Dr. Ryan Wei presents "Updates in Pediatric Sport Related Concussions" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
Right. Welcome back, everyone. We're gonna close out with two talks on concussions today. Uh It's my pleasure to welcome doctor Ryan. We, he is our primary care sports medicine fellow here at U CS F. Uh He attended medical school at Temple University in Pennsylvania and completed his family medicine residency at Kaiser Permanente in Santa Rosa. Uh in his fellowship. He's currently serving as a team physician at Lowell High School in S F and is also taking care of athletes at Cal Berkeley. Um He is also also covering some of the roots games, so big roots uh provider presence here today and then uh also works with the S F Valley. Uh his interests are in endurance sports, performance wearables and lifestyle medicine and he's here today to give us a talk about updates in pediatric sport related concussions. Welcome, Doctor Wei, everyone. I'm Ryan. Um Nice to meet you all. Uh Thanks for being here for all the days and I'm excited to talk to you all about concussion and kind of some of the updates actually, I think and then so and some of the updates and kind of how we manage it and look at concussion for some of our athletes. Uh and so disclosures wise, I don't have any. So here's our objectives for today. So we'll talk about uh the latest definition of sports related concussion. I think that's somewhat of a, uh, like a moving target, but we're always trying to redefine our, our definition so we know better. Uh what, what we're looking at when we look at our athletes, uh, we'll talk about some recent management tools. Um, ones that probably many of you commonly use, uh, you know, both in like the medicine, the training and anyone that works with athletes or in primary care, and then we'll talk about some risk factors for prolonged recovery from concussion. All right. So, um, what is the concussion in 2016? And I write, um, in 2016 because that's when that Berlin Consensus statement came out or 2017 anyways, uh, which was the concussion in sports group. Uh, and, you know, for, uh, defining concussion and what we do is really like, driven a lot by these, uh, uh, I guess statement, uh, like consensus statements, right? They gather a lot of, uh, evidence and data and they come out this was meant to be every four or five years where they bring an update and those have been going on since 2001 and 2016 when this has happened. Uh, and it's, uh, usually a gathering of expert panels. And so, and they come together to say, well, what's a concussion? So, uh sports related concussion, um from that Berlin consensus statement was that it's a traumatic brain injury uh induced by biomechanical sour uh forces. And they share these common features, a direct blow. Um They have a rapid and short lived impairment in neurologic function that resolves spontaneously. Uh There's no structural abnormalities and there is plus or minus uh loss in consciousness. Uh and then re recovery follows a sequential or a sequential course. And so, uh let's see. And so then comes 2019 when we have a, a consensus statement for, from the A MS S M, the American Medical Society for Sports Medicine. And uh this was re reinterpreting the data and their definition of the concussion is that that's similar, but a subset of mild traumatic brain injury, which is classified based on acute injury characteristics at the less severe end of the brain injury spectrum. Um Similar. Uh they also clarify that those symptoms can't be explained by uh drug, alcohol and medication or other injuries um or any other real explanation. Um And then it's defined as a transient disturbance and brain function that involves a complex physiologic process, which we'll talk about in a little bit and then came 2021 where this is from the T PC C, which is the team physician consensus conference. And that's part of the American College of Sports Medicine. And they have a similar say as well or a similar definition where they say traumatic brain injury, pathophysiology process affecting the brain by a direct blow to the head or body. And again, like normal imaging, acute signs show functional but no structural damage. Uh and then you can't be explained by any medical condition or uh comorbidities. And so, you know, I think this is where I was saying that even they state that the diagnosis of sport related concussion is a challenge due to nonspecific symptoms and really the lack of objective biomarkers to diagnose it. And so what's a concussion in 2023? Um Well, we don't know yet and it's probably pretty, going to be pretty similar, but at the end of 2022 that same group, the CS, uh C I S G, the Consensus and Sports uh sports group, uh same one that wrote the Berlin Consensus met in Amsterdam. Uh And so, you know, this is actually a pretty interesting uh meeting because, uh this is after Paul mcroy, uh who was the chair previously, uh retired from the C I S G. And, uh and so, you know, part of the excitement about it is, well, what does like the, or the controversy anyways is what is C T E S relation to con um concussion. So it'll be interesting to see what they come out with. Um In addition, they'll probably have a new SCAT as well. Uh So, and that's uh the assessment we do afterwards. Right. And so let's just go back and talk about concussion. Uh, after all the updates, I mean, that, that's one of the big updates in it, but let's go back and just, uh, uh, review concussion a little bit. So it's estimated that one oh 1.9 million related, uh, sports related concussions occur annually in the US in Children under 18. Um, you know, a lot of the data comes from emergency room datas that N E I S the National Electronic Injury Surveillance and that's uh over like 100 emergency rooms is where that data comes from. And what and you know, because that comes from emergency rooms, it's likely an underestimation of how many we actually see because we know that not every kid with a concussion goes to the emergency room. Uh And you know, we can see that from 2001 and 2009. Anyways that uh two, there was a patient under 19, had a 61 increase in concussions there within the United States. Here's a chart from the CDC. Um We can see that age groups, you know, between 12 and 17 have the highest percent of concussion and probably because of their involvement in sports. Uh And then here's one from 2020 that subdivides uh uh by uh by gender and as well as by uh reported ethnicities. And we can see that uh you know, non Hispanic whites seem to be the highest for their rating as well as boys. And so, uh how does it happen? Right. And we talked about it not being completely understood. Um We're understanding a little bit more, um and the understanding is that there's this biomechanical force to the brain and it leads to a head injury that causes a accidental shearing. Um And then from there, there's a release of, you know, exci excitatory, um amino acids and uh and different uh ions. Um And what that shows here, I'll show you in this graph. So what we see is that there's this influx of potassium as well as glutamate. Um and you know, that's from, you know, this big force and you know what those causes call cause in the brain is, you know what that high potassium causes this large depolarization of brains, uh brain function. And then um what that ends up leading to because the body has to pump out the potassium uses more energy. And what happens is called the metabolic mismatch. And so that's the disruption in the ion balance and normal metabolism of the brain. And because of that mismatch, it makes the brain really susceptible to another injury. Um or, you know, and that's probably where all of our symptoms come as well. Um Let's see here. And so, yeah, there's the, the mismatch and that's called the energy crisis. Another word for that, that they've used is um a wave of spreading depression and that's not like depressive symptoms but depression and function that you may see, um, concussion rates. Um, you know, usually these are reported in athletes exposures. Uh, and what we see is that, um, rugby American football, ice hockey, soccer, wrestling and lacrosse are the largest sports that these concussions come from. We see that competition rates are higher than practices and not just rates and rates of those concussions, they also like, uh have more hits and they're probably harder hits in competition. Um And then, you know, in sports with the same rules for both males and females, they have higher incidents in females and uh increases in incidents in high school college of athletes with prior concussion, which is always one of our um big risk factors for concussion or for any like medical condition. Um And then, uh what are the risks of continued exposure? So, uh risk of continued exposure to these head injuries is symptom burden and prolonged recovery. You know, it's something that uh is important for early identification of concussion. So that doesn't happen. Um, you know, risk of we had repeated concussions. Uh And that's something that uh is something that we need to learn more about and figure out what implications that has for young athletes. Um given that probably a lot of their head injuries occur in their uh high school and younger times, uh and then risk of muscular skeletal injury. And then there's the uh you know, the second impact s in them, which we all learn about is, right, which is, uh, when an already symptomatic uh patient, uh, or already concussed athlete sustains another concussion and that's the scariest one. Right. And so that's why we need to identify them, um, long term risks. So, here you can see like these two, uh, football players, they're wearing these guardian caps that, which are meant to, uh, decrease sub concussive hits, hard to know if they're uh helping or in what way they're helping. But, you know, they seem to be, uh they use them in a lot of the NFL teams and I've seen them, we use them over at CAL. Um but in terms of long term risk of concussion, possible risk of mental health problems, um like such as depression anxiety. Uh and then this uh C C T E C T E question about, you know, a pathologic diagnosis at, for it's a pathologic di diagnosis at autopsy. Um You know, with a lot of behavioral and cognitive defects where tau proteins are one of the markers that they've seen. And it's an interesting and I think that's what, and that's what I'm where this new concession statement will be really interesting. Um There's a paper that came out in 2022 applying the Bradford Hill criteria for causation of repetitive head injuries and C T E. And so what this, this paper is interesting because it applies this um this concept of uh the Bradford Hill criteria which is like a a combination of viewpoints used to talk about epidemiologic evidence determine if causation can be deduced. Um you know things that they talk about or the criteria are strength consistency specificity, temporality, biological gradient plausibility coherence experiment analogy. So you ask like does uh the strength of evidence, you know, likelihood greater than one or two are there studies out there that say, hey, concussion can lead to this? Uh There are right? And then consistency is that consistent across the data? And we do see that specificity. So for athletes that do get concussions, is that does that population? Are they um is that where we find C T um uh temporality? Does the concussion precede? Uh does it precede C T which we see as well biological gradient do more concussive hits lead to that um plausibility like, is that a good, I mean, is it a good theory and uh coherence, does that match um the data as well? And other experiments that show that um and then analogy I think is interesting too uh is an interesting way to think about it where uh Brad Hill is actually the person who came up with or uh who designed some of the causality for uh smoking leading to um lung cancer. And so if you think about it, you know, at that time, one of the interesting things they talk about in this paper as well. Like, you know, when we first thought about smoking and does that lead to lung cancer, we would say we don't really know, um, like what types of cigarettes cause it, or how many puffs will take it or how many cigarettes will it? And so applying that rationale, would you say the same thing for concussion? Like what types of hits cause, um, repeated head injuries and long term injuries, um, if they wore X, you know, protective gear, does that cause it? So I think, I think there's like some, it's a great like thinking paper to think about just to um to think about like where, where we're headed with concussion. And so, um another interesting aspect is health disparities uh within uh within the world of concussion. And so this again was information, some of this information was pulled from this N E I S S again, then the 100 hospital survey and uh and what they find they found or what the different papers find, they find that schools with athletic trainers um have greater number of athletes diagnosed with concussion, concussions compared to schools without. Um and I think that's a really important talking point right, that we need to uh like having athletic trainers, especially in California that are certified, can um really help in, help protect our uh athletes at these high schools at the high school level. Um white athletes had more knowledge of a concussion and symptom compared to non Hispanic black, especially when those who had access to an athletic trainer, Black, African American Children are significantly less likely than non Hispanic white to present to an emergency room for concussion. And they're also less likely to be diagnosed and concussed. Children are more likely to uh receive academic support if they have um commercial insurance or his parents. Primary language is English. And so, you know, I think this points to a larger system portion of, you know, how do we support athletes all over, um, or people who are getting concussions, right. And so, you know, if there's, you know, like a, if there's income or where you live and there's big relation to that. Um, you know, I think there's, I mean, that's a probably a larger systemic issue and there's multiple ways to try to do that. And I think that having athletic trainers at these schools could be a really great start or a great move are mandated for that anyways. Um And so now let's talk about uh the management of concussion and I think this is where many people will be pretty familiar, but I think in the primary care setting, um sometimes you see people with uh concussions and you see them once or you see them a couple days after. Um and it's good to review like, what, what do we end up doing? So, you know, for that 1st 24 to 48 hours, uh it's rest, it's eating, it's drinking and that's the main thing we need to do, right, in addition to like monitoring for symptoms. But those really are the mainstays for that 1st, 1st, 1st period of time. Um, here's a handout from the C I F. Uh, and I have a link, there's a link in the uh presentation as well with to the C I F that has a lot of great resources for concussion if you're ever not sure. Uh, what, what you want, if you're ever not sure where, where you are in managing concussion or you wanna give handouts to the families. Um, there's certainly great resources there but, um, this is just for, this is an example of one of the resources of just um informing families and athlete as well. Like what are the things to look for? What are the red flag things? Um, I always find it really useful to review it. Uh, and then here are their recommendations and, um, and these, we try, I try to talk to all athletes about as well as their parents, you know, no medications like I be avoid, uh, medications like Ibuprofen, you know, these NSA medications, uh, because of the risk of bleeding. Uh, Tylenol is a really great, um, headache medic medicine, uh, and then, you know, check for breathing, but you don't need to wake your child up. You know, I think a lot of parents do ask, do I still need to wake them up and it's something that we should continue to say, hey, watch for symptoms, but they really need to sleep. Um, and then, you know, go see your physician within 72 hours, um, track your child's symptoms using the uh like the symptom scales. Uh That's actually something that um we have, I think we have one of those later in the slide, but those are really great to hand out. I give them to the athletes or, you know, people over at the urgent care who come in with concussions every day. So they can um track them every day and then when they see their primary care or, you know, their primary care provider, like in a week or two weeks, you can see a nice little trend of them starting to uh those, those symptoms go down or if they see them sooner, we can see, hey, these people aren't improving and what do we want to do for them? Um How long for recovery is always a question as well. And so, um what we see is that 80 90% of older adolescents and adults take about 10 to 14 days and for uh younger Children, it could take up to four weeks. Um, you know, and that's something that we could talk to our uh patients about as well that it's going to take some times and there is a percentage of uh uh people that don't get better in that time and we'll talk about what we can do for them. Um, but for the most part, 80 90% will match this if they follow, uh, you know, or if they do the correct steps and slow. And I guess in that time frame to recover from concussion. Um And then of course, every child has, it is unique and will follow their own trajectory. Um So, you know, what is recovery and the two keeping components are the return to learn and the return to sport. Um And I put these little arrows because we want to return to learn before we return to sport. Um So what is return to learn it? Well, it's pretty similar to return to sport, right? In this like graded uh methodology of each day, you do something different if you can tolerate it before going back to concussion. Um So, you know, it's certainly stage one that 1st 24 48 hours is complete, rest, eat sleep, you know, and don't really want to do too much. Stage two is uh like the next and the, the next level which is like slight brain activity, something like reading a book could be a great start. Um Stage three is when you really start the homework at home. Stage four is go to school part time. Uh And you can write some accommodations for that. And then stage five is full day of school and then stage six is back to school, uh, full time. Um, and, you know, of course, like, if they're not doing well on any of these stages, uh, going backwards or, or, I mean, holding at that stage or moving back could be a good way to let their brain rest a little more. Right. It's just a little too much stimulation for them at that time. Um, and it's, you know, over at like, the high school you see, like sometimes the, uh, concussed athletes, I think we've had several for like a month or so. They're just lingering on and they're still going to some class and they haven't done like a, they sometimes they don't always do the full return and by their own method because they're pushing it a little more on their end. And so really educating them, educating our athletes about or our, our patients anyways about, you know, you really need to take the rest and take it slow. Um, we'll just keep them in season longer back to their sports longer in the long term because they won't be out for that long. Um And then on the A MS S M uh position statement in 2019, you know, these are some, this is their return to learn and it mirrors it pretty well. So what we can see daily activities at home that don't give the child symptoms, then you move on to school activities, return to school part time and then full time I think this is a really great simple way to think about it just home that doesn't have symptoms, then you can start school and part time and um academic accommodations is something as a primary care provider that you can write for your uh for your patient, which I think can be really helpful. You know, you have to break the lazy athlete stereotype where they're, you know, not working. But this is actually because they do need, you know, they actually do need a break from uh from work. And so, you know, you can see that you can write. Uh, this is what, uh a printout from the C I F actually, that you can print out uh from the link that you'll get in a sec later on, uh that you can print out for guidance if you're not sure which ones to give to your uh athletes. Um And here's the link here. Uh So this is from the C I F. You'll get, there's an information sheet, there's a notification form for parents, there's graded symptom checklist, there's a school letter, there's a return to learn and return to play protocol. Uh And it's available in Spanish. I tried the link earlier, so it should work as well. I'll just leave it up for a few seconds here. All right, great. And then um for return to sports. So, uh Darby and Lauren will come up next and talk about this more as well. As, uh, part of the Buffalo Concussion protocol. But I just like quickly it's, it's similar and in the, in the way that it's step wise. Uh, and, um, and so, you know, step one symptom, limited light aerobic sport specific, non contact, full contact and then you return to sport. Now, there's some important places that you can intervene, um, you know, as the primary care provider where you should, probably should see the patient first. Right. And that's between probably non contact training drills and full contact practice. Um, just because you want to make sure that their symptoms are resolved. If you have, uh, you know, like a scat or, you know, balance testing that those are come down to baseline as well. It was really important before going back to hitting, um, any kind of like contact activity. Um, and, uh, and this is, and so actually, this is not the newest, but in 2014, there was this bill A B 2027 21 27 to be aware of that, uh, mandated this return to play protocol, um, for all return athletes returning. And that after you're, uh, diagnosed with a concussion, you can't return sooner than seven days. Um, and, and then you have to be cleared by, um, a, a certified athletic trainer or a physician. Um, before you go back, coaches have to receive training on concussion, which is a really like has been really helpful for our school. Anyways and like getting everybody on board since, you know, coaches, trainers, physicians, um, you know, strength coaches are all part of the team to take care of these athletes. Uh, and that's, and there's a free course through the National Federation of State high school associations. Um, here's the C I F return to play, matched up with the return to play that we just talked about earlier. And then what you can see here actually is uh here at this point, you know, after this non contact sport specific drills, this is where, you know, minimum of six days to pass this. And then please make sure a written uh physician MD or D O clearance for return of play after stages. One and two, that's these top and that's where I was saying this is where you can intervene and you probably should. Um and this is before going back to contact. Um And then, so, you know, the other part of like doing uh evaluating your concussion is thinking about well, where's uh where's my patient really affected by uh the concussion? Is it the cognitive, the somatic, the visual vestibular sleep or mood? Like what realm um are they really affected in? And that's important because uh you know, when you do your testing, these things come up, but for people with persistent symptoms, that's how we can find more guided uh support for them. And of course, like more research is warranted into exploring all of these realms and, uh, learning more about them. Um, and then, you know, for ex and so exercise for concussion recovery is something that's that, I think there are a lot of, uh, that's gets a lot of practice that gets a lot of practice now and that's, you know, over at CAL, you know, that you're ok to do light aerobic activity, light biking if that's something that doesn't, uh, trigger your concussion symptoms. So this isn't like using it, you know, right away if you're getting symptomatic, but something that can um help your recovery once you're past that, you know, whether it's 24 or 48 hours and your symptoms are decreasing. Uh And so, and what do, what do we find that exercise has beneficial effects on the autonomic nervous system, cerebral blood flow, um cardio cardiovascular physiology and brain neuros um plasticity. Um It improves uh cortico connectivity and activation, improves spatial memory and um increase in brain derived neurotrophic factor B D N F. So all these, you know, all of these to say that, you know, we know that prolonged rest after concussion actually isn't helpful. You know, it may worsen secondary symptoms like fatigue or depression and some early aerobic exercise can be really uh can be really helpful in helping athletes return sooner. Um And here's the Buffalo concussion treadmill test um that you know that you'll hear more about next and get many more details on, but you know what it is briefly is just, it's a validated test to measure the amount of aerobic exercise that's safe to perform even in the acute phase. And so, uh, really what you're looking for is, uh, the target heart rate that your person, your patient can, um, go up to before symptoms start to, uh, occur. Um, and so here's our graduate return to sport again and that's that light aerobic stage where you can use that um Buffalo concussion test. And, um, and this is what we talked about a second ago. And, yep. And here and so like the overall is identify the heart rate that symptoms start to occur. And that's just for like targeted return again. Um Here's just a brief outline and, um, we'll talk more about that in a second. Um The other thing I wanted to say that is with aerobic activity, we see this Kaplan Meyer curve and that people who do early aerobic exercise, um return have shorter durations of uh concussion symptoms and therefore able to return to uh, uh play quicker. So aerobic exercise 13 days median uh stretching participants versus 17 of uh comparing it to athletes that just do stretching exercises. Um, and then prolonged recovery is something that was talked about that, that we talk about as well. Um Also talked about in that A MS S M 2019 position statement. Um What are things that uh cause it, what are things that are associated with it uh and excessive activity before completing your recovery. So, you know, we know that uh athletes that report early concussions return to play sooner. So if they're still playing, then that recovery is gonna take a little longer, um, greater number of severity, uh symptoms, greater number of symptoms, severity of symptoms, and then the duration of symptoms after the concussion, youth athletes tend to have a little pro lot more longer uh recovery course and then um dizziness at the time of the concussion and then migraine cognitive or migraine symptoms. And I think this is one that was uh previously thought before to be a really like a risk factor for prolonged, which was learning disability disability or a DH D. And it was, uh you know, and we don't think that it's a risk factor anymore for prolonged symptoms on a lot of the templates. I find that they ask, you know, you know, that you have for concussion, they ask is, you know, do you have any learning disability or a DH D? And, you know, I, I think it's still fine to ask, but not necessarily a prognostic factor. Uh and then this, uh and then this persistent postconcussive syndrome P P CS. And so there's like a defined definition of it and it's, you know, if your symptoms last beyond two weeks in adults and for, for Children, um there's this, this study here that came out in 2022 that, uh, aimed to find again an emergency department. How many, uh, how many, uh, how many, uh, I guess patients, pediatric patients anyways had, uh, post concussive, persistent postconcussive syndrome. And they compared, uh, sports related, uh, to, uh, coming in with a auto accident. Um, and, oh, excuse me, it was just, um, auto accidents, uh, admit to the E D for auto accidents with concussion. And so what they found was that for this age 8 to 16, um, that 25% of the uh E D patients that had concussion or pediatric E D patients had this post post per persistent postconcussive syndrome. And uh all that to say is that, you know, again, 25 to 30% of these uh patients may have this longer s symptom. So isn't completely uncommon. And um, and there's some, and there's, and there's some treatments that are, you know, this is where those treatments of realms can those, those realms of your concussion, whether that's physio vestibular, those things can come into play because we have reso you can find a resource like a neuropsychiatrist, a neuropsychologist, they can help with it. Um There's uh some people using methylphenidate as a way to help uh kind of reboot these persistent symptoms as well. Um or then like just vestibular therapy, if their balance is off for, for uh for a long amount of time and then um the resources that what are some of the resources that are available to all of us for um concussion management. And so these are the two that we, I talked about earlier. So this is that 2019 statement, here's that 2016. And then um on the b um the British Journal of Sports Medicine, that's where that uh T PC C um statement. It is from 2021 just to review and I think looking at the up to date ones are fine. But um and again, look out for the new one probably in within the next year. Uh The CDC has some nice resources uh with their heads up program again, um These are great to send to families, they're great for personal reviewing. Um and then uh the University of Buffalo with this Buffalo concussion treadmill test also has a really great resource as well. Uh And, and here are some references and I want to thank Doctor Hadia and Doctor Center for help with the creation of some of these slides.