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Mild TBI and RTL
Pediatric TBI and RTL
Karen Laugel, MD, FAAP
Chair, CT AAP TBI-RTL Initiative
Medical Director, Head Zone
Founder, Pediatric Care Assoc. of CT
Assistant Clinical Professor,
Quinnipiac School of Medicine
Who is here?
A non-profit organization that provides educational services...
Incidence
A Pediatric Problem:
• ~500,000 ED visits/y
AZ EDs 2012: TBI Rates
634 concussions (out of 84,706 incidents) reported in 2011; Ontario School Board Insurance Exchange (78 School Boards) ; OSBIE 2011
Not just ‘sports’... Reported by Schools
17, 321 children who presented to ED with TBI
Meehan W; J of Peds, Dec 2010; Vol 157 (6)
REPORTED BY ED’S: •Children in 600 ED’s in US •0-19 yo; 2002-2006 •144,000 concussions/y •30% sports related •70% NOT sports related
• 40-70% pediatric TBI is not sports related
• Need a system of care that works outside of the “athletic department”
• Collaboration of Docs & Schools
.
www.CHIRPreports.org
What makes a successful ‘Return to Learn?’
A system of care that:
• includes all children (not just HS athletes)
• encourages collaboration between Docs and schools
• provides individualized accommodations
• monitors & adjusts academics during recovery
>= 2 Concussions... Two or more concussions
223 HS Athletes, 0, 1, 2 concn >6mo; conc < 1wk Baseline NCT testing 1999-2000 Moser RS: Neurosurgery, Vol. 57(2), August 2005
Those with history of two concussions (asymptomatic, >6 mo) scored just as poorly as those with recent concussion (< 1 week)
Decreased attention, concentration, and GPA
Marchi N, Bazarian JJ, www.Plosone.org; March 2013 | Volume 8 | Issue 3 | e56805
Repeated sub-concussive blows
Increased serum astrocytic protein correlates with # head hits; also predicts MRI-DTI abnormalities and cognitive changes 6 mo. later
Metabolic Mismatch
Functional Injury
No Need to Wake Patient
Guskiewicz; J Athl Train. 2004;39(3):280–297.
Trigger Avoidance & Sub-Symptom Pacing
Pediatric Annals Sept. 2012
Home Prescription
• Cognitive rest
• Trigger avoidance
• Sub-symptom pacing
• Medication over-use
syndrome
• Nutrition
• Sleep hygiene
Metabolic Mismatch
I. Neurovestibular History
II. Neuro- vestibular Exam
III. Neurocognitive Testing
3 Part Exam by Day 3
Age appropriate
symptom scales
• Trigger avoidance
• Homework at home before school
• Sub- symptom pacing several times/day; increase the next day
• Ready for school when 30 min sustained reading, 2h paced HW
Readiness for School
The Problem
55 children, age 10-18y
• 90% RTS after four days
• 74% headaches • 65% cognitive
deficits • 75% math most
difficult class
Gioia; Children’s National Medical Center, May 2010
Timing Return to School Back to School Early
3,740 Pediatric Concussion
Patients
• Median 37 missed school days
• Median 66 days until symptom-free
• 13% missed >6mo
• 66% required accommodations
• 61% drop in grades
• 28% comorbid condition (ADD, depression, anxiety)
Corwin, CHOP, AMS Sports Med Conference, April 2013
Not Symptom-Free
Cognitive Exertion
Majerske, CW. JAT, 43(3)
Cognitive Pacing is
Key
Increased cognitive activity is associated
with longer recovery from
concussion.
Mean age 15yo; Mean duration of symptoms 43 days
Brown; PEDIATRICS February 2014; 133 (2); 335 pts, prospective study 10/09-7/11,
Boston Children’s Hospital
Mean age 15yo; Mean duration of symptoms 43 days Brown; PEDIATRICS 133 (2), February 2014;
335 pts, prospective study 10/09-7/11, Boston Children’s Hospital
“Moderate levels of cognitive activity had better outcomes than those engaging in highest and lowest levels of activity.”
Sub symptom pacing is key
Put child in ‘driver’s seat’
Mild TBI
Vestibular
Oculomotor
Cognitive
Migraine
Cervical
Anxiety
> 1 week post injury, can identify type of injury to guide treatment , school accommodations, & exercise
Collins M; Sports Medicine DOI 10.1007/s00176-013-2791-6; Nov 2013
Six Trajectories
“EYES” BALANCE
VOR VSR
Balance assessment
• Stance : adjacent, tandem; floor/pad
• Gait: 10’ tandem,
forward/backward
with head movement
Head and Neck Exam
• Signs of trauma
(hematoma)
• Cervical ROM
• Spurling’s test
(cervical radiculopathy)
Musculoskeletal
therapy of
cervicogenic pain:
manipulative & exercise therapy reduced headache frequency and intensity
Early PT Referral
Jull G.; Spine 2002 Sep 1; 27 (17); 200 patients, through 12 mo. f/u
Oculomotor Pathways
Primary oculomotor
deficits in mTBI: difficulty reading
(oculomotor specific), vergence,
accommodation, and saccadic gain
abnormalities. Eye tracking assessment : examination of saccades,
fixation, and smooth pursuit eye movements
• Dysmetria
• Nystagmus
• Smooth pursuits
• Saccades
• Gaze stability
• Convergence insufficiency
• Confrontational
visual fields
Ped. Annals 41 (9) Sept. 2012
Oculomotor Exam
Cifu DX, J of Head Trauma Rehab, April 2014
Subjects with mTBI had
measurable & SS abnormalities in
saccades and smooth pursuits
Video-based binocular eye tracker; Sixty military service members with PCS and 26 asymptomatic controls
Abnormal Visual Tracking
Rapid number naming Three cards Two minutes
Measures saccadic eye movements & cognition
$45.00 for book
www.KingDevickTest.com
King-Devick >=6yo
“KD testing accurately identifies real-time concussion in adolescents...Athletes should undergo pre- and post-season KD testing.”
Presentation Amer Acad Neurology, 2014
141 HS Hockey Players •20 reported head injury •All had KD > 5sec longer than baseline •Also detected asymptomatic concussion in 11players
Correctly identified concussions:
• 52% by SAC alone
• 79% by K-D alone
• 89% by K-D and SAC
• 100% by K-D, SAC, and BESS
217 Collegiate male and female football, LAX, soccer athletes; Marinedes Z, Neurol Clin Practice, July 2014
Tracks Recovery
“KD test appears effective in objectively monitoring concussion
recovery and symptom resolve
over several months.”
Tjarks BJ; Journal of the Neurological Sciences 334 (2013) 148–153; August 2013
Mucha A., AJSM 42 (10); Aug. 2014 (demo on You Tube)
“VOMS”
Provoked Symptoms
• Symptoms
• Oculomotor exam
• Vestibular provocation
• Balance
• Cognition
Physician’s Exam
Memory, speed,
processing
http://impacttest.com/
Tjarks BJ; Journal of the Neurological Sciences 34 (2013) 148–153; August 2013
Correlation between KD total
time and all composite ImPACT scores.
Mild TBI
Vestibular
Oculomotor
Cognitive
Migraine
Cervical
Anxiety
>1 week post injury, can identify type of injury to guide treatment , school accommodations, & exercise
Collins M; Sports Medicine DOI 10.1007/s00176-013-2791-6; Nov 2013
Six Trajectories
Refer for RX
• PT/Vestibular therapy
• Vision therapy
• Dynamic Exercise
• Speech therapy
(memory, cognition)
• OT /AT (handwriting,
assistive technology)
• Cognitive behavioral RX
• Neuropsychology
• Pharmacotherapy
Post-Trauma Vision Syndrome
Vision Therapy: www.eyecanlearn.com
Ciuffreda. Optometry. 2008. 79 (1)
Identify Triggers & Readiness
•Avoid bus ride •Partial day school •Lunch in quiet place •No band/chorus/noisy gym •Pass early in hall •Ear plugs •Limit screens (computers, Smart Boards) •Dim screen •Sunglasses •Note-taker, pre-printed notes •Sit in back of class •Reduced work load •Scheduled breaks •No testing; no timed testing •Alternative testing •No gym •Protected gym for aerobics
140 School Nurses
Washington D.C.
•
True Stories
TRUE STORIES:
• RTS “left in mailbox”
• RTS “stuck in email”
• “I don’t oversee the teachers”
• “the teachers don’t believe injury”
• “I don’t speak to the gym
teacher unless he passes my door”
• did not inform the recess monitor
• did not inform the substitute
• did not inform the coaches
• informed the DED, but DED doesn’t
follow medical advice for CMTs,
CAPTs, SBACs, etc
Need organization... Need to work together
BRAIN 101
School
Concussion
Management
Policy and
Teams
Oregon Concussion Management Program www.brain101.orcasinc.com
School Policy
determines
chain of
communication
Staples HS, Westport, CT
Physician to School
Physician should: •Determine readiness •Ask parent to meet with nurse upon re-entry •Fax accommodations attention: nurse •Follow-up call to student after first day
SM + AM
to coordinate:
• Students
• Parents
• Physicians
• Teachers
• Coaches, ATCs
Need School Team
Westport Schools: SNAP Note
Academic Adjustments:
The above student will benefit from the following checked short term academic supports for proper concussion management in school
□ No school for ______ days
□ No school until re-evaluated on _________________
□ No recess
□ No Music/Band class
□ No Computer
□ Shortened day or modified schedule, as indicated
□ Homebound tutoring as tolerated
□ Extra time to complete coursework, assignments, tests, No more than one test per day every other day
□ No significant classroom testing or standardized testing
□ Pre-printed material/notes, if available
□ Schedule periodic rest breaks as needed in health office during day
□ Allow student to go to health office if symptoms worsen during the day
□ Allow school concussion team to gradually modify accommodations if student remains symptom free
□ Other recommendations: ______________________________________________________________________
Physical Exertion Accommodations
The above student should adhere to the following recommendations regarding physical education (PE) and athletic participation (checked items apply):
□ May not return to PE or sports/athletics until further notice
□ Aerobic, non-contact PE as tolerated (walk, run, jog)
□ Is medically cleared to participate in full PE
□ May gradually return to school sports/athletics (for student athletes)under the supervision of an appropriate person (e.g. athletic trainer, coach). Return to play as per return-to-play guidelines
These recommendations will be reviewed and updated on ___________________________________.
Westport Public Schools: Sample E-mail Template
Symptom Monitor
• Symptom Monitor=Nurse
• Meet with parent and child upon re-entry
• Establish contact with doctor
• Notify teachers & coaches
• Evaluate child regularly
• Weekly follow-up with teachers, coaches, ATCs, Dr.
Symptom Monitor
Extracted from PA “BrainSTEPS”
Rapid number naming Three cards Two minutes
Measures saccadic eye movements & cognition
$45.00 for book
www.KingDevickTest.com
King-Devick >=6yo
• Guidance, Teacher, Psychologist, SW
• Feedback from teachers
• Meets w/Nurse
• Educate school staff
Academic Monitor
Extracted from PA “BrainSTEPS”
• Evaluates child regularly
• Follow-ups with Dr, teachers, coaches, ATCs
• Develops a Concussion Management Plan
• RTL before RTP
• Concur with RTP or initiate “504 Plan” process if recovery is prolonged
The School CMT
www.brain101.orcasinc.com
As appropriate, the school nurse will obtain data from the academic team and report follow-up data including school attendance, academic performance and symptom assessment to the physician prior to the medical evaluation.
• It is essential that the Medical Provider hear from the school as to present level of functioning and present adjustments in place.
• Give feedback to physician regarding progress of recovery in school
Communication with Medical Provider
Recovery time unique
Estimated 20% > 4 weeks 20% take > 4 weeks
• Student continues to be symptomatic with headache, fatigue, irritability and difficulty sleeping
• Attendance has been impacted and she is beginning to fall behind in academics
• Although sub clinical pacing has been instituted she has not made progress in recovery from concussion
Westport Public Schools: Week Three
When the student is requiring educational adjustments beyond three weeks as determined by recommendations from the student’s physician after a follow –up appointment and receipt of recommendations, a team meeting with the academic team will be convened to develop a Concussion Management Plan to address appropriate health services/educational supports and accommodations and to review the ‘return to learn’ process.
• A meeting is scheduled with parent, student, administrator, guidance counselor and school nurse
• Plan developed and sent to all teachers
• Review again in 1 month
• Consider eligibility for 504 plan
WPS: Concussion Management Plan
WPS: Individual Concussion Management Plan
WPS: Concussion Management Plan
WPS: Concussion Management Plan
WPS: Concussion Management Plan
WPS: Concussion Management Plan
•An individual with a disability means any person who has a mental or physical impairment that substantially limits one or more major life activity
504 Plans
•Section 504 is a part of the Rehabilitation Act of 1973 that prohibits discrimination based upon disability... in public schools, colleges and universities
504 Eligibility ADA Amendments Act of 2008:
• "major life activities” include: seeing, reading, bending, concentrating, thinking, learning, sleeping
• “major bodily functions” include neurological & brain
• “six month rule no longer applies”: impairment that is episodic or in remission is a disability
Assistive Technology
For “Low Vision” Students:
IPAD Use
VoiceOver Audio Textbooks Speech to Text Text to Speech
Video Magnifiers Readers & Scanners
Info Scan Pens Electronic Notetakers
Screen filters
American Foundation for the Blind www.afb.org
Audio Books
bookshare.org learningally.org
iBooks App
Dictate, Upload,
Transcribe document in
minutes
Breathe 2 Relax
Clear Record
Study Tools and Organizers
Audible Books
www.brainline.org
Learning Strategies Online
Study aids and guidelines (also for 504 Plans & IEPs)
projectlearnet.org
cokidswithbraininjury.com
What do we do with...
Symptoms Lasting: •1-4 weeks •4-8 weeks •and beyond
http://cokidswithbraininjury.com
Help with the chronic injury
http://cokidswithbraininjury.comf/
At 3-4 weeks: Some students may have permission for non-contact aerobics before academic test-taking
“Conditioning is not RTP”
Leddy. Clin J Sport Med 2010;20:21–27; treadmill, 5-6 d/wk, 80% symptom threshold HR
“Treatment with controlled exercise is a safe program that appears to improve PCS symptoms.” (decline in PCS symptoms correlated with peak exercise heart rate, 12 adults)
Combination of school and PE
“Athletes participating in school activity and light activity at home (e.g., slow jogging, mowing the lawn) performed better on ImPACT” (than athletes with higher or lower levels of exertion).
Majerske CW. J of Athletic Training 2008; 43 (3)
Conditioning during recovery
UPMC Restore: The Science of Concussion. Advancement in Assessment, Management, and Rehabilitation; UPMCPhysicianResources.com/Ortho; March 2013
Striking a balance:
• Recovery is not linear
• Cognitive fatigue
• Trigger avoidance
• Sub-symptom threshold pacing
Management of RTL
• “Homework at home before schoolwork at school”
• RTS: 30 min reading
• Partial Day: 2 h paced homework
• Full Day: 3-4 h paced homework
• Testing: if full academic load (extra time, untimed, >= qd-qod testing)
RTL Progression
ACE:
graduated
progression of
cognitive load
Coordinate with Physician
Available on
website
ORCAS: Brain 101
ConcusssionCORPS.org
Return to full
academics
(including test-
taking)
before initiating
“Return to Play”
protocol
Academic Monitor
School Readiness
School Accommodations
School Progression
RTL before RTP
ATC to Doc...
& Vice Versa
• Walk
• Jog
• Run
• Sports Drills
• (Contact
Practice)
RTP initiated by Doctor
Supervised by Coaches, ATCs, or PTs
Metabolic Mismatch
I. Neurovestibular History
II. Neuro- vestibular Exam
III. Neurocognitive Testing
Post-RTP Medical Exam
McGrath, N. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Injury, 2013. 27(1), 103-113
A total of 27.7% of concussed
student-athletes who were symptom-free and returned to baseline on ImPACT at rest (i.e. no longer demonstrated
performance deficits on neurocognitive tests) exhibited cognitive decline following moderate physical exertion
27.7% of concussed student-athletes who were symptom-free and returned to baseline on ImPACT at rest exhibited cognitive decline in memory scores following moderate physical exertion (54 student-athletes; 15-25 min 60-80% HR aerobics)
Nine Days More
Medical Clearance to Play
Your Call to
Action
“Best Practices”
Ped Annals Sept. 2012 Pediatrics Oct 2013
www.ConcussionCORPS.org: Awareness: Scholarly Articles
Do Online Training
www.CDC.gov
Online training
programs
Clinical Shadowing
www.ConcussionCORPS.org
•ConcussionCORPS.org •Awareness We Raise •Partnering With Schools
Organize your
school :
policies
and teams
Post on website (names, phone, fax)
Post School Policy
Form Your CMT
Link to Education
Ask
Questions