Sports Concussions in Children & Adolescents

Donna K. Broshek, Ph.D.Associate Professor

Co-Director, Neurocognitive Assessment LabDepartment of Psychiatry & Neurobehavioral Sciences

Associate DirectorUVA Brain Injury & Sports Concussion Institute

Outline

• Why so much emphasis on concussions now?

• Concussion definition, symptoms, & associated features

• Individualized concussion management • When to refer• Temporary academic accommodations• Return to healthy physical activity

Sports concussions…

Not just football…

Not just contact sports…

Not just males…

Not just adults…

Not just organized sports…

Colorado – Senate Bill 40Jake Snakenberg Act (2012)• Jake Snakenberg – Died at age 15

(2004)

Lystedt Law – July 2009Zackery Lystedt injured 2006 – age 13

Virginia Senate Bill 652• Mandates concussion education in all public high

schools for coaches, student-athletes, & parents, as well as policies and procedures

• Student-athletes & parents to receive annual education

• Any athlete with suspected concussion shall be removed from play/activity– Shall not return the same day– MUST be evaluated by health care professional with

• Licensed physician, physician assistant, osteopath, athletic trainer, neuropsychologist, or nurse practitioner

– Must be asymptomatic with increasing exertion (Zurich)– Requires written clearance for return to activity

Concussion definition (Zurich, 2013)

• Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. – May be caused by a direct blow to the head or body with

“impulsive” force transmitted to the head

– Typically results in rapid onset of short-lived neurologic dysfunction that resolves spontaneously. However, in some cases, symptoms & signs may evolve over minutes to hours.

– May result in neuropathologic changes, but acute symptoms typically reflect functional disturbance

• Standard structural neuroimaging is typically negative

– May or may not involve LOC & symptoms follow sequential course; small percent have prolonged PCS

Concussion: Signs & Symptoms

Cognitive Symptoms“Fogginess”Cognitive fatigueInattentionMemory deficits

MoodIrritabilityLability↓frustration toleranceSadnessAnxiety

Sleep DisturbanceInsomniaFragmented sleepHypersomniaHyposomnia

Somatic SymptomsHeadachesNauseaDizziness/Poor balanceLight/Sound Sensitivity

Common Acute Symptoms

• Observable within minutes to hours:– Lack of awareness of surroundings, confusion– Nausea and/or vomiting– Headache– Amnesia– Dizziness– Vertigo

Concussion Pathophysiology

Concussion Pathophysiology

Pediatric Recovery

• About 5-10 days in healthy college age adults with no previous concussion history

• Kids take longer to recover– 30 days or more

• Be more conservative with younger athletes

Gessel et al. J Ath Training, 2007

The adolescent brain may take slightly longer to recover

McCrory et al. British J Sport Med, 2013

RehabilitationStage

Functional exercise at each stage of rehabilitation

Objective at each stage

1. No activity Complete physical and cognitive rest Recovery

2. Light aerobic exercise

Walking, swimming, or stationary cycling keeping intensity <70% MHR. No resistance training

Increase heart rate

3. Sport-specific exercise

Skating drills in ice hockey, running drills in soccer. No head impact activities

Add movement

4. Non-contact training drills

Progression to more complex training drills (passing). May start progressive resistance training

Exercise, coordination, cognitive load

5. Full contact practice

Following medical clearance, participate in normal training activities

Restore confidence, assessment of functional skills by coaching staff

6. Return to play Normal game play

AAN Guidelines (2013)

• Evidence based – Immediate removal from play if concussion

suspected– Moved away from concussion grading

system:• Focus on individual management• No set timeline for return to play

• Concussion is a clinical diagnosis– Checklists, computerized testing, and balance

assessments are tools and should not be used alone to make a diagnosis.

AAN Guidelines (2013)

• No return until assessed by a licensed health care professional trained in concussion.

• Return to play slowly after acute symptoms resolve.

• High school and younger – manage more conservatively due to longer recovery.

• First 10 days after a concussion is the period of greatest risk for another concussion.

Why do we use baseline cognitive testing?

HeadMinder Case StudyAge of Athlete: 16 years

Gender: Female

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116

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Baseline Day 1 Day 8 Day 9 Day 14

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PSI

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Sample Results using Reliable Change

All standard scores adjusted for retest (practice) effects

Neuropsychological Testing in Sports Concussion Management

• Generally assesses several functional domains affected by concussion– Attention– Learning and Memory– Complex Problem Solving– Processing Speed/Efficiency– Reaction Time and Motor Dexterity– Psychological Factors

• Domains that are resistant to concussion (e.g., language) not typically assessed – unless retirement decisions are being considered

When to Refer to a Neuropsychologist• Symptoms > 2 to 4 weeks, especially if course is getting

worse & not better• Prior concussions, LOC, post-concussive seizures,

hemorrhage, etc.• Pre-concussion history of migraines, seizures, ADHD• Very protracted recovery course

– May need 504 Plan, IEP or college students needing accommodations

• Psychological overlay or secondary gain suspected.• Retirement decisions

Academic Accommodations• Academic support during recovery

– Impact of headache, fatigue, dizziness, light/noise sensitivity, poor sleep, ringing in ears

– Impact of cognitive deficits like inattention, poor concentration, memory disruption, slowed processing, slowed task performance

• Critical issue is to ensure rest during the acute recovery period– Individualized plan: balance work and respite

(Temporary) Academic Accommodations• Rest (as needed, but within reason)

– Excused absence initially– Rest periods while at school

• Relax time demands– Extending deadlines– Staggering or delaying some tests– Increased time for taking tests

• Reduced work– Excuse from portions of homework– Reduce value of test/excuse from test or quiz

(Temporary) Academic Accommodations• Modified environment

– Avoidance of intolerable light (fluorescent)– Reduced stimulation room (less “noise”)– Excuse from athletics/gym– Use of a test reader to read questions aloud– Tape recorder for classes/tests– Preferential seating (minimize distractions)– Provide temporary tutoring/extra instruction

The Benefits of Physical Activity and Sport Powell et al. (2011)

Concussion Management

• Children (10-17 years) with post-concussion symptoms 4 weeks after injury (n=16)– Most had headache, fatigue, depression and/or poor

endurance– Introduced supervised aerobic exercise– All showed rapid improvement in symptoms

• Gagnon et al. (2009)

Exercise as TBI Treatment (Griesbach, 2011)

• Post-acute injury exercise enhances recovery through increased brain derived neurotrophic factor (BDNF)– BDNF enhances learning & memory

• Can counteract increased oxidative stress that leads to free radicals

• Can regulate post-TBI neuroendocrine dysfunction

If in doubt, sit them out!