Understanding Sports Concussion: Should Our Kids Play Contact - - PowerPoint PPT Presentation

6/20/2018

Understanding Sports Concussion: Should Our Kids Play Contact Sports?

Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco

UCSF Advances in Internal Medicine May and June 2018

Disclosures

Sports concussion care

Education Research

UCSF Sports Concussion Program Outline

1. Epidemiology 2. Evaluation 3. Treatment

• How much rest?
• Return to learn / work
• Return to sports

4. How many concussions is too many?

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Concussions are common Concussions are common

Concussion numbers increasing

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.

Sports Concussion 2017

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

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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)

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.

Concussion definition

• mTBI: mild traumatic brain injury
• Blow to head, neck, body  neurological symptoms within

48 hours

• CT and MRI normal
• May or may not include loss of consciousness
• Cannot be explained by drug, alcohol, medication use, or
• ther injuries or comorbidities

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017. Physical Cognitive Emotional Sleep

Concussion symptoms

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Concussion pathophysiology

Force to brain, axonal stretching Ion fluxes; vasocon- striction Need glucose but less blood flow

Energy crisis

Giza CC and Hovda DA, J of Athletic Training, 2001. Vespa et al, J Cerebral Blood Flow and Metabolism, 2005.

Giza and Hovda, JAT 2001

• May be unsafe to

return to competition until brain activity has returned to normal

• In rats, that time

period averages ~10 days

Window of vulnerability

• The period between the concussion and the recovery.
• Return to play during this time could cause worse, even

catastrophic, brain injury

How severe is my concussion?

http://thehoopla.wpengine.netdna-cdn.com/wp- content/uploads/2012/10/rage-meter-1.jpg

Concussion recovery

• Concussion severity is determined retrospectively
• Does not correlate with LOC nor amnesia
• Grading scales no longer used
• Typical time to resolve
• Adults: 10-14 days
• Kids: Up to 4 weeks

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

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Case #1

• 27 y/o software engineer presenting with concussion.
• 5 days ago fell while skiing, helmeted. No LOC but immediate

headache.

• Friends took her to local ED, no head CT needed. Advised to rest

and to follow up the following week in primary care.

• Has not returned to work or exercise.
• Mild-moderate headache is worse with bright light and with using

computer / screens. Also feels foggy and tired.

• Medications: none
• PMHx: none (incl no h/o concussion, HA, ADHD, psych)
• SHx: work is understanding of her injury. No drug use. 1-2 alcoholic

beverages/week.

Which of the following is the most consistent predictor of slower recovery from sports related concussion?

• A. Higher initial symptom burden
• B. History of migraine headache
• C. History of mental health problem
• D. Development of post injury depression
• E. Development of post injury migraine

H i g h e r i n i t i a l s y m p t

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. . . H i s t

• r

y

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m i g r a i n e h e a . . . H i s t

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m e n t a l h e a l t h . . . D e v e l

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m e n t

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t i n j . . . D e v e l

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29% 7% 7% 21% 36%

Higher symptom burden post concussion predicts longer recovery

• The strongest and most consistent predictor of slower recovery

from sport related concussion

• Lower symptom burden during this time period predicts more rapid

recovery

• In 531 patients ages 7-26 (mean 14.6), average initial visit

symptom score was 26 +/- 26. 86% of patients with initial symptom score < 13 recovered within 28 days of injury. (Meehan WP et al.

• Neurology. 2014 Dec 9;83(24):2204-10.)

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

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Concussion evaluation

1. Self-reported symptom assessment 2. Neurological exam including Balance Error Scoring System (BESS

• r modified BESS)
• Symptom severity score?
• How are symptoms

clustering?

• Should I order a head CT
• r brain MRI?
• Establish initial post-injury
• Memory
• Balance
• Reaction time

https://www.seata.org/resources/Pictures/Sport%20concussion%20assessment%20 tool%20-%205th%20edition%20(1).pdf. Accessed June 26, 2017.

• 1. Self-reported symptom assessment

Symptom severity score = 46 Clusters: headache, emotional

• 2. Neurological exam with balance

Balance Error Scoring System: BESS

http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg

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BESS scoring

• 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
• Also if cannot maintain for minimum 5 seconds then

score = 10

BESS norms: adults

Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: implications for brain injury evaluations. Brain Inj. 2008 Feb;22(2):147-52.

Returning to case #1

• Symptom severity score high (46)
• Clustering in headache, light sensitivity, mood
• Neurological exam non-focal
• BESS score of 15 (10-24th percentile for her age group)

27 y/o woman 5 days s/p fall while skiing with concussion. Software engineer. Has been off work since injury.

How would you treat this patient?

• A. Order urgent head CT to rule out

subtle post traumatic bleed, return to clinic after CT.

• B. Gradually return to work now as

tolerated, rest from physical activity, f/u 1 week.

• C. Rest from work and from physical

activity until symptom free, f/u 1 week.

• D. Return to work and physical activity

now.

O r d e r u r g e n t h e a d C T t

• .

. . G r a d u a l l y r e t u r n t

• w
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k . . . R e s t f r

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w

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k a n d f r

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. . . R e t u r n t

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k a n d p h y s i c . .

23% 0% 64% 14%

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Concussion treatment

• Cognitive rest
• Physical rest
• Medication: acetaminophen
• r NSAIDs* prn headache
• No driving
• No EtOH

*Avoid NSAIDs acutely due to theoretical risk of intracranial hemorrhage.

How much rest after a concussion?

• 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 return to activity

• Neurocognitive and balance outcomes same at 3 and 10d

post injury

• Strict rest group had more daily post concussive symptoms

and slower symptom resolution over the 10d study period

Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23. Slide courtesy of Cindy Chang, MD

Berlin Consensus 2017 on Rest

• “There is currently insufficient evidence that prescribing

complete rest achieves these objectives.” (those of mitigating symptoms and/or promoting recovery by minimizing brain energy demands post concussion)

• “After a brief period of rest …24-48 hours after injury,

patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds…”

• “The exact amount and duration of rest is not yet well

defined in the literature and requires further study.”

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

Return to learn / work progression

No school / work. OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms. 15 min cognitive activity at a time. Return to full day of school.

http://www.chop.edu/service/concussion-care- for-kids/returning-to-school.html

30 min schoolwork at a time until can do 1-2 hours. Return to ½ day of school.

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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

http://www.cifstate.org/sports-medicine/concussions/index Accessed June 26, 2017.

CIF: Return to Learn protocol

www.cifstate.org/sports- medicine/concussions/CIF_Concussion_RTL_Protocol.pdf

Diet or supplements?

• Diet: literature is sparse
• No strong evidence for use of supplements in concussion

management at this time.

• Promising results in animal studies and a few human studies on

traumatic brain injury in recovery or prevention of concussion:

Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9.

• Omega-3 fatty acids
• Curcumin
• Resveratrol
• Melatonin
• Creatine
• S. baicalensis
• Vitamins C, D, E

Case #2

• 15 y/o high school girls soccer player
• Concussion f/u in clinic
• Injured 1 week ago
• Rested at home x 2 days then gradually returned to school

with RTL protocol

• Tolerating school 100%
• Has not done any physical activity
• No concussion symptoms
• Soccer championship game in 2 days. She requests your

clearance to play.

• What do you recommend?

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What do you recommend?

• A. Clear her for game play in 2 days.
• B. Clear her to practice today and if no

symptoms, clear for game in 2 days.

• C. Clear her for practice today and to

follow a gradual return to play protocol

• f 7 days.
• D. Recommend 1 more week of rest from

physical activity then f/u in office.

• E. Recommend 1 month out of soccer

post injury then f/u in office.

C l e a r h e r f

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g a m e p l a y i . . . C l e a r h e r t

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0% 18% 27% 9% 45%

Follow gradual RTP progression

California concussion legislation

• AB 25 –Concussion Law 2012
• 3 parts (education, remove from play, written medical note to return)
• AB 1451—Coaches Concussion Training Law 2013
• Mandatory education every 2 years
• AB 2127 – Concussion Safety Law 2015
• Limit FB full-contact practices
• Mandatory RTP protocol of no less than 7 days from the diagnosed

date of concussion

• RTP under the supervision of LHCP
• AB 2007 Concussion Mgmt in Youth Sports Act 2016
• Requires youth sports participants to undergo the same safety

protocols as high school athletes

Slide courtesy of Cindy Chang, MD

Return to play progression

Daily activities that don’t provoke symptoms Light aerobic activity Sport specific activity Non- contact training Full contact practice Game play

Clinician clearance After 24-48 hours

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

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Return to play activity examples

Step Objective Activities 1 Symptom-limited activity Gradually reintroduce work/school 2 Light aerobic activity: Increase heart rate Walking, swimming, or stationary bike. < 70% max heart rate. No weights. 3 Sport Specific: Add movement Skating drills in hockey, running drills in

• soccer. No head impact activities.

4 Non contact training: Add coordination and cognitive load More complex drills (passing). Can start weights. 5 Restore confidence and assess functional skills by coaching staff Full-contact practice 6 Normal game play

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699. Accessed June 26, 2017.

CIF: Return to play handout Case #3

SJ is a 23 y/o semi pro rugby player presenting to you 6 months after her 5th concussion sustained when she was elbowed in the head during a game. Following her most recent injury she had 3 months of headache and light

• sensitivity. She missed one month of work but has

now returned to full time work without issue. She would like to know if and when she can return to rugby.

Post concussion syndrome

• Concussion symptoms persist x months, usually

<1 year.

• Frequency unclear (0-15%).

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Think about post concussion syndrome when…

• Symptoms not improving
• Adults: expected recovery 10-14 days
• Kids: expected recovery around 4 weeks
• Unable to return to school or work after 1-2 weeks
• f treatment.
• History of migraine, anxiety, depression, sleep

disorder.

• History of concussion.

Post concussion syndrome treatment: Multidisciplinary approach

UCSF Sports Concussion Program concussion@ucsf.edu

Sports Medicine • Physical Medicine and Rehabilitation • Neurology • Neuropsychology • Athletic Training • Physical Therapy

What are the risks, benefits and alternatives

• f SJ returning to rugby?

https://pulse-static-files.s3.amazonaws.com/worldrugby/photo/2015/03/03/82973c9c- cad7-491b-b13c-f4880bcbf21f/453038172.jpg

Repeat concussion: short term risks

• Increased risk of
• Repeat injury
• More severe symptoms
• Longer duration of symptoms
• Interruption of school / work / physical activity

Guskiewicz KM et al. JAMA 2003.

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Concussion and long term risks

• Traumatic brain injury (TBI) and neurodegenerative disease
• Multiples studies have shown TBI increases one’s risk for

neurodegenerative disease (Wilson L et al. The chronic and evolving

neurological consequences of traumatic brain injury. Lancet Neurol. 2017 Oct;16(10):813-825.)

• Sport-related TBI and relationship to neurodegenerative disease

a recent focus

Chronic Traumatic Encephalopathy (CTE)

• Originally thought to be exclusive to boxers: “punch drunk”
• Now described in athletes, military personnel, survivors of intimate

partner violence

• Pathologic diagnosis made at autopsy: tau protein deposition in

specific pattern

• Chronic, progressive neurodegenerative syndrome
• Behavioral changes: depression, aggression, impulsivity
• Parkinsonism
• Dysarthria
• Cognitive deficits

Mez J et al. Clinicopathological evaluation of CTE in players of American football. JAMA. 2017;318(4):360-70. Rabinovici G. Advances and gaps in understanding CTE. JAMA July 25, 2017.

Development of CTE may be multifactorial

Solomon G. Chronic traumatic encephalopathy in sports: a historical and narrative

• review. Dev Neuropsychol. 2018;43(4):279-311.

CTE

Head injuries Medical conditions Psychiatric illness Genetic factors Substance abuse

How are these factors related?

Dementia

• CTE

mTBI (aka concussion)

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What are the chances SJ will develop CTE?

• Difficult to draw causality between subconcussive blows +

concussion and CTE

• However, no reports of CTE without preceding traumatic brain

injury

• Concerning association between participation in collision sports and

long term neuropsychiatric problems

• We do not know the dose-response relationship between number of

concussions and/or subconcussive blows and likelihood of CTE.

• Need prospective, longitudinal data

http://i00.i.aliimg.com/img/pb/573/767/888/888767573_942.jpg

Can we lower SJ’s risk by recommending protective gear? Protective gear?

Benson BW et al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med. 2013.

Consider lower contact, lower risk sport. If returning to same sport consider lower risk position or longer time for recovery. Yellow flags

• Multiple concussions
• Post concussion

syndrome

• Higher symptom

burden with each injury

• Decreased injury

threshold

• Younger age

Red flags

• Abnormal imaging
• Ongoing symptoms

Treat symptoms. Recommend non- contact, low risk sport or exercise

My approach to this conversation

Elicit and validate benefits of this sport and all physical activity for this athlete Discuss short term risks repeat injury Discuss potential long term risks of TBI (modify based

• n h/o TBI)

Davis-Hayes C et al. Medical retirement from sport after concussions: A practical guide for a difficult discussion. Neurol Clin Pract. 2018 Feb;8(1):40-47.

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Have you thought about playing sports other than rugby?

Decrease exposures

http://www.ncaapublications.com/productdownloads/MD15.pdf. Accessed 12/5/15.

Incidence of concussion

Sport Male Female Pooled incidence Rugby 4.18 NR 4.18 Hockey NR NR 1.20 American football 0.53 NR 0.53 Lacrosse 0.29 0.17 0.24 Soccer 0.19 0.27 0.23 Wrestling 0.17 NR 0.17 Basketball 0.10 0.17 0.13 Softball NR 0.10 0.10 Field hockey NR 0.10 0.10 Cheerleading NR 0.07 0.07 Baseball 0.06 NR 0.06 Volleyball NR 0.03 0.03

Reported as events per 1000 athlete exposures (AEs)

Pfister T et al. The incidence of concussion in youth sports: a systematic review and meta-analysis. Br J Sports Med. 2016 Mar;50(5):292-7.

Highest risk positions by sport

• Water polo – goalie (Blumenfeld RS et al. The Epidemiology of Sports-

Related Head Injury and Concussion in Water Polo. Front Neurol. 2016 Jun 24;7:98.)

• Baseball –catcher during fielding (vs batting or running)

(Green GA et al. Mild traumatic brain injury in major and Minor League Baseball players. Am J Sports Med. 2015 May;43(5):1118-26.)

• Football – 1. quarterback, 2. running back, 3. linebacker

(Powell JW. Traumatic brain injury in high school athletes. JAMA. 1999 Sep 8;282(10):958-63.)

• Ice Hockey – forwards (Hutchison MG et al. A systematic video

analysis of National Hockey League (NHL) concussions, part I: who, when, where and what? Br J Sports Med. 2015 Apr;49(8):547-51.)

• Soccer – goalkeepers and defensive midfield players due to

collision with other player (Helmich I. Game-specific characteristics

• f sport-related concussions. J Sports Med Phys Fitness. 2016 Sep 14.)
• Volleyball – “libero” position due to hits from the ball (Helmich
• I. Game-specific characteristics of sport-related concussions. J Sports Med

Phys Fitness. 2016 Sep 14.)

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Take-home points: Understanding concussion 2018

1. Concussion is a blow to head, neck or body leading to neurological symptoms within 48 hours. 2. Treatment is cognitive and physical rest x 24-48 hours 3. Gradual return to learn / work as tolerated 4. Once symptom-free, gradual return to play 5. Average recovery time 14 days in adults, 4 weeks in kids 6. Risk of repeat concussion in short term: repeat injury, more symptoms, longer duration of symptoms (post conc syndrome) 7. Risk of repeat concussion in long term: less clear. CTE concern.

Concussion resources

• UCSF Sports Concussion Program
• concussion@ucsf.edu
• California Interscholastic Federation

http://www.cifstate.org/sports-medicine/ concussions/index

• Consensus statement on concussion in sport,

2017.

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017- 097699

• CDC concussion toolkit for physicians

www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

https://www.seata.org/resources/Pictures/Sport%20concussion%20assessment%20 tool%20-%205th%20edition%20(1).pdf. Accessed June 26, 2017.

Thank You!

Carlin Senter, M.D. Carlin.Senter@ucsf.edu UCSF Sports Medicine