Sports Concussion: Return to Play Guidelines

Eric Small, MD, FAAP, CAQSM Assistant Clinical Professor of Pediatrics, Orthopedics, and Rehabilitation Medicine Mount Sinai School of Medicine New York, NY Email: sportsdr@yahoo.com Website: www.sportsdoc4kids.com

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Sports Concussion: Return to Play Guidelines Eric Small, MD, FAAP, CAQSM Former Chair, Council on Sports Medicine and Fitness American Academy of Pediatrics 666 Lexington Ave. Mount Kisco, NY 914-666-7900 website: www.sportsdoc4kids.com email: sportsdr@yahoo.com

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Case Scenarios 6 year old hit head on floor in gym class 12 year old had concussion with amnesia while skiing one week ago 16 year old star soccer player with three concussions in 1 year

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Concussion Definition Research Management Return to play

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Terms Concussion Head Trauma TBI Dinger

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Definition Traumatically induced alteration in mental status often manifest by confusion or amnesia +/- loss of consciousness

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Broader definition A collision involving head or body that results in: Any observable change in mental status or consciousness The presence of loss of consciousness and/or presence of anterograde or retrograde amnesia Evidence of a constellation of post-concussion symptoms, such as cognitive fogginess, nausea/vomiting, dizziness, balance problems, visual changes, presence of post-traumatic headache

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Statistics 300,000 sports related concussion per year 2-10% of athletes depending on sport per season

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Sports with concussion Football Soccer Hockey Basketball Wrestling Cheerleading

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How long does it take to recover from concussion? 1 week 2 weeks 4 weeks More than 4 weeks

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Predictive Factors Age Sex Prior Concussion Preexisting Conditions (ADD, Learning Disability)

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Relation Between Subjective Fogginess and Neuropsychologic Testing Following Concussion 110 high school students who sustained a sports related concussion. Evaluated at day 5-10 (mean=6.8 days) Two groups (fogginess vs. no fogginess) Abstract National Academy of Neuropsychology Annual Conference, Miami Fl Oct 2002-Collins et al.

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Athletes with persistent fogginess experienced a large number of post-concussive symptoms (slower reaction times, reduced memory, slower processing speed) Those athletes with self-reported fogginess 7 days out are likely to have persistent adverse effects.

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Concussion Rates and Return to Play in High School Football Players 3 year prospective study 2,141 high school athletes from 17 schools Ongoing Neuropsych/Neurocognitive testing (Collins et al. Neurosurgery 2006)

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On Field Assessment Loss of consciousness 16.1% Confusion/Disorientation 64.5% Retrograde amnesia 28.8% Posttraumatic amenesia 27.4% Headaches 90.3% Dizziness 77.4% Balance Problems 46.8% Visual Changes 38.7% Personality Changes 22.6% Fatigue 50.0% Sensitivity to light or sound 43.5% Numbness or tingling 17.7%

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Method of Contact Head-head 71.0% Head-ground 16.1% Head-body 9.7% No head contact 1.6% Missing data 1.6%

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Region of Head Hit Frontal 56.5% Right Temporal 16.1% Left Temporal 12.9% Occipital 12.9% Missing Data 1.6%

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Recovery From Concussion How Long Does it Take? N=134 High School athletes WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 Collins et al., Neurosurgery 2006

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Old system of Concussion Grade I-no loc Grade II-loc <5 min Grade III-loc >5min (Colorado Guidelines, Cantu Rules)

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New Grading System Grade I-simple Grade II-complicated Prague Guidelines, British J Sports Med (2005)

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Grade I-simple No loc No amnesia Symptoms resolve in 2-7 days

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Grade II-complicated LOC Amnesia Seizure Prolonged symptoms

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NEUROCOGNITIVE TESTING and CONCUSSION MANAGEMENT N=215, MANOVA p<.000000 (Lovell, Collins et al., 2004) Testing reveals cognitive deficits in asymptomatic athletes within 4 days post-concussion

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VALUE ADDED OF NEUROCOGNITIVE EVALUATION 201 concussed High School and collegiate athletes tested with 2 days of injury. Abnormal performance determined by RCI’s (van Kampen, AJSM 2006). Neurocognitive testing increases Diagnostic yield to 91%

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Commonly known Symptoms Headache Blurred Vision Nausea/Vomiting Attention Problems Forgetfullness Personality Changes

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Other symptoms Verbal Memory Problems Visual Memory problems Problems reading Problems writing Personality Changes Forgetfullness

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Processing of Brain Visual Memory Verbal Memory Reading Writing Problem solving

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fMRI and NEUROCOGNITIVE TESTING 18 Year Old Running Back With 3 Concussions 4 DAYS POST INJURY 25 DAYS POST INJURY Concussed Athlete Control Athlete

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Children are different from adults Poor self esteem, loneliness, and antisocial behavior (Andrews et al. 1998-Brain Injury 1998; 12(2):133-8) Children/adolescents take longer to recover than young adults/adults (Field et al. J Peds 2003 142(5): 546-553) After TBI children often still have memory problems at day 7

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Incidence of Concussion 5-20% of high school football 2-10% of college football

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Second Impact Syndrome Underlying Cerebral edema Second head trauma that leads to cerebral dysregulation and possibly death 50% mortality

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ER Management History Physical Exam Special Tests Instruction Sheet

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Pediatrician Management Rest from physical activity Rest from school work and mental activity

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Imaging studies CT, MRI, EEG only good for structural problems Concussion is a metabolic problem not a structural one!!!

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School Nurse Management Gym or not After school sports or not The Sports Physical

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The Team Approach Coach Athlete Parent Physician School Teacher School Nurse

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Follow-Up 3 days 7 days 1 month 2 months 6 months

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Management 48-72 hours Rest from school ½ day or just 1 or 2 classes No tests

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Management Day 3-7 May return to school/work Normal activity

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When is it safe to return to sport 1 week 2 weeks When the athlete is symptom free

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Return to Play: Prague Guidelines Must be symptom free for one week Must be symptom free at rest Must be symptom free with noncontact exercise Must be symptom free with contact exercise McCory P et al. Br J. Sports Med 2005 Apr 39 (4) 196-204

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Return to Play Simple-No loc, no amnesia-1-2 weeks Complex- Amnesia- 2-3 weeks Multiple concussions with concentration memory problems- probably shouldn’t do a contact sport forever

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Return to Play too soon Risk-concentration/learning problems for rest of life, persistent headache, second impact syndrome Benefit-”macho, part of team” It’s a really important tournament (MH-age 11)

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Functional Testing Running Sprinting Sit-ups Push-ups

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Functional MRI and Sports Concussion

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6 year old No gym or sports until symptom free for one week No specialist referral required

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12 year old with amnesia Should be kept out of school and physical activity initially Noncontact, mild/moderate exertion; noncontact moderate severe exertion; contact activity sport Psychologist Sports Medicine/Neurology Ensure adequate follow-up

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16 year old with multiple concussions Neuropsych testing Should be kept out of school for several days or certainly modify schedule More gradual return to aerobic exercise Psychologist Sports Medicine/Neurologist Ensure follow-up for many years

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Prevention Education (coaches, physicians, nurses, parents, athletic directors, athletes) Research Advocacy

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Prevention II Mouthguards Proper fitting equipment (helmets) Role of nutrition/hydration

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Resources The Preparticipation Physical Exam (McGraw Hill 2005) CDC-TBI Project University of Pittsburgh (Collins and Lovell)

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Summary Children take longer to recover from mild concussion/head trauma Young athletes must be asymptomatic at rest, with noncontact exercise, and with contact exercise before competing

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Summary High Index of suspicion for concussion Coordinate care and follow-up Education of parents, coaches, physicians, nurses, athletes

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