Sports-related concussion in children and adolescents

AGENDA: CONCUSSION MANAGEMENT UPDATE MEETING SEAFAIR MINOR HOCKEY - NOVEMBER 8 TH, 2013 Introduction: Medical Panel and Seafair Background on Baseline Testing and Concussion Management (Cody Kusch) Background: Concussions and Recent Findings (Naznin Virji- Babul) Medical Evaluation and Recovery Process (Dr. William Panenka) Baseline Testing: SCAT 3 and Axon, update on testing to date, protocol for study, Return to play Protocol (Jonathan Sun) Panel: Question and Answer Period (Cody, Bill, Naznin, Dr. Will Panenka, Jonathan Sun, Dr. Paul Korn)

Background: Concussion/mTBI currently considered a silent epidemic Sports activities are a major cause of concussions 300,000 sports related concussions occur each year in the United States

What happens to the brain during a concussion?

Shearing in the wiring of the brain

Issues for coaches/clinicians/parents: Standard neuroimaging tools not sensitive to detect subtle changes in brain structure and function Diagnosis and evaluating functional recovery very difficult

Advanced MRI can see subtle changes in the wiring of the brain No concussionConcussed athlete

fMRI measures thinking

Brain activity is more scattered ControlConcussed

Signs and Symptoms of Concussion By an observer – not only LOC! – Dazed or stunned, confused about assignment – Forgets instruction, game score, opponent – Off balance, answers slowly, loses consciousness – Mood, behavior or personality changes. – Amnesia for events around injury By the athlete – – Headache, nausea or vomiting – Balance problems or dizziness – Double or blurry vision – Sensitivity to light or noise – Concentration or memory problems, confusion

Recovery From Concussion: How Long Does it Take? N=134 High School athletes Collins et al., 2006, Neurosurgery

Concussion Modifiers McCrory P, et al. Br J Sports Med 2013;47:250–258. doi: /bjsports

Medical Evaluation Individual clinical decision A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance. A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality

Persistently symptomatic patient Persistent symptoms (>10 days) in about 10-15% Important to consider other issues Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion Table from Ontario Neurotrauma mTBI Guidelines, and adapted from Current Treatment Options in Neurology. 2006;8:

Child/teenage athletes Consider age specific physical and cognitive rest issues – school attendance and activities need to be modified No return to sport or activity until returned to school successfully Symptom resolution may take longer, modifiers apply even more More conservative RTP approach recommended: – Consider extending symptom-free period before starting return to play protocol – Consider extending length of the graded exertion protocol Never return to play same day

Issues in the field No gold standard for assessment Return to play/learn protocols are based on expert opinion not hard evidence

Seafair Study Use 2 different assessments to evaluate which one is most sensitive Never been done before

Baseline and End of season Assessments: SCAT3 Baseline: 341 players tested to date AXON Baseline: Only 73 completed to date

Concussion Protocol Dr. Naz to screen players for MRI study Must be within 1 week of concussion Repeat scan if symptomatic at 6 weeks Referral to BCCH/Dr. Korn/Dr. Panenka as needed Suspected Concussion Coach/Manager pulls player off the iceSCAT3/AXON repeated

Return to play protocol 1. No Activity. Complete physical and cognitive rest 2. Light aerobic exercise (Walking, swimming or stationary cycling keeping intensity <70% maximum predicted heart rate. No resistance training 3. Sport-specific exercise (Skating drills in ice hockey, running drills in soccer. No head impact activities) 4. Non-contact training drills. Progression to more complex training drills, e.g. passing drills in football and ice hockey. May start progressive resistance training 5. Full contact practice following medical clearance, participate in normal training activities 6. Normal game play