Concussion in Youth Athletes: Where Are We Heading? Thomas L. - - PowerPoint PPT Presentation

Concussion in Youth Athletes: Where Are We “Heading?”

Thomas L. Pommering, D.O.

Division Chief, NCH Sports Medicine Assistant Clinical Professor, Departments of Pediatrics and Family Medicine The Ohio State University College of Medicine

The definition didn’t change

Classification of Concussion

No unanimous consensus Previously: Simple vs. Complex) 80-90% of concussions resolve in a short period (7-10 d), although this recovery time may be longer in children & adolescents

Concussion: Why should we care?

30 million children and adolescents participate in sports in the US each year “Silent” epidemic

– Up to 3.8 million sports-related concussions each yr – 300,000 sports-related TBI’s resulting in LOC (10%)

Over half go unreported

CONCUSSIONS ARE UNDER- REPORTED IN HS ATHLETES

(McCrea M, et al. Clin J Sport Med, 2003)

Only 47% of high school athletes reported their concussion Most common reasons for not reporting: – Not serious enough to warrant medical attention (66%) – Didn’t want to be withheld from play (41%) – Lack of awareness of probable concussion (36%)

COMMON SIGNS OF CONCUSSION

Vacant stare “glassy eyed” Poor coordination or balance Confused LOC (<10%) Inappropriate behavior Unusual emotions Slow to answer or follow instructions Personality change Disoriented Unusually quiet Motor phenomena: – Short lived seizure – Tonic posturing S/S of concussion may be progressive and evolving

COMMON SYMPTOMS OF CONCUSSION

Headache Difficulty w/ memory Dizziness/vertigo Generalized weakness Numbness/tingling Vision changes Poor concentration “seeing stars or lights” “foggy” or “dazed” Phonophobia Photophobia Depressed mood Nervousness/anxiety Insomnia/hypersomnia Emotional lability Nausea/vomiting Tinnitus Fatigue

Do Cumulative Effects Exist?

Depression (Guskiewicz KM, et al. Med Sci Sports Exec, 2007) Memory and concentration problems Delayed recovery with subsequent concussions Increased susceptibility for additional concussions Chronic Traumatic Encephalopathy (CTE) Apolipoprotein (APOE) genotype (Tierney, et al. Clin J Sport

Med, 2010)

– all 4 alleles (rare) – 10 x more likely to report prev concussion – Promotor allele only – 8.4 x more likely to report prev concussions

Cumulative Effects cont’d

For HS and College Athletes with > 3 concussions: More severe on field presentation of s/s (Collins et al, J

Neurosurg, 2002)

More likely to report HA’s at baseline (Register-Mahalik et al.,

Clin J Sport Med 2007)

More vulnerable to subsequent injury than those w/no concussion hx (Iverson et al., Brain Inj, 2004) 3 x more likely to sustain additional injury (Guskiewisz et al.,

JAMA 2003)

Had prolonged recovery (Collie et al., B J Sports Med 2006;

Couvassin et al., J Athl Train 2008; Slobounov et al., Neurosurg 2007)

Cumulative Effects cont’d

For Collegiate Athletes with > 2 concussions: Delayed recovery of verbal memory and Rxn time (Couvassin et al., J Athl Train 2008) Independently predicted long-term deficits in executive function, processing speed and self-reported symptom severity

(Collins et al., JAMA 1999)

What do you do when faced with a young athlete with a possible concussion?

NO Same Day RTP for Athletes < 18 y/o

SECOND IMPACT SYNDROME (SIS)

Sanders R, Harbaugh R. JAMA, 1984) (McCrory, P. Neurology, 1998) (Cantu, RC. Clin Sports Med, 1998)

Occurs when an athlete sustains a second head trauma before the original head injury or concussion has healed leading to… Acute loss of autoregulation of cerebral blood flow Diffuse Brain swellingBrain herniation! Mortality = 50% / Morbidity = 100%

SECOND IMPACT SYNDROME (SIS)

(Bey, T West J Med, 2009) (Mueller & Cantu; National Center for Catastrophic Injury Research http://www.unc.edu/depts/nccsi/)

1980-1993: 35 cases 2008: 5 cases Takes about 2-5 min for the herniation to occur (much faster than for an epidural hematoma ) S/S:

– Loss of EOM – Dilated/fixed pupils – Respiratory distress

SIS is has almost exclusively been documented in children and teens!!!

Best Tx is PREVENTION

What Current Tools are at our Disposal?

Become educated - parents, coaches, league administrators, officials, athletic trainers, physicians Seek advice and care from medical professionals who have expertise in concussion management “Sideline” assessment tools (training room or

• ffice setting)

– SCAT – BESS

Neuropsychological Testing (NP)

BESS (Balance Error Scoring System)

(Iverson et al., Brain Injury, 2008)

Rapid, easy to admin and cheap Measure postural stability (balance) – a sensitive indicator of brain injury Requires AIREX foam pad ($60) Confounders: ankle instability, fatigue, slight practice effect BESS testing most useful when interpreted in conjunction with other testing ( SCAT2 and NP)

Role of Neuropsychological (NP) or Neurocognitive Testing

Allows us to objectively measure cognitive function as it relates to brain injury Pen and paper tests (Trail making Test - 10 min) Computer / web-based systems (10-25 min) Formal NP testing with a trained and certified Neuropsychologist (4-6 hrs)

Computerized NP Testing

COGSPORT IMPACT ANAM HEADMINDER

Computerized NP Testing:

Advantages Disadvantages

Relatively quick and easy Measure verbal and visual memory, processing speed and reaction time Most effective when baseline testing can be done in conjunction with post-injury testing Useful and reliable clinical tool if administered and interpreted properly and has value to the athlete, coach and parent

Cost: $10-35 per test… ….Limited Availability “Proprietary interests do exist.” (McKeag: JAMA, 2003) Perception that they are the “Cat’s Meow” & are the absolute Standard of Care Baseline testing is not always feasible Practice effect

RETURN TO PLAY (RTP)

Cornerstone of management is physical and cognitive rest Athletes must be asymptomatic for at least 24 hrs before they’re permitted to start a supervised progression

RTP Guidelines

Modifying Factors in the Mgmt of Concussion

Note: “Gender” was left

• ff of this list at the time
• f publication, though

evidence points toward increased risk in females d/t:

• Smaller head mass
• Weaker neck mm
• More likely to report

symptoms than males

What’s on the Horizon in Terms of Future Concussion Management

(Davis et al., BJSM, 2009)

Structural Imaging

– CT, MRI, diffusion tensor imaging

Functional Imaging

– fMRI, PET, brain SPECT

Spectroscopy

– MR spectroscopy (MRS), Near infrared spectroscopy (NIRS)

Balance testing

– BESS, Sensory Organizational Test (SOT), gait testing, virtual reality)

Electrophysiological tests

– EEG, evoked potentials (EK), event related potentials (ERP’s), magneticoencephalography (MEG), HR variability

Genetics

– APoE4, channelopathies

Blood markers

– S100, neuron-specific enolase, cleaved Tau protein, glutamate

Prevention – Can Protective Equipment Make a Difference?

(Benson et al., BJSM, 2009)

1.

Helmets: reduces injury risk in cycling, skiing and snowboarding; but effect on concussion was nonconclusive!?

2.

Mouthguards: No strong evidence to reduce concussion risk, but they’re good for the teeth!

3.

Face shields: No strong evidence to reduce concussion risk

4.

Full face protection in hockey can reduce concussion severity (time loss from competition)

Football helmets – FRIEND OR FOE:!

designed to prevent head bleeds and skull fx’s, PERIOD

THE END –THANKS!