Concussions:
What’s the big deal?
Carla Bystricky, MD
Pediatrician at Parkview Whitley
Some facts about
concussions:
Football has the highest number of
concussions per year BUT girls
have a higher concussion rate in
similar sports (example girl soccer
players get more concussions
than boy soccer players)
There are an estimated 3.8
MILLION recreation and sport
related concussions in the US
each year
8.9% of all high-school related
sports injuries are concussions
What is a Concussion?
• A brain injury
• A complex pathologic process that affects the brain due
to traumatic biomechanical forces secondary to direct or
indirect forces to the head
• An alteration to mental status with or without loss or
consciousness due to trauma
• Medical Term- also known as a mild Traumatic Brain
Injury
• Often no STRUCTURAL damage (normal MRI, CT) but
FUNCTIONAL damage is present
Pathophysiology of Concussion
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Release of Excitatory Neurotransmitters
Altered Cerebral Blood Flow
Changes in Glucose metabolism
Production of Lactic Acid and Free
Radicals
• Mitochondrial dysfunction
• Axonal injury
Concussions cause an “Energy
crisis” in the brain
Signs and Symptoms
• 4 categories:
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Physical
Cognitive
Emotional
Sleep
• Headache is the MOST common reported symptom
• Loss of Consciousness occurs in less than 10% of
concussions but may be clue that further imaging and testing
should be done
• Amnesia (before or after event) and vomiting are also
concerning signs
• Assess for bruising of mastoid (battle sign) and raccoon eyes
(blood around eyes)-signs of skull fractures
Physical Signs and Symptoms
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Headache
Nausea
Vomiting
Balance Problems
Visual Problems
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Fatigue
Sensitivity to light
Sensitivity to Noise
Dazed
Stunned
Cognitive Signs and Symptoms
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Feeling “foggy”
Feeling “slowed down”
Trouble concentrating
Trouble remembering
Forgetful of recent information
Confused about recent events
Answers questions slowly
Repeats questions
Emotional Signs and Symptoms
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Irritability
Sadness
More Emotional
Nervousness
May appear similar to depression, anxiety or
ADHD
• Kids with pre-existing ADHD, mental health
issues or migraines are likely to have a more
difficult to control course
Sleep Signs and Symptoms
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Drowsiness
Sleeps more than usual
Sleeps less than usual
Difficulty falling asleep
Short Term Effects
• The signs and symptoms for each child
can be very different
• Most kids recover within 2-4 weeks if
treated appropriately
• 85-95% fully recover by 3 months
• Home life, school life and academic
performance, peer relationships all can be
affected.
Diagnosis and Management:
What to Do
• Grading and severity are no longer
recommended for use by several medical
organizations, as much of the symptom
checklists and symptoms by the individual
are subjective and/or related to prior
existing medical conditions. Thus, severity
would be difficult to predict
Sideline Assessment Tools
• Many different Versions
• Sports Medicine and Pediatric professional
organizations lean towards:
• SCAT 2 (Sports Concussion Assessment Tool 2)
• The American College of Sports Medicine Assessment
Tool
• Concussion Recognition and Response App (free!)
• The American Academy of Neurology recommend:
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GSC (Graded Symptom Checklist)
SAC (Standardized Assessment of Concussion)
BESS (Balance Error Scoring System
Concussion Quick Check App (free!)
Portable Technology…
Immediately After:
• Remove from the Game!!! (As discussed)
• No NSAIDS (Motrin, Ibuprofen, Advil, Aleve, Naproxyn)
or Aspirin until at least 24 hours after injury
• After the initial 24 hours, may wish to take for some
symptom relief but will not necessarily speed recovery
• For the most part, the child does NOT need to be
awoken during the night
• Rest/sleep is a chance to let the brain heal
If assessment is suspicious for
concussion:
• Do not return to game if concussion is suspected
• If no loss of consciousness, no amnesia, no
vomiting the child should not need any brain
imaging and may not need to see a doctor until
the next day or 2.
• The child should see a doctor and be placed on
an INDIVIDUALIZED return to learn and return
to play protocol
Other Assessment and
Diagnostic Tools
• New Research in 2014 JAMA Neurology
• T-tau biomarker peaks within 12 hours of
concussion and remains elevated up to 6
days.
• T-tau decreases as the patients signs and
symptoms improve
ImPACT Testing
• Immediate Post-Concussion Assessment and
Cognitive Testing
• Used by many schools and Universities for
athletes
• A Neuropsychiatric test, performed on athletes at
“baseline” then after concussion to monitor
cognitive effects of the concussion
• Developed in early 1990s by a neuropsychiatrist
(Dr Lovell) and Neurosurgeon (Dr Maroon)
• Should only be used as an adjunct, not the sole
diagnostic eval to guide return to play
ImPACT- Maybe not as good as
we thought
• Some “risks”:
• Recent review of data showed a 30-40 % false +
AND false negative rate (missing some and overincluding others)
• Company claims “Reliable and Valid” based on
many studies but many of these studies done by
developers and did not report conflict of interest
• 2007 Journal of Athletic Training- study on
athletes concussion free for at least 6 months,
study at “baseline”, repeated 45 days later, 38%
identified as having concussion
Beware of “Sandbagging”
• Athlete deliberately performs poorly on
baseline testing, so that if there is a
concussion that occurs, it will not keep
them out of play
• Several professional athletes are now
admitting to this
Return to Learn?
• Start with “Cognitive Rest”- minimal activities that
activate the brain, like TV, video games, computer
games, homework
• Once good symptom control at rest and can concentrate
at least 30-45 minutes, may start back to school but may
need extra time for tests, lower homework load
• Recent studies show prolonged (>48 hours) “strict rest” delays
recovery
• NO STANDARDIZED TESTS (ex ACT, SAT) should be
taken while the child is recovering as this can cause
lower than expected score that are not truly
representative of abilities.
Return to Learn
• Some other school adjustments:
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Shortened days
Work 30-45 min then 15 min break
Provide class notes
Tutoring
Decrease course expectations
Limit hours of homework
Sunglasses
Quiet environments
Decrease particular subjects that exacerbate symptoms
Extra time for tests
• If special school adjustments needed longer than 3 weeks,
athlete may require 504 or IEP (longer & more extensive)
Consequences
• The graduated returning to learning can be
hard in several aspects
• Teachers may not understand why child
needs special treatment because child looks
“normal”
• Friends may not understand or talk to child as
much when can cause stress
• Can get behind in school work which makes
more stress for child
Return to Play (RTP)
• American Academy of Pediatrics has a 6 Phase
program for RTP
• May progress to next phase every 24 hours if
SYMPTOM FREE
• If has symptoms, return to the PREVIOUS phase
for another 24 hours
RTP Phases
1. Baseline
• No physical or cognitive symptoms for 24
hours
2. Increase Heart Rate
• Increase HR for 5-10 minutes with mild
activity (walking, light jog, exercise bike)
3. Moderate Exercise
• Limit body and head movement (brief running,
moderate weight lifting
RTP Phases (continued)
4. Noncontact Exercise
• Increase intensity but no contact (intense
running and non-contact sport specific drills)
5. Practice
• With full contact
6. Play/Game
• Return to competition
Long Term Risks
• After 1st concussion, it take less impact/injury to
cause a 2nd concussion that may take an even
longer time to heal than the 1st.
• 3 months after, studies show some kids have
persistent processing issues
• Athletes with 2 or more concussions show on
average to have lower grade point averages
Long Term Risks:
Postconcussion Syndrome
• If the child takes longer than normal for the concussion
symptoms to resolve, this is known as post concussive
syndrome.
• Most kids heal in 2-4 weeks
• The definition of the length of time is not agreed on
but is usually greater than 6 weeks
• Early postconcussive syndrome and cognitive
impairments are longer lasting in younger athletes
compared to older athletes
• Most concussion assessments have not been validates on preteens or younger
• AAN recommends more conservative management regarding
RTP in athletes high school age and younger
Long Term Risks:
Second Impact Syndrome
• A rare problem in which someone with a
concussion returns to play before symptoms
resolved and gets a second injury that causes
vascular “congestion” in the brain
• (bad blood flow in the brain)
• This can cause brain swelling and death
• Kids and Teens at highest risk for this
(compared to college age kids and adults)
Long Term Risks:
Chronic Traumatic Encephalopathy
• Basically, long term brain damage
• Highest risk in those that have had 3 or
more concussions
• This is the ongoing debate in the NFL now
When to see a Concussion
Specialist
• Parental Concern
• Worsening symptoms despite appropriate
accommodations and management
• Symptoms longer than 6 weeks
• Multiple concussions
• Risk factors for prolonged recovery
• These specialists would make decisions
about “Retirement from Play”
Prevention?
• Recognition and Education are KEY!!!
• Kids, Parents, Teachers, Coaches,
Trainers, even Doctors!!!
• Proper Equipment with appropriate fit
• Good Sports technique
• Adherence to Rules of the Sport
Resources for PT/ATC and
parents/families/coaches
• Kidshealth.org
• Healthychildren.org
• Cdc.gov
• Heads Up program
• American Academy of Neurology
• American Academy of Pediatrics
• www.evanshealthlab.com (search
concussion 101)
Questions?