Dr. Joseph Rempson Co-Medical Director of the Atlantic HealthConcussion Center at Overlook Hospital Director of he Department of Rehabilitation at Overlook Hospital Atlantic Neurosurgical 310 Madison Avenue Morristown, New Jersey 07960 Appointment: 908 522-6395 Office: Tel 973.285.7800

Cell: 973 908-1091 E-mail: [email protected]

1) 1.6 to 3.8 million sports and recreational mild traumatic brain injuries/year 2) Closed head injury (Acceleration/Deceleration Injury)

 Academics  Social Relationships  Behavior  Emotions

High school sports participation has grown from an estimated 4 million participants during the 1971--72 school year to an estimated 7.2 million in 2005—06.

1.1 million played high school football in 2008 and 2009 and 43,000 to 67,000 were diagnosed with concussion

TABLE 1 Concussion Rates in High School

Football 0.47–1.03a,b Girls’ soccer 0.36a

Boys’ lacrosse 0.28–0.34c,d Boys’ soccer 0.22a

Girls’ basketball 0.21a

Wrestling 0.18a

Girls’ lacrosse 0.10–0.21c,d Softball 0.07a

Boys’ basketball 0.07a

Boys’ and girls’ volleyball 0.05a

Baseball 0.05a

a Data from Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and c ollegiate athletes. J Athl Train. 2007;42(4):495–503. b Data from Guskiewicz KM, Weaver NL, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643– 650.

c Data from Lincoln AE, Hinton RY, Almqueist JL. Head, face, and eye injuries in scholastic and collegiate lacrosse: a 4-year prospective study. Am J Sports Med. 2007;35(2): 207–215.

d Data from Hinton RY, Lincoln AE, Almquist JL. Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study. Am J Sports Med. 2005;33(9): 1305–1314 .

All of the recent consensus statements on sport-related concussions recommend a more conservative approach to concussion management for athletes under the age 18 than for older athletes:



Third International Conference on Concussion in Sport, Zurich 2008

 The American College of Sports Medicine's 2006 Consensus

Statement on Concussion (Mild Traumatic Brain Injury) and the Team Physician



National Athletic Trainers' Association 2004 Position Statement: Management of Sport-Related Concussion

 Brain tolerance to biomechanical forces differ between adults and children (2-3 fold force is needed to create similar symptoms in children)  Immature brain may be 60 times more sensitive to glutamate-mediated N-methyl-D-aspartate (NMDA): one example an increase in intracellular calcium  Significant neural development of the brain through the age of 15  Second Impact Syndrome (felt to only occur in adolescence)

    Why are girls at increased risk?

Neck musculature?

Muscle mass in boys likely diminishes force transmission Susceptibility?

Boys and girls brains are not the same More likely to report?

Boys may be more likely to hide symptoms Also take longer to recover.

 SCAT 2  SAC  Maddock’s Questionnaire  Balance Error Scoring System (BESS)

On field/sideline evaluation

    ABC’s and cervical spine (most important) Basic neurologic exam is often normal Asking month, year, and day not sensitive.

Symptoms can take up to 48 to 72 hours to fully manifest themselves.

Don’t forget

       

Headaches (pressure) 70%

Feeling slowed down (58%)

Poor concentration (57%) Dizziness (55%) Feeling Foggy (53%)

Fatigue (50%)

Visual blurring or double vision (49%)

Irritablity          

Light sensitivity (47%)

Memory Dysfunction (43%)

Balance problems (43%) Increased sensitivity to loud noises

Anxiety and/or depression Sleep disturbances

Nausea Vomiting

Feeling sluggish

Seizure (on field)

Neuro-imaging (CT) should be considered whenever suspicion of an intracranial structural injury exists. Signs and symptoms that increase the index of suspicion for more serious injury include severe headache; seizures; focal neurologic findings on examination; repeated emesis; significant drowsiness or difficulty awakening; slurred speech; poor orientation to person, place, or time; neck pain; and significant Irritability. Any patient with worsening symptoms should also undergo neuroimaging. Patients with LOC for more than 30 seconds may have a higher risk of intracranial injury, so neuroimaging should be considered for them.

Grading Scales are not used !!!!!!!!!! Individualized care of each patient is now the standard of care !!!!!!

     Baseline Neuropsychological testing Balance Error Scoring System (BESS)

Cognitive Rest/Physical Rest !!!!!!!!!!!!!!!!!!!

Symptom Free Repeat Neuropsychological Test when available Exertion Protocol (if no test available one suggestion is 1 week symptom free then start exertion: NJSIAA 2010)    Minimize medications (no evidence medications facilitate healing) Special groups for consideration: Migraines, ADHD, learning disabilities, depression, and other underlying disorders

Remember in children symptoms can resolve before neuropsychological testing returns to baseline (different than adults) Basic Management Consideration

 School  Television  Video Games  Noise (ear plugs)  Lights (glasses)  Hanging out with friends  Riding in a car  Computers  Going to games

Academic Modifications (Not a 504) for cognitive rest in school.

_____No gym class.

_____Restricted gym class activity as specified below: _____Full academic accommodations as specified below: _____untimed tests _____preprinted class notes _____tutoring _____reduced workload when possible _____frequent breaks from class when experiencing symptoms _____modified homework assignments _____extended time on homework, projects _____Other: _____Additional recommendations below:

When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. Step 1: rest until asymptomatic (physical and mental rest) Step 2: light aerobic exercise (e.g. stationary cycle) Step 3: sport specific training Step 4: non-contact training drills (start light resistance training) Step 5: full contact training after medical clearance Step 6: return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to the prior stage if symptoms recur. Resistance training should only be added in the later stages.

 Children shouldn’t return to play until completely symptom free which may require a longer time frame than for adults.

 “ Cognitive rest ” was highlighted with special reference to a child’s need to limit exertion.

 It is appropriate to extend the amount of asymptomatic rest and/or length of the graded exertion in children and adolescence.



Children aren’t professional athletes?

A recently proposed definition of post-concussive syndrome is the presence of cognitive, physical, or emotional symptoms of a concussion lasting longer than expected, with a threshold of 1 to 6 weeks of persistent symptoms after a concussion to make the diagnosis.

• Headaches • Visual Problems • Dizziness • Noise/Light Sensitivity • Nausea Somatic Symptoms Emotionality • More emotional • Sadness • Nervousness • Irritability •Attention Problems •Memory dysfunction •Fogginess” •Fatigue •Cognitive slowing Cognitive Symptoms Sleep Disturbance • Sleeping less than usual • Difficulty falling asleep

• Headaches (Magnesium, Riboflavin, Elavil, Topamax) •Vestibular Symptoms: Vestibular Rehabilitation Somatic Symptoms Emotionality •Antidepressants •Sports Psychologists •Psychiatry •Neuropsychologists •Learning Disability Specialists •Cognitive Therapists • Medications Cognitive Symptoms Sleep Disturbance • Melatonin

 Gradual exercise may help restore brain auto-regulation  Helps restore sense of self  Not exercising changes the physiology of the body We start this about 4 to 6 weeks into the injury. We find this to be invaluable.

 Compared with similar students without a history of concussion, athletes with 2 or more concussions also demonstrate statistically significant lower grade-point averages.

  Three months after a concussion, children 8 to 16 years of age have been found to have persistent deficits in

processing complex visual stimuli.

Headaches (which can be migraine like) can be debilitating and difficult to treat.

Section 504 is a civil rights law that prohibits discrimination against individuals with disabilities. Section 504 ensures that the child with a disability has equal access to an education. The child may receive accommodations and modifications.



CTE



Depression



Alzheimer's

 Zurich 2008 (3 rd conference): international Epidemiologic studies have suggested an association between repeated sports concussions during a career and late-life cognitive impairment. A panel discussion was held and no consensus was reached on the significance of such observations at this stage.

18 yo HS athlete - 2 documented concussions in football - Multi-sport athlete - Early CTE changes on autopsy

 With the use of the HIT system, Impact testing, and fMRI they tested 11 high school football players ages 15-19. They found 3 categories of players: 1) No diagnosis of concussion and no change in clinical behavior. (4 patients) 2) Diagnosis of concussion and a change in clinical behavior. (3 patients) 3) No diagnosis of concussion, but a change in visual working memory and fMRI (altered activation in the dorsolateral prefrontal cortex). Greater number of hits to the top of the head in this category. (4 patients) Small sample size so must be careful how to interpret !!! However, raises questions.

      Halsted M, Walter K. Clinical Report: Sports Related Concussions in Children and Adolescents. Pediatrics 2010; 3: 597-615 McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Concensus statement on concussion in sport – The 3 rd International Conference of Concussion in sport, held in Zurich November 2008 McDonald JW, Johnston MV. Physiological pathophysiological roles of excitatory amino acids during central nervous system development. Brain Res Rev 1990; 15:41-70 Omaya AK, Goldstein W, Thibault L. Biomechanics and neuropathology of adult and pediatric head injury. Br J Neurosurg 2002, 16 (3): 220-242 Talvage T, Nauman E, Breedlove E, Yoruk: Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically – Diagnosed Concussion. Journal of Neurotrauma. Submitted by Author 9/27/2010. For Peer Review Leddy J, Kozlowski K, Fung M. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post-concussion syndrome: Implications for treatment. NeuroRehab 2007, 22: 199-205