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Sports Concussion:Questions Our Patients Are Asking and the Evidence-Based ResponsesCarlin Senter, MDCo-Director UCSF Sports Concussion ProgramAssociate ProfessorPrimary Care Sports MedicineUCSF Medicine and Orthopaedics

UCSF Primary Care Sports Medicine Course December 9, 2016

I have no financial disclosures.

Questions our patients are asking about concussion1. What is a concussion?

2. When will I recover?

3. Is there a diet or supplement that will expedite my recovery?

4. When can I return to school (work)?

5. When can I return to sports?

6. Should I wear head protection when I return to sports?

7. Should I avoid heading when I return to soccer post concussion?

8. Should I go to physical therapy to work on neck strengthening to lower my risk of concussion?

9. How many concussions is too many?

1.What is a concussion?

http://head-zone.com/about-concussions/

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Definition�Blow to head, neck, body � force to head

�Rapid onset of neurologic impairment

�Symptoms usually resolve in weeks, spontaneously, but in some cases can be prolonged.

�Does not have to include loss of consciousness.

�CT and MRI studies are normal

Force to

brain

Ion fluxes;

vasocon-striction

Need glucose but less blood

flow

Energy crisis

Giza CC and Hovda DA, J of Athletic Training, 2001.Vespa et al, J Cerebral Blood Flow and Metabolism, 2005.

Sequence of events

Window of vulnerability

Giza and Hovda, JAT 2001

�The period between the concussion and the recovery.

�Return to play during this time could cause worse, even catastrophic, brain injury

2. When will I recover from my concussion?

http://kidstoyhire.com.au/2014/12/05/mum-im-bored/

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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

Majority return to play in < 1 month in FB� 15.5% of concussions required ≥30 days before return to play.

�Odds of return-to-play time of ≥30 days were greater in youth (odds ratio = 2.75; 95% CI, 1.10-6.85) and high school (odds ratio = 2.89; 95% CI, 1.61-5.19) athletes than in college athletes.

�No difference was found between high school and youth.

Percentage of concussions in youth, high school, and college football requiring ≥30 days before return to play, 2012 to 2014 seasons.

0%

5%

10%

15%

20%

25%

Youth High School College Total

Con

cuss

ions

, %

Kerr ZY et al. Concussion Symptoms and Return to Play Time in Youth, High School, and College American Football Athletes. JAMA Pediatr. 2016 Jul 1;170(7):647-53.

Who is at risk for longer recovery?

�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.

3. Is there a certain diet or supplement that you would recommend for my child to expedite his/her recovery from

concussion?

http://www.nutrascienceusa.net/pages/blog[2]

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Diet�Sparse literature

�High fat diet exacerbated behavioral problems post mTBI in rats (Mychasiuk et al. Diet, age, and prior injury status differentially alter behavioral outcomes following concussion in rats. Neurobiol Dis. 2015 Jan;73:1-11.)

Supplements�No strong evidence for use of supplements in concussion

management at this time.

�Promising results in animal studies and a few human studies on traumatic brain injury in recovery or prevention of concussion:

• Omega-3 fatty acids

• Curcumin

• Resveratrol

• Melatonin

• Creatine

• S. baicalensis

• Vitamins C, D, E

Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9.

Omega-3 fatty acids�Promising animal data (mainly rats)

• Mostly using docosahexaenoic acid (DHA)

• Protective effects before injury - role for prevention?

• Reduces effect of concussion post injury – expedite recovery?

� 2 double-blind RCTs presently underway in US:

• NCAA D1 athletes taking 2200mg DHA x 30 days post injury to see if this affects recovery

• UT Southwestern supplementing kids 14-18 y/o 2000mg DHA daily x 3 mo post injury to see if this affects recovery

Ashbaugh A, McGrew C. Curr Sports Med Rep. 2016 Jan-Feb;15(1):16-9.

Melatonin�May have utility in reducing post traumatic headache after mTBI

• Kuczynski A et al. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Dev Med Child Neurol. 2013;55(7):636–41.

• Study underway: Barlow KM et al. A double-blind, placebo-controlled intervention trial of 3 and 10 mg sublingual melatonin for post-concussion syndrome in youths (PLAYGAME): study protocol for a randomized controlled trial. Trials. 2014 Jul 7;15:271.

�Growing interest in sleep disorders that contribute to post concussion syndrome - ?role for melatonin as treatment (Sullivan KA et al. Poor sleep predicts subacute postconcussion symptoms following mTBI. Appl Neuropsychol Adult. 2016 Nov-Dec;23(6):426-35.)

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Acupuncture� 1 case study on acupuncture + neck manipulation in concussion

(Gergen DM. Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report. J Chiropr Med. 2015 Sep;14(3):220-4.)

� Lack of high quality studies precludes ability to make conclusion regarding risk/benefit in TBI. (Wong V et al. Acupuncture for acute management and rehabilitation of traumatic brain injury. Cochrane Database Syst Rev. 2013 Mar 28;(3):CD007700.)

4. Should I wait until I am 100% better before I return to school?

How much rest after a concussion?

� 88 patients (11-22 y/o) seen at pediatric ED randomized

�Strict rest x 5 days vs. “usual care” of 1-2 days rest, then stepwise return to activity

�Neurocognitive and balance outcomes same

�Strict rest group had more daily post concussive symptoms and slower symptom resolution

Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015 Feb;135(2):213-23.

Slide courtesy of Cindy Chang, MD

Return to learn after a concussion

�Return to learn ASAP

�Ok to return to learn with symptoms

�Avoid disruptions to the student’s life with return to school

�Physician should suggest academic adjustments if needed

�Most concussions resolve within 3 weeks so 504 plan or IEP usually not necessary

Halstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

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Team approach to return to learnHalstead ME et al. Pediatrics. 2013 Nov;132(5):948-57.

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.

CIF: Physician letter to school

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5. When can I return to sports after my concussion?

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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 healthca re professional trained in evaluation and management o f 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 proto col of at least 7 days under supervision of licensed pr ovider

Return to Play Progression

Light aerobic activity

Sport specific activity

Game play

Non-contact training

Full contact practice

Clinician clearance

Asymptomatic

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.

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CIF: Return to play handout 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

6. This is my daughter’s 3rd concussion while playing soccer. Should she keep

playing?

https://www.football.com/en-us/soccer-is-heading-for-trouble/

Is Concussion Really a “Mild” Traumatic Brain Injury?

http://www.bu.edu/cte/about/what-is-cte/

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Chronic traumatic encephalopathy�Athletes and military personnel

�Chronic, progressive depression, cognitive impairment, aggression

�Symptoms develop 8-20 years after retirement from sport

� 158 potential CTE cases reported, 6 high school age

�Diagnosed at autopsy: tau protein deposition

�Difficult to draw causality – no prospective data yet

�Concerning association between professional sports participation and long term neurologic/psychological problems

Gardner A et al. Chronic traumatic encephalopathy in sport: a systematic review. BJSM. 2013 Jun 26.Randolph C. Is chronic traumatic encephalopathy a real disease? Current Sports Med Review, 2014.Love S and Solomon G. Talking with parents of high school football players about chronic traumatic encephalopathy: a concise summary. AJSM 2015.

How Many Concussions is Too Many?

� Individualized to athlete.

� Short term risk vs long term risk

� 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.

I think best to have this conversation once the athlete has recovered from their most recent injury.

7. Would you recommend we purchase head protection for my child in order to reduce the risk of repeat concussion when he/ she returns to sport?

http://i00.i.aliimg.com/img/pb/573/767/888/888767573_942.jpg

Protective gear?

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

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Do I lower my concussion risk in soccer if I avoid heading?�Contact with another player is most common reason f or

concussion in soccer. Fewer concussions from impact of head with ball . (Comstock RD et al. An Evidence-Based Discussion of Heading the Ball and Concussions in High School Soccer. JAMA Pediatr. 2015 Sep 1;169(9):830-7.)

�Highest head acceleration: head-to-head impacts and unintentional head impacts by the ball (Hanlon EM, Bir CA. Real-time head acceleration measurement in girls’ youth soccer. Med Sci Sports Exerc. 2012;44(6):1102–8; Withnall C et al. Biomechanical investigation of head impacts in football. Br J Sports Med. 2005;39(Suppl 1):i49–57.)

�Purposeful heading unlikely to cause concussion but the effect of heading (chronic sub concussive blows) on brain long term is unclear (Caccese JB and Kaminski TW. Minimizing head acceleration in soccer: A review. Sports Med 2016 Nov;46(11):1591-1604.)

Neck strengthening to reduce risk�Hypothesis: strong neck muscles may diminish the acceleration of

the head on impact, lowering concussion risk

�Studies measure isometric neck strength in flexion + extension, sometimes with left and right-lateral flexion

� Increased neck strength was associated with lower risk of concussion in high school athletes (Collins CL et al. Neck strength: a protective factor reducing risk for concussion in high school sports. J Prim Prev. 2014 Oct;35(5):309-19.)

�Neck strengthening programs can increase neck strength in athletes (Hrysomallis C. Neck Muscular Strength, Training, Performance and Sport Injury Risk: A Review. Sports Med. 2016 Aug;46(8):1111-24.)

�Next step = development of neck strengthening intervention to see if can reduce risk of concussion in athletes

Have you thought about playing sports other than soccer / football / rugby?

Decrease exposures

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

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Incidence of concussionSport Male Female Pooled incidenceRugby 4.18 NR 4.18Hockey NR NR 1.20American football 0.53 NR 0.53Lacrosse 0.29 0.17 0.24Soccer 0.19 0.27 0.23Wrestling 0.17 NR 0.17Basketball 0.10 0.17 0.13Softball NR 0.10 0.10Field hockey NR 0.10 0.10Cheerleading NR 0.07 0.07Baseball 0.06 NR 0.06Volleyball NR 0.03 0.03

Reported as events per 1000 athlete exposures (AEs)

Pfister T et al. The incidence of concussion in youth sports: a systematic review and meta-analysis. Br J Sports Med. 2016 Mar;50(5):292-7.

Highest risk positions by sport�Water polo – goalie (Blumenfeld RS et al. The Epidemiology of Sports-

Related Head Injury and Concussion in Water Polo. Front Neurol. 2016 Jun 24;7:98.)

�Baseball –catcher during fielding (vs batting or ru nning) (Green GA et al. Mild traumatic brain injury in major and Minor League Baseball players. Am J Sports Med. 2015 May;43(5):1118-26.)

�Football – 1. quarterback, 2. running back, 3. lineb acker (Powell JW. Traumatic brain injury in high school athletes. JAMA. 1999 Sep 8;282(10):958-63.)

� Ice Hockey – forwards (Hutchison MG et al. A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what? Br J Sports Med. 2015 Apr;49(8):547-51.)

�Soccer – goalkeepers and defensive midfield players due to collision with other player (Helmich I. Game-specific characteristics of sport-related concussions. J Sports Med Phys Fitness. 2016 Sep 14.)

�Volleyball – “libero” position due to hits from the ba ll (HelmichI. Game-specific characteristics of sport-related concussions. J Sports Med Phys Fitness. 2016 Sep 14.)

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

Concussion@UCSF.edu

UCSF Sports Concussion Program

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Questions our patients are asking about concussion1. What is a concussion?

2. When will I recover?

3. Is there a diet or supplement that will expedite my recovery?

4. When can I return to school (work)?

5. When can I return to sports?

6. Should I wear head protection when I return to sports?

7. Should I avoid heading when I return to soccer post concussion?

8. Should I go to physical therapy to work on neck strengthening to lower my risk of concussion?

9. How many concussions is too many?

My evidence-based responses1. Concussion = energy crisis of the brain.

2. Majority of high school athletes recover within 1 month of injury

3. No specific diet or supplements recommended yet

4. Return to learn (work) asap

5. Return to play once asymptomatic with gradual RTP protocol

6. Risk reduction

1. Head protection – data equivocal. Increases aggressive play?

2. Neck strengthening – too early to know risks/benefits

3. Heading – not the primary cause of concussion in soccer

4. Decrease the exposure to contact: lower risk sport/position

7. Retirement from sport is an individual decision

8. In most cases concern re: short term rather than long term consequences of concussion.