CONCUSSION IN CHILDREN Not just little adults Dr Leesa Huguenin, Clinical director, MP Sports Physicians

INCIDENCE OF CONCUSSION Adolescent Rugby League 7% over 7 seasons (2 or more 1%, three or more 0.2%) Under 20 Elite Rugby Union UK 48.1 % at least one concussion, 27.1% sought medical attention for concussion over career South Africa 14.1 % of 3000 players at least one concussion New Zealand amateur RL, average 4.1 concussive incidents in U15 and 3.8 in U17 team Averaged out, 0.3 – 11.4 % chance concussion per season RU, 7.7 – 22.7 RL.

SEQUELAE OF CONCUSSION IN CHILDREN Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury (American Medical Society for Sports Medicine Position statement 2013) Children are yet to develop compensatory strategies in the brain to cope with temporary reduction in function. Therefore similar injury may result in much larger deficits, although these are likely to recover completely. (Keightly BJSM 2012) Young adult males with repeat concussion have poorer cognitive function at least 3 months since last concussion. Higher risk of second impact syndrome

PREVENTION OF CONCUSSION HELMETS MOUTH GUARDS RULE CHANGES ? NECK STRENGTHENING PARENTAL AND SIDE LINE EDUCATION

EDUCATION REQUIRED COACHING/ FIRST AID STAFF Possible significant sequelae if concussion ignored Coaches and first aiders CANNOT diagnose Remove player and seek medical assessment ATHLETES Dispel myths generated by TV coverage Cannot return to play until medically cleared SOCIAL MEDIA PRESENCE Many leagues are now placing information on websites. Through social media to increase awareness of the facts MEDICAL PERSONELL The days of just pushing through are long gone Symptoms = NO PLAY SEM physicians can help with specifics of return to play

ASSESSMENT OF CONCUSSION IN CHILDREN IN THIS CASE, THEY ARE JUST LIKE LITTLE ADULTS (SORT OF) Sideline assessment SCAT 3 for children Involves modified questions and tests Rooms assessment Excluding any other predisposing factors SCAT 3 can be used for monitoring progress Must involve parental input (behaviour/ mood) Scans Rarely required Possibility of functional MRI scanning in future being able to detect metabolic abnormalitites to clarify diagnosis

POTENTIAL TECHNOLOGIES FOR ACCURATE ASSESSMENT Functional Neuroimaging MRI – assesses for changes in BOLD (Blood Oxygen Level Dependent) signal changes Lots of studies Still trying to clarify specifics Issue is that all concussion may not be the same beast Quantitative EEG some changes have been identified reproducibly, but not specific to concussion Recovery mimics concussion recovery timeframes ? Future promise Doppler US

BUT………………………….. Current weaknesses with testing children 1. impact on developmental stage on performance 2. lack of baseline data in most cases 3. impact of attention deficit/ mood disorders on performance 4. if baselines are available, significant brain development can occur between test times

AND……………………… “While standardised sideline tests are a useful frame work for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined” Am Med Soc position statement 2013

MANAGEMENT OF CONCUSSION IN CHILDREN THERE IS NO SAME DAY RETURN TO SPORT FOR A CONCUSSED ATHLETE NO NEED FOR IMAGING UNLESS SUSPECT INTRA CEREBRAL BLEED MOST CONCUSSIONS CAN BE MANAGED ADEQUATELY WITHOUT NEUROPSYCHOLOGICAL TESTING ANALGESICS REST THE BRAIN (COMPUTERS/ TV/ BOOKS/ SCHOOL) MODIFIED ACTIVITIES – STAY SYMPTOM FREE MONITOR RECOVERY – FOLLOW UP AT ELAST WEEKLY UNTIL AFTER RTP GRADED RETURN TO ACTIVITY

ANALGESICS NON SEDATING NO NSAIDS/ ASPIRIN PARACETAMOL +/- ANTI EMETICS?

REST SCHOOL – MAY NEED DAYS OFF/ REDUCED HOURS/ SPECIAL CONSIDERATION TV – LESS STIMULATING THAN SLEEP BUT……… VIDEO GAMES READING ACTIVITY – DO NOT INDUCE SYMPTOMS SPORT – RTP AFTER GRADED INCREASE IN ACTIVITY ONLY AND UNDER MEDICAL GUIDANCE

MONITOR RECOVERY Weekly at least Firstly monitor symptoms Then consider neuropsych testing if indicated Then gradually increase activity Must be symptom free at each step, as for adults, but anticipate slower recovery

ROADBLOCKS TO RETURN Children describe fear of being hit again Concern when NP tests remain abnormal when all symptoms are resolved Baseline NP tests are not commonly done in juniors and there is still contention as to whether they can be compared to tests done many weeks or months later Baseline tests may change as part of normal maturation and developmental process and can be dependent on current mood, fatigue and other factors Huge difficulty when recovery patterns have not been adequately studied in atheltes under 15 yo Cosideration should be made to with hold from sport until academic functions have normalised

BIGGEST HURDLES TO CURRENT CONCUSSION MANAGEMENT DISSEMINATION OF ACCURATE KNOWLEDGE Shifting embedded beliefs – helmets/ mouthguards Education regarding symptoms Education regarding risks of playing on Education regarding appropriate follow up Education regarding requirement for medical input in diagnosis and RTP decisions

THANK YOU !