ADOLESCENT CONCUSSIONS

1. ADOLESCENT CONCUSSIONS Darien High School Presentation Michael A. Lee, M.D., FAAP Member, Connecticut Concussion Task Force Charter Member, AMSSM Member, AAP-COSMF, Former Chairman, CSMS Committee on Medical Aspects Sports Former Editor, SPORTSMed Newsletter

2. Overview What is a Concussion Pathophysiology (brief) Female concussions When to go the the E.R. Cognitive rest Return to School Post-concussion Syndrome and ADD Disclaimers: I have had one concussion

3. Concussions: They are a part of sports participation at all levels One of the most discussed problems in US sports media coverage today Perhaps the most misunderstood problem Prevention would be great but not entirely possible Very difficult to manage especially when the symptoms are prolonged.

5. Concussion is derived from the Latin word concussusor concutere, which means to shake or be shaken violently.

6. Concussion Redefined Vienna, November 2001 – First International Conference on Concussion in Sport Prague, November 2004 – Second Conference Zurich, October 2008 – Third Conference Zurich- 2013

7. VIENNA/ZURICH DEFINITION “A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” Several common features to help define Force transmitted to head (direct or indirect) Rapid onset of short-lived impairment that resolves spontaneously Acute symptoms reflect functional disturbance rather than a structural injury (no bleeding) Resolution follows sequential course May or may not involve LOC Neuroimaging studies normal Major change since last conference is to include balance testing. 7

8. Pathophysiology Acute Changes Potassium Glucose Calcium Cerebral blood flow Magnesium

9. FACTS AND STATISTICS 1.5 million head injuries per year in USA 20% or 300,000 are sports related Majority of these are in pediatric age group 20% of football players will sustain a concussion per season Athlete who sustains a concussion is 4 to 6 times more likely to sustain a second one “Bell ringers” or mild concussions account for 75% of all concussive injuries Effects of concussions are cumulative in athletes returning to play prior to recovery

10. Facts continued 90% of concussions are relatively mild and no abnormalities or symptoms may exist during a time when we know the brain continues to be at increased vulnerability. Pediatric developing brain is actually more vulnerable (rather than less so) than an adult to damage from an injury. (Brain maturation occurs to age 21) The best way to prevent problems with concussion is to manage them effectively when they occur. No athlete should return to play while experiencing the symptoms of a concussion.

11. Grading Scales 11

12. No “classification” system Concept: Majority (80-90%) resolve in 7-10 days May be longer in children and adolescents (may be?!) EVERYONE deserves individualized management Recovery will vary based on: Prognostic factors (history, comorbidities, etc.) Advice YOU give your athlete Athlete’s willingness/ability to follow advice 12

13. How long does it take to recover from a concussion? Less than a week? AAP CT – 3 days? Sports authorities say less than a week

14. Individual Recovery From Football-Related mTBI: How Long Does it Take? WEEK 3 WEEK 1 WEEK 2 WEEK 4 WEEK 5 40% RECOVERED 80% RECOVERED 3 Year Prospective Study of 17 High School Football Teams N=2,141 60% RECOVERED N=134 Concussed High School Football Players Collins et al., 2006, Neurosurgery

15. FEMALE CONCUSSIONS

16. Girls have a higher rate of concussion than boys, particularly in similar sports Lincoln, et.al., Am J Sports Med 2011; Giza, Kutcher, et al., Neurol 2013

17. FEMALE CONCUSSIONS Tend to be worse and last longer Likely related to weaker neck muscles Progesterone?

18. CHEERLEADING Often is not considered a sport, YET 50% of deaths in college woman’s sports Seem to have more PCS and are more difficult to manage in my experience

19. ON-FIELD SIGNS/SYMPTOMS OF CONCUSSION • Concussion Signs • Appears dazed • Confused about play • Answers question slowly • Personality/behavior change • Forgets plays prior to hit • Retrograde amnesia • 10x more likely to have poor outcome • Forgets plays after hit • Anterograde amnesia • 4.2x more likely • Loss of consciousness • Concussion Symptoms • Headache (generalized) • Nausea • Balance problems • Double vision • Sensitivity to light • Sensitivity to noise • Feeling sluggish • Feeling mentally foggy • Change in sleep pattern • Cognitive changes

20. WHEN TO GO TO THE E.R • Seizures (twitching or jerking movement of parts of the body; may look stiff) • Weakness or tingling in the arms or legs • Cannot recognize people or places • Confused, restless or agitated • Impaired consciousness • Difficult to arouse or unable to awaken • Repeated vomiting • Slurred speech • Bloody or clear fluid from the nose or ears

21. INITIAL TREATMENT - BRAIN REST “Cocoon Therapy” Sleep a lot in dark room first day only or two days if multiple blows to head. Minimize activities first 3-5 days No reading No computer, video-games, I-pods, No walking No hot tubs No socializing with friends or going to movies No watching the team practice No Cell phones or text messaging 21

22. COGNITIVE FATIGUE On day two or three, to prevent cognitive fatigue, do activities in 10-15 minute intervals. Set a timer. Then take a 15 minute break. Initial 15 minute activities starting with: Soft music Cooking Books on tape Drawing Television Parents can read school work to student so they will not get too far behind in school. 22

23. When your child is able to do one to two hours of homework at home for one to two days, he/she may try to return for a half day of school. Alternately, if your child is able to do three to four hours of homework at home for one to two days, he/she may try to return to school for a full day. • If symptoms develop while your child is at school, a break should be taken in a quiet, supervised area until symptoms resolve. When symptoms resolve, she may return to class.

24. Headache Management Keep the dull and achy headache from becoming pounding and throbbing. Discontinue any activity that increases the headache Tylenol as needed (Ibuprofen after a few days) 24

25. SCHOOLStudents recover quickly during Christmas, Spring and Summer vacationsNeed to remember (remind parents) the first priority is to get kids back to school ASAP. Sports is a secondary priority

26. The return to school is a very critical time. If cognitive work is overdone, the concussion symptoms will return, sometimes almost as much as right after the injury.

27. SCHOOL MODIFICATIONS (when they return to school)

28. SCHOOL (initial return) Need to be driven to school initially (should not ride the school bus) Elevator passes if stairs (unless this makes them “dizzy”) Avoid halls and cafeteria initially No gym class or exercising initially (are not to be allowed in P.E. class) 28

29. Trial and error needed (balancing act) 1 period, ½ day, full day Go to nurse’s office when HA increases May need to audit classes initially Frequent breaks with rest periods Alternate class with rest period Gradually increase hours May need home schooling No extra-curricular activities or work 29

30. SCHOOL (initial return) No note taking (may need scribes) Audio books helpful Workload may need to be reduced 50-75% Homework less than 1-2 hours a night Frequent breaks while doing homework Term papers postponed Pre-printed class notes helpful (should be sent home while not in school) Tutoring to help catch up 30

31. SCHOOL (initial return) continued It is imperative that the student advocate for his/her needs. If an increasing headache develops they should not stay in class but should go to the nurse’s office. They can rest there (skip a period and try another class if the headache resolves). If it returns they need to go home.

32. SCHOOL TESTS (AFTER STUDENTS CATCH UP ON THEIR SCHOOLWORK!!!) Quizzes, tests, PSAT/SAT tests, final exams may need to be delayed or postponed. Initially, if test results are poor, they should be voided or retaken. Extra time (un-timed tests) may be necessary when test taking is resumed. Tests may need to be taken over multiple sessions. No more than one test a day when test taking resumed. If concentration and memory problems: Oral exams may be necessary if students develop headaches taking written tests. Open book tests may be needed for some students (especially if memory issues are present) 32

33. IF NOISE INCREASES SX Should not listen to loud music (especially in cars or on I-pods) Should avoid attending dances, parties, music concerts and sports events until symptoms are gone No music class 33

34. IF LIGHT INCREASES SX Avoidance of bright sunlight and exposure to flashing lights (strobe/computer games) Sunglasses may be necessary if photophobia is present (outdoors and sometimes indoors) No movietheaters (loud noise and bright flashing lights) 34

35. How many concussions are too many?NO EASY ANSWER

36. Each athlete needs to be evaluated individually. • There is no magic number as to how many concussions are too many. • Return to play should probably be guided by symptoms and neuro-psych testing regardless of the number of concussions. • If it takes exceedingly longer to recover from each concussion or PCS occurs, perhaps it may be time to do a non-contact sport. • Do you allow fewer concussions in youngsters ( What if 3 or 4 concussions before age 12?)

37. ADHD AND CONCUSSIONS

38. ??? Is it possible that some of the children we see who are diagnosed as having ADD are really concussion or post-concussion syndrome patients that have suffered permanent residual damage from their concussion(s). 38

39. RETURN-TO-PLAY PROTOCOLBegin after no symptoms in school 24 hours (or longer) for each stage No activity, complete rest. Once asymptomatic without headache, etc. (on no medications) proceed to step 2. Day 1 - Light aerobic exercise such as walking or stationary cycling. No resistance training. Day 2 - Jogging for 20-30 minutes Day 3 - Sport specific exercise (e.g. skating in hockey, running is soccer). May add resistance training. Day 4 - Non-contact training drills Day 5 - Full contact training after medical clearance. Game play RETURN TO PREVIOUS STEP IF SYMPTOMS RECUR

40. RETURN-TO-PLAY (CONTINUED) When symptom free, athletes should not be taking any medications or pharmacological agents that may affect or modify concussion symptoms.