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Sports-related concussion in children and adolescents Slide 2 AGENDA: CONCUSSION MANAGEMENT UPDATE MEETING SEAFAIR MINOR HOCKEY - NOVEMBER 8 TH, 2013 Introduction: Medical Panel and Seafair Background on Baseline Testing and Concussion Management (Cody Kusch) Background: Concussions and Recent Findings (Naznin Virji- Babul) Medical Evaluation and Recovery Process (Dr. William Panenka) Baseline Testing: SCAT 3 and Axon, update on testing to date, protocol for study, Return to play Protocol (Jonathan Sun) Panel: Question and Answer Period (Cody, Bill, Naznin, Dr. Will Panenka, Jonathan Sun, Dr. Paul Korn) Slide 3 Background: Concussion/mTBI currently considered a silent epidemic Sports activities are a major cause of concussions 300,000 sports related concussions occur each year in the United States Slide 4 What happens to the brain during a concussion? Slide 5 Shearing in the wiring of the brain Slide 6 Slide 7 Issues for coaches/clinicians/parents: Standard neuroimaging tools not sensitive to detect subtle changes in brain structure and function Diagnosis and evaluating functional recovery very difficult Slide 8 Advanced MRI can see subtle changes in the wiring of the brain No concussionConcussed athlete Slide 9 fMRI measures thinking Slide 10 Brain activity is more scattered ControlConcussed Slide 11 Signs and Symptoms of Concussion By an observer not only LOC! Dazed or stunned, confused about assignment Forgets instruction, game score, opponent Off balance, answers slowly, loses consciousness Mood, behavior or personality changes. Amnesia for events around injury By the athlete Headache, nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light or noise Concentration or memory problems, confusion Slide 12 Recovery From Concussion: How Long Does it Take? N=134 High School athletes Collins et al., 2006, Neurosurgery Slide 13 Concussion Modifiers McCrory P, et al. Br J Sports Med 2013;47:250258. doi:10.1136/bjsports-2013-092313 Slide 14 Medical Evaluation Individual clinical decision A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance. A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality Slide 15 Persistently symptomatic patient Persistent symptoms (>10 days) in about 10-15% Important to consider other issues Should be managed in multidisciplinary manner by healthcare providers experienced in sport concussion Table from Ontario Neurotrauma mTBI Guidelines, and adapted from Current Treatment Options in Neurology. 2006;8:415-426 Slide 16 Child/teenage athletes Consider age specific physical and cognitive rest issues school attendance and activities need to be modified No return to sport or activity until returned to school successfully Symptom resolution may take longer, modifiers apply even more More conservative RTP approach recommended: Consider extending symptom-free period before starting return to play protocol Consider extending length of the graded exertion protocol Never return to play same day Slide 17 Issues in the field No gold standard for assessment Return to play/learn protocols are based on expert opinion not hard evidence Slide 18 Seafair Study Use 2 different assessments to evaluate which one is most sensitive Never been done before Slide 19 Baseline and End of season Assessments: SCAT3 Baseline: 341 players tested to date AXON Baseline: Only 73 completed to date Slide 20 Concussion Protocol Dr. Naz to screen players for MRI study Must be within 1 week of concussion Repeat scan if symptomatic at 6 weeks Referral to BCCH/Dr. Korn/Dr. Panenka as needed Suspected Concussion Coach/Manager pulls player off the iceSCAT3/AXON repeated Slide 21 Return to play protocol 1. No Activity. Complete physical and cognitive rest 2. Light aerobic exercise (Walking, swimming or stationary cycling keeping intensity