1. TM
Prepared for your next patient.
Sport-Related Concussions in Children and Adolescents What you need to know
Mark Halstead, MD, FAAP Assistant Professor, Depts. of Pediatrics and Orthopedics
Washington University Sports Medicine -- St Louis, MO
Director, Sports Concussion Clinic
Welcome slide for use during audience walk-in.

2. Disclaimers
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.
Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.
Session agenda

3. Disclosure
Faculty Disclosure Information In the past 12 months, I have not had any relevant financial relationships with the manufacturer of any commercial product and/or provider of commercial services discussed in this webinar. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
Session agenda

4. Objectives Understand the epidemiology of sport-related concussion.
Determine appropriate in-office evaluation of a sport-related concussion.
Analyze the role of computerized neurocognitive assessment of a concussion.
Implement appropriate return to play protocols following a concussion.
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5. Definition
Complex pathophysiological process affecting the brain, induced by biomechanical forces
1st Int’l Symposium on Concussion in Sport (Vienna, 2001) Organized by FIFA, IIHF, IOC
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6. Definition: 5 Major Features
May be due to direct blow to face, head, neck, or elsewhere on body with “impulsive” force to head
Rapid onset of short-lived impairment of neurologic function that resolves spontaneously
Acute symptoms usually due to functional disturbance rather than structural injury
Results in graded set of clinical syndromes that may or may not involve loss of consciousness (LOS)
Typically associated with grossly normal neuroimaging studies
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7. Epidemiology: Boys Sports
Session agenda
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755 7

8. Epidemiology: Girls Sports
Session agenda
Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755 8

9. Concussion Epidemiology
Session agenda
Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755 9

10. Mechanism of Injury Session agenda 10
Gessel LM, Fields SK, Collins CL, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503 10

11. Pathophysiology Neuronal Disruption Increased Potassium Efflux
Potassium Efflux, Release of Glutamate
Increased Potassium Efflux
Increased Demand for ATP and Glucose
“Metabolic Crisis” Lactate accumulates; decreased cerebral blood flow
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12. Common Signs and Symptoms
+/- LOC
Headache
Dizziness
Nausea/vomiting
Unaware of period, opposition, score
Confusion
Amnesia
Unaware of time, place, date
Vacant stare/glassy eyed
Slurred speech
Feeling “dinged,” “slow,” “foggy”
Visual changes
Sensitivity to light/sound
Unusual/inappropriate emotions (cry, laugh)
Inappropriate playing behavior (running in wrong direction)
Seizure
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13. Common Symptoms Session agenda 13
Meehan WP 3rd, d’Hemecourt P, Comstock RD. High school concussions in the academic year: mechanisms, symptoms, and management. Am J Sports Med. 2010;38(12):2405–2409; and Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes Br J Sports Med. 2012;46(8):603–610 13

14. On the Field: Sideline Assessment
Various tools
Standardized Assessment of Concussion (SAC)
Symptom Assessment
Balance Error Scoring System (BESS)
Sport Concussion Assessment Tool 2 ([SCAT2] includes SAC, BESS, others)
Question: Which is the best one to use and what do results mean?
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15. Utility of the SCAT2 What are baseline norms for high schoolers?
11th and 12th graders were better than 9th graders
88.7 and 89.0 vs 86.9 (p<0.001)
Athletes with self reported concussion history had lower scores than those with no history
87.0 vs 88.7 (p<0.001)
Females scored better than males
88.7 vs 87.7 (p=.03)
Cannot assume ‘baseline’ of 100 as norm
Session agenda
Valovich McLeod TC, Bay RC, Lam KC, et al. Representative baseline values on the Sport Concussion Assessment Tool 2 (SCAT2) in adolescent athletes vary by gender, grade, and concussion history. Am J Sports Med. 2012;40(4):927–933 15

16. Utility of the SCAT2 Session agenda 16
Valovich McLeod TC, Bay RC, Lam KC, et al. Representative baseline values on the Sport Concussion Assessment Tool 2 (SCAT2) in adolescent athletes vary by gender, grade, and concussion history. Am J Sports Med. 2012;40(4):927–933 16

17. BESS: Balance Error Scoring System
Postural Stability
Flat and 10cm foam
20 seconds each
Count errors to score
Eyes opening
Movement
Hands off hips
Affected by environment
Test after 15 minutes
Footwear
Surfaces
Some rater reliability issues
Some practice effect noted
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18. When to Refer to Emergency Department
General guidelines
LOC—how long?
Focal neurological findings
Worsening mental status
Seizure activity
Worsening headache
Repeated emesis
Concern is for structural injury requiring computed tomography (CT) scan
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19. Neuroimaging
Consider for all the things referral to emergency department (ED)
CT scan initially
Consider magnetic resonance imaging (MRI) if more prolonged recovery
Remember, CT scan does not diagnose concussion
Also, normal CT scan ≠ No concussion !!!
Newer imaging (primarily research role)
Functional magnetic resonance imaging (fMRI)
Positron emission tomography (PET)
Single-photon emission computed tomography (SPECT)
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20. In the Office Assessment
Same assessments that are done on the field may not be as helpful in the office
SCAT2―“S” is for “Sideline”
Symptom score checklists
Neurological examination
Concussion history
Balance assessments
Most helpful first 3 days
Vestibular system assessments
School difficulties
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21. Symptom Checklist
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22. When to Refer to a Specialist
Prolonged symptoms
Severe symptoms that are not improving
Your own individual comfort factor
Patient with multiple concussions
Decisions on retirement?
No “magic number”
Parental request
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23. Neurocognitive Testing
What is available?
ImPACT (multiple tests)
Axon Sports (playing cards test)
Concussion vital signs
Automated Neuropsychological Assessment Metrics ([ANAM] primarily military)
HeadMinder
Formal pencil and paper testing with neuropsychologists
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24. Neurocognitive Testing
Benefits
Gives ‘data’ of brain function
In use for many years with good normal values
Computerized test is easy to administer
Much less time needed compared to formal pencil and paper testing
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25. Neurocognitive Testing
Issues
Standards for assessment
How often? Testing while symptomatic?
“We suggest initial evaluation 24–72 hours after injury. Consult a physician for interpretation of ImPACT test results…second post-injury test should be administered 1–2 weeks after the initial post-injury test. We strongly discourage testing more than once a week.”
Baseline vs No Baseline
Not validated below age 12
Pediatric ImPACT likely to be released by end of year
Cost
Who will interpret?
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26. Issues that Affect Test
Environment
Group testing vs individuals
Practice effects
Prior computer use
Baseline depression
Overall effort
Changing baselines
Felt to be stable after 10th grade
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27. What Role Do They Have?
May be a part of a comprehensive concussion evaluation program
May help identify the ‘not so forthcoming’ athlete
For more concrete and specific neurocognitive evaluation, especially when considering significant or prolonged school adjustments → involve neuropsychologist for more formal testing
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28. What They Do Not Do Predict length of recovery.
Provide prognosis for future problems.
Act as the sole determining factor for return to play.
Act as a red light/green light.
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29. How to Use
First, develop a comprehensive concussion program for your clinic/school
Consultants
Education on the issues―stay current―rapidly evolving topic
Appropriate plan for testing
Setting
Post-injury evaluation
Physician or neuropsychologist to interpret the testing
Do not treat to the test
Do not just use computer results/summary score
Electrocardiogram (EKG)
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30. Future Directions Further evaluation on true utility of the test
Appropriate time to test
Is it really worth testing while symptomatic?
Why is there now a post-testing symptom score on ImPACT?
Are all components helpful?
Is there one program that is better than others?
At least two more were being marketed at the National Athletic Trainers' Association (NATA)
Are there more appropriate evaluations?
Should we keep trying to get shorter and quicker evaluations when assessing a brain injury?
Session agenda 30

31. Recovery Time Numerous studies suggest
The younger the athlete, the longer the recovery
Girls may take slightly longer than boys to recover and often have more symptoms
Majority of concussions (80%+) are back to ‘normal’ by 3 weeks following injury
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32. “Brain Rest”
Initially restrict all physical activity that increases heart rate or blood pressure
Gym/recess
Sporting activities
Working out
Recreational activities (skateboarding, etc.)
These restrictions may change based on development of post-concussive syndrome.
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33. “Brain Rest” Consider reducing cognitive stress
Reduced school day/off school
Reduced school load
Untimed tests
Tutoring
May need to limit video games, texting, reading, computer use, television
Consideration for restrictions on driving → reduced reaction time is issue
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34. “Brain Rest” Involve the school early Make adjustments ? days off
Follow up with schools on adjustments being made
High achieving students may not ‘give in’ to adjustments
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35. Returning to Play No return to play in an acute concussion until
Asymptomatic at rest
Asymptomatic with exertion
Have completed full ‘return to activity’ progression
Cognitively back to baseline at school
If concussion is suspected
Pull from practice/game
No return to play same day
Medical evaluation and clearance before return
State law in 41 states
Session agenda 35

36. Return to Play
Do not allow to return to game/practice if suspected or diagnosed concussion on day of injury
Do not allow return to play/practice/exertion until asymptomatic at rest
Not a defined, set time frame (ie, 7 days, 2 weeks, etc.)
Progressive, step-wise approach to return to play
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37. “Concussion Rehab” Step-wise Return to Play
No activity until asymptomatic
Light aerobic activity
Sport-specific training
Non-contact training drills
Full contact training after medically cleared
Game play
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38. Medication Use
No evidence for efficacy and safety of nonsteroidal anti-inflammatory drugs (NSAIDs) or other medication in management of sport concussion
May be helpful for symptoms of post-concussive symptoms (typically all off-label uses)
Sleep aids, attention-deficit disorder (ADD) medications, non-conventional headache medications, antidepressives
Athlete must be off medication and symptom-free before return to sports
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39. Retirement from Sports
TRICKY!
No magic number
Consider for prolonged symptoms, multiple concussions
Involve someone experienced in sport concussion management
Session agenda 39

40. THANK YOU!
Questions?
Session agenda 40

41. For More Information…
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