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Pediatric Sports Medicine - Concussion Management ...
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Hello, everyone, and welcome. My name is Mary Juvon. I am the current chair of Pediatric Sports Medicine Community for AAPMNR. And I'm really excited to have you guys today for what's going to be a really exciting presentation on a topic that's probably relevant for most people's practice, which is concussion management. So today, we're going to be talking about concussion management in children with and without disabilities. And so if we go to next slide, let's talk a little bit about our speakers here. Oh, before I do so, just some reminders, some housekeeping things. This is being recorded. Please mute your mic if you are not speaking. And then there is a little Q&A box that you can put some questions. We do have a little segment here that we're going to be looking at that Q&A and having our skilled panelists answer some questions for you guys. I know sometimes people use the chat, sometimes people use the Q&A. It may make it a little bit easier on us if you put it in the Q&A so that we make sure we don't miss it. And then there is tech support that's here to help us out in case we do run into any tech problems. So if you're running into any issues, feel free to put something in the chat box there. So today, we have two speakers and then at the end here, we're going to be announcing our newest chair of our community as I'll be passing the torch on. So our two speakers today are Dr. Colby Hansen and Dr. Amy Rabotin. So I'm going to actually pass it along now to Dr. Colby Hansen to get us started and we'll go from there. Thanks, Mary. Let me share my screen here with everybody. All right. So yeah, I appreciate the opportunity to chat with everybody today and share some ideas and principles around concussion management in children and adolescents. I am at the University of Utah and have run our concussion clinic for a number of years and happy to represent the Craig Nielsen Rehab Hospital here at the University of Utah. If you get a chance to come visit us, I'd be happy to show people around to this beautiful facility. I am hoping if there's enough participants to engage in a little bit of polling, if you're inclined to do so, you can go to this URL, pollev.com and just enter my name there. I'll have two or three polled questions here later on. So let me get myself advanced here. Some of my objectives today are to talk some ideas around recovery trajectories after concussion and then dive into some ideas around assessments once kids come to clinic, review some principles of recovery, what it means to be cleared, and how we might start to address some of the tough questions that we receive when we're seeing these kids. As many of you know, there's been a number of guidelines put out there by different groups over the years, and I just wanted to highlight what some of those are here. In relation to sports management, the most relevant ones here would be the concussion sport group, whose last statement came out about five years ago, and the CDC, who proposed some guidelines for the management of pediatric mild TBI two or three years ago. So understanding recovery trajectories. If you are inclined, I'll just ask you to respond to this question. Which variables do you feel are predictive of a slow recovery from a concussion in school-aged children? And feel free to select as many as are applicable. All right. So kind of a 50-50 split here between female sex and history of migraine. Okay, let's talk about this. So when we think of recovery after concussion, we, you know, kind of have this, or at least I have this picture in my head. This is old data from several years ago, but I think it represents the concept pretty well. So at around a week, about half of kids tend to be recovered. At about two weeks, about three quarters. Three weeks, 80 to 90 percent, and then that sort of slowly tapers off after that. Now this has been replicated pretty well in other data sets, but there is still some variability depending on what kind of patient cohort you're looking at. So here's an example of a cohort of kids presenting to emergency departments, and in these groups, around 12 percent remain with problems, ongoing symptoms at three months and in the single digits at a year. If you look at a different cohort, so this is data from kids presenting to specialty concussion clinics, not the ED. This data was published last year, several hundred kids between the ages of 5 and 18, recovery being defined by a combination of both clinician and parent reporting, and, you know, double the number, 22 percent are still remaining with problems at about three months. So, you know, depending on where you tend to see these kids, you know, that trajectory may look a little differently. So how good are we at predicting those who are slow to recover? So there was a nice project done a few years ago by a multi-center group in Canada looking at children presenting to the ED with concussion, and they tried to derive a prediction model for those who would have persistent symptoms at a month, and the curve in blue there is how well their risk score performed. You can see the area under the curve is 0.70, which, you know, for reference sake, qualifies as a fair test. So it's certainly not perfect, but it is better than just guessing, which you can see the curve there for physician's prediction alone. So what were some of their variables that they found to be significant predictors? So they looked at things like age group, younger age, or I'm sorry, older age, having a higher risk of persistent symptoms, gender, prior concussion with a relatively long duration of symptoms, migraine history, and so on and so forth you see on the table there. And then they stratified these in sort of different risk point strata. So you have low risk for persistent symptoms if you have 0 to 3 points, medium 4 to 8 points, and so on. And this, again, you know, that first curve I showed a couple slides ago is from this project, and it performed fairly. So, you know, there is some help there with using a tool like that or at least being aware of what those variables are. One of those variables, interestingly, was poor performance on balance testing on tandem stance, highlighted here, in addition to, you know, presence of headache, noise sensitivity, fatigue, etc. So in the CDC guidelines and this project that they undertook a few years ago, they focused in on these six questions. And the one I've highlighted here, number four, for children with MTBI, which factors identify patients at increased risk for ongoing impairment, more severe symptoms, or delayed recovery, looking at a timeline at one year or less post-injury. And, you know, their review was quite extensive, and at the same time, a little difficult to interpret, simply because, you know, a lot of these studies that are, again, looking at variables that predict poor recovery, there's a lot of heterogeneity in terms of, you know, at what point in the care pathway are they capturing these patients? Is it emergency room patients or clinic patients or, you know, primary care, etc., etc. But, you know, some general statements can be made from their summary or their review of the existing data at the time. So for age, older age has some greater risk. And the middle column there is sort of their confidence level with, you know, making these statements. Gender, maybe, maybe not. For girls, race, ethnicity, there is some data that suggests Hispanics may be at risk of poor quality of life outcomes. And I don't need to, you know, run through this entire laundry list, but, you know, being aware of some of these issues and these comorbidities, like neuropsychiatric diagnoses, etc., that may play a role in sort of altering what we sort of have in our heads as a typical recovery pathway. So again, while we think that, like to think that it'll go something like this, you know, I think as physiatrists, we appreciate as well as anybody that it's a lot more complicated than just a simple recovery curve. And there's a lot of factors, you know, pre-injury factors, variables related to the nature of the injury itself, post-injury factors, comorbidities, etc., that all sort of interplay in this, you know, what we call an outcome or a recovery from a concussion. And I found this graph in an article a while back and thought it to be kind of interesting just to consider how all these different things overlap and interrelate from, you know, on the right, sort of the social construct of who this patient is and where they're at to the, you know, all the way to the left, to the cellular level and the different, you know, ways this injury can be moderated. So moving on to assessment. One of the most important things in my estimation is, you know, being comprehensive in assessing someone's symptoms. And I think the best way to do that is to get in the habit of using a standardized symptom scale, of which there are a number, but they all essentially try to, you know, recognize that symptoms from a concussion kind of cross over these four domains. And being mindful of that and then actually trying to measure that can be useful. So again, there's different examples of these types of forms. The acute concussion evaluation you can get from the CDC website. The SCAT-5 is the most recent version of the sport concussion assessment tool. And their most recent version, they proposed a sort of an adolescent assessment and a child, you know, from five to 12 assessment. The instrument I like to use is the PCSI, the post-concussion symptom inventory. The PCSI was developed by Dr. Gioia out at Children's National in DC. And the nice thing about it is that, A, it incorporates a parental reporting scale, which I think is valuable when you're assessing kids who may not have the best insight into how they're doing. And then also age-specific scales. So there's one for ages 5 to 7, 8 to 12, and 13 to 18 that have been validated and standardized and have age-appropriate types of questions. You can see with the youngest age group, the PCSI is much simpler, only five items to try to keep it, again, age and developmentally appropriate. And their group likes to do both a pre-injury assessment of these scores and then a post-injury assessment so they can derive a change score, which can be helpful to try to control for some people's comorbidities, you know, say an adolescent has coexisting migraines or depression and anxiety that may be responsible for some of their symptom scores. And, you know, I think the helpful thing with actually formally tracking this, and this is just an example of a kid come to clinic, and is the ability to, you know, track and monitor this over time and, you know, A, help objectify some of the subjective improvements that people experience and maybe identify areas that may still be lingering on those follow-up assessments. Beyond just symptom reporting, I find some value in measuring balance. The, you know, there's obviously different balance tests out there. I have come to be a little partial to the balance error scoring system developed initially by Kevin Guskiewicz at North Carolina many years ago. I think I like it because it's, you know, it's certainly more challenging than just like a simple Romberg or something like that, and which helps bring out some deficits that may not otherwise be readily apparent. But at the same time, it's not overly cumbersome or overly time-consuming, and I would argue that it is feasible to do in kids. We did a project a few years ago where we tested several hundred normal school-age kids normal school-age kids between 5 and 14 to try to derive some normative data for the best, which are presented here on these tables, and broke that down into these different age categories, which were, you know, significantly different from the younger age onto the older age groups. And, you know, with this kind of data, I find it helpful in clinic to, you know, say test a kid who's 10 years old and he scores, you know, a 32 when I administer the best, and I can quickly look at a table like this and be like, oh, yeah, 32, that, you know, that fits for his age group below the 10th percentile. You know, that's probably not normal. You know, certainly there's, you know, not an insignificant variability in the performance on these tests, but, again, I think having some normative data like this can be useful. And we did find that there was, you know, pretty decent reliability in kids, both inter-rater, intra-rater reliability, test-retest reliability was pretty good, so there didn't seem to be a really obvious learning effect. In the, in these younger kids, and published some kind of minimal detectable change scores with these different confidence intervals down here on the bottom right. So, you know, if you're testing a kid again the second time and they're improving by, you know, seven or more points, you can be fairly confident that that's a real change and not just a random test-to-test variability. Beyond balance testing, I think many centers are pretty well in tune with the vestibular ocular motor system and testing that. The instrument that, or testing protocol that most people, I think, use is the VOMS, vestibular ocular motor screening, which, you know, is, is, again, fairly easy to perform. You don't need a lot of high-tech equipment that they, you know, might use in a hearing and balance center, and it can give some, some idea of, like, which issue, what issues are maybe still bothering them and help steer folks maybe into the right, right therapies. So, looking at a combination of pursuits, saccades, convergence, vestibular ocular reflex testing, and really then, as much as anything, trying to decipher if these, doing these activities provokes symptoms. For my experience, most of the time, especially if you're not seeing them super acutely, you know, they're able to do these tests normally, but they will certainly, many of them have, you know, moderate to significant symptom propagation in doing these things, which I think can be insightful. There may be, even be some role in helping to identify those who may be slow to recover. This was a project done, published a few years ago, that looked at, you know, a cohort of, of concussed kids who had either a normal near point of convergence or an abnormal near point of convergence, and their subsequent recovery, and having a poor near point of convergence increased their odds of a prolonged recovery quite significantly. Now, how reliable is doing this testing in kids? So, this, I think, is a useful paper to be aware of. You know, they looked at a few hundred non-concussed kids presenting to the ED for various reasons, and then performed, performed, you know, this battery of tests, and 24 percent, or one out of four, failed at least one element. 13 percent failed two or more, five percent failed three or more, and 10 percent were developmentally unable to complete the exam. So, you know, there are, that, that is an issue to be aware of, but I think that's a reasonable number where you can still perform this test, especially if they have problems with many components of it, and be confident that it's, that it's not just because they're, they're a kid, or whatnot. And again, I, I find this to be helpful to try to document and track over time to monitor recovery. So, here's just an example of how, how we try to do that in our clinic, and you can see, you know, from one point to the next, they have a steadily decreasing number of, or severity of symptom provocation with the bombs and their balance steadily improves over time. Now certainly there's other tools, other instruments that may be coming more and more relevant. There's a fair bit written about dual tasks, gate kind of assessments in a dual task environment that show some differentiation between normals and injured subjects. I think some of the challenge with something like this is getting precise with what are reasonable cutoff scores to then be able to make interpretations about any given child's performance and the best way to administer them. And at least to my knowledge, haven't come across that type of really useful data to make this helpful implementing in a clinic environment. I'm shifting on to some principles of recovery. I'm going to just share a few, some of my biases and some of the things that we do here at Utah. We see a lot of kids with mild TBI and in talking to parents, having some easy to remember framework like here you see on the right, our safe goals tends to be a pretty helpful framework for starting this conversation, helping them understand what will help their child recover most optimally. So first addressing sleep and doing everything that you can to ensure adequate sleep and maintaining kind of a normal day, night cycle and schedule activity, reminding them of things that they should be doing and things that they should be avoiding while they're in this recovery phase. Food and fluid is our F, which we don't necessarily put people on specific diets or anything, but just reminding them the importance of staying plenty hydrated, especially if they're having maybe problems with dizziness or having problems with headaches, making sure they're well hydrated and well nourished certainly can make a difference there. And then lastly, recognizing the environmental factors that may exacerbate symptoms and helping them clue them into recognizing that and providing for a balance of quiet times when they need to, et cetera. So we found that to be a helpful sort of discussion point for many of our families. Along these lines, helping them understand the balance, appropriate balance to strike between rest and activity and then supporting their academic return, I think is super, super important for us to do who manage these kids. So, you know, balancing rest and activity, I think is interesting. I, for those who managed concussion for a while, you know, in, in the early stages of these return to play guidelines, there is certainly a lot of emphasis being placed on rest and, and things of that nature until symptoms go away and that you don't progress through the return to play protocol until your symptoms are gone. And the first step in that protocol is no physical activity. And, and I think, you know, and certainly there's plenty of data now that is borne out that, you know, that's a little too much in the wrong direction. And there really is a need to try to strike a balance between rest and activity. So, you know, while we maybe used to say early on, you need to rest, rest, rest, I really try to avoid even using that word and instead try to emphasize this idea of, you know, pacing themselves and, and trying to find a healthy balance between rest and activity. There are, in terms of, you know, other therapeutic targets, again, addressing sleep with, you know, whether it's just behavioral things like sleep hygiene strategies, or even pharmacologically, you know, I personally, I am, I feel like that's appropriate to do early on. Managing headache, you know, these things tend to be fairly high yield therapeutic targets. Being cognizant to recognize other comorbid issues like cervicogenic pain, I think is very common in, in, in these, in these types of injuries and, and finding that and addressing that can be super helpful and get, get kids going in the right direction. And then again, emphasizing exercise in the right way. So, you know, I think the message now is that we recognize more and more that this idea of symptom threshold or subsymptom threshold or subsymptom threshold exercise is not only safe, but efficacious and, and helpful in facilitating recovery. And this is just one example of that published a couple of years ago by the group out of Buffalo, Dr. Letty. So in this, you know, when we have these conversations, it's easy for people to get confused or to hear, no, you shouldn't go back to soccer yet or football yet. And then, but they confuse that with like doing nothing. And, and that's super important to try to help them understand, like, you know, we want you to try to stay active. We want you to try to do what you're able to do exercise wise in a safe environment at a, at an intensity level that does not exacerbate symptoms to try to understand where that threshold of tolerable exercise is and exercise just below that. And kids who seem to be successful with that, you know, just my subjective experience would be that, you know, those kids tend to do better. Facilitating recovery in the classroom. So again, super important. And I think a primary role that, that we need to play. So I would just pose this question to the group here. School-aged children who sustain a concussion should get what from their healthcare provider, a doctor's note, excusing them from class for coming to the appointment, a letter excusing them from any school activities for a week, a letter recommending accommodations to assist in the classroom, 504 plan, or an IEP. 504 plan or an IEP. Give this just a few more seconds. Okay. So the consensus seems to be a letter recommending accommodations to assist in the classroom. And I would agree with that. I think, well, we'll just talk through some of these issues. You know, this, this return to learn concept, you know, the rationale is that a child may need to gradually be reintroduced to academic activities, just like they may need to be for sports and physical activities. And that there may be different levels of sort of intensity of academic activities that, that could exacerbate symptoms. And so, you know, it, it is important to, to recognize that, and there is, you know, maybe some rationale for backing off some in school. I fear though, that sometimes we, we tend to go too far. And at least in my experience from, you know, referrals that come from primary care providers or from the community, you know, kids are often coming to my clinic and their parents are like, yeah, we haven't been to school in forever. And, and, and we try to steer them maybe in a more productive direction. So, you know, there have been some different proposed return to school strategies that basically, you know, the concept is you gradually do more as they're as tolerated by their symptoms. And I think, you know, a general framework like that isn't, isn't bad, but I think if you're too rigid to it, it can be problematic at times and end up keeping kids out of school for longer really than maybe they should be, which my fear is that that can tend to breed some of its own set of problems. So it is important for us to understand kind of how this works. And, and as, as, as we interface with the school system, you know, we have somewhat limited power to, to what happens in the school environment. There's different layers of support from informal accommodations, which I think is the most frequent and frankly, the most appropriate for kids with concussion on up to 504 plans, which keep kids in a regular classroom environment, but make some of these accommodations in a more formal way. And, you know, depending on, on the culture and where you're at, I think this, you know, whether you, you do things in, in the construct of a 504 plan or more informally, it's really more about implementing it than it is about, you know, what it's labeled. And then say occasionally IEPs may be, may be relevant if, if you need to involve special education services. Depending on where you're at, some, some districts may have school districts may have brain injury teams to help facilitate these, or even formal protocols that various school systems have worked out. And, you know, I know in different parts of the country there, these are more or less advanced to help facilitate these kids getting back in the learning environment. But I think some key principles here regardless are, you know, do your part to educate patients and their parents and to try to empower them for a, you know, what things to be looking out for, you know, from just difficulty learning and paying attention to behavioral issues or, you know, what kinds of activities exacerbate headache and things like that to, you know, then empowering parents to advocate for their child, you know, provide that letter of support with what you would recommend as far as a potential set of accommodations. But even more than, than, you know, A, B and C accommodation is, is really advocating for flexibility and adaptability as a kid is, is recovering. And if something isn't working, you know, have the sense to, like, talk to the school about it and advocate to the parents to talk to the school about it and, and maybe find an alternate strategy. The best plan on paper doesn't do a bit of good if it's not implemented in the classroom. And, and that is, can be challenging depending on, on a teacher. So, but there's a whole host of accommodations that you could look at that, that have, you know, appropriate rationale. And I don't, you know, intend to go through all of these and, and, you know, certainly you can look up these references or, or refer to this talk later, but, you know, being, being in tune with, with what some of these might be and how they might be helpful, I think is, is useful to review. So what does it take to be cleared? You know, if the parents ask, well, when can my kid go back to play? Well, the answer in the most simple form is when they are completely recovered. And so how do we define that? Well, you know, frankly, the gold standard for defining recovery in most papers is when their symptom burden has normalized those symptom scales. But also, you know, they should have normalized back to their prior school performance. They should be tolerating high intensity exercises without difficulty. They should have a normal exam. Again, focusing on, on some of these key areas we talked about earlier and normal cognition. And, you know, do you try to measure that with specific testing batteries or go off of more just like, you know, their, their functional daily real life performance to get a sense of, of normal cognition. Some of these batteries can be useful, a little time consuming, and sometimes tricky to figure out how to implement them into an efficient workflow. And I think there is some question as to the usefulness in younger children on some of these. So, but as far as, you know, working through a return to play protocol, the last statement put out by the concussion and sport group a few years ago, again, reiterated this great graduated return to play strategy, progressing from light aerobic activity to more sports specific exercise, moderate intensity types of things to full speed, non-contact drills. And then at that point, only at that point, progressing on onto contact practice and return to play. This statement from a few years ago did address some pediatric specific types of issues. So, you know, in most circles, these return to play protocols emphasize the need for at least 24 hours to pass before progressing from one stage to the next. But they did recognize that the pediatric population is, you know, perhaps a unique group that may require a longer period of time to recover and thus a more conservative approach may be appropriate. But beyond a general statement like that, you know, there isn't any specific guideline to really how that should be implemented. You know, does that mean you should give 72 hours between steps or one week between steps or whatever? That type of concrete guideline is not out there. And they did make a point to say that, you know, in children and adolescents, they shouldn't be returning to contact sports until they have successfully returned to school. And again, this needs to be not forgotten about. So, you know, what are some of the tough questions that we have to address here in just these last few minutes? What do, you know, these are questions that I frequently get from concerned parents, you know, what do I need to be worried about with my kid who's maybe already had a few injuries? Is he doomed to permanent brain damage? What if my kid's recovery is taking a long time? And again, long, I would say is, you know, longer than that one to three month time frame. How long should that return to play process be? How many injuries is too many? You know, when to direct kids to other activities, et cetera. So I'm curious to get folks, let me clear this out, folks' feelings on this statement. A positive concussion history means what? It makes you more likely to get another concussion, makes the recovery from a subsequent concussion significantly longer, makes you get a subsequent concussion at lower magnitude of forces or all of the above. Give you a few seconds here, see what folks say. So fortunately this isn't an exam and there's a definite right or wrong answer, but I would argue that the most convincing data supports the idea that A is maybe the most correct answer. So this is an interesting study I came across some time ago where they tried to do biomechanical reconstruction of a bunch of injuries in kids and to try to determine if those who had a history of concussion and then sustained a subsequent injury sustained that injury at lower biomechanical forces. And the short answer was no, they did not in this paper. Now certainly anecdotally, we encounter situations where, you know, a kid maybe has had a few prior injuries and it seems that maybe they are more prone or more vulnerable to the effects of additional trauma. But at least according to this paper, globally speaking, it didn't seem to be predictive. What about having a prior concussion? Does it affect their recovery trajectory? Again, I think you'll find, you know, varied data on this, but this is pretty large cohort. Now this incorporates not just high school athletes, but some college athletes as well. This is from the CARE Consortium. And they tracked several hundred concussions and those with a concussion history didn't actually have a significantly different recovery trajectory as depicted on the graph there. So again, how to consider their injury history? Well, for me, I think the most compelling data suggests that it's really the risk of subsequent injury seems to go up when you've had a couple, two or three prior concussions. And this is data that's been around quite a long time, but I think paints the picture fairly well. So, you know, I feel most comfortable telling people that the biggest risk of having had prior injuries is the risk of getting another injury. It doesn't necessarily mean that that next injury is going to be really bad, but the risk is certainly higher. What if my kid's recovery takes a long time? There are some data that suggests that the risk of repeat injury could likely be higher if they had a more than one month recovery versus a short, quick recovery. And I'm just going to kind of quickly run through these last couple of slides. What about the return to play process? Should it be longer? I think this is pretty interesting data, again, from the CARE Consortium. They compared some of these original NCAA studies in the early 2000s to the CARE Consortium. And, you know, they managed these injuries more conservatively. They had a longer time before they returned to play, a longer time of being symptom-free, and their rates of repeat injury were significantly lower. So, you know, I think the message here is that, you know, if you can reasonably extend out that return to play process, you may be providing some protection against repeat injury. And then these other questions really start to get at, like, what are the long-term effects? And that's a whole separate talk in and of itself, and I don't intend to get into that. But I would just argue that there's a balancing there between, you know, these potential risks that people worry about, like CTE or post-concussion syndrome, et cetera, to the benefits of physical activity. And there are a lot of benefits that shouldn't be lost in having these discussions with patients and families. So, with that, thank you for your time and attention. And here's a picture of a beautiful Salt Lake Valley in the University of Utah campus. So, come visit anytime. And now we'll turn the time over to Amy Robertson from the Mayo Clinic. Thank you so much. Thank you so much. All right. Well, thanks, Colby. That was awesome. And we're going to switch gears just a little bit in what we're thinking about here in talking about concussion and talking about it in kids with disability. And so, really building a lot on what Colby was talking about for how we think about concussion and where it's going. But, you know, I think the interesting thing with some of the Berlin consensus is that, you know, there really wasn't much talked about in terms of children with disability that play sports and get concussion. And really, the statement that they put in there, they considered whether special populations should be managed differently. And that's kind of where it stopped. And so, I think that's a highlight in how different and how little data, really, there is in kids with disability and their concussions. So, what I hope to accomplish today is a few objectives. Reviewing the difference in sports that may have higher risk of concussion. So, children with disability may play different sports. And we know that over time into the Paralympics. To discuss the challenges in concussion assessment in children with disability. And to discuss management of concussion in children with disability. And so, you know, keep in mind what Colby was talking about and kind of think, how would that be different in a child that has disability? Is it the same? Is it different? And we'll talk about that. So, there's risk factors of concussion, which are the same in a child with disability versus not. But there's risk factors of exposure, of speed, of collision, of contact sports. And participation in sports by athletes with a disability, including physical impairment, visual impairment, or hearing impairment, it continues to increase in the level of competition. And the intensity continues to increase as well. And so, we'll talk a little bit more about these sports as well. So, what other sports could you think about that our kids are participating in that maybe have a lot of speed or collision factors? So, you know, when you think about winter sports versus summer sports, and some of these are all year round sports. But there's, you know, speed sports, so skiing. So, sit skiing or different kinds of skiing. Collision sports, such as sled hockey. Summer sports that are, there's a lot of contact sports, such as wheelchair basketball, and that's year round in many places. Wheelchair rugby, judo, football five-a-side, and track. So, lots of different ones that present opportunity for our athletes, which is great, but also present some opportunity for concussion. So, do concussions happen in our patient population? Well, yes, they do. You know, if you look at these para sports pictures here, track and field is really different, potentially, in, for example, the Paralympics, or in what our children with disability are participating in. So, in the case of track and field, you know, the typical Olympic track and field events, the risk of concussion is low. In fact, there's never been a, you know, a case of a concussion. In fact, there's never been a reported concussion in a track and field event at the Olympics, but there obviously have been crashes like this at Paralympics. And we maybe see this in our children with disability who are participating in track and field at home. So, this is not uncommon to have these kinds of crashes. And then there's the different kind of sports. So, football five-a-side, which is soccer with a blindfold. And these athletes have a very high risk. So, it's a sport in typical or able-bodied. They play and have risk of concussion. And then the risk of concussion is just as is the same or is higher, potentially, in football five-a-side, for example. I think the interesting thing is, if you read this paper by Dr. Reborn, there were, for example, with this picture taken, I don't know if it was this example or this picture exactly, but no, there was head butts and heads hitting together and even sounds that you could hear on film of heads hitting together, but yet no concussions were reported in these games. These were the Rio games. So, pretty interesting that we're not even recognizing it sometimes. So, if we all start to recognize that children with disability can be at risk of concussion in their sports, how do we diagnose the concussion in them? It's not an easy question to answer. And, you know, do we use the SCAT-5 for everybody or do we find other ways to make it more appropriate for the appropriate patient? So, there was a study that was published in the New York Times So, there was a study on neurocognitive, the SCAT-3. So, that was the previous version. Baseline test scores, are they different between football players? So, soccer players living with and without a disability. And of the 249 England footballers, 85 without a disability and 64 with a disability, they showed that male, excuse me, male blind footballers had higher symptom scores, higher symptom severity scores than peers without disability. And more specifically, the male blind footballers, which of there were 10, had higher for total concentration and delayed recall symptom scores. So, this is really showing that there is a significant difference between the baseline section scores for footballers with and without disability. So, should we assume that the tools that we use, you know, the tools that Colby just reviewed with us, are they not appropriate for us to use, such as the SCAT-5? You know, how do they apply to this athlete population? I guess, how and do they in general? So, it's kind of a diagnostic dilemma. And there's a great paper, again, by Weborn that goes through and looks at the SCAT-5 symptom evaluation. And how would it apply, or the SCAT-5 in general, how would that apply to our athletes? So, how do you assess vision changes in a visually impaired person? So, how do you assess vision changes in a visually impaired athlete? How do you assess hearing and balance in a person with known deafness due to an impairment? How do you assess balance in a paraplegic, a bilateral amputee, or someone with spina bifida, for example? So, the tools that we have for immediate or on-field assessment aren't adequate necessarily. And even in our clinic, if we're reusing some of those post-concussion symptom inventories, they're not adequate if the athlete has baseline visual impairment, or motor impairment, or hearing impairment, or other balance issues. The tools for symptom evaluation here, like the SCAT-5 symptom, the step two of that, the symptoms evaluation, it might result in a higher score for an athlete, even at the athlete's baseline. So, if you ask all these questions of an athlete, maybe they have these symptoms just in their everyday life. Tools for cognitive screening will have potential challenges in athletes with cognitive impairment or speech impairment, for example. The tools for neurologic screening may not apply to an athlete with an amputation or wheelchair user, as their balance examination may be challenged at baseline. So, in this slide, kind of trying to help us to see that concussions can go under-reported and under-recognized because of kind of lack of knowledge and the lack of how we're thinking through concussions in our athletes with disability. So, think about your pediatric patient presenting to your clinic with concussion. A typical, I'm sorry, a typical patient, a typical pediatric patient presenting with a concussion, they might have symptoms of a headache and fatigue and dizziness, taking longer to think. But then that pediatric athlete with a disability, that might already be their baseline. So, they might have dizziness as their baseline, as part of their baseline medical condition. And if you didn't know what their baseline was, how would you know if it's a concussion or not? So, this is exciting work that just came out in the British Journal of Sports Medicine, and it's the Concussion in Parasport. And it's a position statement on concussion in parasports group. And I think this is a really great tool. And I highly recommend everybody go find this paper because it's kind of starting to have that conversation of how we need to think about this. And hopefully, it will drive a lot of research for us in the future. So, what they do in this paper is they actually take the SCAT-5 and they take all the steps of the SCAT-5 and parts of evaluation. And they use a stoplight kind of process to say what applies as is. The yellow applies with caution and the red doesn't apply at all to this particular athlete population. And then they take the SCAT-5 and they take all the steps of the SCAT-5 and parts of evaluation. And at the very end of the paper, they walk through different disabilities that we may see in our athletes. So, for example, I've posted two here. The one on the left is the cerebral palsy athlete with spastic hemiplegia. And the one on the right is an athlete with muscular dystrophy. So, you can see the differences in kind of the red, yellow, green in what would apply and what wouldn't and what maybe some of the accommodations might need to be. So, how do we really need to think about our athletes? How do we use this? And what is this helping us to think about? Well, the important thing is to really get a baseline evaluation, if possible, on your athletes. So, what is their baseline symptom evaluation? Is this a change from normal? So, this is where it's really important in our pre-participation exams to figure this out for our athletes and have it well-documented. We don't have alternatives to this testing at this time, but maybe at some point we will. But if we start with baselines, then we can kind of know what the difference is and also get their concussion history. And so, for example, what we've been doing here is we've been getting a baseline SCAT-5 on our sled hockey athletes at the beginning of the season so that we can know kind of where things are at. And we have that available to us at practices and games. And to be honest with you, I think we have one athlete with a baseline symptom score of zero. So, it's really important to know what kids are feeling. And the concussion history, as I said, is super important because we need to know this for their medical history. And all of this information is so important to have available for the medical team and the coaching staff to help us determine if a concussion has happened or not. So, just like Colby was saying, there's the BESS and the modified BESS. And so, think about this in terms of your athlete, right? How is an athlete gonna perform on this if they've had an amputation or one of our patients with cerebral palsy or with visual impairment? What would their scores be? Can they even perform it? And so, it's really important to kind of think about how is this gonna be helpful to us, if at all, in our athletes? So, can we have that baseline for them? And because of this, a lot of great, people are thinking really about great things. So, if a patient is a wheelchair user, how do you assess their balance? So, there's now the West that's being trialed in different research studies. And I know we've used it in different situations as well. So, it's the wheelchair error scoring system. And so, it's comparable to the BESS. But again, it's for an athlete in a wheelchair. So, looking at rather than standing on one leg, how long can they, or how do they handle their chair with a wheelie and that kind of thing? So, eventually, we hope that there'll be normative data for the West. And we'll have different kind of normative data for different classifications of athletes in different sports. It's a huge task. And so, hopefully, as a population of people who want to do great research, we can start to figure these kinds of things out and get some normative data out there. So, in concussion management for these kids, there are some things that we have to think about. And it's just like, it's all of the things from the return to sport and everything that Colby just went through. So, you recognize and remove. And so, in the paper, in the new consensus statement, for example, in any state, for example, in any sport that for disability, there's no difference in that. So, you still remove the athlete from the sport. For the rest perspective, how does this look for a child with a disability that uses a wheelchair? Can they have physical rest because they're propelling their chair? Does this need to be modified for them? Does this need to be part of their return to school kind of accommodations? So, active rest. Is active rest different? So, a lot of times in active rest, when we're getting kids back, we have them on a bike or we have them doing kind of those low impact activities. Well, what does that look like for your athlete with disability? And then return to school is no different in this case in what their assessment is. So, this is just our example of return to play guidelines. And so, thinking through this, and again, in the consensus statement or the position statement, they actually go through and do the green, yellow, red, light process again through all of these stages of return to activity after concussion for different sports to help them get back to school. And then they do the green, yellow, red, light process for different sports to help kind of think through, what does this look like at each stage of the game? And really, a huge thing is education. So, education is key. You know, if we're not, just like in one of the first slides I showed you that the football five-a-side players had hit their heads together and they were staggering. These players were staggering on the field, obviously concussed, but not pulled necessarily from play. It's really important for us to educate our patients and educate them in terms of their risk for a concussion and that it can happen. And that if their symptoms feel different, we need to hear about it and talk about it. Educate their teammates. Maybe teammates are the first person to say like, you know, did you get a concussion there? Educate families. You know, families are on the sidelines or in the stands watching. They're also helpful. And also to help with baselines too, because a lot of times they're able to help determine is something different or not. Coaches need to be aware. Coaches need to be aware of how important it is that we are acknowledging this and pulling our athletes if we need to and then doing appropriate return to sport. Referees and then medical professionals. All of us as team physicians and athletic trainers and therapists, we need to be out there with this knowledge that it happens. We need to address it and we need to treat them with equity. So a few key points. We have a few incidents data for concussion in athletes with disability, but we know they're occurring. They're under-recognized and under-reported. And so, you know, part of our job is to start to help that happen. There's challenges with the current tools for diagnosis, but there's lots of great minds starting to think about how do they apply. And that's what we need to do with our athletes in general is what applies and what makes sense to apply to our particular patients. Getting your athletes baseline. Again, that understanding what their symptom scores are at baseline will be of the utmost importance. And then adapt the management of concussion depending on the athlete impairment in sport. So all the things that Colby went through totally apply to our athletes, but they might have to be adjusted or adapted so that our athletes can do the appropriate recovery through the process. And then think about kind of risk reduction strategies. So how do we make our sports safer? How do we get educated so that we can share this with our athletes, share it with the teammates, share it with the family, share it with the coaching and referee staff, so that there is awareness of concussion. We're talking about it and we're diagnosing it and treating it. So with that, thank you. And we'll move on to questions. Wonderful. Thank you both so much for a really excellent overview of really everything that we know currently for our patient populations in terms of concussion and some things that we don't quite know yet and what we do with that information. So I would ask that anyone who has questions, you could either put it in the chat or we actually have a bit of time today that we could actually have our attendees actually ask the questions themselves too, if we go ahead and allow the unmute feature. So the first question is actually from Jolene. And Jolene, if you want to unmute yourself and kind of ask your question, that'd be great. Great. Sorry about that. I didn't have my microphone set up. So thanks. Thanks a lot, Mary, for that. So something that I tend to run into in clinic and I see the kids who often are struggling to get better. I don't see the vast majority that do get better. And one of the things that I'm always asked is how do you return a kid to play who now has developed a chronic post-traumatic migraine? How do you, do you hold them out of sports entirely for the rest of their lives? Or what is the protocol that you use or how do you get these kids back to playing? I guess I'll take that question, at least a first crack at it. You know, these kids who develops really any form of chronic symptom are certainly challenging. There's no doubt about that. I guess I feel like personally, if someone's truly having problems that they didn't have before, I'm reluctant to clear them to get back to, if it's a high risk sport. If it's sort of a sport where there's either low, low risk, or, you know, you can, you can control some of the variables there reasonably well. I think you can have a thoughtful discussion with, with the patients and their families about, you know, well, what are the, what are the pros and cons of, of what you're wanting to do? And, and are you, you know, are you willing to, to sort of subject yourself to the possibility of additional injury and the possibility that that could mean worsened headaches in this example, or, or whatever the case might be. I'm, if it's a high context for like football, hockey, you know, rugby, you know, I'm frankly reluctant to, to clear them if they're, if they're clearly having difficulties that they didn't have before. It gets even more muddy when, you know, maybe it is a kid who had chronic headaches before and trying to decipher like, well, are they, are they back to baseline? Are they not back to baseline or whatnot? But I don't know, that's, I don't know if that's a great answer, but that's some of my thought process at least. And if I can steer folks into, you know, a healthier direction or maybe a lower risk activity and still encourage them to, to find avenues for physical activity that they can enjoy and, and reap all the benefits of, then, you know, I'm, I will try to do that the best I can. Amy, did you have anything you wanted to add for that too? I don't, it's really tough. And, you know, we see the same patients since we're at the same place. And so, you know, I think it's, it is really tough and it's always, it's that risk benefit analysis. And I think I talk a lot more about the risks in this particular topic with families than I would if they, if this wasn't the question, you know, like if it was some other, if they, if this wasn't the question, you're like, if it was some other kind of injury or whatever, but chronic migraines, you know, this is, you don't want that as a lifelong sentence. And so I kind of have that conversation. That's really helpful. And I could add to, I agree with both of you guys. And I think the other piece which I recognize that not every center has, but I would imagine both of your guys center has is oftentimes that's when I'm referring to neurology, headache specialists also. And I find a lot of these patients might have a family history of migraines, or as Colby kind of mentioned, maybe was having some migraines before and is having more now. And so I take that as an opportunity to, you know, really plug into a headache clinic, recognizing that they kind of specialize in that too. And see if there's any tips or techniques or things that they have for overall management that can complement the treatments that we're doing for concussion as well. But I also wouldn't be clearing somebody with those new symptoms until things are resolved as well. Wonderful. So if I think Jonathan, thank you for putting in the chat, just if you, there's the little raise hand icon. So if you just put the raise hand icon, you can, we can call on you to ask a question. And I think we were trying to do the, the speaking questions just to make it a little bit more interactive, because I know we're not all in person with each other. But I also totally recognize that some people might actually feel a little bit more comfortable typing questions in. So that is fine too. If you type your question in, sorry, Jolene, that you were the, the experiment originally, but if you type your question in, I will take that as a sign. You want me to read it off, that's fine. Or if you raise your hand, then I'll have you ask the question directly to Colby, Amy, or either. Can I ask a question? Colby, do you have any recommendations? Like when you have to tell a kid that, gosh, sorry, you're done, you know, like, do you, do you have a good script for that or some good words or anything that you use for the trade? That's an awful conversation. No, I don't know that I do. I was just kind of reflecting on, on maybe some experiences. I think that, well, some of the times it sort of becomes an inevitable conclusion that the, the, the, the patient and the families have kind of reached anyways. And so that becomes easier to be like, I agree. Probably not the best idea to, to put on a football helmet this year or, you know, ever again. I don't know. I, I, yeah, I, I don't, I don't know. I don't even know what I would say to that. It's a lot of kind of reading the moment and trying to, you know, certainly try to put a perspective on it that, you know, there's certainly a lot of other things that they things that they can do. I, I, I always try to make sure people aren't misunderstanding, you know, when I say like, you shouldn't be doing X, Y, or Z, but that doesn't mean you shouldn't be finding ways to be active and like being, being active, finding any other activities that you could do and enjoy new hobbies or whatever is super important and not just kind of leave them hanging. Like, you know, I took this away from you and now you're, you're going to hate me for the rest of your life. Thank you. That's helpful. I would agree with that as well. And I, I have another question for, for both of you too, which is when do you consider getting an MRI and what do you do if you make that decision, you get an MRI and then you find an incidental finding that has nothing to do with the concussion? Obviously we don't see concussions on MRI. We're getting into a lot of other things, but for instance, recently I got one and there was arachnoid cysts that had come back. And so what any thoughts that you guys have on what you do in those circumstances, and I know different centers focus differently on, on protocols or when they would get MRIs. I'm just curious from both of you guys, what your perception is on that. I mean, briefly, I don't order a lot of MRIs. Often I'm, I am ordering them if the family's pretty insistent on getting a scan. And I try to just have a discussion that, you know, the likelihood of finding something is extremely low. The likelihood of finding something actionable that would change management is even lower. But if, you know, if it would bring some peace of mind to you to, to know that structurally things are okay, then, you know, then let's move forward. And I mean, yeah, I guess incidental findings happen occasionally and you just address them as they come. You know, if it, if it's something, if along those lines, it might prompt me to at least, you know, reach out to our neurosurgery colleagues to decide if they feel like it's something that merits monitoring or further investigation. But that's what I would say. Yeah, I, I echo exactly that. And you know, it's really, it's reading the family. You know, there's sometimes like if there's somebody, if there's a kid that it's like, you know, this really should be better. And like, if it's, there's something in my head, that's like, I feel like we're missing something here. You know, like this headache is too, it's really changed in nature and, you know, now they're having blurry vision with it and, you know, it's waking them up at night. And, you know, like, so those things that are like, am I thinking, am I getting red flags now? You know, like that goes through my head and that's going to weigh into my decision as well. And so, you know, I think there's part of that is, has this really changed so much that we're actually dealing with something new and different? And then, you know, referring to, if there is some, is there, if there is an incidental finding, you know, yeah, it's the phone a friend, you know, do you want to see him? Do you know, do you not want to see him? How do we want to handle this? You know, it's neurology, neurosurgery, or whoever it makes sense to call. But that's a pretty quick phone call for me, because I know parents then see the results and, you know, my phone's going to be ringing too. So usually I kind of go about it that way. Perfect. And yeah, I think that that that's pretty consistent with how I practice as well. It's interesting. I don't know current practice in Seattle, but I know when I had trained there, there was a protocol that was more than four weeks and things were still not really kind of progressing. They would be getting MRIs and a lot of incidental findings happened. And so I think there was a lot of plan to revisit that policy because then there's a lot of stress, right, of families seeing things and whatnot. My individual case recently, patient actually had decreased facial sensation on one side on exam, which was kind of surprising and didn't really seem to line up with the rest, but I'm like, okay, we see it. And I actually think that was migraine that was causing that symptom and completely different area of the brain. There was a arachnoid cyst. And so I think it just highlights the point that sometimes these things can kind of come up and it just, it does put you in a whole different type category of situation because in this particular case, then the neurosurgeon is also talking about the risk of increased injury and bleeding because of that too. So it just, it's kind of another interesting piece that sometimes we don't always think about. So there is another question here in the chat. So do you think there's an age cutoff for which a pediatric concussion patient becomes far better served being seen by a pediatric PMNR provider versus a TBI or sports specialized physiatrist, mainly seeing an adult population, or do you think it's an individual provider comfort and judgment? Yeah. Interesting question. I think it probably just totally varies and depends on where you're at and how, I mean, I have a colleague who has seen a lot of TBI, but hasn't seen a kid in many years. And I would, but I have another colleague who's TBI physiatrist and recently out of fellowship. And we feel very comfortable having him sort of educate and assess an adolescent. I probably, if there was an age cutoff, it's probably in that adolescent category, maybe early teens. But I think it varies from the situation. Yeah. And I think it's like at our facility, people come in multiple different ways. So it's actually kind of not everybody comes in through pediatric PMR or they might come in originally through sports. So I think it kind of varies. And a lot of times what will happen in our institution is that these patients will get referred to PEDS PMR because of ongoing symptoms and difficulty with recovery. So it almost kind of goes the reverse in our institution at times. I would agree with all that as well. I know where I change for PEDS rehab fellowship. After a certain point, if the symptoms were ongoing, it would transition from PEDS sports to PEDS PMR for that reason. And I do think, you know, they're just in general with sports injuries, whether it's concussion or otherwise, there are certain different considerations in kids as we're kind of discussing today. And so somebody who sees kids on a regular versus somebody who, as Colby said, you know, maybe hasn't seen them in over a year. I think that's a huge difference. I would imagine most adult providers are not going to be comfortable with somebody who's eight or somebody, right. You know, so I think that adolescent cutoff, whoever in that adolescent cutoff is a pretty appropriate one. So I'm looking at, oh, perfect. I was just about to say it and see any other questions, but I do see another question. So how does the return to play in school look differently for those with disabilities? As someone that said they weren't, they were a little bit late, so they weren't sure if this is a redundant question, but would you consider prolonging return to play as they may have delayed in more difficulty with healing or would it differ for different disabilities? Yeah, so perfect question. And the answer is the exact, is the last question right there, is it differs for different disabilities. So again, that's the importance of knowing your patient's baseline, but kids may, I think what some of the data is showing that kids with disability do take sometimes longer to recover from their concussion. So, you know, a return to sports that maybe is that five-day return to sport or, you know, like the, or the five stages and, you know, a week, maybe it doesn't apply to those athletes. So in the, in the paper, I referenced actually have a really great red, yellow, green kind of play-by-play for different disabilities in that return to school or return to play, primarily not return to school, which is helpful. It's really helped me kind of think through what questions I'm asking of the athlete and what I'm saying is okay or not. So they definitely may have prolonged recovery and need a little bit more support through that. So hopefully I answered that question for them. But if you want, I can show you, I'm going to be, oops, I can't, it won't show because I have my background on. In the slide deck, there's the, the article, the consensus, the concussion and para-sport first position statement in the BJSM. So I'd highly recommend finding that. It's a really great resource for us right now. That was really helpful. And still more, more work to be done, I'm sure in that population, right? So, you know, research, anyone who's interested, reach out to Amy Robotin. There's the email address right there, which is a great segue. So here is the email contact for our panelists today. And if you're watching this recorded, or if you're watching this currently and you had other questions or you do want to collaborate and want to reach out, everyone on the panel is very much open to you reaching out. So hang out to those email addresses. And then we can go to the next slide actually here. And we wanted to talk about our passing of the baton now. So as of this meeting, I am going to be past chair. So it's been such a pleasure being the Pete Sports Medicine member community chair of our really inaugural two years. So it's been a lot of fun collaborating with others who are in the Pete Sports Medicine world and putting together things like we had tonight to talk about specific topics and special topics in pediatric sports medicine. I'm very delighted to be introducing Dr. Jonathan Napolitano, who is a colleague of mine across the country, who, you know, Amy and I have collaborated with a ton and hopefully will continue to do so. And he's going to be taking the position of chair moving forward for the next two years. So I'm going to pass the torch on to him officially now. And you can talk a little bit about any thoughts and visions for the community moving forward. Yeah, thanks so much, Mary. And thanks, Colby and Amy. That was a really great session. So yeah, I'm excited. My name is Jonathan Napolitano. For those of you I haven't met in sports medicine, pediatric sports medicine position at Nationwide Children's Hospital, our butterflies all over here. So in Columbus, Ohio, Mary and I have worked together on a lot of different kids sports projects. And we're I feel like a couple of the first desires to go through pediatric sports medicine training. And I see both in our panelists and Amy and then in our participants with Stephanie and Jenny and everybody else who's kind of coming through the ranks to follow these leads of interest in pediatric sports medicine. We're really excited to take it from here and and lead this group. Mary, I'll force her to stay involved in some way. But the way we're moving forward here, the virtual format of this meeting doesn't lead to a lot of networking opportunities. So we're going to follow AAPMNR with a Zoom virtual business meeting. I'll post it to that his forum as far as opportunities. But here's your save the date. It'll be Tuesday, December 7th. The AA offices are in the central time zone. So that's 7 to 8 p.m. Central Time. Make your calculations to figure out what that means for you. But what we're going to do at that meeting is really just kind of have an open forum. It'll be an opportunity to network with other people interested in pediatric sports medicine. If that's part of your career, if that's an interest of yours, our goal will be what's our programming for the year? How can we truly hit the needs of our members and truly expand our scope and membership as well? What are the things we're going to do throughout the year to match that? And then what do we do for AAPMNR 2022 to really capture the whole population of our organization? I'd love to expand the leadership roles here, too. So if you are interested in being more involved or even a resident or fellow who's looking for kind of leadership roles, we'd love your help there, too. So it'll be an open discussion. Again, Tuesday, December 7th. Look forward to I'm receiving something in your email and putting it on your calendar. But thank you, Mary. And thanks again to our panelists. I don't think if we have any other questions. As we know, this session has been recorded, so you can reference those slides later on if you missed Amy or others' references. But thank you all for attending, and we look forward to seeing you on the 7th. Thanks, guys. Thank you.
Video Summary
In this presentation on concussion management in children, Dr. Colby Hansen and Dr. Amy Rabotin discuss various aspects and challenges related to treating concussions in pediatric populations, including those with disabilities. Dr. Hansen starts by addressing the recovery trajectories post-concussion, factors that may influence recovery times, and how to assess symptoms comprehensively using tools like standardized symptom scales and balance tests. He emphasizes the importance of balancing rest and activity and the need for a structured return-to-school strategy. He also touches on the need for subsymptom threshold exercise to facilitate recovery, and addresses common concerns from parents about the recurrence of concussions and recovery processes.<br /><br />Dr. Rabotin shifts focus to concussions in children with disabilities, explaining how sports like wheelchair basketball or sled hockey may have different concussion risks. She highlights the difficulty in applying standard concussion assessment tools, such as the SCAT-5, to disabled athletes due to baseline impairments in cognition, vision, balance, or other areas. Dr. Rabotin advocates for individualized baseline evaluations, emphasizing the role of understanding each athlete's unique challenges to tailor concussion management effectively. She also stresses the necessity for education and awareness among athletes, families, and coaching staff regarding concussion risks and management for children with disabilities. Both speakers emphasize the importance of adapting management plans based on individual needs and sport-specific demands to enhance recovery and participation safety.
Keywords
concussion management
pediatric populations
recovery trajectories
standardized symptom scales
balance tests
return-to-school strategy
subsymptom threshold exercise
children with disabilities
individualized baseline evaluations
concussion risks
adapted management plans
sport-specific demands
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