Donna K. Broshek - "Sports Concussions in Children and Adolescents"


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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.


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  • Mention Zachary Lystedt
    Appropriate licensed health care provider means a
  • Donna K. Broshek - "Sports Concussions in Children and Adolescents"

    1. 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. 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. 3. Sports concussions…
    4. 4. Not just football…
    5. 5. Not just contact sports…
    6. 6. Not just males…
    7. 7. Not just adults…
    8. 8. Not just organized sports…
    9. 9. Colorado – Senate Bill 40 Jake Snakenberg Act (2012) • Jake Snakenberg – Died at age 15 (2004)
    10. 10. Lystedt Law – July 2009 Zackery Lystedt injured 2006 – age 13
    11. 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. 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. 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. 14. Common Acute Symptoms • Observable within minutes to hours: – – – – – – Lack of awareness of surroundings, confusion Nausea and/or vomiting Headache Amnesia Dizziness Vertigo
    15. 15. Concussion Pathophysiology
    16. 16. Concussion Pathophysiology
    17. 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. 18. The adolescent brain may take slightly longer to recover Gessel et al. J Ath Training, 2007
    19. 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. 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. 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. 22. Why do we use baseline cognitive testing?
    23. 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. 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. 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. 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. 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. 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. 29. The Benefits of Physical Activity and Sport Powell et al. (2011)
    30. 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. 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. 32. If in doubt, sit them out!