1. Sports Concussion Update 10 th Annual Steadman Hawkins Sports Medicine Symposium June 7 2013 Chae Ko, MD Steadman Hawkins Clinic of the Carolinas Primary Care Sports Medicine Fellow

2. Action

3. What Is Concussion? It’s pretty simple… It’s pretty simple…

6. Definition “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces” “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces”

7. Definition Concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head Concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head Concussion typically results in the rapid onset of short- lived impairment of neurologic function that resolves spontaneously. However, in some cases symptoms and signs may evolve over a number of minutes to hours. Concussion typically results in the rapid onset of short- lived impairment of neurologic function that resolves spontaneously. However, in some cases symptoms and signs may evolve over a number of minutes to hours. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and as such, no abnormality is seen on standard structural neuroimaging studies.

11. Headaches Dizziness Insomnia Fatigue Gait Nausea Vision Seizures Attention difficulties Concentration Memory problems Orientation Irritability Depression Anxiety Sleep Disorders Emotional Control Relationships, marriage, school and employment

12. Sideline Evaluation The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician is arranged The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician is arranged Once the first aid issues are addressed an assessment of the concussive injury should be made using the SCAT 3 or other sideline assessment tools Once the first aid issues are addressed an assessment of the concussive injury should be made using the SCAT 3 or other sideline assessment tools The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury A player with diagnosed concussion should not be allowed to return to play on the day of injury A player with diagnosed concussion should not be allowed to return to play on the day of injury

13. “OLD”

14. “NEW”

17. Grading / Classification of Concussion Many different guidelines and classification systems in the past There has been nearly one new guideline every year for the past 20 years As of the 4th International Symposia on Concussion in Sport (Zurich), concussion is no longer graded or classified

18. Neuropsychological Evaluation Important in overall assessment and RTP Important in overall assessment and RTP Should not be sole basis of management decisions Should not be sole basis of management decisions Aid to clinical decision making Aid to clinical decision making Formal NP testing not required for all Formal NP testing not required for all Best done when asymptomatic but may be beneficial at other stages in certain situations Best done when asymptomatic but may be beneficial at other stages in certain situations Baseline testing is not mandatory Baseline testing is not mandatory

20. Cognitive Adjust academic workload and school attendance Adjust non-academic activities Leisure reading Video games Texting and computers

21. Management Cornerstone  initial period of rest until acute symptoms resolve Cornerstone  initial period of rest until acute symptoms resolve 80 – 90% resolve in short period 80 – 90% resolve in short period 7 – 10 days 7 – 10 days Children and adolescents Children and adolescents May take longer May take longer Expect gradual resolution Expect gradual resolution Gradual return to school and social activities that does not significantly exacerbate symptoms Gradual return to school and social activities that does not significantly exacerbate symptoms

24. Graduated RTP Protocol

26. Same Day Return To Play? NO! NO!

27. Postconcussive Symptoms Persistent symptoms > 10 days Persistent symptoms > 10 days 10-15% 10-15% Consider other issues Consider other issues Depression Depression Anxiety Anxiety Should be managed in multidisciplinary manner Should be managed in multidisciplinary manner Pharmacotherapy Pharmacotherapy

28. Child And Adolescent Athlete Child SCAT3 Child SCAT3 Adult recommendation may apply down to age 13 Adult recommendation may apply down to age 13 Modify school attendance and activities Modify school attendance and activities No return to sport or activity until successful return to school No return to sport or activity until successful return to school More conservative RTP approach recommended More conservative RTP approach recommended Extend symptom free period before RTP protocol Extend symptom free period before RTP protocol Consider extended graded exertion steps Consider extended graded exertion steps

29. Elite Athletes Managed the same regardless of level of participation Managed the same regardless of level of participation

30. Prevention Protective equipment Protective equipment Mouthguards Mouthguards No evidence of concussion reduction No evidence of concussion reduction Helmets Helmets Reduction in biomechanical forces but no evidence in reducing concussion incidence Reduction in biomechanical forces but no evidence in reducing concussion incidence

32. Neurology Sports Medicine

37. Chae Ko, MD cko@ghs.org Thank You

38. Barkhoudarian G, Hovda DA, Giza CC. The Molecular pathophysiology of concussive brain injury. Clin Sports Med. 2011 Jan; 30 (1): 33-48, vii-iiii. Campbell A, Ocampo C, DeShawn Rorie K, Lewis S, Combs S, Ford-Booker P, Briscoe J, Lewis-Jack O, Brown A, Wood D, Dennis G, Weir R, Hastings A. Caveats in the neuropsychological assessment of African Americans. J Natl Med Assoc. 2002 Jul;94(7):591-601. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Heads up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). www.cdc.gov/NCIPC/pub-res/tbi_toolkit/physicians/mtbi/mtbi.pdf. Accessed 2012 September 21. Charles, JD, Bejan A. The Evolution of Speed, Size, and Shape in Modern Athletics. J Experimental Bio. 2009 May; 212: 2419-25. Iverson G. Predicting Slow Recovery From Sport-Related Concussion: The new Simple-Complex Distinction. Clin J Sport Med. 2007 Jan;17(1): 31-7. Ma R, Miller C, Hogan M, Diduch B, Carson E, Miller M,. Sports-Related Concussion: Assessment and Management. J Bone Joint Surg Am. 2012 September; 94(17): 1618 – 1627. Mills JD, Bailes JE, Sedney CL, Hutchins H, Sears B. Omega-3 Fatty Acid Supplementation and Reduction of Traumatic Axonal Injury in a Rodent Head Injury Model. J Neurosurg. 2011 Jan; 114(1):77-84. McCrory P, Meeuwisse W, Aubry M, Cantu B, Dvorak J, et al. Consensus statement on Concussion in Sport 4 th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med 2013;23:89–117. Putukian M. The Acute Symmptoms of Sport-related Concussion: Diagnosis and On-Field Management. Clin Sports Med. 2011 Jan;30(1):49-61, viii. Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006 Oct;34(10):1630-5.

39. Child SCAT3 Differences Child Maddocks questions Child Maddocks questions Symptom scale Symptom scale Child specific Child specific 4 point rating scale 4 point rating scale Parent rating of child’s symptoms Parent rating of child’s symptoms Orientation Orientation No time of day No time of day Reverse days of the week Reverse days of the week No single leg stance No single leg stance

40. Canadian Head CT Rule Applies to patients with GCS=13-15 following minor head trauma with witnessed LOC. Applies to patients with GCS=13-15 following minor head trauma with witnessed LOC. Patients with any of the below need a CT: Patients with any of the below need a CT: 1.GCS<15 after 2hrs. 2.Suspected open or depressed skull fracture. 3.Any sign of basilar skull fracture. 4.Two or more episodes of vomiting. 5.Age 65 or older.

41. New Orleans Criteria Applies to patients with GCS=15 following minor head trauma. Applies to patients with GCS=15 following minor head trauma. Patients with any of the below need a CT: Patients with any of the below need a CT: 1.Headache 2.Vomiting 3.Age > 60 4.Intoxication 5.Persistent anterograde amnesia 6.Visible trauma above the clavicle 7.Seizure

42. NEXUS II Criteria “BEAN BASH” Criteria “BEAN BASH” Criteria Behavioral Abnormality Emesis (intractable) Age >65 Neurological Deficit Bleeding Disorder Altered Mental Status Skull Fracture Hematoma of the Scalp

43. Age and Developmental Level Younger athletes take longer to recover Younger athletes take longer to recover High school versus college High school versus college High school versus professional High school versus professional Children undergo more cerebral swelling with more severe mild TBI, which may account for delayed recovery compared to older athletes Children undergo more cerebral swelling with more severe mild TBI, which may account for delayed recovery compared to older athletes Immature brain is up to 60x more sensitive to glutamate (part of the metabolic cascade that follows concussion) Immature brain is up to 60x more sensitive to glutamate (part of the metabolic cascade that follows concussion) All this may account for SIS only occurring in children. All this may account for SIS only occurring in children.

44. Gender Differences Females have a higher rate of concussion Females have a higher rate of concussion Females are cognitively impaired 1.7x more frequently than males Females are cognitively impaired 1.7x more frequently than males Females had significantly more post- concussive symptoms as well as poorer performance on follow- up testing (ImPACT) Females had significantly more post- concussive symptoms as well as poorer performance on follow- up testing (ImPACT)