Concussion in Pediatric and Adolescent Athletes

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. 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. 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. 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. Neurometabolic Cascade Giza & Hovda, 2001

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

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

10. Physical Education Injuries • Concussion • 1.9% Elementary School • 1.6% Middle School • 1.9% High School

11. 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

13. Signs and Symptoms

14. Concussion symptoms ends play and school that dayWhen in doubt, sit them out and notify the parents!!!

15. 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. 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

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

21. Balance Testing

22. 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. Concussion-Specific Neurological Exam

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

28. Concussion Treatment – Acute PhaseOverall 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. 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. 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. 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