Transcription:
Baseline Concussion Screening for Teen Athletes

Melanie Cole (Host): Sport-related concussion is a hot topic in the media and in medicine. It's a common injury that's likely under reported by pediatric and adolescent athletes. You may think that concussions only happen to football players, but that's not the case. Concussions can happen for all sorts of reasons, including a bike crash, a fall on the playground, or yes, while playing sports. My guest today is, Dr. Alcy Torres, he's the director of the concussion clinic for children, and assistant professor of pediatrics and neurology at Boston University School of Medicine. Welcome to the show, Dr. Torres, so, what exactly is a concussion?

Dr. Alcy Torres (Guest): A concussion is a type of mild traumatic brain injury, that has gained significant attention over the past 10 years, with a better understanding of the reach of its functional effect. The CDC defines a concussion as a complex, but a physiologic process affecting the brain, induced by traumatic barred mechanical forces, that contribute to the direct or indirect forces to the head. The duration of the symptoms can vary widely from minutes to months, and even longer than in a small number of cases.

Melanie: So, what do we know about the symptoms of concussion Dr. Torres, and who would be the person, would it be the coach, would it be the buddy system, other players on the field or the athlete themselves, who, as I said, in my intro might be hesitant to report some of the symptoms because they don't want to be removed from play, who would be the person to notice some of the symptoms?

Dr. Torres: So, you’re absolutely right when you say that. First of all, it is difficult to diagnose, when you look at the games, you realize that even the low motion has difficulties in finding the moment of the impact of the injury, and it is only on several repetitions that you can identify these. So, there will be extremely unfair to put all the burden into the end to the bad ends, the coaches or the people that are watching an activity or a game. I do think that with the understanding or recognition that it is difficult to diagnose is the first step. This is so true, there’s States like, Massachusetts, for example, where I practice medicine.

The law establishes that if somebody suspects, so that means the coach or the parent, usually that's what happens in youth sports. Suspects that that has been a concussion, the player needs to be pulled out immediately out. And he just said, “It is very difficult sometimes to realize the moment in which these occur.” There is some established parameters or guidelines for every individual. So, most towns now are developing policies that describe the behavior, so the attitude that the coaches need to take, or the steps that these coaches need to take, at the moment that they suspect the concussion, but also could be the parents that needs to be informed. They also need to be educated in when to take the child to the emergency room, and there will be evaluations, either pediatrician or any pediatric neurology or a sports concussion clinic is specialized.

Melanie: So, I was wondering, is this considered an emergent condition if the parents notice problems walking or balance issues or irritability, we used to, as parents look at the eyes to see if there was any kind of imbalance in there, but nowadays we have other ways to identify it, but do we rush them to the emergency room. What's a parent to do?

Dr. Torres: So, not always is necessary. As a matter of fact, the majority of cases is not necessary to go to the emergency room, but certainly when there is a numinous sign, a Red-flag that we call, in which, that patient is manifesting, such as severe headache, vomiting, difficulties with speech or gate or alteration of mental status or any worsening of these symptoms, then the patient needs to be taken immediately to the emergency room. In addition, if there has been a suspicion that there has been and neck injury, the neck needs to be stabilized before they transfer that is taking place. In that case, better by emergency services. And so, it is what is happening now is that, more organizations and educate them titans and coaches, and what will be the symptoms, and the policies in several estates in the union, now require that that patient be seen by a concussion specialist, before they can return to their game, if they were suspected to have a concussion.

Melanie: So, when in doubt, sit it out. Certainly, seems to be the mantra that everybody uses, but now, we also hear about some pre-concussion screening that's available for student athletes. Tell us about the impact test and who should be receiving this.

Dr. Torres: So, the majority of these evaluations are only helpful if you can compare to a baseline because they require certain intellectual functions, and therefore, it is important if these patients at least have a baseline evaluation, these are of two types. They could be a set of neurological tasks, an equilibrium, that is included on what we call now, cap five, which is the sports concussion assessment. In the latest version, number five after the last meeting in Berlin, I know, so sometimes it requires a computerized neurocognitive assessment. There are several ways or means to do that. One of the most common prudence that have spread in the United States is called impact testing, and if you have a baseline, and then when the patient suffers an injury then you can repeat these days and compare. And so, there is always… The physician needs to use clinical judgment to make a diagnosis and decide who to treat.

Melanie: And as far as the parents, again, Dr. Torres, what do we do if our children do have a concussion? We keep them home from school? Do we keep them away from electronics? Do we help them with headaches with end SEDS? Or do we not really do some of those things? What do you recommend as treatment?

Dr. Torres: So, at the moment in different moments, different treatments, and when this occurs in a game, the decision has to be made whether he needs to go to the ER or not. Let's say, that he does not have all the red flags that we just talk. And so, the next step will be for you to contact your pediatrician, and have him seen at the office. If the athlete has syndromes then he will be diagnosed with a concussion, and then, it is important to have some type of physical rest at the beginning. This is only for a short period of time. And as soon as the patient is able to tolerate exercise, then this should be allowed, and this is something that has changed over the past few years because there is evidence that if you send a patient to exercise, at the right time, and to increase, according to the evidence then the recovery will be faster than if you keep them sitting all long. Not to say that the patients or their young adolescent children that need to be sitting him for a long time, will become depressed because you're separating them for their social networks completely. And obviously, any person will be sad and depressive if you are an adolescent.

Now, when you have several symptoms, depending on the severity then besides risk, and then definitely, there are medications that we can use to treat, in particularly, a sleep, which we have noticed that if we don't correct the sleep then it will be very difficult to fix any other symptom. Sometimes, we use medications for headaches because they could be interfering with the life of the patient, and sometimes we do have a part for medications with rehabilitation processes, and these should not be overlooked by physicians.

If you establish a physical therapy from the very beginning, this might help you with coordination, with conditioning. This may also help you with dizziness and the best table or system. In our clinic, we also have psychologist available because we have noticed that there is a significant co-morbidity with mood symptoms, and sometimes patients have already pre-conditions that require aggressive interventions if they are allowed to recover quickly. And then, so after these initial brief rests, we want them to go back to school, and we want them to go back to exercise, not to contact sports if they are symptomatic and not to fill their schedules. And we try to prescribe a tight schedule for all of these activities, and have good communication with the school departments, and educate the athletes to be successful. The good message is that the majority of the patients are athletes, they recover in 90 percent of the cases. So, there is a message of optimism, and there is only a less than 10 percent of the patients that will develop chronic symptoms, and those present with different challenges.

Melanie:  And that's great information about returning to play because that's definitely something parents wonder, and before we finish up, Dr. Torres, is there a way to prevent concussions, and are we not really…are we too trusting of the equipment? We think, “Oh, this isn't going to happen because they have these great helmets and things like that,” but do they protect our children from concussion or is there anything else we can do?

Dr. Torres: So, the helmets do not prevent concussion, as a matter of fact, they might give you the false impression that they do, and the signs have shown significant evidence that the injuries maybe even higher on this group, especially in food, well it is easier to grab the mask of the helmet, and that produce more rotation than if you were not wearing a helmet, but they do prevent external injuries, so the chances to have a fracture or a hematoma, then are less, obviously if you are wearing the helmet. In terms of prevention, obviously, in an extreme case, will be you don't take any risk injury activities, but that is impossible.

And so, there are some air forces in sports organizations, and to develop some laws that will protect the children that are vulnerable or more vulnerable than others. For example, there is a big push in the United States, to boy tackle football below pitch 12. Soccer organizations have changed the rules, and they do not allow heading below age 12 because most of the systems, neurological systems are very immature, prior to that, they believe that if the systems are immature, they are more prone to do damage.

I would like to add, however, that when it comes to when the patient becomes a-symptomatic, and you decide that they are ready to start the process of returning to play, this should be gradual. You should never be like, from sitting, directly to a final game, an important game. It is a process in which you test whether the athlete is developing symptoms, as time goes by, and only if they tolerate, then you continue to throw out the process. And I would say, that if you do that then there is a big chance to be successful. However, in patients that have risk factors like, ADHD, migraine, a mood disorder or ADHD or a psychiatric illness, then we have noticed that the process might take longer to recover and more intervention.

Melanie: Thank you so much, Dr. Torres, for being with us today. This is Boston MED Talks with Boston Medical Center. For more information, you can go to, BMC.org, that's, BMC.org. This is Melanie Cole, thanks so much for listening.