Sport-Related Concussions in Children and Adolescents What you need to know

1. TM Prepared for your next patient. Sport-Related Concussionsin Children and AdolescentsWhat you need to know Mark Halstead, MD, FAAPAssistant Professor, Depts. of Pediatrics and Orthopedics Washington University Sports Medicine -- St Louis, MO Director, Sports Concussion Clinic

2. Disclaimers • Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. • Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

3. Disclosure • Faculty Disclosure InformationIn the past 12 months, I have not had any relevant financial relationships with the manufacturer of any commercial product and/or provider of commercial services discussed in this webinar.I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

4. Objectives • Understand the epidemiology of sport-related concussion. • Determine appropriate in-office evaluation of a sport-related concussion. • Analyze the role of computerized neurocognitive assessment of a concussion. • Implement appropriate return to play protocols following a concussion.

5. Definition Complex pathophysiological process affecting the brain, induced by biomechanical forces 1st Int’l Symposium on Concussion in Sport (Vienna, 2001)Organized by FIFA, IIHF, IOC

6. Definition: 5 Major Features May be due to direct blow to face, head, neck, or elsewhere on body with “impulsive” force to head Rapid onset of short-lived impairment of neurologic function that resolves spontaneously Acute symptoms usually due to functional disturbance rather than structural injury Results in graded set of clinical syndromes that may or may not involve loss of consciousness (LOS) Typically associated with grossly normal neuroimaging studies

7. Epidemiology: Boys Sports Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

8. Epidemiology: Girls Sports Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

9. Concussion Epidemiology Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

10. Mechanism of Injury Gessel LM, Fields SK, Collins CL, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503

11. Pathophysiology

12. Common Signs and Symptoms • +/- LOC • Headache • Dizziness • Nausea/vomiting • Unaware of period, opposition, score • Confusion • Amnesia • Unaware of time, place, date • Vacant stare/glassy eyed • Slurred speech • Feeling “dinged,” “slow,” “foggy” • Visual changes • Sensitivity to light/sound • Unusual/inappropriate emotions (cry, laugh) • Inappropriate playing behavior (running in wrong direction) • Seizure

13. Common Symptoms Meehan WP 3rd, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanisms, symptoms, and management. Am J Sports Med. 2010;38(12):2405–2409; and Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610

14. On the Field: Sideline Assessment • Various tools • Standardized Assessment of Concussion (SAC) • Symptom Assessment • Balance Error Scoring System (BESS) • Sport Concussion Assessment Tool 2 ([SCAT2] includes SAC, BESS, others) • Question: Which is the best one to use and what do results mean?

15. Utility of the SCAT2 Valovich McLeod TC, Bay RC, Lam KC, et al. Representative baseline values on the Sport Concussion Assessment Tool 2 (SCAT2) in adolescent athletes vary by gender, grade, and concussion history. Am J Sports Med. 2012;40(4):927–933 • What are baseline norms for high schoolers? • 11th and 12th graders were better than 9th graders • 88.7 and 89.0 vs 86.9 (p<0.001) • Athletes with self reported concussion history had lower scores than those with no history • 87.0 vs 88.7 (p<0.001) • Females scored better than males • 88.7 vs 87.7 (p=.03) • Cannot assume ‘baseline’ of 100 as norm

16. Utility of the SCAT2 Valovich McLeod TC, Bay RC, Lam KC, et al. Representative baseline values on the Sport Concussion Assessment Tool 2 (SCAT2) in adolescent athletes vary by gender, grade, and concussion history. Am J Sports Med. 2012;40(4):927–933

17. BESS: Balance Error Scoring System • Postural Stability • Flat and 10cm foam • 20 seconds each • Count errors to score • Eyes opening • Movement • Hands off hips • Affected by environment • Test after 15 minutes • Footwear • Surfaces • Some rater reliability issues • Some practice effect noted

18. When to Refer to Emergency Department • General guidelines • LOC—how long? • Focal neurological findings • Worsening mental status • Seizure activity • Worsening headache • Repeated emesis • Concern is for structural injury requiring computed tomography (CT) scan

19. Neuroimaging • Consider for all the things referral to emergency department (ED) • CT scan initially • Consider magnetic resonance imaging (MRI) if more prolonged recovery • Remember, CT scan does not diagnose concussion • Also, normal CT scan ≠ No concussion !!! • Newer imaging (primarily research role) • Functional magnetic resonance imaging (fMRI) • Positron emission tomography (PET) • Single-photon emission computed tomography (SPECT)

20. In the Office Assessment • Same assessments that are done on the field may not be as helpful in the office • SCAT2―“S” is for “Sideline” • Symptom score checklists • Neurological examination • Concussion history • Balance assessments • Most helpful first 3 days • Vestibular system assessments • School difficulties

21. Symptom Checklist

22. When to Refer to a Specialist • Prolonged symptoms • Severe symptoms that are not improving • Your own individual comfort factor • Patient with multiple concussions • Decisions on retirement? • No “magic number” • Parental request

23. Neurocognitive Testing • What is available? • ImPACT (multiple tests) • Axon Sports (playing cards test) • Concussion vital signs • Automated Neuropsychological Assessment Metrics ([ANAM] primarily military) • HeadMinder • Formal pencil and paper testing with neuropsychologists

24. Neurocognitive Testing • Benefits • Gives ‘data’ of brain function • In use for many years with good normal values • Computerized test is easy to administer • Much less time needed compared to formal pencil and paper testing

25. Neurocognitive Testing • Issues • Standards for assessment • How often? Testing while symptomatic? • “We suggest initial evaluation 24–72 hours after injury. Consult a physician for interpretation of ImPACT test results…second post-injury test should be administered 1–2 weeks after the initial post-injury test. We strongly discourage testing more than once a week.” • Baseline vs No Baseline • Not validated below age 12 • Pediatric ImPACT likely to be released by end of year • Cost • Who will interpret?

26. Issues that Affect Test • Environment • Group testing vs individuals • Practice effects • Prior computer use • Baseline depression • Overall effort • Changing baselines • Felt to be stable after 10th grade

27. What Role Do They Have? • May be a part of a comprehensive concussion evaluation program • May help identify the ‘not so forthcoming’ athlete • For more concrete and specific neurocognitive evaluation, especially when considering significant or prolonged school adjustments → involve neuropsychologist for more formal testing

28. What They Do Not Do • Predict length of recovery. • Provide prognosis for future problems. • Act as the sole determining factor for return to play. • Act as a red light/green light.

29. How to Use • First, develop a comprehensive concussion program for your clinic/school • Consultants • Education on the issues―stay current―rapidly evolving topic • Appropriate plan for testing • Setting • Post-injury evaluation • Physician or neuropsychologist to interpret the testing • Do not treat to the test • Do not just use computer results/summary score • Electrocardiogram (EKG)

30. Future Directions • Further evaluation on true utility of the test • Appropriate time to test • Is it really worth testing while symptomatic? • Why is there now a post-testing symptom score on ImPACT? • Are all components helpful? • Is there one program that is better than others? • At least two more were being marketed at the National Athletic Trainers' Association (NATA) • Are there more appropriate evaluations? • Should we keep trying to get shorter and quicker evaluations when assessing a brain injury?

31. Recovery Time • Numerous studies suggest • The younger the athlete, the longer the recovery • Girls may take slightly longer than boys to recover and often have more symptoms • Majority of concussions (80%+) are back to ‘normal’ by 3 weeks following injury

32. “Brain Rest” • Initially restrict all physical activity that increases heart rate or blood pressure • Gym/recess • Sporting activities • Working out • Recreational activities (skateboarding, etc.) • These restrictions may change based on development of post-concussive syndrome.

33. “Brain Rest” • Consider reducing cognitive stress • Reduced school day/off school • Reduced school load • Untimed tests • Tutoring • May need to limit video games, texting, reading, computer use, television • Consideration for restrictions on driving → reduced reaction time is issue

34. “Brain Rest” • Involve the school early • Make adjustments • ? days off • Follow up with schools on adjustments being made • High achieving students may not ‘give in’ to adjustments

35. Returning to Play • No return to play in an acute concussion until • Asymptomatic at rest • Asymptomatic with exertion • Have completed full ‘return to activity’ progression • Cognitively back to baseline at school • If concussion is suspected • Pull from practice/game • No return to play same day • Medical evaluation and clearance before return • State law in 41 states

36. Return to Play • Do not allow to return to game/practice if suspected or diagnosed concussion on day of injury • Do not allow return to play/practice/exertion until asymptomatic at rest • Not a defined, set time frame (ie, 7 days, 2 weeks, etc.) • Progressive, step-wise approach to return to play

37. “Concussion Rehab”Step-wise Return to Play • No activity until asymptomatic • Light aerobic activity • Sport-specific training • Non-contact training drills • Full contact training after medically cleared • Game play

38. Medication Use • No evidence for efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDs) or other medication in management of sport concussion • May be helpful for symptoms of post-concussive symptoms (typically all off-label uses) • Sleep aids, attention-deficit disorder (ADD) medications, non-conventional headache medications, antidepressives • Athlete must be off medication and symptom-free before return to sports

39. Retirement from Sports • TRICKY! • No magic number • Consider for prolonged symptoms, multiple concussions • Involve someone experienced in sport concussion management

40. THANK YOU! Questions?

41. For More Information… On this topic and a host of other topics, visit www.pediatriccareonline.org.Pediatric Care Online is a convenient electronic resource for immediate expert help with virtually every pediatric clinical information need. Must-have resources are included in a comprehensive reference library and time-saving clinical tools. Haven't activated your Pediatric Care Online trial subscription yet?It's quick and easy: simply follow the steps on the back of the card you received from your Mead Johnson representative. Haven't received your free trial card?Contact your Mead Johnson representative or call 888/363-2362 today.