  3. Objectives • Review the most recent international, national and state guidelines1,2,3 • Review AAP guidelines4 • Discuss sideline evaluation tools & management • Discuss clinical management • Return to school & return to play decisions

  4. Zurich DefinitionMcCrory P, et al. Clin J Sport Med. 2009;19(3):185–200 • “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” • Five common features include: • “Concussion may be caused either by a direct blow to the head, face, or neck or elsewhere on the body with an ‘impulsive’ force transmitted to the head.” • “Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.” • “Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.” • “Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however, it is important to note that in a small percentage of cases, postconcussive symptoms may be prolonged.” • “No abnormality on standard structural neuroimaging studies is seen in concussion.”

  5. Biokinetics • Acceleration, deceleration and rotational forces4 • Threshold of injury is elusive6 • Developmental immaturity may affect threshold • Head impact telemetry (HIT) system6 • Avg head impact acceleration: 29.2 g • Avg head impact acceleration resulting in injury: 103.3 g (high school), 95 g (collegiate)

  6. PathophysiologyAnimal Studies ENERGY CRISIS!! From Halstead ME, Walter KD, 20104

  7. Grading Systems • Many described in the literature • American Academy of Neurology • Colorado Medical Society • Cantu • 2004 Prague CIS statement2 abandoned grading systems • Simple vs. complex categorization • 2008 Zurich CIS statement3 abandoned 2004 categorization • Symptom-based approach (subjective) • Postural & cognitive testing (objective)

  8. Epidemiology • Attempts in the literature to identify incidence &/or prevalence • Annual incidence (0-14yrs) 475,0007 • Prevalence (Canada) 200 per 100,0008 • Prevalence (Canada) 135 per 100,0009 • Incidence US ED visits for SRC 2001-20055 • 4 in 1000 8-13 yrs • 6 in 1000 14-19 yrs • ALL of these underestimate true incidence/prevalence of pediatric concussion4 • Annually up to 3.8 million recreation and sport related concussions in US (CDC) • Gender difference and sport difference

  9. From Bakhos LL et al, 2010, Figure 2.5

  10. Adapted from Halstead ME, Walter KD, 2010, Figure 1.4

  11. From Bakhos LL et al, 2010, Figure 1.5

  12. Signs and Symptoms • Symptom clusters • Physical (migraine), Cognitive, Emotional (neuropsychiatric), Sleep • <10% have LOC • Severity of amnesia (retrograde and anterograde) may correlate with severity • Mental “fogginess” and symptom clusters may predict length of recovery10

  13. Headache Nausea, Vomiting Balance problems Visual problems Fatigue Sensitivity to light Sensitivity to noise Dazed Stunned Irritability Sadness More emotional Nervousness Drowsiness Sleeping more than usual Sleeping less than usual Difficulty falling asleep Feeling mentally “foggy” Feeling slowed down Difficulty concentrating Difficulty remembering Forgetful of recent information Confused about recent events Answers questions slowly Repeats questions

  14. On the Front Line

  15. On-Field Evaluation • Primary survey • “ABCs”, level of consciousness, C-spine evaluation • Assume C-spine injury if unconscious after head or neck trauma • Secondary survey • PE for facial & dental trauma, neuro exam • Sideline Assessment Tools • SAC (Standardized Assessment of Concussion) • BESS (Balance Error Scoring System) • Maddocks questions • SCAT2 (Zurich) • Incorporates elements from all three of the above

  16. From McCrea et al. 1997

  17. Balance Error Scoring System (BESS) • Developed at UNC Sports Medicine Research Laboratory • portable, cost-effective, and objective assessment of static postural stability • 10-15 min to administer • Materials • 2 surfaces: ground and foam pad • Stop watch (6s, 20s trials) & spotter • BESS Testing Protocol • BESS Score Card From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

  18. BESS Score Card From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

  19. From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

  20. From www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf

  21. Maddocks Questions • At which ground are we? • Which quarter is it? • How far into the quarter is it- the first, middle, or last 10 min? • Which side kicked the last goal? • Which team did we play last week? • Did we win last week? From Maddocks et al. 1995.

  22. Sideline Management • Athlete removed from practice/ game remainder of day • ANY TSSAA sanctioned sport athlete must be seen by MD/DO prior to return to competition • Monitor athlete for several hours for any deterioration • Immediate motor phenomena may accompany a concussion4 • Tonic posturing or convulsive movements are generally benign • ED referral • Potential C-spine injury • Recurrent emesis • Severe or progressively worsening headache • Deterioration in mental status • Seizure activity • Focal neurological symptoms (Unsteady gait, slurred speech, weakness or numbness in the extremities) • Signs of a basilar skull fracture or skull fracture • Altered mental status resulting in a GCS <15 • Unusual or very irritable behavior

  23. Clinical Follow-up (1-5d) • History • Post-Concussion Symptom Scale • Previous head injuries • Comorbid conditions • PE • Head and C-spine examination • Neurologic examination, including gait and cerebellar function • Assessment of cognitive function (computerized neuropsych testing) • Additional testing • C-spine films if neck pain, iROM • Advanced imaging • Other tests?

  24. Post-Concussion Symptom Scale From http://impacttest.com/resources

  25. Post-Concussion Symptom Scale • Helpful to have a baseline • Consider comorbid pre-existing conditions that may affect the symptom scale • ADHD, learning disabilities, sleep disturbances, depression, chronic migraines, environmental allergies, medications, etc

  26. Caveats to Symptom Scale • Minimize or even lie about symptoms to avoid loss of playing time • Lack maturity to express symptoms or understand symptom score • Need cognitive function to even know there is a deficit of cognitive function • Developing adaption for the 5-12yo age group

  27. Computerized Neuropsychological Testing • Another tool to assess cognitive function of a concussed athlete • Does not independently confirm diagnosis • Does not independently determine RTP • Does not replace need for physician evaluation • Does not replace formal neuropsych testing • Computerized tests easily administered & widely available • Insurance sometimes do not cover formal neuropsychological testing • Most clinically useful with a baseline

  28. Computerized Neuropsychological Testing • ImPACT: www.impacttest.com • Has normative data for 11-14yo • http://www.impacttest.com/pdf/ImPACTchildnorms2003.pdf • Developing pediatric ImPACT for 5-12yo • US Army Med Dept ANAM (Automated Neuropsychological Assessment Metrics): www.armymedicine.army.mil/prr/anam.html • CogState: www.cogstate.com/go/sport • Available in several languages • Headminder: www.headminder.com • CNS Vital Signs: www.cnsvs.com

  29. Computerized Neuropsychological Testing • No standard protocol for test administration • 1st post-injury test within 72hrs • 2nd post-injury when symptom-free on exertion • Additional post-injury tests as indicated by clinical course or results of 2nd post-injury test • When interpreting take into account comorbid diagnoses (ADHD, LD, etc), age and baseline academic status • NEVER return an athlete who remains symptomatic no matter their test results!

  30. Advanced Imaging • CT or MRI typically normal • Conventional imaging identifies structural pathology • cervical spine injury, skull fracture, intracranial hemorrhage (subdural, epidural, intracerebral, or subarachnoid) • Worrisome symptoms for structural pathology • severe headache; seizures; focal neurologic findings; recurrent emesis; significant drowsiness or difficulty awakening; slurred speech; poor orientation; neck pain; significant irritability4

  31. Advanced Imaging • CT test of choice 1st 24 to 48 hrs • Intracranial hemorrhage • Skull fracture • MRI test of choice >48hrs • Cerebral contusion • Petechial hemorrhage • White matter injury • Emerging MRI modalities better at detecting white matter alteration, esp. in younger patients • Gradient echo (GRE) sequences • Perfusion & Diffusion tensor imaging (DTI) • Magnetization transfer imaging (MT) • Useful in patients with persistent cognitive complaints

  32. Functional Advanced Imaging • fMRI • Measures metabolic and hemodynamic changes • Patterns correlate with symptoms during concussion • PET (positron emission tomography) • SPECT (single photon emission computed tomography) • MRS (magnetic resonance spectroscopy)

  33. Biochemical & Genetic Markers • Serum tests to identify concussion • S-100 proteins, neuron-specific enolase (NSE), cleaved Tau protein (CTP) • Poorly predictive of clinical course • Genetic predisposition? • Apolipoprotein E4 gene (APOE4), S-100 calcium binding protein gene, Neuron specific enolase • No significant differences in head injury characteristics or clinical outcomes

  34. Concussion Management • EDUCATION, EDUCATION, EDUCATION • Cognitive Rest • Limit schoolwork, reading, playing video games, using a computer, watching television • Physical Rest • No physical exertion until symptom-free • What is left to do? • SLEEP!

  35. Concussion Management • Medications (2-14d) • Recommend sleep as best management of headache pain • Acetaminophen first line, but NSAIDs are fine if no suspicion of bleed (negative CT) • Continued medication use to control concussion symptoms indicates incomplete recovery • Before RTP athlete must remain symptom-free off medication.

  36. Concussion Management • Restrict driving if necessary • Slowed reaction time • Return to school • Always write school note (academic form) • May return when school does not greatly exacerbate symptoms (half-days)

  37. Concussion Management • DOCUMENT everything • Second Impact Syndrome • Post-traumatic encephalopathy • Cumulative effect of repeated concussions • Lifelong implications • Importance of honesty about symptoms • Because of TSSAA policy they must be cleared by a physician

  38. Return to Play • “Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion.”4 • “When in doubt, sit them out!”4 • No return to play while symptomatic • All decisions individualized • Usually in the range of 7-10d • The younger they are, the more conservative you are

  39. Concussion Rehab Protocol From Halstead ME, Walter KD, 20104, Figure 5

  40. Complications

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