Sports Concussion What the Clinician Needs to Know Carlin Senter, - PDF document

I have no disclosures. Sports Concussion What the Clinician Needs to Know Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco UCSF Essentials of Women’s Health July 7, 2016 Sports Concussion 2010 UCSF Sports Concussion Program  Concussion is serious public health issue  Need clinical care for sports concussion patients Education  Need community education  Need to advance diagnostic tools Sports concussion  Need prevention measures care Research

UCSF PlaySafe Outline: Sports Concussion 2016 1. Epidemiology 2. Evaluation 3. Treatment • How much rest? • Return to learn • Return to play • Preparticipation • Athletic trainer at high school exams 4. Legislation • M.D. on sideline and in clinic • Baseline testing 5. How many concussions is too many? • Education Concussions are common Concussions are common

Concussion numbers increasing Put these high school sports in order of highest to lowest incidence of concussion. A. Soccer (boys) B. Soccer (girls) C. Basketball (girls) D. Wrestling (boys) E. Football (boys) Marin JR et al. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014 May 14;311(18):1917-9. Rates of sports concussion in high school sports U.S. 2011-2012 Sport Rate per 1000 athletic exposures Football (boys) 0.94 Soccer (girls) 0.73 Wrestling (boys) 0.57 Soccer (boys) 0.41 Basketball (girls) 0.37 Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014 Jul;42(7):1710-5. Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014 Jul;42(7):1710-5.

Concussion definition Concussion symptoms  Type of mild traumatic brain injury Physical  Blow to head, neck, body  force to head  Rapid onset of neurologic impairment  Symptoms usually resolve in weeks, spontaneously, but in some cases can be Sleep Cognitive prolonged.  May or may not include loss of consciousness.  CT and MRI studies are normal Emotional Symptom Resolution Who is at risk for delayed return to play?  50% recovered and returned to play in 1 week; 90% in 3  LOC > 1 minute  Younger age weeks (Collins et al. Neurosurgery, 2006.)  Amnesia  Migraine headaches  Recovery in athletes may be faster than recovery in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol  Convulsions  Depression 2015; 14: 506-17.)  History of multiple  ADHD  Recovery in kids may take longer than recovery in adults 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.

Case #1 3-pronged evaluation recommended 1. Self-reported symptom assessment  16 y/o high school soccer goalie 2. Motor control: Neurologic exam including balance. Balance  Presents to you in urgent care with wrist pain Error Scoring System (BESS or modified BESS)  Also, she hit heads with teammate in practice earlier today and had 15 minutes of headaches and dizziness. She took a nap after 3. Mental status: Standardized Assessment of Concussion (SAC) practice as she felt unusually tired.  Now she has no headache: “I feel fine.”  What do you do next? Case courtesy of Cindy Chang, MD Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014. Case courtesy of Cindy Chang, MD 1. Self-reported symptom assessment Consensus statement on concussion in sport: the 4th International Conference on Concussion 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. in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8

2. Neurological exam with balance Symptom norms Balance Error Scoring System: BESS 9 th grade 10 th grade 11 th grade Symptom score 17 +/- 5 16 +/- 5 17 +/- 6 Valovich McLeod TC et al. Representative baseline values on the sport concussion assessment tool 2 (SCAT2) in adolescent athletes vary by gender, grade and concussion history. AJSM 2012. http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg BESS scoring BESS norms: ages 10-17  Each error is counted as one point  Score = the sum of the error points for all six trials  Errors • Eyes opening • Hands coming off the hips • Hip flexion or abduction of greater than 30 • Changing foot placement from the stance • Remaining out of the test position for > 5 seconds  Max score 10 errors Khanna NK, Baumgartner K, LaBella CR. Balance Error Scoring System Performance in  Also if cannot maintain for minimum 5 seconds Children and Adolescents With No History of Concussion. Sports Health. 2015 then score = 10 Jul;7(4):341-5.

3. Mental status BESS norms: adults Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: Consensus statement on concussion in sport: the 4th International Conference on Concussion implications for brain injury evaluations. Brain Inj. 2008 Feb;22(2):147-52. in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8. Case #2  9 y/o boy playing ice hockey, slipped and hit back of his head.  Friends said he was “out” for 5 seconds.  When he came to he felt “fine” but stopped practicing due to neck pain.  Mom brings him to see you the next day because at school he felt “foggy” and had headache worse with noise. He says it’s hard to pay attention.  What tool should one use in evaluating a child with concussion?  When should he return to school? 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

Can the Child SCAT3 be validated? Can the Child SCAT3 be validated?  Cognition  Balance (modified BESS)  Over 1/3 of all children didn’t know the date  Statistically significant differences between • 70% 5-7 yo , 39% 8-10 yo, 23% 11-13 yo males/females ( males worse ) and ages 5-9/10-  Concentration—days of week 13 ( younger worse )  88% correct  Tandem Gait • Of 56 who couldn’t, 63% were 5-7 yo  Statistically significant differences between ages 5-9/10-13 ( younger worse) Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending Concussion treatment How much rest after a concussion?  Cognitive rest Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23.  Physical rest  88 patients (11-22 y/o) seen at pediatric ED randomized  Medication  Strict rest x 5 days vs. “usual care” of 1-2 days rest, then stepwise return to activity • Tylenol  Neurocognitive and balance outcomes same at 3 and 10d post • Ibuprofen after first 72 injury hours  Strict rest group had more daily post concussive symptoms and slower symptom resolution over the 10d study period  No driving  No Etoh Slide courtesy of Cindy Chang, MD

Return to learn after a concussion Team approach to return to learn Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57. Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57 .  Return to learn ASAP  Ok to return to learn with symptoms  Avoid disruptions to the student’s life with return to school  Physician should suggest academic adjustments if needed  Most concussions resolve within 3 weeks so 504 plan or IEP usually not necessary Return to learn progression Return to full Return to Learn day of school. Return to ½ BEFORE day of school. 30 min Return to Play schoolwork at a 15 min time until can cognitive No school. do 1-2 hours. 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  Concussion Information Sheet  Acute Concussion Notification Form  Graded Concussion Symptom Checklist  Physician Letter to School After Concussion Visit  Concussion Return to Learn (RTL) Protocol  Physician Recommended School Accommodations Following Concussion  Concussion Return to Play (RTP) Protocol Case #3  15 y/o high school girls soccer player  Concussion f/u in clinic  Injured 2 weeks ago  Rested at home x 2 days then gradually returned to school with RTL protocol  Tolerating school 100% Follow gradual RTP progression  No concussion symptoms  Soccer championship game in 2 days. She requests your clearance to play.  What do you recommend?