ADOLESCENT CONCUSSIONS

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ADOLESCENT CONCUSSIONS

• Darien High School
• Presentation
• Michael A. Lee, M.D., FAAP
• Member, Connecticut Concussion Task Force
• Charter Member, AMSSM
• Member, AAP-COSMF,
• Former Chairman, CSMS Committee on Medical
  Aspects Sports
• Former Editor, SPORTSMed Newsletter

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Overview

• What is a Concussion
• Pathophysiology (brief)
• Female concussions
• When to go the the E.R.
• Cognitive rest
• Return to School
• Post-concussion Syndrome and ADD
• Disclaimers I have had one concussion

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Concussions

• They are a part of sports participation at all
  levels
• One of the most discussed problems in US sports
  media coverage today
• Perhaps the most misunderstood
• problem
• Prevention would be great but not entirely
  possible
• Very difficult to manage especially when the
  symptoms are prolonged.

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Concussion is derived from the Latin
word concussus or concutere, which means to shake
or be shaken violently.
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Concussion Redefined

• Vienna, November 2001 First International
  Conference on Concussion in Sport
• Prague, November 2004 Second Conference
• Zurich, October 2008 Third Conference
• Zurich- 2013

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• VIENNA/ZURICH DEFINITION
• A complex pathophysiological process affecting
  the brain, induced by traumatic biomechanical
  forces
• Several common features to help define
• Force transmitted to head (direct or indirect)
• Rapid onset of short-lived impairment that
  resolves spontaneously
• Acute symptoms reflect functional disturbance
  rather than a structural injury (no bleeding)
• Resolution follows sequential course
• May or may not involve LOC
• Neuroimaging studies normal
• Major change since last conference
• is to include balance testing.

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Pathophysiology

• Acute Changes
• Potassium
• Glucose
• Calcium
• Cerebral blood flow
• Magnesium

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FACTS AND STATISTICS

• 1.5 million head injuries per year in USA
• 20 or 300,000 are sports related
• Majority of these are in pediatric age group
• 20 of football players will sustain a concussion
  per season
• Athlete who sustains a concussion is 4 to 6 times
  more likely to sustain a second one
• Bell ringers or mild concussions account for
  75 of all concussive injuries
• Effects of concussions are cumulative in athletes
  returning to play prior to recovery

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Facts continued

• 90 of concussions are relatively mild and no
  abnormalities or symptoms may exist during a time
  when we know the brain continues to be at
  increased vulnerability.
• Pediatric developing brain is actually more
  vulnerable (rather than less so) than an adult to
  damage from an injury. (Brain maturation occurs
  to age 21)
• The best way to prevent problems with concussion
  is to manage them effectively when they occur.
• No athlete should return to play while
  experiencing the symptoms of a concussion.

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Grading Scales
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No classification system

• Concept
• Majority (80-90) resolve in 7-10 days
• May be longer in children and adolescents
  (may be?!)
• EVERYONE deserves individualized management
• Recovery will vary based on
• Prognostic factors (history, comorbidities, etc.)
• Advice YOU give your athlete
• Athletes willingness/ability to follow advice

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• How long does it take to recover from a
  concussion?
• Less than a week? AAP CT 3 days?
• Sports authorities say less than a week

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Individual Recovery From Football-Related mTBI
How Long Does it Take?
WEEK 3
WEEK 1
WEEK 2
WEEK 4
WEEK 5
40 RECOVERED
80 RECOVERED
3 Year Prospective Study of 17 High School
Football Teams N2,141
60 RECOVERED
N134 Concussed High School Football Players
Collins et al., 2006, Neurosurgery
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FEMALE CONCUSSIONS
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Girls have a higher rate of concussion than
boys, particularly in similar sports
Lincoln, et.al., Am J Sports Med 2011 Giza,
Kutcher, et al., Neurol 2013
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FEMALE CONCUSSIONS

• Tend to be worse and last longer
• Likely related to weaker neck muscles
• Progesterone?

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CHEERLEADING

• Often is not considered a sport, YET
• 50 of deaths in college womans sports
• Seem to have more PCS and are more difficult to
  manage in my experience

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ON-FIELD SIGNS/SYMPTOMS OF CONCUSSION

• Concussion Signs
• Appears dazed
• Confused about play
• Answers question slowly
• Personality/behavior change
• Forgets plays prior to hit
• Retrograde amnesia
• 10x more likely to have poor outcome
• Forgets plays after hit
• Anterograde amnesia
• 4.2x more likely
• Loss of consciousness

• Concussion Symptoms
• Headache (generalized)
• Nausea
• Balance problems
• Double vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish
• Feeling mentally foggy
• Change in sleep pattern
• Cognitive changes

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WHEN TO GO TO THE E.R

• Seizures (twitching or jerking movement of parts
  of the body may look stiff)
• Weakness or tingling in the arms or legs
• Cannot recognize people or places
• Confused, restless or agitated
• Impaired consciousness
• Difficult to arouse or unable to awaken
• Repeated vomiting
• Slurred speech
• Bloody or clear fluid from the nose or ears

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INITIAL TREATMENT - BRAIN REST Cocoon Therapy

• Sleep a lot in dark room first day only or two
• days if multiple blows to head.
• Minimize activities first 3-5 days
• No reading
• No computer, video-games, I-pods,
• No walking
• No hot tubs
• No socializing with friends or going to movies
• No watching the team practice
• No Cell phones or text messaging

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COGNITIVE FATIGUE

• On day two or three, to prevent cognitive
  fatigue, do activities in 10-15 minute intervals.
  Set a timer. Then take a 15 minute break.
• Initial 15 minute activities starting with
• Soft music Cooking
• Books on tape Drawing
• Television
• Parents can read school work to student so
  they will not get too far behind in school.

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• When your child is able to do one to two hours of
  homework at home for one to two days, he/she may
  try to return for a half day of school.
  Alternately, if your child is able to do three to
  four hours of homework at home for one to two
  days, he/she may try to return to school for a
  full day.
• If symptoms develop while your child is at
  school, a break should be taken in a quiet,
  supervised area until symptoms resolve. When
  symptoms resolve, she may return to class.

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Headache Management

• Keep the dull and achy headache from becoming
  pounding and throbbing.
• Discontinue any activity that increases the
  headache
• Tylenol as needed (Ibuprofen after a few days)

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SCHOOLStudents recover quickly during
Christmas, Spring and Summer vacationsNeed to
remember (remind parents) the first priority is
to get kids back to school ASAP. Sports is a
secondary priority
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• The return to school is a very critical time. If
  cognitive work is overdone, the concussion
  symptoms will return, sometimes almost as much as
  right after the injury.

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SCHOOL MODIFICATIONS (when they return to
school)
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SCHOOL (initial return)

• Need to be driven to school initially
• (should not ride the school bus)
• Elevator passes if stairs
• (unless this makes them dizzy)
• Avoid halls and cafeteria initially
• No gym class or exercising initially
• (are not to be allowed in P.E. class)

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• Trial and error needed (balancing act)
• 1 period, ½ day, full day
• Go to nurses office when HA increases
• May need to audit classes initially
• Frequent breaks with rest periods
• Alternate class with rest period
• Gradually increase hours
• May need home schooling
• No extra-curricular activities or work

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SCHOOL (initial return)

• No note taking (may need scribes)
• Audio books helpful
• Workload may need to be reduced 50-75
• Homework less than 1-2 hours a night
• Frequent breaks while doing homework
• Term papers postponed
• Pre-printed class notes helpful
• (should be sent home while not in school)
• Tutoring to help catch up

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SCHOOL (initial return) continued

• It is imperative that the student advocate for
  his/her needs. If an increasing headache develops
  they should not stay in class but should go to
  the nurses office. They can rest there (skip a
  period and try another class if the headache
  resolves). If it returns they need to go home.

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SCHOOL TESTS

• (AFTER STUDENTS CATCH UP ON THEIR SCHOOLWORK!!!)
• Quizzes, tests, PSAT/SAT tests, final exams may
  need to be delayed or postponed.
• Initially, if test results are poor, they should
  be voided or retaken.
• Extra time (un-timed tests) may be necessary when
  test taking is resumed. Tests may need to be
  taken over multiple sessions.
• No more than one test a day when test taking
  resumed.
• If concentration and memory problems
• Oral exams may be necessary if students develop
  headaches taking written tests.
• Open book tests may be needed for some students
  (especially if memory issues are present)

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IF NOISE INCREASES SX

• Should not listen to loud music (especially in
  cars or on I-pods)
• Should avoid attending dances, parties, music
  concerts and sports events until symptoms are
  gone
• No music class

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IF LIGHT INCREASES SX

• Avoidance of bright sunlight and exposure to
  flashing lights (strobe/computer games)
• Sunglasses may be necessary if photophobia is
  present (outdoors and sometimes indoors)
• No movie theaters (loud noise and bright flashing
  lights)

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How many concussions are too many?NO EASY ANSWER
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• Each athlete needs to be evaluated individually.
• There is no magic number as to how many
  concussions are too many.
• Return to play should probably be guided by
  symptoms and neuro-psych testing regardless of
  the number of concussions.
• If it takes exceedingly longer to recover from
  each concussion or PCS occurs, perhaps it may be
  time to do a non-contact sport.
• Do you allow fewer concussions in youngsters
• ( What if 3 or 4 concussions before age 12?)

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• ADHD AND CONCUSSIONS

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???

• Is it possible that some of the children we
  see who are diagnosed as having ADD are really
  concussion or post-concussion syndrome patients
  that have suffered permanent residual damage from
  their concussion(s).

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RETURN-TO-PLAY PROTOCOL Begin after no
symptoms in school 24 hours (or longer)
for each stage

1. No activity, complete rest. Once asymptomatic
   without headache, etc. (on no medications)
   proceed to step 2.
2. Day 1 - Light aerobic exercise such as walking or
   stationary cycling. No resistance training.
3. Day 2 - Jogging for 20-30 minutes
4. Day 3 - Sport specific exercise (e.g. skating in
   hockey, running is soccer). May add resistance
   training.
5. Day 4 - Non-contact training drills
6. Day 5 - Full contact training after medical
   clearance.
7. Game play
8. RETURN TO PREVIOUS STEP IF SYMPTOMS RECUR

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RETURN-TO-PLAY (CONTINUED)

• When symptom free, athletes should not be taking
  any medications or pharmacological agents that
  may affect or modify concussion symptoms.

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Connecticut Concussion Task Force

• Helped pass Connecticut concussion law
• Created program for high school coaches
• Created school form for concussions
• Created website with concussion information
• connecticutconcussiontaskforce.org

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