Concussion in Pediatric and Adolescent Athletes

Arlene Goodman, MDPediatric and Adolescent Sports Medicine

The Division of Orthopaedic SurgerySports Medicine and Performance Centerat The Children’s Hospital of Philadelphia

goodmana@email.chop.edu

A Goodman

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

A Goodman

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

A Goodman

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

A Goodman

Neurometabolic Cascade

Giza & Hovda, 2001

A Goodman

MTBI: Pathophysiology

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

A Goodman

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

A Goodman

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

A Goodman

Physical Education Injuries

• 21.6% Elementary school (5-10 y)

• 52% Middle school school (11-14 y)

• 26.4% High School school (15-18 y)

Increased 150%

A Goodman

Physical Education Injuries

• Concussion– 1.9% Elementary School– 1.6% Middle School– 1.9% High School

A Goodman

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

A Goodman

A Goodman

Signs and Symptoms

Physical •Cognitive Emotional Sleep•Headache

•Dizziness

•Nausea

•Vomiting

•Balance problems

•Visual problems

•Fatigue

•Photophobia

•Phonophobia

•Numbness/tingling

•Dazed or Stunned

•Tinnitus

•LOC

•Amnesia

•Feeling mentally “foggy”

•Felling slowed down

•Difficulty concentrating

•Difficulty remembering

•Confused about recent events

•Answers questions slowly

•Repeats questions

•Irritability

•Sadness

•More emotional

•Nervousness/anxiety

•Depressed mood

•Personality change

•Emotional lability

•Drowsiness

•Sleeping less than usual

•Sleeping more than usual

•Trouble falling asleep

A Goodman

Concussion symptoms ends play and school that day

When in doubt, sit them out and notify the parents!!!

A Goodman

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

A Goodman

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

A Goodman

A Goodman

A Goodman

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)

A Goodman

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

Tandem stance

A Goodman

Balance Testing

A Goodman

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

A Goodman

Concussion-Specific Neurological Exam

A Goodman

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

A Goodman

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

A Goodman

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

A Goodman

Management Considerations

Concussion Modifiers:

• Amnesia

• Prolonged LOC (>1 minute)

• Cumulative Effects of Previous Concussion

• Age

• Symptoms

• Co- and Pre-morbidities

A Goodman

Concussion Treatment – Acute PhaseOverall Goal

Protect the brain during vulnerable state of metabolic mismatchBrain activity will increase demand for glucose and aggravate/prolong symptomsExercise diverts needed resources to exercising muscles and aggravates/prolongs

symptoms

Treatment = Cognitive/Physical Rest

A Goodman

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

A Goodman

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

A Goodman

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