How To Help Your Kids With A Concussion

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1 Concussion Kevin D. Walter, MD, FAAP Associate Professor, Medical College of Wisconsin Program Director, Children s Hospital of Wisconsin Sports Medicine

2 Young Athletes Not Just Little Collegiate or Professional Athletes Youth Less coordination = less body control Lower speed, size & strength = less blunt force trauma Adolescent Increased injury risk (during growth spurts) Greater speed, size & strength Yet still developing complex motor skills More immature = impulsive & emotional Invincibility Parental expectations Children s Specialty Group. All rights reserved.

3 Realistic Expectations? "Atlas Sports Genetics testing was very informative and the process was quite simple. Although my daughter is only 9, she now knows that she had a the Sprint, Power, & Strength advantage which we can use to market her Athletic Career and hopefully a wonderful scholarship from this process. Sincerely, Brad Marston of Bountiful, Utah Story of using the left foot in 7 year old soccer

4 Skill Development Baby book or early milestones are better Kids are a blank canvas Parents can help them paint a beautifully colored picture or a dark one 15% kids under 10 have used athletic supplements Early childhood (2-5y) Focus on remaining upright with activity Throw Respond best to show & tell, no verbal learning Childhood (6-9y) <10y approach competition differently than adults Throw for accuracy Visual and verbal commands

5 Skill Development Preadolescent (10-12y) Throw for accuracy & timing Begin to integrate memory strategies needed for more complex skill sports Adolescent (13-16y) Puberty regression - avoid negative reaction Identify with their sport Suzie the basketball player, not Suzie who plays basketball Therefore bad game = bad girl/person Need to work to separate identity & value from performance

6 CONCUSSION

7 All Concussions Are Serious Athletes, coaches and parents have better concussion knowledge than 5 years ago Physicians too! School professionals have not shown increase Gaps remain: Trouble identifying Unclear about return to learn and play Research shows too many athletes: Do not report symptoms Are not removed from play / Continue to play with symptoms Return to play too soon

8 What is a Concussion? Complex process Shakes brain, sets off metabolic cascade that causes dysfunction Mild traumatic brain injury (Not a ding or bell ringer!) It s NOT bleeding or bruising It IS temporary cannot predict duration It isn t always from a hit to the head You CANNOT see it on a CT or MRI <10% are knocked out <30% have any amnesia

9 WHAT CAN GO WRONG FOLLOWING A CONCUSSION?

10 Second Impact Syndrome Seen only in young persons (<23y) Occurs when a second concussion (often minor) sustained while still symptomatic from earlier concussion Loss of brain blood flow regulation Swelling, bleeding, increased intracranial pressure Takes minutes 50% mortality, but 100% have lifelong problems

11 Post Concussion Syndrome 80% of patients recover within 3 weeks Prolonged recovery (>4 weeks) 10-20% of adolescent patients Academic, social, mood problems

12 Chronic Traumatic Encephalopathy Progressive neurologic deterioration likely related to repetitive non-concussive blows to head Unable to diagnose during life More study needed media reports far in front of science

13 Concussion It s never OK to return on the same day It s never OK to return with any symptoms still present Always get medical clearance to return

14 How Often? CDC = million per year Still underreported ER visits over last decade 8-13 y/o doubled y/o more than doubled #1-2 injury in nearly every HS sport (9% of all HS injuries) Why? Increased awareness More exposure Bigger, stronger, faster kids Youth football Risk 3.5-4% per season Game rate = HS Practice rate > HS HS football Risk 10% per season Game rate > practice College football Risk 5.5% per season Game rate >> practice

15 High School Sports with Highest Risk Football Soccer Ice Hockey Lacrosse Wrestling Basketball Softball Cheer Baseball Volleyball

16 Did the athlete lose consciousness? NOT REQUIRED FOR A CONCUSSION!! Confused or dazed Behavior or personality changes Glassy eyed Repeats questions Post traumatic amnesia Answers questions slowly Signs (what you can see)

17 Symptoms Cognitive Physical Emotional Sleep Confusion Headache Irritable Hard to fall asleep Disoriented Nausea/Vomit Sad Wakes at night Amnesia Dizzy Nervous More fatigued Distractible Fatigue Mood swings Foggy Vision changes Slow response Photo/phono phobia Numbness / tingling More emotional

18 Emergency Department? Comfort level Environmental issues Knocked out = c-spine immobilization Abnormal neurologic exam Worsening Mental status, level of consciousness, headache/symptoms, neurologic function Seizure activity Repeated vomiting Severe symptoms

19 Management Every patient is different Treatment varies from person to person & injury to injury They look normal! Don t make symptoms a lot worse by overstimulating brain If identified and treated properly, kids do very well

20 Management Activity/Exercise Nothing beyond every day life No lifting, training, running, etc. UNTIL MEDICALLY CLEARED Slows recovery May increase concussion risk

21 Management Screen time Minimize computer, video games, texting, TV, etc. Live well good diet & hydration No driving until medically cleared Like a drunk Better sleep = faster recovery Good sleep habits Consistent bedtime Some kids need medication

22 Management Headache Doing too much Acetaminophen Some kids need more Emotional Moody Irritable Can progress to depression / anxiety

23 Return to Learning (RTL) Don t need to be 100% recovered to RTL Communication is key <40% teachers are aware if a student has a TBI Even if known, accommodations not routinely made Need academic adjustments 504 or IEP only if prolonged

24 Return to Learning Often need to miss school Progress from partial days to full days Focus on key points Homework Give extra time to complete Reduce amount Prorate missed work Pre-printed notes Gradually work back up to full levels Tutoring

25 Return to Learning Tests No standardized testing Consider oral/open note/book/take home Extra time to complete Be able to go back to review & improve Classes No PE (don t watch it either) No shop?computer classes, music/band?

26 Return to Play No symptoms off meds, full school Activity progression (about a week) Medical clearance Low > Moderate > High level aerobic activity Medical clearance Full contact practice > Full clearance

27 Neuropsychological Evaluation Written (the novel) Can provide guidance for school-based intervention Need experienced neuropsychologist Especially with comorbidities Computerized testing (cliff s notes) Multiple platforms (CogState, ImPACT, etc) Must have a plan It s a TOOL Need to be certified to interpret

28 Baseline Computer Testing CHW baseline Computer testing + Balance testing + King-Devick testing I see too many kids tested in uncontrolled manner Poor supervision Distraction too many kids Poor effort Poor motivation rather be at practice Psychological distress, poor sleep Sandbagging

29 Computerized Testing Sold as a way to diagnose concussions I see too much post-injury testing Not ideal for tracking recovery Retest when ASYMPTOMATIC (decision point) Prefer well-controlled environment (physician office > school setting) My philosophy Helps catch kids that are lying about recovery There is likely a cohort that feels good but is not completely recovered Baseline very important for at risk population

30 Equipment Equipment does not prevent concussion Helmets Virginia Tech STAR rankings UW study found no difference in helmet type Mouth guards Soccer headgear 70% of all football concussions are result of head to head contact Decrease illegal helmet contact Children s Specialty Group. All rights reserved.

31 WIAA Contact Limitations DRILL CONTACT Air run unopposed without bags or opposition Bags activity executed against bag, shield, bag to allow soft surface contact with teammate or coach standing behind bag Wrap or Control drills run at full speed until contact, which is above waist and all players remain on feet

32 WIAA Contact Limitations COMPETITION / FULL CONTACT Thud Same as wrap, but competitive tempo without a predetermined winner & players not tackled to ground Full contact Drills or games situations where live action occurs game speed with tackling to ground

33 WIAA Contact Limitations Acclimatization Regulations apply Week 1 Unlimited drill contact No competition contact Week 2 Unlimited drill contact Competition contact <75 min/week (excluding scrimmage) Week 3 and beyond Unlimited drill contact Competition contact <60 min/week (excluding games)

34 NFHS Minimizing Head Impact Exposure Two-way or Three-way players Multiple levels of practice/competition (varsity, JV, etc.) Twice-daily practice (only 1 should include contact) Avoid back to back days of contact Limit competitive contact to <30 min/day and no more than min/week Consider limitations on quarters per week or games per week

35 Concussion Legislation: WI Sidelined for Safety Act All youth sports (<19 years of age) Educational info Parental & athlete agreement sheet Immediate removal Medical clearance by HCP Effective Apr 2012

36 Awareness & Education Education FREE webinar CDC Head s Up Tool Kits CHW Sports Concussion Program

37 CHANGING THE CULTURE

38 Problems 800 HS athletes 69% played with symptoms 40% said coaches unaware of concussion 50 HS athletes I would keep playing and see how I felt I would take a quick break and return Nobody would stop playing entirely 150 young athletes 39% returned on the same day 58% returned without medical clearance 58 young athletes championship game 52% would always report 36% would sometimes report 7% would never report

39 Culture Problems The way coaches talk about concussion influences decisions Negative messages, insulted by coaches for reporting injury less like to report and feel pressured to play Positive messages and praise for reporting more likely to report 314 youth coaches remove if concussion symptoms? 92% would remove when importance of game not included in scenario Scenario is championship game: 17-20% would allow kid to continue playing

40 Culture Problems Why not report? Are worried about letting coach, teammates and parents down Are worried about losing position on team Worry about jeopardizing future sports career Don t want to stop playing

41 Change Culture Expect Safe Play Kids look to parents & coaches to learn what actions are OK in team s culture Model Safe Play 96% helmeted ski/snowboard kids had parents that wore helmet Non-helmeted parents = 17% kids wore helmet Reinforce Safe Play 25% of HS concussions from illegal or aggressive play A culture that supports unsportsmanlike & aggressive behavior increases injury risk and hiding symptoms Reward good citizens

42 Change Culture Coaches Positive environment Before & during season discuss concussions & injuries Keep list of concussion signs & symptoms visible for athletes Have concussion action plan Be alert for potential injuries Everyone Talk about concussion Learn how to spot concussion & what to do if concussion suspected Model, expect and reinforce safe play Support recovery, return to learn & return to play process

43 The Sports Concussion Program at CHW The CHW Sports Medicine (Musculoskeletal) Program Multidisciplinary Clinic Directors: Kevin Walter, MD & Mike McCrea, PhD Jennifer Apps, PhD; Shayne Fehr, MD; April Benoit, APNP; Leah Hunt, PA-C Clinical care, research, community education & policy Delafield Clinic Greenfield Clinic Only care for young athletes College age and below Partnership with PT groups Rapid access for surgical evaluation

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