The Youth-Nex Conference on Physical Health and Well-Being for Youth, Oct 10 & 11, 2013, University of Virginia Donna K. Broshek - "Sports Concussions in Children and Adolescents" Broshek is an Associate Professor and Co-Director of the Neurocognitive Assessment Lab at the University of Virginia Medical School. Panel 5 -- Injury Prevention and Treatment. While being physically active is important for positive youth development, injuries can result. This panel will discuss ways to minimize injury, particularly concussions, while addressing the impact of sport-related injury on quality of life. The panel will also provide a blueprint for encouraging life-long physical activity. Website: http://bit.ly/YNCONF13

1. Sports Concussions in
Children & Adolescents
Donna K. Broshek, Ph.D.
Associate Professor
Co-Director, Neurocognitive Assessment Lab
Department of Psychiatry & Neurobehavioral Sciences
Associate Director
UVA Brain Injury & Sports Concussion Institute

2. Outline
• Why so much emphasis on concussions
now?
• Concussion definition, symptoms, &
associated features
• Individualized concussion management
• When to refer
• Temporary academic accommodations
• Return to healthy physical activity

3. Sports concussions…

4. Not just football…

5. Not just contact sports…

6. Not just males…

7. Not just adults…

8. Not just organized sports…

9. Colorado – Senate Bill 40
Jake Snakenberg Act (2012)
• Jake Snakenberg – Died at age 15
(2004)

10. Lystedt Law – July 2009
Zackery Lystedt injured 2006 – age 13

11. Virginia Senate Bill 652
• Mandates concussion education in all public high
schools for coaches, student-athletes, & parents, as
well as policies and procedures
• Student-athletes & parents to receive annual
education
• Any athlete with suspected concussion shall be
removed from play/activity
– Shall not return the same day
– MUST be evaluated by health care professional with
• Licensed physician, physician assistant, osteopath, athletic
trainer, neuropsychologist, or nurse practitioner
– Must be asymptomatic with increasing exertion (Zurich)
– Requires written clearance for return to activity

12. Concussion definition (Zurich, 2013)
• Complex pathophysiological process affecting
the brain, induced by traumatic biomechanical
forces.
– May be caused by a direct blow to the head or body with
“impulsive” force transmitted to the head
– Typically results in rapid onset of short-lived neurologic
dysfunction that resolves spontaneously. However, in some
cases, symptoms & signs may evolve over minutes to hours.
– May result in neuropathologic changes, but acute symptoms
typically reflect functional disturbance
• Standard structural neuroimaging is typically negative
– May or may not involve LOC & symptoms follow sequential
course; small percent have prolonged PCS

13. Concussion: Signs & Symptoms
Somatic Symptoms
Headaches
Nausea
Dizziness/Poor
balance
Light/Sound Sensitivity
Sleep Disturbance
Insomnia
Fragmented sleep
Hypersomnia
Hyposomnia
Cognitive Symptoms
“Fogginess”
Cognitive fatigue
Inattention
Memory deficits
Mood
Irritability
Lability
↓frustration tolerance
Sadness
Anxiety

14. Common Acute Symptoms
• Observable within minutes to hours:
–
–
–
–
–
–
Lack of awareness of surroundings, confusion
Nausea and/or vomiting
Headache
Amnesia
Dizziness
Vertigo

15. Concussion Pathophysiology

16. Concussion Pathophysiology

17. Pediatric Recovery
• About 5-10 days in healthy college age
adults with no previous concussion
history
• Kids take longer to recover
– 30 days or more
• Be more conservative with younger
athletes

18. The adolescent brain may take slightly longer to
recover
Gessel et al. J Ath Training, 2007

19. Rehabilitation
Stage
Functional exercise at each stage of
rehabilitation
Objective at each stage
1. No activity
Complete physical and cognitive rest
Recovery
2. Light aerobic
exercise
Walking, swimming, or stationary cycling
keeping intensity <70% MHR. No
resistance training
Increase heart rate
3. Sport-specific
exercise
Skating drills in ice hockey, running drills
in soccer. No head impact activities
Add movement
4. Non-contact
training drills
Progression to more complex training
drills (passing). May start progressive
resistance training
Exercise, coordination,
cognitive load
5. Full contact
practice
Following medical clearance, participate
in normal training activities
Restore confidence,
assessment of functional skills
by coaching staff
6. Return to play
Normal game play
McCrory et al. British J Sport Med, 2013

20. AAN Guidelines (2013)
• Evidence based
– Immediate removal from play if concussion
suspected
– Moved away from concussion grading
system:
• Focus on individual management
• No set timeline for return to play
• Concussion is a clinical diagnosis
– Checklists, computerized testing, and balance
assessments are tools and should not be used alone to
make a diagnosis.

21. AAN Guidelines (2013)
• No return until assessed by a licensed health
care professional trained in concussion.
• Return to play slowly after acute symptoms
resolve.
• High school and younger – manage more
conservatively due to longer recovery.
• First 10 days after a concussion is the period of
greatest risk for another concussion.

22. Why do we use baseline
cognitive testing?

23. Sample Results using Reliable Change
HeadMinder Case Study
Age of Athlete: 16 years
Gender: Female
120
All standard scores adjusted for retest (practice)
effects
116 114
111
110
Standard Score
107
100
112
106*
118
116
116
107
103*
SRT
CRT
PSI
90
81**
80
74**
70
60
60**
60**
50
Baseline
* .05<p<.15
** p<.05
Day 1
Day 8
Day 9
Day 14

24. Neuropsychological Testing in
Sports Concussion Management
• Generally assesses several functional domains
affected by concussion
–
–
–
–
–
–
Attention
Learning and Memory
Complex Problem Solving
Processing Speed/Efficiency
Reaction Time and Motor Dexterity
Psychological Factors
• Domains that are resistant to concussion (e.g.,
language) not typically assessed
– unless retirement decisions are being considered

25. When to Refer to a
Neuropsychologist
• Symptoms > 2 to 4 weeks, especially if course is getting
worse & not better
• Prior concussions, LOC, post-concussive seizures,
hemorrhage, etc.
• Pre-concussion history of migraines, seizures, ADHD
• Very protracted recovery course
– May need 504 Plan, IEP or college students needing
accommodations
• Psychological overlay or secondary gain suspected.
• Retirement decisions

26. Academic Accommodations
• Academic support during recovery
– Impact of headache, fatigue, dizziness,
light/noise sensitivity, poor sleep, ringing in
ears
– Impact of cognitive deficits like inattention,
poor concentration, memory disruption,
slowed processing, slowed task performance
• Critical issue is to ensure rest during the
acute recovery period
– Individualized plan: balance work and respite

27. (Temporary) Academic
Accommodations
• Rest (as needed, but within reason)
– Excused absence initially
– Rest periods while at school
• Relax time demands
– Extending deadlines
– Staggering or delaying some tests
– Increased time for taking tests
• Reduced work
– Excuse from portions of homework
– Reduce value of test/excuse from test or quiz

28. (Temporary) Academic
Accommodations
• Modified environment
–
–
–
–
–
–
–
Avoidance of intolerable light (fluorescent)
Reduced stimulation room (less “noise”)
Excuse from athletics/gym
Use of a test reader to read questions aloud
Tape recorder for classes/tests
Preferential seating (minimize distractions)
Provide temporary tutoring/extra instruction

29. The Benefits of Physical Activity
and Sport
Powell et al. (2011)

30. Concussion Management
• Children (10-17 years) with post-concussion
symptoms 4 weeks after injury (n=16)
– Most had headache, fatigue, depression and/or poor
endurance
– Introduced supervised aerobic exercise
– All showed rapid improvement in symptoms
•
Gagnon et al. (2009)

31. Exercise as TBI Treatment
(Griesbach, 2011)
• Post-acute injury exercise enhances
recovery through increased brain derived
neurotrophic factor (BDNF)
– BDNF enhances learning & memory
• Can counteract increased oxidative stress
that leads to free radicals
• Can regulate post-TBI neuroendocrine
dysfunction

32. If in doubt, sit them out!