Concussion in the pediatric athlete is fought with difficult decision trees, pressure from parents and coaches, and potential for serious harm and even death if mismanaged. Jordan G. Roberts, PA-C discusses an overview of what's new in this rapidly evolving field at the AAPA national meeting in May 2018.
3. Alla S, Sullivan SJ, Hale L, et al. Self-report scales/checklists for the measurement of concussion symptoms: a systematic review.
British Journal of Sports Medicine 2009;43:i3-i12.
Bryan MA, Rowhani-Rahbar A, Comstock RD, Rivara F. Sports- and Recreation-Related Concussions in US Youth. Pediatrics.
2016;138(1). doi:10.1542/peds.2015-4635.
Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. The
Journal of head trauma rehabilitation. 2016;31(4):233-241. doi:10.1097/HTR.0000000000000165.
Carney N, Ghajar J, Jagoda A et al. Concussion Guidelines Step 1. Neurosurgery. 2014;75:S3-S15.
doi:10.1227/neu.0000000000000433.
Clark J, Hasselfeld K, Bigsby K, Divine J. Colored Glasses to Mitigate Photophobia Symptoms Posttraumatic Brain Injury.
Journal of Athletic Training, 2017; DOI: 10.4085/1062-6050-52.4.04
Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D, Grant G. Translational Research in Traumatic Brain
Injury. CRC Press; 2016.
Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE Rules for Children
with Minor Head Injury: A prospective cohort study. Annals of emergency medicine. 2014;64(2):145-152.e5.
doi:10.1016/j.annemergmed.2014.01.030.
References
4. Ellis MJ, Mcdonald PJ, Cordingley D, Mansouri B, Essig M, Ritchie L. Retirement-from-sport considerations following pediatric
sports-related concussion: case illustrations and institutional approach. Neurosurgical Focus. 2016;40(4).
doi:10.3171/2016.1.focus15600.
Press Announcements - FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults. U S Food
and Drug Administration Home Page. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm.
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References
5. McCrory, Paul et al. "Consensus Statement On Concussion In Sport—The 5th International Conference On Concussion In Sport
Held In Berlin, October 2016". British Journal of Sports Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.
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prevention. Clin J Sport Med. 2004 Jan;14(1):13-7. PubMed PMID: 14712161.
Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions:
Preliminary Findings. The American journal of sports medicine. 2014;42(10):2479-2486. doi:10.1177/0363546514543775.
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With Common Concussion Screening Tools - Nov 11, 2016. Sage Journals. 2017. Available at:
http://journals.sagepub.com/doi/full/10.1177/1941738116678411. Accessed February 2, 2017.
References
6. 1. Discuss the initial evaluation of the student athlete with a
suspected sports-related concussion (SRC) in the primary
care setting
Objectives
2. Describe techniques for supporting student athletes during
Return-to-Learn (RTL) phase of recovery
3. Recognize indications for Return-to-Play (RTP) by weighing
risks against benefits of continued participation
8. Concussion is a traumatic brain injury and is induced by
biomechanical forces
• Rapid onset, transient neurological impairment that resolves spontaneously
• Symptoms evolve over minutes to hours
• Resolution follows a sequential course (but not always)
• May result in neuropathologic changes, but functional > structural disturbance
Definition
McCrory, Paul et al. "Consensus Statement On Concussion In Sport—The 5th
International Conference On Concussion In Sport Held In Berlin, October 2016".
British Journal of Sports Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.
10. Mechanism of injury
● Rotational
● Acceleration-deceleration
➔Neurometabolic cascade
Pathophysiology
Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D,
Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.
11. Mechanism of injury
● Rotational
● Acceleration-deceleration
➔Neurometabolic cascade
Pathophysiology
LOSS OF CONSCIOUSNESS:
ONLY 10% OF CASES
Clark, M Guskiewicz K. Sport-Related Traumatic Brain Injury. In: Laskowitz D,
Grant G. Translational Research in Traumatic Brain Injury. CRC Press; 2016.
18. Description of the incident
➔Do they remember what happened?
Symptom onset
➔Immediate v delayed
◆If delayed, activity in the meantime
Any on-field documentation
History
20. Graded checklist of symptoms
➔ Used to monitor course & recovery
Several iterations; ever-evolving
➔ Post Concussion Symptom Scale
➔ Graded Symptom Checklist
➔ Rivermead Post Concussion Scale
Tool #1: Symptom Scale
Alla S, Sullivan SJ, Hale L, et al. Self-report scales/checklists for the measurement of
concussion symptoms: a systematic review. British Journal of Sports Medicine 2009;43:i3-i12.
25. A Brief Vestibular/Ocular
Motor Screening (VOMS)
Available for download at
ModernMedEd.com/conference
Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular
Motor Screening (VOMS) Assessment to Evaluate Concussions:
Preliminary Findings. The American journal of sports medicine.
2014;42(10):2479-2486. doi:10.1177/0363546514543775.
27. ● Loss of consciousness
● Multiple episodes of vomiting
● Neck pain with motor dysfunction or radiculopathy
● Neurologic deficits (weakness, anisocoria, GCS<13)
Red Flags
29. To scan or not to scan?
CT or MRI?
With or Without Contrast?
Imaging
Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of
PECARN, CATCH, and CHALICE Rules for Children with Minor Head Injury: A
prospective cohort study. Annals of emergency medicine. 2014;64(2):145-
152.e5. doi:10.1016/j.annemergmed.2014.01.030.
30. Brain Trauma Indicator
“FDA authorizes marketing of first blood test to aid in the
evaluation of concussion in adults”
News Release from FDA.gov
February 14, 2018
Laboratory Investigation
33. ‘Relative’ rest
➔Mushroom theory of strict rest
When can an athlete return to
competition?
What exactly is ‘relative’ rest?
Management
Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest
May Not Improve Concussion Recovery Time. The Journal of head trauma
rehabilitation. 2016;31(4):233-241. doi:10.1097/HTR.0000000000000165.
35. MOST important part of
recovery process
Stages
Step 1: ‘Relative’ rest
Step 2: Modified school schedule
Step 3: Full day of school, no testing
Step 4: Full days, limited testing
➔ Mastery Learning Materials
Step 5: Return to full academic load
Can start anywhere on the list, and
advance or step back as tolerated
Return-To-Learn
40. Tinted lenses
●Red or orange: media/screens
Support During Return-to-Learn
Clark J, Hasselfeld K, Bigsby K, Divine J. Colored
Glasses to Mitigate Photophobia Symptoms
Posttraumatic Brain Injury. Journal of Athletic
Training, 2017; DOI: 10.4085/1062-6050-52.4.04
41. Tinted lenses
●Red or orange: media/screens
○“Night Mode”
●Gray: sunlight
Support During Return-to-Learn
Clark J, Hasselfeld K, Bigsby K, Divine J. Colored
Glasses to Mitigate Photophobia Symptoms
Posttraumatic Brain Injury. Journal of Athletic
Training, 2017; DOI: 10.4085/1062-6050-52.4.04
42. Encourage art & creativity
➔Avoid inactivity (aka boredom)!
Support During Return-to-Learn
44. Indications
Contraindications
Return-To-Play
McCrory, Paul et al. "Consensus Statement On Concussion In
Sport—The 5th International Conference On Concussion In
Sport Held In Berlin, October 2016". British Journal of Sports
Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.
45. Supervised progression of activity
● Both intensity and duration
● Should be sport-specific
Goal: safely return to pre-injury activity
levels
Look for ANY symptom recurrence
Protocol
Day 1: Light aerobic conditioning
Day 2: Moderate aerobic conditioning
Day 3: Full aerobic conditioning, drills requiring
physical and mental dexterity
Day 4: Non-contact practice
Day 5: Resume normal activity
For extra liability protection: have a form letter
sent to school with athlete
- Athlete signs
- Parent signs
THEN you provide a letter of clearance
Return-To-Play
McCrory, Paul et al. "Consensus Statement On Concussion In
Sport—The 5th International Conference On Concussion In
Sport Held In Berlin, October 2016". British Journal of Sports
Medicine (2017): bjsports-2017-097699. Web. 27 Apr. 2017.
46. Considerations for Retirement
Return-To-Play
Traumatic structural lesion, especially
if craniotomy is required
Prolonged inability to complete RTL or
RTP without symptoms returning
Psychiatric outcomes
How many concussions is too many?
Recovery gets ‘harder’ → increasing:
○ Frequency of mTBI
○ Time to symptomatic recovery
○ Severity/number of symptoms
Ellis MJ, Mcdonald PJ, Cordingley D, Mansouri B, Essig M, Ritchie L.
Retirement-from-sport considerations following pediatric sports-related
concussion: case illustrations and institutional approach. Neurosurgical
Focus. 2016;40(4). doi:10.3171/2016.1.focus15600.
47. 1. Concussions are unique, complex brain injuries
4 Take-Home
Lessons For Practice
2. The presentation & course can be extremely variable
3. Sorry, you can’t rely on lab tests or imaging to diagnose
4. Focus on the Return-to-Learn, even if the athlete is focused
on the Return-to-Play
