Learner Outcomes
- The participant will be able to describe at least two current recommendations for the evaluation of pediatric sport-related concussion.
- The participant will be able to identify at least three merits of computerized neurocognitive testing among pediatric athletes.
- The participant will be able to list at least three recommended management strategies following a concussion.
- The participant will be able to describe at least three of the recommended return to activity (physical and cognitive) progressions following a concussion.
- The participant will be able to describe the importance of an interdisciplinary collaborative management team.
Introduction
This presentation is loosely based off of a paper that we published in 2015 that looked at the pediatric perspective on the current literature regarding sport-related concussion. The presentation has also been supplemented with additional information published recently and information on the Berlin Consensus statement from a meeting that was held in October of last year. One of the systemic reviews that will accompany that statement, is specifically tied to the pediatric athlete. We will focus on what is the current best evidence for which has been an interest of mine since my dissertation where I looked at the applicability and usefulness of various assessment tools that had been commonly used in high school and collegiate populations, but we really weren't sure whether or not they were appropriate from a developmental standpoint for younger individuals. At that time I focused primarily on the standardized assessment of concussion and the balance error scoring system which are two clinical assessments that are often used both on the sideline and in athletic training facilities because they are low-cost and low-equipment. Since that time, my research has really continued in three primary areas related to pediatric concussion. The first is with respect to knowledge and awareness which as we'll discuss today, is a key component of a good concussion management program. The second relates to assessment tool validation and looking at different characteristics of assessment tools. That is an area where there has definitely been a lot of new information, especially with the use of technology. We are starting to see various apps and other modalities available for assessing various aspects of concussion, on iPads, iPhones and other portable and mobile electronic devices. And lastly, we've been looking prospectively at a couple of different areas that I'm personally tied to. One being a health related quality of life and how a concussion can affect these individuals outside of the typical areas that we often assess. We've also looked at a series of studies called the BAKPAC that have looked at the healthcare provider and school personnel with respect to concussion management, the use of academic adjustments and collaborative management of concussion. I'll share some of our findings with you on that particular project, as well.
Concussion
Definition
The commonly used definition of concussion from the American Academy of Neurology is a clinical syndrome of biomechanically induced alteration of brain function that typically affects memory and orientation, which may involve loss of consciousness. The concussion and sport group has elaborated on this definition, which has a lot of big words but may not necessarily be clinically applicable. They focus on features of concussion and this may include the mechanism of injury from a direct blow to the head, face, neck, or elsewhere that transmits impulsive forces to the head. It typically results in a rapid onset of short-lived impairments and neurologic function that resolve often spontaneously. However, in some cases, these signs and symptoms may evolve over time and may be prolonged. It may result in neuropathological changes, but these are primarily dysfunctional disturbances, rather than a structural injury. Some of what we'll talk about relates to imaging and the fact that in children, we need to be a little bit thoughtful in how we might use imaging. CT scans are often used in emergency departments to rule out any type of bleeding in the brain, such as an epidural or subdural hematoma. There is a risk of radiation for CT scans and with a concussion, because it's a functional injury, most CT scans are negative. We also know that a feature is a graded set of clinical symptoms that may or may not involve loss of consciousness, these typically follow a sequential course in recovery, although they may be slightly delayed in younger children. If we look on a spectrum of concussion or head trauma, and we categorize it based on mild, moderate or severe, often with the Glasgow Coma Scale, we'll see the concussion is really on that far left end in that mild brain injury area. There are some that may actually shift it even further to the left and there was some significant discussion at the Berlin meeting about what do we call this, and should concussion be called something different than brain injury? And is it different? I will say there was a lot of people that were really discouraged or disheartened with trying to take concussion out of this realm of brain injury. This is because of all the work done, especially in the United States with concussion legislation, concussion education, and education the public, athletes, coaches, parents, to understand that a concussion is a brain injury and should be taken seriously.
Institute of Medicine Key Recommendations
If we look at the Institute of Medicine, they came out with a key report in 2013,2014, specific to youth concussion. They had six key recommendations and some of the information that I will present today are actually stemming from some of these recommendations and things that now we know more about. The first recommendation was that we need to do a much better job using surveillance systems and relevant data to truly understand the number of individuals who are sustaining sport-related concussions from the lower ages of three to five all the way up to college-aged individuals. The second was to begin to establish research that might investigate markers of concussion diagnosis prognosis and recovery and develop age-specific evidence-based guidelines. While there is a lot of work going on in this area, we still do not have a gold standard diagnosis. There is no one particular imaging test, biomarker, or other assessment that truly diagnoses a concussion. A concussion is diagnosed through a clinical examination, primarily based off of the signs and symptoms reported by the patient or evaluated by the healthcare provider. At this time, we are starting to understand some symptoms and clusters of symptoms that might indicate a prolonged recovery and give us some indication of prognosis, although the ability to establish timelines for recovery is not an area that we are at, at this point. There are some very general timelines, but a concussion is a very individualized injury and one of the things we really aim to not do when counseling patients is give them any indication of the recovery timeline because it can be different based on a number of different factors. A recommendation was also made to conduct controlled longitudinal large scale studies to assess both short and long term effects of concussion and there is a project that is underway currently. It is funded by the NCAA, and the Department of Defense. It is called the Care Consortium, and there are about 20 colleges and universities across the country that are part of this initiative. They are doing preseason baseline testing with all of the athletes at their institutions. Follow-up assessments are completed after a concussion with a number of different tools measuring symptoms, cognition, balance, ocular motor function, quality of life, and in a subset of schools, they are doing blood draws for biomarker analysis and additional imaging. I would assume that within this year we're going to start to see some of the preliminary results. They have collected, I believe just under 1,000 concussed athlete cases, and the investigators who are involved in that project are starting to analyze some of the data. Now not all of it is going to be specific to a younger individual, but it should give us a very good template as to what types of studies we might be able to undertake in children and adolescents. The next recommendation was to evaluate the effectiveness of age appropriate techniques, rule changes, and playing in practice standards to reduce the risk of concussion and I will present some data that we've been involved with along with other sites across the country that have actually begun to do this. When we start to think about prevention, rule changes and behavioral modifications are two of the most promising avenues for concussion prevention. They also want to fund research on age and sex related determinants of concussion risk in youth and lastly, develop, implement, and evaluate the effectiveness of large-scale efforts to improve concussion knowledge and awareness. The CDC has an FOA that just closed mid-February, to look at implementation and evaluation of primary and secondary prevention efforts that do include knowledge and awareness. So we have made a lot of strides since this was originally published in 2013, 2014. And hopefully, it provides us with a good template of what we may be able to do in numerous areas related to concussion.
Epidemiology
So if we look at the numbers, a newer paper that came out last year (2016) by Bryan. Previously, you may have heard about the CDC statistic that said 1.4 to 3.4 million concussions annually accounting for under-reporting. These updated numbers in 2016 study are a little bit less but we will see in a few slides that in some cases, we are actually seeing more concussions which are not necessarily a bad thing. Of this group, the majority of patients reported their entry into the healthcare system in the outpatient setting. The outpatient setting with primary care providers and pediatricians are where the majority of these patients were seen. Smaller numbers presented initially to the emergency department. A good number of these were younger children closer to the age of five which is probably an appropriate place to seek care for those children who are sustaining concussions from mechanisms outside of sports. Eighty-six thousand concussions were reported through the high school RIO system where they're seeing the athletic trainer only as their key healthcare provider. Now if we look at specific sports, football does account for the majority of concussions across all high school sports, and in total, concussions were about 8.9% of all sport-related injuries sustained at the high school level. What's interesting is after that we have boys ice hockey, which is another collision sport, but then followed by girls' soccer, girls' basketball, boys' soccer and boys' basketball. One other interesting trend is when we start to look at male and female sports, females tend to have higher concussion rates in sports where in general the rules are similar to those that the boys are playing, specifically soccer and basketball. In fact, the increase is about two times in girls' soccer, compared to boys' soccer.
Prevention of Concussion
One of the areas where we're starting to see more work done related to concussion is in the area of prevention, and this is taking a bit of public health approach to concussion as a condition that affects the health of the public in general and a large number of individuals. When we look at prevention, there are several different ways that we can study this. The first is through primary prevention.
Primary prevention. Primary prevention is protection from a concussion happening in the first place. This could be something such as a rule change. Equipment has been potentially implicated, although the evidence on equipment is that it does not prevent concussion. These are typically efforts done in the preseason and they tend to be athlete focused. So changing the rules of the game and changing contact restrictions during practices are some of the components that we see from a primary prevention standpoint.
Secondary prevention. Secondary prevention is limiting long term disability and preventing re-injury. That includes education, legislation, proper assessment and proper management. They are done post-injury and they tend to be more provider focused. Where the healthcare providers are the ones insuring that there is an appropriate assessment, appropriate documentation of deficits, and that the return to activity does not occur until the individual has been cleared using a clinician chosen test.
Tertiary prevention. Tertiary prevention is an area where I think the concepts of rehabilitation and treatment are going to be key and it is certainly a direction where concussion management is moving. Tertiary prevention aims to soften an impact of an ongoing or illness that has long lasting effects. Where the goal is to improve function and quality of life. This is where we want to try and avoid prolonged symptoms, having the patient be subsequently diagnosed with post-concussion syndrome, and doing what we can to try and improve their recovery time as opposed to just kind of a wait and see, or the wait and rest management plan.
