Sports ConcussionWhat the Clinician Needs to KnowCarlin Senter, MD Associate ProfessorCo-Director UCSF Sports Concussion ProgramPrimary Care Sports MedicineUniversity of California San Francisco

UCSF Essentials of Women’s Health July 7, 2016

I have no disclosures.

Sports Concussion 2010

Concussion is serious public health issue

Need clinical care for sports concussion patients

Need community education

Need to advance diagnostic tools

Need prevention measures

UCSF Sports Concussion Program

Sports concussion

care

Education

Research

UCSF PlaySafe

• Athletic trainer at high school

• M.D. on sideline and in clinic

• Preparticipationexams

• Baseline testing

• Education

Outline: Sports Concussion 2016

1. Epidemiology

2. Evaluation

3. Treatment

• How much rest?

• Return to learn

• Return to play

4. Legislation

5. How many concussions is too many?

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.

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) 0.37Rosenthal 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

Type of mild traumatic brain injury

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 prolonged.

May or may not include loss of consciousness.

CT and MRI studies are normal

Physical

Cognitive

Emotional

Sleep

Concussion symptoms

Symptom Resolution

50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.)

Recovery in athletes may be faster than recovery in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol2015; 14: 506-17.)

Recovery in kids may take longer than recovery in adults

Who is at risk for delayed return to play?

LOC > 1 minute

Amnesia

Convulsions

History of multiple concussions

Injuries close together in time

Repeat injuries with less and less force

Younger age

Migraine headaches

Depression

ADHD

Sleep disorders

Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014.

Case #1

16 y/o high school soccer goalie

Presents to you in urgent care with wrist pain

Also, she hit heads with teammate in practice earlier today and had 15 minutes of headaches and dizziness. She took a nap after practice as she felt unusually tired.

Now she has no headache: “I feel fine.”

What do you do next?

Case courtesy of Cindy Chang, MDCase courtesy of Cindy Chang, MD

3-pronged evaluation recommended

1. Self-reported symptom assessment

2. Motor control: Neurologic exam including balance. Balance Error Scoring System (BESS or modified BESS)

3. Mental status: Standardized Assessment of Concussion (SAC)

Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014.

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

1. Self-reported symptom assessment

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.

Symptom norms

9th grade 10th grade 11th 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.

2. Neurological exam with balanceBalance Error Scoring System: BESS

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

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: ages 10-17

Khanna NK, Baumgartner K, LaBella CR. Balance Error Scoring System Performance in Children and Adolescents With No History of Concussion. Sports Health. 2015 Jul;7(4):341-5.

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. 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.

3. Mental status

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?Cognition

Over 1/3 of all children didn’t know the date

• 70% 5-7 yo, 39% 8-10 yo, 23% 11-13 yo

Concentration—days of week 88% correct

• Of 56 who couldn’t, 63% were 5-7 yo

Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending

Can the Child SCAT3 be validated?

Balance (modified BESS)

Statistically significant differences between males/females (males worse) and ages 5-9/10-13 (younger worse)

Tandem Gait

Statistically significant differences between ages 5-9/10-13 (younger worse)

Brooks et al. AMSSM Research Podium Presentation April 2015; publication pending

Concussion treatment

Cognitive rest

Physical rest

Medication• Tylenol

• Ibuprofen after first 72 hours

No driving

No Etoh

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

Return to learn after a concussion

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

Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

Team approach to return to learnHalstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

Return to LearnBEFOREReturn to Play

Return to learn progression

No school.

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.

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

CIF: Physician letter to school

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%

No concussion symptoms

Soccer championship game in 2 days. She requests your clearance to play.

What do you recommend?

Follow gradual RTP progression

Return to play progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

2nd International Conference on Concussion in Sport (2004).

2005 Br J Sport Med 39:196.

Return to play activity examples

Step Objective Activities

1 Recovery No activity

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

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.

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

CIF: Return to play handout

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

Slide courtesy of Cindy Chang, MD

Hawaii concussion legislation

Act 197 enacted 7/3/2012

• Hawaii High School Athletic Association members must

‒ Provide annual concussion training for coaches, faculty, staff, parents and students who play sports

‒ Immediate removal from play if signs or symptoms of concussion

‒ Student must be evaluated and cleared by LHCP prior to return to learn/play

Case #4

A 15 y/o lacrosse player presents to you 3 months after her 5th concussion sustained when she was elbowed in the head during a game. She has had a headache with light sensitivity since the injury. She and her father would like to know if and when she can return to lacrosse.

What is her diagnosis?

What do you do next?

Post Concussion Syndrome

Frequency unclear (0-15%).

Concussion symptoms persist x months, usually <1 year.

Patients benefit from multidisciplinary approach to treatment.

Think about post concussion syndrome when…

Symptoms not improving after 2 weeks of treatment.

Unable to return to school or work after 1-2 weeks of treatment.

History of migraine, anxiety, depression, sleep disorder.

History of concussion.

Post concussion syndrome treatment: Multidisciplinary approach

How Many Concussions is Too Many?

Individualized to athlete.

Concussion hx.

• Number.

• Less force.

• More frequent.

• Increased severity of sxs

• Increased duration of sxs.

• Age: possibly more consequences if younger at time of concussion.

Corrigan JD, Concussion webcast 10/18/2011.

Outline: Sports Concussion 2016

1. Epidemiology

2. Evaluation

3. Treatment

• How much rest?

• Return to learn

• Return to play

4. Legislation

5. How many concussions is too many?

Keys to managing sports concussion in 2016

3-pronged evaluation: Symptoms, Neuro/balance exam, Cognitive

Treatment is rest

Gradual return to learn

Return to play protocol at least 7 days since day of diagnosis (in state of California)

Majority recover within 3 weeks

Consider referral for post concussion syndrome

Repeat injuries: individual approach

Concussion resources

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

Consensus statement on concussion in sport, 2012.

http://bjsm.bmj.com/content/47/5/250.full

CDC concussion toolkit for physicians www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

Thank You!

Carlin Senter, M.D.

Carlin.Senter@ucsf.edu

UCSF Sports Medicine