1. Concussion in Pediatric and Adolescent Athletes Arlene Goodman, MD Pediatric and Adolescent Sports Medicine The Division of Orthopaedic Surgery Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia goodmana@email.chop.edu

2. A Goodman Objectives Concussion = Mild Traumatic Brain Injury To learn the definition of concussion To learn the signs and symptoms of concussion To introduce concussion specific neurologic exam To learn the return to learn plan after a concussion To learn the variety of school modifications that may be required following a concussion To learn return-to-play guidelines

3. A Goodman Mild Traumatic Brain Injury (MTBI) Complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces –Blow to head or to the body with “impulsive” force transmitted to the head –Rapid onset of impaired neurological function that resolves spontaneously –Functional disturbance not a structural injury –Grossly normal imaging

4. A Goodman MTBI: Pathophysiology After a brain injury –Alterations in the metabolites (Ca, K) in brain cells –Altered glucose metabolism Following a concussion –Decreased cerebral blood flow (and glucose) to the brain This mismatch between increased glucose needs and decreased blood flow slows brain healing

5. A Goodman Neurometabolic Cascade Giza & Hovda, 2001

6. A Goodman MTBI: Pathophysiology The cornerstone of current concussion management is to protect the brain during this vulnerable state of metabolic mismatch.

7. A Goodman Pediatric and Adolescent Considerations 1.6-3.8 million sports-and recreational-related concussions per year in the US 2001-2005, 6% of ED visits in children ages 5-18 years were related to SR-related concussions 20% will have symptoms lasting over a month

8. A Goodman Pediatric MTBI: Epidemiology The 5 leading sports or recreational activities in 5-18 year-old that result in MTBI: –Bicycling –Football –Basketball –Playground activities –Soccer MTBI rates vary by sport Football and ice hockey have the highest rates for males Soccer and basketball in females

9. A Goodman Physical Education Injuries 21.6% Elementary school (5-10 y) 52% Middle school school (11-14 y) 26.4% High School school (15-18 y) Increased 150%

10. A Goodman Physical Education Injuries Concussion –1.9% Elementary School –1.6% Middle School –1.9% High School

11. A Goodman Second Impact Syndrome Thought to occur in the setting of a healing (symptomatic) brain injury Cerebral blood flow dysregulation Rapid cerebral swelling, brain herniation, and ultimately coma and death within minutes Documented only to occur in the adolescent aged population –35-40 probable cases in the literature in last decade

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13. Signs and Symptoms PhysicalCognitiveEmotionalSleep Headache Dizziness Nausea Vomiting Balance problems Visual problems Fatigue Photophobia Phonophobia Numbness/tingling Dazed or Stunned Tinnitus LOC Amnesia Feeling mentally “foggy” Felling slowed down Difficulty concentrating Difficulty remembering Confused about recent events Answers questions slowly Repeats questions Irritability Sadness More emotional Nervousness/anxiety Depressed mood Personality change Emotional lability Drowsiness Sleeping less than usual Sleeping more than usual Trouble falling asleep

14. A Goodman Concussion symptoms ends play and school that day When in doubt, sit them out and notify the parents!!!

15. A Goodman Initial Evaluation ABCC’s –Airway, Breathing, Circulation, C-spine History Physical Exam –Neurological Exam Cranial nerves Pupils – a late sign Strength Coordination Balance –Romberg, tandem walking

16. A Goodman Evaluation Cognitive Evaluation –Orientation, Memory, Concentration –Sideline Concussion Assessment Tool 3 (SCAT3) CHILD SCAT3 : 5 - 12 years old SCAT3 >13 years old Speed of response is as important as content

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19. On-field Mental Status Evaluation Orientation –What stadium, city, month, day is it? –Who is the opposing team? –Who scored last? –What school period are we in? Retrograde amnesia –What do you remember just prior to the hit? –What happened in the prior quarter or half? Score? –Do you remember the hit? Anterograde amnesia –Repeat the following words: girl, dog, green Concentration –Repeat the days of the week backward, starting with today –Repeat these numbers backward (63) (419) (6294) Delayed memory –Repeat the 3 words from earlier (girl, dog, green)

20. A Goodman Double leg stance Single leg stance: using non-dominant foot Tandem stance

21. A Goodman Balance Testing

22. A Goodman Concussion-Specific Neurological Exam Dysmetria –Finger-nose-finger Convergence deficit –Hold item with words at arms length and bring closer to face, as words become blurry, document measurement –Normal – < 6 cm Saccades –Hold two stationary targets placed shoulder width apart, have them move eyes quickly from target to target as head stays still Gaze stability testing –Focus on fixed object with horizontal/vertical head movement Nystagmus –Rapid lateral gaze tracking

23. A Goodman Concussion-Specific Neurological Exam

24. A Goodman Guidelines for the concussed athlete: Child should not be left alone Serial monitoring over the initial few hours following injury –Symptoms might be delayed several hours following a concussive episode Rest and avoid strenuous activity Tylenol for headache Teenagers: No driving until medically cleared

25. A Goodman Red Flags for Structural Injury Increasing headache Decreasing level of consciousness Seizure temporally remote from the injury Increasing tiredness or confusion Focal neurologic signs Lateralizing weakness Persistent vomiting Prolonged loss of consciousness

26. A Goodman Additional Signs of Deteriorating Neurological Function Can’t recognize people or places Slurred speech Weakness or numbness in arms or legs Neck pain Unusual behavior change Significant irritability or increasing irritability

27. A Goodman Management Considerations Concussion Modifiers: Amnesia Prolonged LOC (>1 minute) Cumulative Effects of Previous Concussion Age Symptoms Co- and Pre-morbidities

28. A Goodman Concussion Treatment – Acute Phase Overall Goal Protect the brain during vulnerable state of metabolic mismatch Brain activity will increase demand for glucose and aggravate/prolong symptoms Exercise diverts needed resources to exercising muscles and aggravates/prolongs symptoms Treatment = Cognitive/Physical Rest

29. A Goodman What is Cognitive Rest? Complete cessation of metabolically demanding activities that elicit symptoms –Physical exercise –School attendance –Computer use –Videogames –Text messaging/social media –Reading for school and homework Short amounts of television may be permitted if it does not elicit symptoms

30. A Goodman Treatment – Return to Learn Return to learn plan in 4 steps If symptoms return, go back to the previous step Families want direction –Patients/parents direct progression through plan –No need to re-visit provider at every step

31. A Goodman Treatment – Return to Learn Protocol 1. No Activity for the first few days Complete physical and cognitive rest –Do not participate in physical exercise, computer use, videogames, text messaging, reading for school –Okay to quietly watch television for 15-20 minutes if it does not make headaches worse –Consider activities that do not worsen symptoms - baking, cooking, crafts, Legos