The Quarterly Consult is a quarterly publication highlighting pediatric clinical expertise. If you have an item of interest to include in the Quarterly Consult, contact Dr. Steve Dassel at 206-625-7373, mailbox 8588.
December 2009: Sports Concussions
Monique Burton, MD, and Stan Herring, MD
The topic of this issue of the Quarterly Consult is sports concussions and return-to-play criteria. To do this, I met with Monique Burton, MD, and Stan Herring, MD. Monique is the interim chief of the Sports Medicine program at Seattle Children’s Hospital and the medical director of the Seattle Public Schools athletic training program. She is a clinical assistant professor in the Departments of Pediatrics and Orthopedics at the University of Washington School of Medicine. She is Seattle Children’s representative to the Seattle Sports Concussion Program (SSCP), which is a collaborative venture involving Seattle Children’s, Harborview and the University of Washington. Stan Herring, MD, a physiatrist, practices at Harborview Medical Center. He is the co-medical director of SSCP along with Richard Ellenbogen, MD. Stan is a clinical professor in Rehabilitation Medicine, Neurosurgery, Orthopedics and Sports Medicine at the University of Washington. He is also the director of Spine Care for UW Medicine.
Q: Monique, what is the purpose of SSCP?
A: It is a collaborative venture of Children’s Hospital, Harborview and the University of Washington to standardize the approach to patients with sports concussions. It discusses evaluation and management of such patients especially as it relates to on-field, sideline and office return to play considerations.
Q: How broad is the scope of this approach, Stan?
A: SSCP provides clinical care, education to lay people and professionals and research and advocacy as it relates to sports concussions.
Q: Monique, tell me a little bit about the history behind this program.
A: The program grew out of an incident involving 13-year-old Zackery Lystedt, who sustained a concussion during a middle school football game here in Seattle. After that he returned to play in the same game and sustained a significant brain injury. His parents were passionate about preventing this from happening to any other youth athlete. They secured the help of Dr. Herring and Dr. Richard Ellenbogen, and legislation at the state level, known as the Lystedt Law, was passed, requiring appropriate evaluation and management of concussions by a licensed healthcare provider before the athlete can return to play. The Seattle Sports Concussion Program was established and, in turn, guidelines were established for evaluation and management of sports concussions. Although sports concussions had previously been managed at Seattle Children’s, Harborview and the University of Washington, the Lystedt story acted as a catalyst to the official formation of the SSCP.
Interviewer’s note: Both Monique and Stan stress that the management of sports concussions must be individualized based on the athlete’s age, severity of the trauma and the presence of other conditions such as attention deficit disorder, attention deficit hyperactivity disorder and migraine headaches. And the younger the child, the more conservative one should be; youth athletes are known to take longer to recover than teen athletes.
Q: Monique, how can SSCP help the primary care physician?
A: Providers of the SSCP are willing to consult or to assume care based on the primary care provider’s preference. We are also willing to come to your offices to discuss sports concussions and return-to-play decision-making.
Q: Do you have a telephone number we can use when we need you?
A: 206-987-2109 at Seattle Children’s and 206-744-8000 at Harborview.
Q: Space doesn’t allow a detailed discussion of sports concussion and management of return-to-play, but let’s spend a little bit of time on that topic. Stan, please tell us a bit about epidemiology.
A: There are about 1.5 to 2.6 million sports concussions per year in amateur athletes in the U.S., and that’s probably just the tip of the iceberg because of underreporting. Sports concussions are common in both helmeted and non-helmeted sports. They account for approximately 9% to 10% of all high-school injuries and are even more common in college.
Q: Monique, what is Seattle Children’s Hospital’s experience?
A: The Sports Medicine clinic sees two to four concussions each day and the time lapse since the trauma varies from “yesterday” to a week out.
Q: Stan, in what sports are concussions most likely to occur?
A: The most common sport is football, but girls’ soccer has almost the same rate as boys’ football. No sport is immune.
Q: What’s the pathophysiology of a sports concussion, Stan?
A: Based on animal studies, we think that there is injury to a part of the brain that causes ionic shifts and imbalances, while at the same time the part of the brain that is injured has decreased blood flow. This is a problem because the only way to correct the ionic imbalances is by delivering fuel to that part of the brain. So the fuel delivery system via blood flow is decreased while the metabolic demand is increased. As long as there is a mismatch between fuel delivery and metabolic demand the brain remains vulnerable to further injury.
Q: How do concussions present on the sports field?
A: They can present with a wide variety of symptoms, including cognitive (confusion, amnesia), somatic (headache, fatigue, dizziness, nausea) and affective (mood changes such as irritability, emotional lability). It is important to understand that less than 10% of sports concussions involve loss of consciousness.
Q: What is the best practice for on-the-field evaluation?
A: Obviously, first is the ABC's: airway, breathing, circulation, and then a focused neurologic examination including mental status, neurological deficits and cervical spine status. Based on these findings, the disposition of emergency transport to a hospital versus sideline evaluation can be made. Even if an athlete, especially a youth athlete, is not sent to the hospital, if there is any suspicion of concussion there is no return to same-day practice or play.
Q: What does one look for on the sideline?
A: A more detailed history and physical examination are carried out, including a concussion-symptom checklist and evaluation of orientation, immediate recall, delayed recall, concentration, coordination and balance. Because concussion symptoms can worsen over time, never leave the player unsupervised, and continue to perform serial neurological assessments. It is essential that the details of the concussion be established, as they will have certain prognostic significance with respect to a prolonged recovery period. Certain findings such as amnesia and migraine-like headaches have been associated with longer recovery. Ultimately, decisions regarding disposition can be made — either the athlete will be sent to the emergency room or will be sent home with supervision. Instructions on physical and cognitive rest, medication use, alcohol and the need for medical follow-up should be provided.
Q: Stan, how do we evaluate this athlete presenting in our office several days after the concussion?
A: It is essential to understand the history of the current concussion as well as the history of all previous concussions. The athlete’s age, the sport of choice, and modifiers such as learning disabilities, ADD and ADHD, seizures and depression, anxiety and mental illness must be considered. This comprehensive history is accompanied by a thorough neurologic examination, and the determination is made about physical activity level and level of participation. The athlete must be completely symptom-free at rest before considering any return to activity, and when return to activity is considered it should be done in a graduated, medically supervised fashion.
Q: Stan, how can sports concussions be prevented, or at least reduced?
A: Unfortunately, they cannot be completely prevented. Enforcement of rules such as no head-to-head contact in football is a helpful way to limit concussions.
Q: And finally, Monique, what mistakes do you see us primary care providers making in caring for athletes with sports concussions?
A: Basing return-to-play duration on a set formula rather than based on successive evaluations after progressive aerobic and resistance exercise challenge tests. At best, that sets the athlete up for disappointment, and at worst, it allows the athlete to manage his own return-to-play.
Q: Monique and Stan, thank you for this very helpful discussion.