12/10/2016 I have no financial disclosures. Sports Concussion: Questions Our Patients Are Asking and the Evidence-Based Responses Carlin Senter, MD Co-Director UCSF Sports Concussion Program Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics UCSF Primary Care Sports Medicine Course December 9, 2016 Questions our patients are asking about concussion 1. What is a concussion? 2. When will I recover? 1. What is a concussion? 3. Is there a diet or supplement that will expedite my recovery? 4. When can I return to school (work)? 5. When can I return to sports? 6. Should I wear head protection when I return to sports? 7. Should I avoid heading when I return to soccer post concussion? 8. Should I go to physical therapy to work on neck strengthening to lower my risk of concussion? 9. How many concussions is too many? http://head-zone.com/about-concussions/ 1
12/10/2016 Definition Sequence of events � Blow to head, neck, body � force to head � Rapid onset of neurologic impairment Ion Need Force fluxes; glucose but Energy � Symptoms usually resolve in weeks, to vasocon- less blood crisis brain spontaneously, but in some cases can be striction flow prolonged. � Does not have to include loss of consciousness. Giza CC and Hovda DA, J of Athletic Training, 2001. � CT and MRI studies are normal Vespa et al, J Cerebral Blood Flow and Metabolism, 2005. Window of vulnerability 2. When will I recover from my � The period between the concussion and the recovery. � Return to play during this time could cause worse, even concussion? catastrophic, brain injury Giza and Hovda, JAT 2001 http://kidstoyhire.com.au/2014/12/05/mum-im-bored/ 2
12/10/2016 Symptom resolution Majority return to play in < 1 month in FB � 15.5% of concussions required ≥ 30 days before return to play. � 50% recovered and returned to play in 1 week; 90% in 3 weeks � Odds of return-to-play time of ≥ 30 days were greater in youth (odds (Collins et al. Neurosurgery, 2006.) ratio = 2.75; 95% CI, 1.10-6.85) and high school (odds ratio = 2.89; 95% CI, 1.61-5.19) athletes than in college athletes. � Recovery in athletes may be faster than recovery in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.) � No difference was found between high school and youth. � Recovery in kids may take longer than recovery in adults 25% Concussions, % 20% 15% 10% 5% 0% Youth High School College Total Percentage of concussions in youth, high school, and college football requiring ≥30 days before return to play, 2012 to 2014 seasons. Kerr ZY et al. Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes. JAMA Pediatr. 2016 Jul 1;170(7):647-53. Who is at risk for longer recovery? � LOC > 1 minute � Younger age 3. Is there a certain diet or supplement � Amnesia � Migraine headaches that you would recommend for my child � Convulsions � Depression to expedite his/her recovery from concussion? � History of multiple � ADHD concussions � Sleep disorders � Injuries close together in time � Repeat injuries with Broglio SP et al. NATA Position Statement on less and less force Concussion. J of Athletic Training, 2014. http://www.nutrascienceusa.net/pages/blog[2] 3
12/10/2016 Diet Supplements � No strong evidence for use of supplements in concussion management at this time. � Sparse literature � Promising results in animal studies and a few human studies on � High fat diet exacerbated behavioral problems post mTBI in rats traumatic brain injury in recovery or prevention of concussion: (Mychasiuk et al. Diet, age, and prior injury status differentially alter behavioral outcomes following concussion in rats. Neurobiol Dis. • Omega-3 fatty acids 2015 Jan;73:1-11.) • Curcumin • Resveratrol • Melatonin • Creatine • S. baicalensis • Vitamins C, D, E Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9. Omega-3 fatty acids Melatonin � Promising animal data (mainly rats) � May have utility in reducing post traumatic headache after mTBI • Mostly using docosahexaenoic acid (DHA) • Kuczynski A et al. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a • Protective effects before injury - role for prevention? prospective cohort. Dev Med Child Neurol. 2013;55(7):636–41. • Study underway: Barlow KM et al. A double-blind, placebo-controlled • Reduces effect of concussion post injury – expedite recovery? intervention trial of 3 and 10 mg sublingual melatonin for post-concussion � 2 double-blind RCTs presently underway in US: syndrome in youths (PLAYGAME): study protocol for a randomized controlled trial. Trials. 2014 Jul 7;15:271. • NCAA D1 athletes taking 2200mg DHA x 30 days post injury to � Growing interest in sleep disorders that contribute to post see if this affects recovery concussion syndrome - ?role for melatonin as treatment (Sullivan KA • UT Southwestern supplementing kids 14-18 y/o 2000mg DHA et al. Poor sleep predicts subacute postconcussion symptoms following mTBI. daily x 3 mo post injury to see if this affects recovery Appl Neuropsychol Adult. 2016 Nov-Dec;23(6):426-35.) Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9. 4
12/10/2016 Acupuncture � 1 case study on acupuncture + neck manipulation in concussion (Gergen DM. Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report. J Chiropr Med. 2015 4. Should I wait until I am 100% better Sep;14(3):220-4.) before I return to school? � Lack of high quality studies precludes ability to make conclusion regarding risk/benefit in TBI. (Wong V et al. Acupuncture for acute management and rehabilitation of traumatic brain injury. Cochrane Database Syst Rev. 2013 Mar 28;(3):CD007700.) How much rest after a concussion? Return to learn after a concussion Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57. Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23. � Return to learn ASAP � Ok to return to learn with symptoms � 88 patients (11-22 y/o) seen at pediatric ED randomized � Strict rest x 5 days vs. “usual care” of 1-2 days rest, then stepwise � Avoid disruptions to the student’s life with return to school return to activity � Physician should suggest academic adjustments if needed � Neurocognitive and balance outcomes same � Most concussions resolve within 3 weeks so 504 plan or IEP usually not necessary � Strict rest group had more daily post concussive symptoms and slower symptom resolution Slide courtesy of Cindy Chang, MD 5
12/10/2016 Team approach to return to learn Return to learn progression Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57. Return to full day of school. Return to ½ day of school. 30 min schoolwork at a 15 min time until can cognitive do 1-2 hours. No school. activity at a time. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html CIF: Physician letter to school 5. When can I return to sports after my concussion? 24 6
12/10/2016 Concussion Legislation Concussion legislation � California Assembly Bill 2127 (in effect 1/2015) � 50 states have adopted youth concussion laws • Adds to AB 25 � California: education code 49475 (effective 1/2012) ‒ FB full-contact practice limits: 1. Athletes and guardians sign a concussion information form � No more than 2/week during preseason and season yearly � These practices cannot exceed 90 minutes 2. Athlete suspected of having concussion removed at time of injury for the rest of the day � No full-contact in off-season 3. Athlete can return only after cleared by healthcare ‒ Once clear must follow gradual return to play protocol professional trained in evaluation and management of of at least 7 days under supervision of licensed provider concussion Return to Play Progression Return to play activity examples Step Objective Activities 1 Recovery No activity Clinician 2 Light aerobic activity: Walking, swimming, or stationary bike. < clearance Increase heart rate 70% max heart rate. No weights. Game play Full contact 3 Sport Specific: Skating drills in hockey, running drills in practice Non- Add movement soccer. No head impact activities. Asymptomatic contact Sport training 4 Non contact training: More complex drills (passing). Can start specific Light aerobic Add coordination and weights. activity activity cognitive load 5 Restore confidence and assess Full-contact practice functional skills by coaching staff 6 Normal game play Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8. 7
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