12/12/2015

Sports Concussion Update 2015

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– Athletic trainer at high school – M.D. on sideline and in clinic – Preparticipation exams

A. Primary care provider, involved in sports coverage. B. Primary care provider, not involved in sports coverage. C. Physical therapist. D. Chiropractor. E. Athletic trainer. F. Other ar y

• UCSF Playsafe and UCSF Sports Concussion Program

Who are you?

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Who are we?

I have no disclosures.

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Carlin Senter, MD Co-Director UCSF Sports Concussion Program UCSF Departments of Medicine and Orthopaedics December 11, 2015

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How many sports concussion cases do you see in your practice?

A. B. C. D.

A few patients/week A few patients/month A few patients/year None

Concussion update 2015

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21%

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Keys to managing sports concussion in 2015

Sports concussion updates 2015 1. Concussion legislation 2. CIF handouts and guidelines 3. US Soccer and heading

3-pronged evaluation Treatment is rest Gradual return to learn then play No available gear that definitively reduces risk of injury • When to refer • • • •

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Put these high school sports in order of highest to lowest incidence of concussion. Soccer (boys) Soccer (girls) Basketball (girls) Wrestling (boys) Football (boys)

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So cc er (b oy s) So cc er (g ir l s) B a sk et ba ll ( gi r ls W ) re st lin g ( bo ys ) Fo o t ba ll ( b o ys )

A. B. C. D. E.

Concussion definition

Rates of sports concussion in high school sports U.S. 2011-2012

Sport

Football (boys) Soccer (girls) Wrestling (boys) Soccer (boys) Basketball (girls)

Rate per 1000 athletic exposures 0.94 0.73 0.57 0.41 0.37

Rosenthal JA, Foraker RE, Collins CL, Comstock RD. National High School Athlete Concussion Rates From 2005-2006 to 2011-2012. Am J Sports Med. 2014 Jul;42(7):1710-5.

Concussion Symptoms

• Type of mild traumatic brain injury

Physical

• Blow to head, neck, body
force to head.

• Neurologic impairment within 48 hours of trauma.

• Symptoms usually resolve in 1-2 weeks spontaneously but in some cases can be prolonged.

Sleep

Cognitive

• May or may not include loss of consciousness.

Emotional

http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf.

Accessed Nov. 9, 2008.

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How Severe is my Concussion? • Concussion grading is retrospective

– Historically concussions were graded on the sideline based on amnesia and LOC at time of injury. – American Academy of Neurology, 1997 – Cantu, 2001

– Studies have shown these factors not to be predictive of recovery.

• Only when the athlete recovers can you tell how severe the concussion was

Who is at risk for delayed RTP? LOC > 1 minute Amnesia Convulsions History of multiple concussions • Injuries close together in time • Repeat injuries with less and less force • • • •

• • • • •

Younger age Migraine headaches Depression ADHD Sleep disorders

Symptom Resolution • 50% recovered and returned to play in 1 week; 90% in 3 weeks (Collins et al. Neurosurgery, 2006.) • Recovery in athletes may be faster than recovery in others (Levin HS and Diaz-Arrastia RR. Lancet Neurol 2015; 14: 506-17.)

• Recovery in kids may take longer than recovery in adults

Case 1 17 y/o high school lacrosse player presents to your clinic with symptoms concerning for concussion. How would you evaluate her? 1. Neck exam Rule out 2. Head exam emergency 3. Neurologic exam 4. Concussion evaluation

Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014.

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Concussion evaluation: physical exam

• Normal neck exam • Normal neurologic exam

3-pronged concussion evaluation 1. Self-reported symptom assessment 2. Mental status: Standardized Assessment of Concussion (SAC) 3. Balance. Balance Error Scoring System (BESS or modified BESS)

Broglio SP et al. NATA Position Statement on Concussion. J of Athletic Training, 2014.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8

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Symptom and SAC norms 9th grade

10th grade 11th grade

Symptom score 17 +/- 5

16 +/- 5

17 +/- 6

SAC

27 +/- 2

27 +/- 3

26 +/- 3

BESS

Valovich McLeod TC et al. Representative baseline values on the sport concussion assessment tool 2 (SCAT2) in adolescent athletes vary by gender, grade and concussion history. AJSM 2012.

http://paulhead.co.uk/wp-content/uploads/2013/11/balance.jpg

BESS scoring

BESS norms: ages 10-17

• Each error is counted as one point • Score = the sum of the error points for all six trials • Errors – – – – –

Eyes opening Hands coming off the hips Hip flexion or abduction of greater than 30 Changing foot placement from the stance Remaining out of the test position for > 5 seconds

• Max score 10 errors • Also if cannot maintain for minimum 5 seconds then score = 10

Khanna NK, Baumgartner K, LaBella CR. Balance Error Scoring System Performance in Children and Adolescents With No History of Concussion. Sports Health. 2015 Jul;7(4):341-5.

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BESS norms: adults

Case 2 16 y/o high school student presents to your office with concussion sustained 3 days ago during football. He reports headache, fogginess, and dizziness that is mild to moderate intensity at home but moderately severe at school. He is resting from sports.

Iverson GL, Kaarto ML, Koehle MS. Normative data for the balance error scoring system: implications for brain injury evaluations. Brain Inj. 2008 Feb;22(2):147-52.

What do you recommend he do with respect to school?

A. Continue school without adjustments. B. Continue school but no test-taking. C. Rest from school until can tolerate 1-2 hours of work at home. D. Rest completely from school until all concussion symptoms have resolved.

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• Cognitive rest • Physical rest • Medication

73%

– Tylenol – Ibuprofen after first 72 hours

• No driving • No Etoh

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Concussion treatment

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New in 2015

CIF: Physician letter to school

31

32

Return to learn progression

No school.

OK to do light reading, little bit TV, drawing, cooking as long as doesn’t worsen symptoms.

15 min cognitive activity at a time.

30 min schoolwork at a time until can do 1-2 hours.

Return to ½ day of school.

Return to full day of school.

Case 3A 16 y/o high school student presents to your office with concussion sustained playing soccer 2 weeks ago. She initially had headache, dizziness, and fogginess, but those symptoms resolved 2 days ago. She is now asymptomatic with a normal neurologic exam. She has no deficits on balance testing. She has no deficits on memory testing.

http://www.chop.edu/service/concussion-carefor-kids/returning-to-school.html

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Assuming she remains asymptomatic, when would you clear her to return to full contact soccer games? 49%

25% 18%

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• 50 states have adopted youth concussion laws

• California: education code 49475 (effective 1/2012) 1. Athletes and guardians sign a concussion information form yearly 2. Athlete suspected of having concussion removed at time of injury for the rest of the day 3. Athlete can return only after cleared by healthcare professional trained in evaluation and management of concussion

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Today Tomorrow In 2 days In 1 week 1 month after symptoms resolved

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A. B. C. D. E.

Concussion Legislation

Concussion legislation

Return to Play Progression

• California Assembly Bill 2127 (in effect 1/2015)

Clinician clearance

– Adds to AB 25

• FB full-contact practice limits:

– No more than 2/week during preseason and season – These practices cannot exceed 90 minutes – No full-contact in off-season

• Once clear must follow gradual return to play protocol of at least 7 days under supervision of licensed provider

Asymptomatic

Light aerobic activity

Sport specific activity

Noncontact training

Full contact practice

Game play

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Return to play activity examples

Step

Objective

Activities

2

Light aerobic activity: Increase heart rate

Walking, swimming, or stationary bike. < 70% max heart rate. No weights.

3

Sport Specific: Add movement

Skating drills in hockey, running drills in soccer. No head impact activities.

4

Non contact training: Add coordination and cognitive load

More complex drills (passing). Can start weights.

1

5 6

Recovery

CIF: Return to play handout

No activity

Restore confidence and assess functional skills by coaching staff

Full-contact practice Normal game play

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8.

Case 3B The student athlete follows up with you as scheduled to consider full contact clearance. She has spent a week on the gradual RTP progression. She did 1 hour of high intensity non contact training yesterday. She felt good except for a very mild headache during the sprinting workouts. The headache is now gone. Her neurologic exam, balance testing, and memory testing is normal.

40

Return to Play Progression Clinician clearance

Asymptomatic

Light aerobic activity

Sport specific activity

Noncontact training

Full contact practice

Game play

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What do you do next? A. Clear her for full contact practice tomorrow followed by full contact game the next day. B. Have her return to sport specific activity tomorrow, then do non contact training and see you next week to consider full clearance. C. Recommend rest from sports for a few days and follow up with you next week. D. Recommend rest from sports for one week, follow up with you in 2 weeks.

Return to Play Progression

Asymptomatic

Sport specific activity

Game play

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Clinician clearance

87%

Symptoms during return to play • If symptomatic during a step of the return to play protocol…

– Stop activity – Rest until symptoms resolve, at least 24 hours. – Resume return to play protocol at the step where athlete was last asymptomatic

2nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196.

Case 4 A 15 y/o soccer player presents to you 3 months after her 5th concussion sustained when she was elbowed in the head during a game. She has had a headache with light sensitivity since the injury. She and her father would like to know if and when she can return to soccer, and whether or not there are ways to minimize her risk of future concussion with soccer.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8

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What would you do?

Post Concussion Syndrome • Frequency unclear (0-15%). • Concussion symptoms persist x months, usually