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Sports Concussion Update 2015Carlin Senter, MD

Co-Director UCSF Sports Concussion ProgramUCSF Departments of Medicine and Orthopaedics

December 11, 2015

I have no disclosures.

Who are we?

• UCSF Playsafe and UCSF Sports Concussion Program– Athletic trainer at high school– M.D. on sideline and in clinic– Preparticipation exams

Who are you?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

P r i ma r y

c a re p

r o vi d e

r , i n. . .

P r i ma r y

c a re p

r o vi d e

r , no . . .

P h ys i c a

l t he r a

p i s t.

C h ir o p

r a ct o r

.A t h

l e t ic t r

a i ne r . O t he r

5%

75%

13%7%

0%0%

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

A. A few patients/weekB. A few patients/monthC. A few patients/yearD. None

A f e w p a t

i e nt s / w

e e kA f e w

p a t i en t s / m

o n th

A f e w p a t

i e n ts / y e

a r N o n e

4%

20%

55%

21%

Concussion update 2015

Sports concussion updates 20151. Concussion legislation2. CIF handouts and guidelines3. US Soccer and heading

Keys to managing sports concussion in 2015

• 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.A. Soccer (boys)B. Soccer (girls)C. Basketball (girls)D. Wrestling (boys)E. Football (boys)

S o cc e r

( b oy s )

S o cc e r

( g i rl s )

B a s ke t b

a l l (g i r l

s ) W r e s t

l i n g ( b o

y s ) F o o

t b a l l (b o y s

)

0% 0% 0%0%0%

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

Sport Rate per 1000 athletic exposures

Football (boys) 0.94Soccer (girls) 0.73Wrestling (boys) 0.57Soccer (boys) 0.41Basketball (girls) 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 definition• Type of mild traumatic brain injury• 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.• May or may not include loss of consciousness.

Physical

Cognitive

Emotional

Sleep

Concussion Symptoms

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

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

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

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

Case 117 y/o high school lacrosse player presents to your clinic with symptoms concerning for concussion. How would you evaluate her?1. Neck exam2. Head exam3. Neurologic exam4. Concussion evaluation

Rule out emergency

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Concussion evaluation: physical exam

• Normal neck exam• Normal neurologic exam

3-pronged concussion evaluation1. Self-reported symptom assessment2. 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 norms9th grade 10th grade 11th grade

Symptom score 17 +/- 5 16 +/- 5 17 +/- 6SAC 26 +/- 3 27 +/- 2 27 +/- 3

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.

BESS

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

BESS scoring• 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

BESS norms: ages 10-17

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

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.

Case 216 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.

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.

C o nt i n u e s

c h o o l w i t h ou t .

. .

C o n t i nu e s

c h oo l b

u t n o t . . .

R e st f r o

m s c ho o l u

n t i l c a .

. .

R e s t c o m p l e t

e l y f r o m s c h

. . .

8% 10%

73%

10%

Concussion treatment• Cognitive rest• Physical rest• Medication

– Tylenol– Ibuprofen after first 72

hours• No driving• No Etoh

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New in 2015

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CIF: Physician letter to school

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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.

Return to full day of school.

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

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

Return to ½ day of school.

Case 3A16 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.

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A. Today B. Tomorrow C. In 2 days D. In 1 weekE. 1 month after symptoms

resolved

Assuming she remains asymptomatic, when would you clear her to return to

full contact soccer games?

T o da y

T o mo r r

o w

I n 2 d a

y s I n 1

w ee k

1 mo n t

h af t e r

s y mp t o

m s . . .

18%

2%

25%

49%

6%

Concussion Legislation• 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

Concussion legislation• California Assembly Bill 2127 (in effect

1/2015)– 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

Return to Play Progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

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Return to play activity examplesStep Objective Activities1 Recovery No activity2 Light aerobic activity:

Increase heart rateWalking, 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.

5 Restore confidence and assess functional skills by coaching staff

Full-contact practice

6 Normal game playConsensus 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.

CIF: Return to play handout

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Case 3BThe 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.

Return to Play Progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

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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.

C l e ar h e

r f or f u

l l c on t a

c t . ..

H a ve h e

r r et u r

n t o s p o

r t . . .

R e co m

m en d

r e s t f r o

m sp . . .

R e co m

m en d

r e s t f r o

m sp . . .

0%7%6%

87%

Return to Play Progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

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

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

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 4A 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.

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What would you do? Post Concussion Syndrome• Frequency unclear (0-15%).• Concussion symptoms persist x months, usually

<1 year.• Patients benefit from multidisciplinary approach

to treatment.

Think about post concussion syndrome when…

• Symptoms not improving after 2 weeks of treatment.

• Unable to return to school after 1-2 weeks of treatment.

• History of migraine, anxiety, depression, sleep disorder.

• History of concussion.

How Many Concussions is Too Many?• Individualized to athlete.• Concussion hx.

– Number.– Less force.– More frequent.– Increased severity of sxs– Increased duration of sxs.– Age: possibly more consequences if younger at

time of concussion.

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Protective gear?

Benson BW et al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med. 2013.

Avoid heading?Reasons for concussion in soccer1. Contact with another player (50-70%)2. Heading (30%)

1. Athlete-athlete contact2. Contact with playing apparatus, including ball3. Contact with playing surface

Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr. 2015 Sep 1;169(9):830-7.

• No heading ages ≤ 10• Reduced heading in

practice ages 11-13• New concussion

substitution rules TBA• Education for coaches,

parents, officials, players

http://www.ncaapublications.com/productdownloads/MD15.pdf. Accessed 12/5/15.

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UCSF Sports Concussion Program• Acute concussion clinic

– Evaluation and treatment– Return to school – Return to play

• Multidisciplinary head injury clinic for complicated cases: once/month– Patient can see multiple doctors at one visit– Post-concussion syndrome– Traumatic brain injury

UCSF Sports Concussion ProgramContact info

• UCSF Orthopaedic Institute at Mission Bay

• Concussion@ucsf.edu

Concussion resources• California Interscholastic Federation

http://www.cifstate.org/sports-medicine/ concussions/index• Consensus statement on concussion in sport,

2012. http://bjsm.bmj.com/content/47/5/250.full

• CDC concussion toolkit for physicians www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

Sports concussion updates 20151. Concussion legislation2. CIF handouts and guidelines3. US Soccer and heading

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Keys to managing sports concussion in 2015

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

of injury• When to refer

Thank You!

Carlin Senter, M.D.Carlin.Senter@ucsf.eduUCSF Sports Medicine