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Pediatric Sports-Related Concussion: Wicked Bell Ringahs !

Pediatric Sports-Related Concussion: Wicked Bell Ringahs !. Ellen F. Lauer, DO UNECOM Class of 2009 10/27/2012. Objectives. Define the term concussion and review the epidemiology of pediatric sports-related concussions Review the biomechanics and pathophysiology of concussion

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Pediatric Sports-Related Concussion: Wicked Bell Ringahs !

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  1. Pediatric Sports-Related Concussion: Wicked Bell Ringahs! Ellen F. Lauer, DO UNECOM Class of 2009 10/27/2012

  2. Objectives • Define the term concussion and review the epidemiology of pediatric sports-related concussions • Review the biomechanics and pathophysiology of concussion • Discuss the typical presentation and assessment of the concussed child/adolescent • Focus on management of the athlete with emphasis on the return to play guidelines. • Briefly discuss some complications related to single and/or multiple concussion episodes • Consider potential prevention strategies

  3. Case #1 • 12 year old little Shannon the soccer player complains of headache and a some dizziness after heading the ball. Her coach removes her from play and she states she feels fine a few minutes later. She asks if she can go back in the game.

  4. Case #2 • 18 year old Cody has been a hockey player since he was 4 years old, and his dream is to play for the NHL. His high school team was undefeated last year, and he’s looking forward to his senior year of play and impressing the college scouts. He sustained a concussion in summer league 3 months ago and is still having daily headaches, trouble sleeping, and his mother relates he is more moody than usual. He says he is fine when he exercises. He is very anxious to get back out on the ice and wants to know if you will sign the paper to clear him.

  5. The hype

  6. 11/1/2011 Safety in Youth Sports Act • Student athletes with signs/symptoms of concussion must be removed from play immediately and cannot return to play until cleared by a medical professional • Depts of Health and Education should develop online guidelines and educational materials • Schools may hold pre-season informational meetings • Parents and students sign paper stating they received info • Coaches take yearly training courses • Penalties for failure to comply (21-24)

  7. Definition(2008 Zurich Consensus Statement) • Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: • 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ''impulsive'' force transmitted to the head. • 2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. • 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. • 4. 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, post-concussive symptoms may be prolonged. • 5. No abnormality on standard structural neuroimaging studies is seen in concussion. (1)

  8. Definition • Zurich consensus statement (2008) specifically differentiates concussion from mild traumatic brain injury (mTBI) and does not define mTBI for the purposes of their statement. (1) • There is some argument in the literature that the term mTBI may be more appropriate • Canadian study (2010)--if term concussion was used, earlier discharge from hospital and earlier return to school and family less likely to consider it as a brain injury (2) • English survey study (2011)--59% of people who admitted to prior concussion said they had no brain injury (25) • CDC website uses terms concussion and mTBI interchangeably (3).

  9. Epidemiology • Approximately 1.6 - 3.8 million sports- and recreation-related TBIs occur in the United States each year. • Most of these are mild TBIs that are not treated in a hospital or emergency department. (3) • The actual incidence is likely higher, but concussion is very underreported. • ~ 75%-90% of the 1.4 million traumatic brain injuries that do come to hospital/medical attention each year are concussions or other forms of MTBI. • Concussion accounts for ~8.9% of all high school sports injuries (4) • ~225,000 new patients (adults and children) each year show long-term deficits from mTBI (6)

  10. Epidemiology • 51% of high school football players who suffer a concussion do not report it!!! • Not aware it was a concussion • Underestimate the seriousness of the injury • Do not want to be withdrawn from competition (30)

  11. Epidemiology • 2011 Prospective epidemiologic study over 11 years at 25 schools in Iowa public high school system (5) • Found an incidence rate of 0.24/1000 players. • Highest rate in football, girls soccer, boys lacrosse • Overall concussion rate increased from 0.12/1000 in 1998 to 0.49/1000 in 2008--yearly average increase of 15.5% • Attributed this increase potentially to an increase in athletic trainer support at all schools as well as increased awareness by athletes, coaches, and families • Girls had increased concussion rate in similar sports (2x risk) • ?more likely to report symptoms, different mechanisms of injury (contact with playing surface or ball vs contact with other players), differences in neck strength and head size (4, 5)

  12. Biomechanics of Concussion • 2 broad categories of forces: • Contact force at the site of injury • Inertial forces • Primary cause of concussive injuries • Linear and rotational acceleration

  13. Biomechanics of Concussion • Research (animals) focused on linear forces and brain pressure • transient increase in pressure causes neurological dysfunction • peak pressure correlates with level of dysfunction. • Rotational forces--main mechanism of injury in concussive injuries • Rapid head rotations generate shearing forces which have to potential to cause injury • Brain tissue deforms more readily in response to shear forces when compared with other tissues. • If head motion is constrained to not allow any rotation, it is hard to produce traumatic unconsciousness (animal studies) (6)

  14. Biomechanics of Concussion • The resulting strain is different if acceleration is applied in the coronal (lateral), horizontal (axial), or saggital planes • Lateral strains most likely to produce damage within deep brain structures and loss of consciousness • Ventricular and membranous systems within the brain have an important damping effects on strains and influence the deformation patterns (animal studies and human surrogate tests) (6) • Newer research using accelerometers in helmets of football players (7, 8) including children playing midget football. (9) • College football players at VA Tech--higher acceleration forces associated with concussion symptoms (8)

  15. Biomechanics of Concussion https://www.youtube.com/watch?feature =player_detailpage&v=cfXIdkMhOuQ

  16. Pathophysiology of Concussion • Animal models reveal that injury starts with disruption of neuronal membrane leading to K+ efflux • glutamate (excitatory amino acid) release • Further K+ release from cells • Depolarization and neuronal suppression • Na+-K+ pump attempts to restore homeostasis which utilizes glucose and ATP • Increased lactate production and decreased cerebral blood flow and creates “energy crisis” • Ca2+ accumulates in cells and may initiate chemical pathways that induce cell death (4, 9, 10, 11)

  17. Pathophysiology of Concussion • Acute changes include: • Metabolic • Altered blood flow • Axonal injury • Abnormal neural activation • These reduce cerebral performance and make the brain more susceptible to cellular injury (11)

  18. Pathophysiology of Concussion • After concussion, patient can demonstrate cognitive deficits associated with abnormal activation of neural circuits. Blood-oxygen dependent sequences obtained with fMRI before and after cognitive tasks demonstrate hyperactivation in post-concussive brain one week following concussion. When this abnormal activation is seen, these athletes tend to have more prolonged recovery (10)

  19. Pathophysiology of Concussion • SPECT, perfusion MRI/CT imaging--measures cerebral blood flow (12) • Hypoperfusion on SPECT correlated with loss of consciousness and postconcussion syndrome • Negative initial SPECT correlates with favorable outcome • Normal perfusion or hyperemia on pCT-- good prognosis • pMRI-- if decreased blood flow more likely to have poor clinical outcome. These changes are usually seen 10 days following concussion

  20. Pathophysiology of Concussion • PET scanning can measure cerebral glucose utilization -- varied results ranging from regional hypometabolism to global hypermetabolism in the chronic phase following injury (12) • Useful in more severe insults, as the edema and vasospasm caused by concussive forces in mTBI may not be severe enough to cause changes in glucose metabolism

  21. Pathophysiology of Concussion • Resting state fMRI study conducted with 17 athletes who sustained single concussion ~10 days post-injury vs 17 healthy controls. • All subjects were asymptomatic based upon clinical and neuropsychological testing. • Study found disrupted functional network both at rest and after exercise in the concussed individuals. (13)

  22. https://www.youtube.com/watch?v=TdSZjBulFfw

  23. Presentation Signs and Symptoms of a Concussion PhysicalCognitiveEmotionalSleep . Headache Feeling mentally "foggy" Irritability Drowsiness Nausea Feeling slowed down Sadness Sleeping more than usual Vomiting Difficulty concentrating More emotional Sleeping less than usual Balance problems Difficulty remembering Nervousness Difficulty falling asleep Visual problems Forgetful of recent information Fatigue Confused about recent events Sensitivity to light Answers questions slowly Sensitivity to noise Repeats questions Dazed Stunned

  24. Presentation • Most commonly reported symptom is headache • Loss of consciousness no longer required for diagnosis (1,4,14) and occurs in <10% of cases (4) • Post-traumatic amnesia (retrograde and/or anterograde)--important prognostic factor (4,14) • Symptoms may not appear until several hours after the event which may complicate diagnosis and management (4)

  25. EVALUATION

  26. Initial Evaluation • On the field: • ABCs and stabilize C-spine • Move to sidelines when deemed safe • Sideline: • Ask athlete about symptoms • Neurological exam • Cognitive evaluation • Balance Error Scoring System (BESS) • If concussion, remove athlete from play and monitor for several hours. • Refer to ED if repeated emesis, severe or worsening HA, seizures, unsteady gait, slurred speech, focal neuro exam, altered mental status, GCS <15, or signs of basilar skull fx (4)

  27. SCAT-2Sports Concussion Assessment Tool

  28. Secondary Evaluation • In ED/office setting: • Thorough hx (including concussion hx) and physical exam, which includes full neuro, cognitive, and cerebellar/balance testing • If there is concern for structural issue, neuroimaging is indicated • No definitive guidelines exist for this, so must use clinical judgment • Give instructions to parents and player regarding signs/symptoms to watch for and when to return for further evaluation • NO return to play that day even if asymptomatic!

  29. Secondary Evaluation • Neuroimaging: • Structural imaging is normal in concussion, so routine CT/MRI contributes little to evaluation and management • Should obtain if history/PE suggestive of intracranial hemorrhage, skull fracture, or c-spine injury • CT is the test of choice in first 24-48 hours • Good for detecting injuries that may require surgical intervention • MRI more useful in subacute phase • More sensitive than CT for diffuse axonal injury, edema, and nonhemorrhagic contusions • Results not always conclusive: 1/4 of patients have good recovery despite lesions seen on MRI and 15% of patients with normal MRI have suboptimal outcomes (12) • Functional imaging is currently only used in research settings.

  30. Tertiary Evaluation • Neuropsychological testing • Computerized tests that can demonstrate deficits in concussed athletes • Ex: ImPACT, HeadMinder, CogState • Ideally, testing is performed pre-season and post-concussion • no official guidelines exist regarding when to administer this testing following concussion • Completing the test may exacerbate symptoms, as it is mentally taxing • Study at UPMC had ED patients complete ImPACT testing in the ED and at follow up and found that immediate assessment results correlated with follow up testing, so it may be a useful tool in the acute workup (15) • Also can refer to neuropsychologist to perform more specialized testing, if deemed necessary or no access to computerized tests

  31. Immediate Post-Concussion Assessment and Cognitive Testing

  32. Evaluation • Potential tools for the future: • Reaction time testing • Univ of Michigan developed test for athletes’ reaction time. Important to study because decreased reaction time and especially head protective reflex may put athlete at risk of repeat head injury (16) • Genetic Testing • ApoE4 gene has been suggested to predict early response to TBI (more likely to have GCS <15), but there is no evidence that this leads to worse long term effects. Has been studied more in adults, limited pediatric research. In adults, the presence of this allele is associated with increased mortality following stroke and earlier age of Alzheimer's onset. (17) • Other potential markers: Tau protein and amyloid protein deposition (6, 11) • More routine use of functional imaging (12, 13)

  33. Evaluation • Can be performed by medical professional trained in concussion management • Neuropsychologist, neurologist, OR sports medicine specialist referral may be indicated if: • co-morbid condition (ADHD, depression, learning disability) • multiple concussions with long recovery times • post-concussion syndrome x several months • No baseline testing and difficulty interpreting post-concussion test scores • Provider unfamiliar with concussion management (4,14)

  34. Management

  35. WHEN IN DOUBT, SIT THEM OUT! WHEN IN DOUBT, SIT THEM OUT!

  36. Management • BRAIN REST! • Physical and cognitive rest • Important to stress to athlete, families, coaching, staff that they must allow time for a full physical and cognitive recovery. • Younger athletes take longer to recover than adult athletes • 2011 ED study in Pittsburgh found that ~41% of children ages 11-17 years old still had not returned to normal activity at 2 weeks post-injury and 10% at 6 weeks (15) • Rat pup studies also confirm this (26)

  37. Management:Physical Rest • No physical activity until asymptomatic at rest • Physical activity includes not only sport, but gym class, other training (weights, cardio), recreational activities (biking, hiking), sexual activity • When asymptomatic x 24 hours, then initiate graded return to play. • No return on same day. Graded RTP will take at least 5 days • If symptoms recur, go down 1 step and try again 24 hours later

  38. Management:Cognitive Rest • Absence from school and/or shortened days, decreased work load and longer time for tests, no standardized tests • Must inform teachers of situation and educate them regarding concussions • Also avoid other activities that require attention and concentration: • Driving!, video games, TV, computer work, texting, reading. If phonophobic, avoid loud noise, consider ear plugs. If photophobic, wear sunglasses. • Reintroduce these activities slowly and stop if symptoms return

  39. Management:Other • Should be under the care of competent adult • Frequent meals rich in carbohydrates • Omega 3 fatty acid supplementation • Possibly provide resistance to oxidative stress (27, 28) • Tylenol is safest medication • No need to wake during the night • Sleep is beneficial to the injured brain

  40. Complications • Post-Concussion Syndrome • Second Impact Syndrome • Increased susceptibility to future concussions • Chronic Traumatic Encephalopathy • Early retirement from sports

  41. Complications:Post-Concussion Syndrome • Persistence of concussion symptoms beyond the expected time of resolution • DSM IV TR criteria: hx of concussive injury, evidence of attention or memory problems, and 3 month duration of 3 or more sx: fatigue, disordered sleep, headache, vertigo/dizziness, irritability or aggressiveness, anxiety or depression, personality changes, and/or apathy. • Will often notice a decline in school performance

  42. Complications:Post-Concussion Syndrome • Depression may result from concussion • British study with 58 patients who sustained mTBI and 72 healthy controls. Separated into 4 groups (mTBI +/- depression and control +/- depression). Highest # of postconcussive symptoms reported in mTBI + depression (18). • as well as influence recovery and length of postconcussive syndrome symptoms • Canadian study with control group and concussed group with no depression, mild, or moderate depression + mTBI. They used fMRI while subjects performed working memory task and found that those who were depressed s/p concussion had fMRI changes consistent with a limbic frontal model of depression. Severity of the depression correlated with neural responses that have been implicated in major depressive disorder (19).

  43. Complications:Second Impact Syndrome • Very rare and only reported in athletes <20 years old • Occurs when an athlete sustains a 2nd head injury before symptoms associated with the first have fully resolved • This results in lack of autoregulation leading to cerebrovascular congestion, diffuse edema, and death in 50% of patients.

  44. Complications:Increased Susceptibility to Future Concussions • Prospective cohort study 2011 • 2905 HS football players over 3 seasons • 196 reported concussions in 184 players (12 with repeat concussions) • Likelihood of sustaining concussion was associated with hx of concussion • Players with hx of >/= 3 concussions were 3x more likely to have concussion during study • Athletes with previous concusison had longer recovery time • In 12 players with repeat concussions, seemed to be 7-10 day window of increased susceptibility • 11 of 12 repeat concussion within 10 days, 9 within 7 days (27)

  45. Complications:Chronic Traumatic Encephalopathy • First described in 1928 by Martland • “Punch Drunk Syndrome” • Chronic progressive neurodegenerative disorder seen in people exposed to repeated mild head injury • Symptoms include memory issues, headaches, mood disorders, agitation, motor problems • Neuropathology reveals atrophy (frontal, temporal, and parietal lobes), substantia nigra pallor, accumulation of tau and amyloid proteins (28)

  46. Complications:Early retirement from sports • No evidence based guidelines • AAP suggests that if an athlete sustains >/= 3 concussions in 1 season or has postconcussive symptoms >3 months, s/he should be considered for refraining at least from the season • Tough decision to make--pressures from athlete, family, coaches, fans, teammates • Financial pressures as well • Scholarship or professional potential

  47. Complications:Early retirement from sports • Decision should be made with consideration of the potential complications of continued play as well as the player’s personal situation. (4, 20) • Should not hesitate to involve specialists in this decision making process

  48. Prevention • Protective gear • Mouthgards--no evidence that these prevent concussions, but they do reduce dental trauma (4) • Helmets/headgear- lab studies show decreased impact force to head, but decrease in incidence of concussion has not been consistently seen in contact sports • There is evidence with respect to decreasing incidence specifically in skiing and snowboarding • Full face shield is better than 1/2 face shield in hockey with respect to length of time for RTP, but not in decreasing incidence of concussion • Soccer headgear: decreased incidence of concussion in collisions but not from heading the ball • Some suggest decreasing protective gear and athletes will instinctively protect their heads(29) • Girls lacrosse less protective gear and more strict rules with respect to contact and less incidence of concussion when compared to boys’ lax • In other comparable sports girls more likely to sustain concussion (5)

  49. Recognition • Education!!! • Athletes, parents, coaches, athletic trainers, teachers, medical personnel • www.CDC.gov: “Heads Up!” Toolkit available free (3)

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