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Concussion in Youth Athletes:
Where Are We “Heading?”
Thomas L. Pommering, D.O.Division Chief, NCH Sports Medicine
Assistant Clinical Professor,
Departments of Pediatrics and Family Medicine
The Ohio State University College of Medicine
The definition didn’t change
Classification of Concussion
No unanimous consensus
Previously: Simple vs. Complex)
80-90% of concussions resolve in a short
period (7-10 d), although this recovery
time may be longer in children &
adolescents
Concussion: Why should we care?
30 million children and adolescents
participate in sports in the US each year
“Silent” epidemic
– Up to 3.8 million sports-related concussions
each yr
– 300,000 sports-related TBI’s resulting in LOC
(10%)
Over half go unreported
CONCUSSIONS ARE UNDER-
REPORTED IN HS ATHLETES(McCrea M, et al. Clin J Sport Med, 2003)
Only 47% of high school athletes reported their concussion
Most common reasons for not reporting:
– Not serious enough to warrant medical
attention (66%)
– Didn’t want to be withheld from play (41%)
– Lack of awareness of probable concussion (36%)
COMMON SIGNS OF
CONCUSSION
Vacant stare
“glassy eyed”
Poor coordination or balance
Confused
LOC (<10%)
Inappropriate behavior
Unusual emotions
Slow to answer or follow instructions
Personality change
Disoriented
Unusually quiet
Motor phenomena:
– Short lived seizure
– Tonic posturing
S/S of concussion
may be progressive
and evolving
COMMON SYMPTOMS OF
CONCUSSION
Headache
Difficulty w/ memory
Dizziness/vertigo
Generalized weakness
Numbness/tingling
Vision changes
Poor concentration
“seeing stars or lights”
“foggy” or “dazed”
Phonophobia
Photophobia
Depressed mood
Nervousness/anxiety
Insomnia/hypersomnia
Emotional lability
Nausea/vomiting
Tinnitus
Fatigue
Do Cumulative Effects Exist?
Depression (Guskiewicz KM, et al. Med Sci Sports Exec, 2007)
Memory and concentration problems
Delayed recovery with subsequent concussions
Increased susceptibility for additional concussions
Chronic Traumatic Encephalopathy (CTE)
Apolipoprotein (APOE) genotype (Tierney, et al. Clin J Sport
Med, 2010)
– all 4 alleles (rare) – 10 x more likely to report prev concussion
– Promotor allele only – 8.4 x more likely to report prev concussions
Cumulative Effects cont’d
For HS and College Athletes with > 3 concussions:
More severe on field presentation of s/s (Collins et al, J
Neurosurg, 2002)
More likely to report HA’s at baseline (Register-Mahalik et al.,
Clin J Sport Med 2007)
More vulnerable to subsequent injury than those w/no
concussion hx (Iverson et al., Brain Inj, 2004)
3 x more likely to sustain additional injury (Guskiewisz et al.,
JAMA 2003)
Had prolonged recovery (Collie et al., B J Sports Med 2006;
Couvassin et al., J Athl Train 2008; Slobounov et al., Neurosurg 2007)
Cumulative Effects cont’d
For Collegiate Athletes with > 2 concussions:
Delayed recovery of verbal memory and Rxn time (Couvassin et al., J Athl Train 2008)
Independently predicted long-term deficits in executive function, processing speed and self-reported symptom severity (Collins et
al., JAMA 1999)
What do you do when faced with
a young athlete with a possible
concussion?
NO Same Day RTP for Athletes < 18
y/o
SECOND IMPACT SYNDROME
(SIS)Sanders R, Harbaugh R. JAMA, 1984)
(McCrory, P. Neurology, 1998)
(Cantu, RC. Clin Sports Med, 1998)
Occurs when an athlete sustains a second head trauma before the original head injury or concussion has healed leading to…
Acute loss of autoregulation of cerebral blood flow Diffuse Brain swellingBrain herniation!
Mortality = 50% / Morbidity = 100%
SECOND IMPACT SYNDROME (SIS)(Bey, T West J Med, 2009)
(Mueller & Cantu; National Center for Catastrophic Injury Research
http://www.unc.edu/depts/nccsi/)
1980-1993: 35 cases
2008: 5 cases
Takes about 2-5 min for the herniation to occur (much faster than for an epidural hematoma )
S/S: – Loss of EOM
– Dilated/fixed pupils
– Respiratory distress
SIS is has almost exclusively been documented in children and teens!!!Best Tx is PREVENTION
What Current Tools are at our
Disposal?
Become educated - parents, coaches, league administrators, officials, athletic trainers, physicians
Seek advice and care from medical professionals who have expertise in concussion management
“Sideline” assessment tools (training room or office setting) – SCAT
– BESS
Neuropsychological Testing (NP)
BESS (Balance Error Scoring
System)(Iverson et al., Brain Injury, 2008)
Rapid, easy to admin and cheap
Measure postural stability (balance) – a sensitive indicator of brain injury
Requires AIREX foam pad ($60)
Confounders: ankle instability, fatigue, slight practice effect
BESS testing most useful when interpreted in conjunction with other testing ( SCAT2 and NP)
Role of Neuropsychological (NP) or
Neurocognitive Testing
Allows us to objectively measure cognitive
function as it relates to brain injury
Pen and paper tests (Trail making Test - 10
min)
Computer / web-based systems (10-25 min)
Formal NP testing with a trained and
certified Neuropsychologist (4-6 hrs)
Computerized NP Testing
COGSPORT
IMPACT
ANAM
HEADMINDER
Computerized NP Testing:Advantages Disadvantages
Relatively quick and easy
Measure verbal and visual
memory, processing speed
and reaction time
Most effective when baseline
testing can be done in
conjunction with post-injury
testing
Useful and reliable clinical
tool if administered and
interpreted properly and has
value to the athlete, coach
and parent
Cost: $10-35 per test…
….Limited Availability
“Proprietary interests do exist.” (McKeag: JAMA, 2003)
Perception that they are the “Cat’s Meow” & are the absolute Standard of Care
Baseline testing is not always feasible
Practice effect
RETURN TO PLAY (RTP)
Cornerstone of management is physical
and cognitive rest
Athletes must be asymptomatic for at
least 24 hrs before they’re permitted to
start a supervised progression
RTP Guidelines
Modifying Factors in the Mgmt of
Concussion
Note: “Gender” was left
off of this list at the time
of publication, though
evidence points toward
increased risk in females
d/t:
- Smaller head mass
- Weaker neck mm
- More likely to report
symptoms than males
What’s on the Horizon in Terms of
Future Concussion Management(Davis et al., BJSM, 2009)
Structural Imaging– CT, MRI, diffusion tensor imaging
Functional Imaging– fMRI, PET, brain SPECT
Spectroscopy– MR spectroscopy (MRS), Near infrared spectroscopy (NIRS)
Balance testing– BESS, Sensory Organizational Test (SOT), gait testing, virtual reality)
Electrophysiological tests– EEG, evoked potentials (EK), event related potentials (ERP’s),
magneticoencephalography (MEG), HR variability
Genetics– APoE4, channelopathies
Blood markers– S100, neuron-specific enolase, cleaved Tau protein, glutamate
Prevention – Can Protective
Equipment Make a Difference?(Benson et al., BJSM, 2009)
1. Helmets: reduces injury risk in cycling, skiing
and snowboarding; but effect on concussion
was nonconclusive!?
2. Mouthguards: No strong evidence to reduce
concussion risk, but they’re good for the teeth!
3. Face shields: No strong evidence to reduce
concussion risk
4. Full face protection in hockey can reduce
concussion severity (time loss from
competition)
Football helmets – FRIEND OR
FOE:!
designed to prevent head bleeds and skull
fx’s, PERIOD
THE END –THANKS!