Kids and Concussions:

Deciphering the Information

Scott L. Simon MD, MPH

Orthopaedic & Neurosurgical Specialists

EPIDEMIOLOGY OF

CONCUSSION IN SPORTS

• Over 300,000 sports related concussions/yr

• Estimated 62,816 concussions/yr in high school contact sports

• 63% from football

• 15-20% high school football players annually

• 34% college football players have had at least one concussion

FREQUENCY, DISTRIBUTION, RATES OF CONCUSSIONS

FOR NCAA GAMES AND PRACTICES COMBINED FOR 15

SPORTS,1988–1989 TO 2003-2004 Frequency % of all injuries

CONCUSSIONS IN

THE FEMALE ATHLETE

• More commonly reported

• Occur more often than males playing same sport

• Occur 68% more in HS female soccer players than

male soccer players

• Occur 3x higher in female HS basketball than

male basketball players

CONCUSSION

Most Common TBI (Traumatic Brain Injury)

• Traumatic process leading to a functional disturbance

• Resolves spontaneously (usually 7-10 days)

• +/- Loss of Consciousness (only ~10% +LOC)

• CT and MRI are often normal

• 15% may have symptoms lasting >1 year

PATHOPHYSIOLOGY

• Sudden acceleration-deceleration of the

brain independent of the skull • Indiscriminant release of neurotransmitters

• Neuronal depolarization

• K+ efflux and Ca2+ influx

• Further release of excitatory

neurotransmitters

• Lactic acidosis and BBB degradation

• Swelling

• Hypermetabolic state

• Derangements in autoregulation

• Decreased CBF

• Hypometabolic state

Does this matter for youth football?

• +/- LOC

• Does not imply severity

• Poor motor coordination

• Poor balance

• Concussive convulsion (impact seizure)

• Dramatic, benign, no specific management

• Slurred of incoherent speech

• Dizziness

• Amnesia

• Emotional lability

• Blurred vision

• Nausea

• Headache

COMMON FEATURES

SIDELINE EVALUATION

• ABC’s

• Assess GCS

• Neuro exam

• C spine immobilization!

• Spine evaluation

• Evaluate for other injuries

• SCAT5>12 y/o

• Child SCAT5<12 y/o

“WHEN IN DOUBT, SIT THEM OUT”

RED FLAGS

• New or progressively worsening headache

• Persistent or increasing neck pain

• Becomes drowsy and can’t be woken up

• Weakness, numbness, tingling, unsteadiness

• Seizures

• Confusion, irritability

• Slurred speech

WHEN TO IMAGE?

POST-CONCUSSIVE SEQUELAE

Media reports highlighting the potential for rare but catastrophic outcomes

• Post Concussion Syndrome (~15%)

• Prolonged symptoms lasting weeks to months

• Concussive Motor Phenomenon

• Post-traumatic seizures

• Second Impact Syndrome

• POTENTIALLY FATAL !!!

POST CONCUSSION IMPACT ON PERFORMANCE

• ~30% of athletes may play worse following a

concussion

• More likely to lose playing time if miss more games

• Neuromuscular control deficits

• Risk of subsequent orthopedic injury

RECOVERY FOLLOWING CONCUSSION

Cognitive recovery usually, but not always, follows symptom recovery

Return to neurocognitive baseline

• Adolescent athletes: 10-14 days

• Collegiate athletes: 5-7 days

• Professional athletes: 3-5 days

• Majority cleared by 3-4 weeks

Risk factors for prolonged recovery:

• Multiple concussions

• Female gender

• h/o migraines

NEUROPSYCHOLOGICAL TESTING

• May be useful in more complicated cases

• Computerized testing is not validated in

children

• Baseline testing not consistent in children and

not recommended

Consensus statement on concussion in sport:

the 4th International Conference on

Concussion in Sport held in Zurich,

November 2012

POST-CONCUSSION TREATMENT

• Manage symptoms

• Avoid aggravating activities

• Rest

• 1-2 days seems better than 5 days of rest

Davis et al. Br J Sports Med 2017.

Thomas et al. Pediatrics 2015.

EMERGING TREATMENTS

• Sub symptomatic Exercise

• Hyberbaric oxygen

• Neuropsychology

• Vestibular rehabilitation

Data are insufficient to show that any

intervention enhances recovery or

diminishes long term sequelae post

concussion.

RETURN TO SCHOOL AFTER

CONCUSSION

• It is reasonable for a child to miss a day or two of

school after concussion, but extended absence is

uncommon.

• Graduated return to school may be needed

• Half days

• Limited computer time

• No timed tests

• No or limited homework

• Quiet time

RETURN TO PLAY

AFTER CONCUSSION

• No return to play or sport until successfully

returned to school / learning, without worsening

of symptoms.

• Never return to play on the same day of injury

• Medical clearance before return to play.

• Once cleared follow a step-wise supervised

program

STEP-WISE RETURN TO PLAY

AFTER CONCUSSION

• At least 24 hours for each stage and the child should drop back to the

previous asymptomatic level if any post-concussive symptoms recur.

PREVENTION

• Education

• Rule Changes

• No spearing

• No head to head contact

• No leading with head

• Risk Compensation

• Protective equipment paradoxically increases injury due to adoption of dangerous playing techniques

• Helmets

• No shear injury protection

• Help protect against

• facial/skull injuries

• No data to show reduction in concussion incidence

• Neck collars

• Face masks

• Padding

• Mouth guards

CONTRAINDICATIONS TO RETURN TO PLAY

• Persistent headache

• Persistent Neck pain

• Arm or leg pain, numbness, tingling

• 3+ concussions: 3x more likely to get another - Guskiewicz et al JAMA 2003

• Weakness

• Dizziness

• Nausea

• Confusion

CONCUSSION AND

THE DEVELOPING BRAIN

• Unclear if concussion leads to long-lasting

changes in cognitive or motor potential - Halstead et al. Pediatrics 2010.

- Foley C, Gregory A, Solomon G. Curr Sports Med Rep 2014

- Sone et al. J Neurosurg Pediatr 2018.

LONG TERM CONSEQUENCES

OF REPETITIVE BRAIN TRAUMA:

CHRONIC TRAUMATIC ENCEPHALOPATHY

• Neurodegenerative disease that occurs

later in the lives of some individuals

with a history of repeated head

trauma.

• Repetitive axonal injury may set up a

series of metabolic, ionic, and

cytoskeletal disturbances that trigger a

pathological cascade leading to CTE in

susceptible individuals.

• No causal relationship between CTE

and concussions has been confirmed

LONG TERM CONSEQUENCES OF REPETITIVE BRAIN TRAUMA

• Chronic Traumatic Encephalopathy (CTE)

• Progressive memory decline

• Cognition difficulties

• Depression

• Suicidal behavior

• Poor impulse control

• Aggressiveness

• Parkinsonism

• Dementia

CHRONIC TRAUMATIC

ENCEPHALOPATHY (CTE)

• Neuropathology • Gross cerebral atrophy

• Microscopic neuropil threads (NTs), glial tangles (GTs), and neurofibrillary tangles (NFTs) made up of the microtubule-associated protein tau

• Distribution and configuration of the NFTs differs from Alzheimer’s

• Beta-amyloid deposits in only 40% of CTE

Normal 65 y/o John Grimsley, Linebacker,

Houston Oilers

CONCUSSION: A SUMMARY

• Most common traumatic brain injury

• Broader definition has lead to greater identification

• Functional but spontaneously resolving disturbance

• No good objective method of diagnosis

• Diagnosis made on signs and symptoms alone

• A concussion can occur with or without a loss of

consciousness

• When in doubt sit them out

• Best treatment: rest

• Follow sequential RTP protocol

THANK YOU