Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Spurs Orthopaedic Surgeon Leah Brown on Recognizing, Ruling Out, and Returning: Concussion Care for Young Athletes

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Spurs Orthopaedic Surgeon Leah Brown on Recognizing, Ruling Out, and Returning: Concussion Care for Young Athletes · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  So, when a concussion is suspected during a game, what are the first steps from a medical standpoint?
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  So, anytime there's a concern for concussion, the first thing is recognizing
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  it and doing an appropriate initial assessment.
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  As we have seen, the recognition of concussion in sports has exploded,
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  and that's really important.
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  We know that there are approximately a million to almost two million concussions
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  sustained by our youth athletes annually just in the United States.
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  So this is really about recognition and appropriate diagnosis.
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  Wow. So for our pediatric practitioner viewers and listeners,
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  what are the most important early signs of a concussion that,
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  of course, no one would ever want to miss?
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  Certainly, we understand that mechanism is huge.
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  And so if these are sport-related concussions, usually there is a mechanism
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  and you can see where something may happen.
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  But usually these symptoms involve cognitive cloudiness or mental fog.
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  You can have headache, noise sensitivity, nausea, light sensitivity.
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  Activity, then you can have even more progressive or more extreme symptoms like
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  neurologic symptoms or other kinds of manifestations that way.
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  So recognizing them early is important.
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  When it becomes a little more difficult is when these types of injuries happened
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  in regular activities like bicycling or on the playground.
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  Can you tell me more about that so we oftentimes consider concussion with athletics
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  and that's great because that is a lot of times where they're happening but
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  children play people get injured you know accidents happen and so you know people
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  ride a bike and you know as much as we say you know use your helmets they may or may not,
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  Scooter use and motorized other vehicles use has increased significantly as
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  our technology has increased.
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  And so recognizing when there can be evidence of a traumatic brain injury from
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  an accident, and it doesn't even have to be a big collision.
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  It can be a whiplash type mechanism. It can be a lot of different things.
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  Falling off the swings, you know, falling down or off the playground or the
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  monkey bars. You know, we see injuries like that all the time.
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  And just for an example, my 14-year-old daughter, she was talking to her friend
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  the other day who does barrel racing.
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  And she was saying, she said that when she had a concussion after barrel racing,
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  she was back on a horse the next day.
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  So to use her friend's words, it's dumb to wait to sit out if you feel like going back in.
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  So, yes, it is up to us as the medical experts to educate parents,
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  athletes, and all of our patients that this is a significant injury.
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  We think of a broken arm or a torn ACL.
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  We recognize that. We want to get the diagnosis, and we're going to go through
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  the treatment protocols so we can return to play.
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  Brain injury is no different and should be respected tremendously.
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  Obviously, brain injury, and we know, especially in our younger population,
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  actually affects adolescents more so than even the adult brain. It is still forming.
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  There are a lot of changes happening. And what is most important is preventing
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  that second hit encounter.
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  So the initial concussion, a lot of times we can recognize and people will shake it off.
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  It's avoiding the second hit while you're still symptomatic.
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  So returning to play while you're still symptomatic is just inviting danger
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  and actually prolonging the potential for an appropriate recovery.
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  Because the brain is more susceptible to that next injury situation.
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  Absolutely. We call it the second hit syndrome. So, you know,
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  we've seen all of the coup, contra coup type mechanisms.
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  You know, this is not a bone. The brain is like a bowl of jelly in a skull.
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  And you can get a second hit that really has a negative impact and people can die.
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  You know, we saw recently this year, unfortunately, there was a college basketball
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  player in Oklahoma that died after a concussion.
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  And so these are things that we really have to take seriously.
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  Here's a question from, and that's such great advice, a question from a pediatric practitioner.
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  She says, I have a few adolescent patients who are into boxing,
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  which of course carries a high risk of concussions.
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  Are there any additional precautions
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  or anything extra I need to do regarding these boxing patients?
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  No, you know, if we keep our protocols in place, we don't need to make exceptions for certain sports.
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  So again, recognizing where you may see them more frequently means that you
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  just need to have a higher index of suspicion.
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  Boxing has done a really good job with making sure they're using pediatric protective,
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  the PPE, protective gear, the head mask, the appropriate gloves.
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  So that helps. But again, if you are in a sport that has a higher risk,
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  like these high collision or contact sports, then that just means you have to
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  have a low index of suspicion.
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  Anyone that has a headache, anyone that has mental fog, anyone that is displaying
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  any types of symptoms, that's an immediate concussion evaluation.
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  If they are symptomatic, they are absolutely prevented from returning to sport within 24 hours.
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  There is no same day return to play with any symptoms of concussion.
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  And then can you go through, again, more about after that, what is the protocol,
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  if we could talk about SCAT?
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  Yes. So there are different SCATs. So you have the SCAT 6 and you have the child
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  SCAT 6, depending on the age.
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  And I think it's somewhere the child SCAT 6 is like 8 to 12,
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  and the SCAT 6 is over 12 or 13 and over.
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  Yes, there's a progression and we have moved away from our previous cocooning
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  of patients with concussion.
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  So it used to be that we would tell individuals that were diagnosed with a concussion,
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  stay in a dark room, don't do anything, sleep, and just minimize exposure.
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  We know that that actually prolongs people's return to school and return to sport.
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  So it's important that we individualize treatment and we continuously monitor symptoms.
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  And these SCAP protocols will help you do that.
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  So early controlled return to activity is important.
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  And it is most important, especially as we're talking pediatrics,
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  you return to learning before you return to sport.
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  If a patient has not returned to full learning, they absolutely are not allowed
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  to return to full sport participation.
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  So, a local pediatric practitioner also asked, she said the SCAT can be a bit
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  cumbersome when used on paper in a clinic setting versus electronically.
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  She's wondering, how do you recommend pediatricians use it outside of the sideline environment?
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  And when following patients over time, is there a level or percentage of symptom
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  improvement you look for before advancing them through a stepwise return to activity protocol?
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  Yes. As you introduce activity, tolerance is the important thing.
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  You know, being asymptomatic is not required.
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  And so if we're putting people maybe on a 10-point scale, so any increase of
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  symptoms greater than two of those points, then they're already baseline symptoms.
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  That means they are not tolerating that activity.
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  So that's a good kind of very, just an easy mechanism to institute.
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  The SCAT-6 is cumbersome. It's cumbersome, but it's accurate. And so it's what we have.
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  However you can utilize it is the best way to utilize it.
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  Some people are better able to utilize it electronically, some people on paper.
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  You know, one of the things that we know that can be a hindrance is just,
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  you know, accessibility.
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  So, you know, some people have a difficult time accessing some of these tools.
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  We do know, though, that, you know, if there is this graduated return,
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  you know, there is the, you know, they do seem to do better.
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  That two-point scale and change in the symptoms is a good way.
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  It's also good to remember to maximize anything that helps.
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  So anything that helps people sleep. So good nutrition, hydration,
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  you know, and reducing outside stimuli to help sleep.
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  Outside of that, minimizing screen time is probably the biggest thing.
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  So we know that screen use has an increased risk of being a trigger or triggering symptoms.
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  But reading does not. light exercise, like walking, you know,
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  those kinds of things, that actually is correlated with a faster recovery.
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  Wow, that's so interesting. Another pediatrician asks about protective headgear.
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  What are your thoughts on halo-style helmets for flag football or non-tackle
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  sports? Do they actually help prevent concussions?
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  You know, there's a lot of literature. There are a lot of studies going on,
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  and we honestly just don't know the answer yet.
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  I think if we did have an answer, we would start seeing implementation of such
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  types of protective equipment.
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  So it's important that we recognize the goal of protective equipment,
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  and that is to prevent or reduce concussion.
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  Ideally, yes, it seems like padding would be great.
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  Sometimes that just doesn't work. Sometimes it's about changing how contact happens.
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  Sometimes it's about changing the rules of the game.
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  They've done this in hockey, in youth hockey, where they're not allowed to do
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  body checks like adults can.
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  They've changed it in youth soccer, where they're not allowed to head the ball
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  until they're a certain age or a certain level.
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  So, you know, we have found that those have a better reduction risk factor than
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  the equipment, but we're working on it for sure.
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  And I saw that ACL injuries are on the rise with teenage girls, especially in soccer.
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  That would be another podcast, though. Yeah.
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  So, Dr. Brown, this pediatrician asks, what are the key red flags after a head
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  injury that should prompt referral to neurology or a higher level of care? Yeah.
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  Well, obviously, any other kinds of physical symptoms that you're concerned.
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  So, you know, we know that neuroimaging is not indicated unless you have very
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  specific concerns like a vascular injury, a skull fracture.
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  If you have neurologic deficits, you know, that's certainly an indication for
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  higher imaging or advanced level evaluation.
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  Additionally, if you see failure to progress, that's another reason to refer
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  to a neurologic or vestibular type clinic because there are different types of lack of progression.
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  But following those factors are usually all that's needed.
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  What's the one thing you wish every pediatric provider and parent understood about concussions?
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  That the brain is worth protecting and that no activity is worth the sacrifice of brain health.
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  And, you know, as much as we enjoy watching our children succeed and perform,
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  whether it's on a field or a court or a gym, it's important that we are having
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  our young athletes engage in athletic activity for health reasons, for team enjoyment,
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  for self-confidence, you know, for total health and not performance.
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  So it's really important that we convey that information as medical experts
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  and as parents to our children who are participating in these activities.
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  Your brain is, you get one brain, so we've got to take care of it.
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  And it's really important. We don't get to see the brain, like we can see maybe
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  bones or skin or something like that, where it's easy to recognize injury.
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  So we have to really keep a close eye on it and be respectful of injuries that we can't see.
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  And what happens after a concussion, it can affect people down the road?
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  Yes. So any, you know, concussion is a type of traumatic brain injury.
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  And so what we are trying to prevent is any prolonged effect.
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  And we are successful most of the time, but there are some times where people
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  are at higher risk of further concussion once they've had concussions.
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  And multiple concussions, you've seen our best, our highest level athletes have
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  to retire from the sport because their susceptibility to concussion now is so low.
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  But what we don't want to happen And is it for it to become a learning impairment
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  or have emotional ability or have some kind of lifelong altering consequence from the injury itself?
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  And Dr. Brennan, do you want to say anything about that athlete you mentioned
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  who passed away from a concussion?
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  Any red flags for parents, this is what you need to get the child to the emergency
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  room, the worst headache of the athlete's life, anything like that?
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  So any red flag symptoms, the worst headache, if they are having further mental
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  fog, any question of consciousness and any neurologic deficit, seek immediate care.
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  Nobody will ever judge a parent for having a low threshold to seek expert information,
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  but those are the red flags where even the medical professionals are starting
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  to institute much higher diagnostic imaging or evaluation. you.
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  And I know with my 18-year-old son, he tends to downplay anything.
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  He did get a concussion in playing basketball, high school basketball,
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  but really he downplayed his symptoms and after the fact then told me how he was really feeling.
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  Yes. This again is about coaching our culture, the culture around sports.
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  We reward the hero. We reward the warrior mentality.
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  And so what we're really having to change around sport culture is it's heroic
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  to take care of your body.
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  It's heroic to recognize limitations and to prevent further injury in the future.
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  So being honest with yourself, being honest with your coaches,
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  that is what's going to enable you to maximize your performance.
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  One small little, you know, minimization like that could have astronomical effects.
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  So being honest because that's the best way people can help you.
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  And I remember being in a high school game and one of the players watching it
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  and one of the players took a looked like a terrible hit to his head, was knocked out.
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  And then his mom was standing up and yelling, get up, get up and play, get up.
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  And this pressure, I mean, it just it's it's just it stops you like the pressure
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  that you're talking about.
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  We it's a societal culture shift. Right. So we want to see that success.
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  And like I said, that hero mentality has been ingrained in us,
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  but at the same time, it's up to us to change the culture around health in general.
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  So being tough is not pushing through injury.
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  Being tough is standing up and saying, hey, I am injured. Let me get assessed.
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  Let me figure out what is going on so I can be the best contributor.
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  Being a 50% contributor isn't always helping the team. And that's the other
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  thing that people also need to understand.
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  And Dr. Brown, as a champion gymnast, how did that prepare you for your role today?
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  I think being an athlete helps other athletes recognize I understand where they're coming from.
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  So I'm not sitting up on some, you know, at some higher level telling them what
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  to do because what they're going to say is that you don't understand or,
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  you know, I have this at stake.
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  I've been there, been there every single level. I absolutely know what is at stake.
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  I absolutely know what it feels like to have put blood, sweat,
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  and tears into something.
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  And so being able to identify that and recognize and respect that and say it
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  out loud helps me better relate to my patients and their parents.
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  And any advice for parents who their child is begging, can I do barrel racing
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  or something that could be high risk? It's tough.
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  I mean, you want them to be able to do what they want to do.
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  Oh, that is a hard thing. And it's different for every family and every goal.
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  I always go back to the purpose of participating in a sport or an activity. Do you find joy in it?
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  You know, is this something that you are going to get something from?
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  Meaning, I'm going to learn how to be, you know, work hard. I'm going to learn resilience.
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  I'm going to learn how to be a team player. I'm going to stay physically fit.
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  You know, we've got to change our mindset from I've got to get this college
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  scholarship or this is my way into to to some other thing, because that is not what sport is about.
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  It is fantastic that opportunities like that exist.
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  But the foundation of youth athletic participation is not about ultimately getting
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  a division one offer or becoming a professional athlete.
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  It's really about the joys of participation and what that brings to you both
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  physically, emotionally and mentally when it comes to finding an activity.
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  That's so well said. Dr.
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  Brown, is there anything else that you want to mention before we go?
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  It's such an honor to be able to talk to you, and I so appreciate you taking time to talk to us.
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  Oh, no. Well, thank you. It's my absolute pleasure. And what I think is really
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  important is that we recognize that we've got to trust our experts.
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  We've got to trust that the science is there to help us be better.
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  And, you know, if you're not sticking by the science of it, then there is an exposure.
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  You're potentially opening up risk for further injury. And what we all want
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  is for everybody's health, wellness, and safety.
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  It's so true. And don't just, after a head injury, try to sleep it off.
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  No, no. Be attuned to your symptoms.
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  Recognize what they are. And be communicative. Seek help.
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  No one is going to criticize anyone for seeking help and expertise.
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  And are you seeing patients at the MARC, or do you want to mention where you see patients?
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  I see patients at the UTHealth Cal Seal Parkway location, and I operate at the
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  Multi-Specialty Research Hospital and at the Outpatient Surgery Center at the
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  Cal Seal Parkway Clinic.
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  Two of our newest locations and beautiful locations.
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  Yes, yes. It's such a tremendous honor being a part of the UT system.
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  I'm excited to be here. I'm excited to be a factor in the San Antonio medical
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  community, and I can't wait to take care of everyone.
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  I see patients anywhere from around 12 years old.
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  Sometimes we see patients a little bit younger than that, up to 80 years old.
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  So I see them all, but I do really enjoy taking care of my adolescent athletes.
• 21:03
  That's great to know. Thank you so much for being here today on Pediatrics Now. Thank you so much.
• 21:09
  Click on the link in this podcast for free credit that may include CME,
• 21:14
  MOC, or ethics credit, depending on our topic or podcast.
• 21:17
  I'm Holly Wayment, and I'll see you next week.