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Seattle Pacific University
Educational Series
February 3, 2015
Chris Ladish, PhDPediatric NeuropsychologyMary Bridge Pediatric Psychology & Psychiatry Service1220 Division AvenueTacoma, WA 98403(253) 403-4437, #2http://www.multicare.org/marybridge/pediatric-
psychology-psychiatry-3
Returning Children to Play & School Following Concussion:
What you need to Know
1. Discuss the physical, cognitive and emotional
symptoms of concussion2. Discuss the educational implications of
concussion symptoms3. Understand risk factors in prolonged
concussion recovery4. Assist in the development of appropriate
physical, educational and cognitive recommendations in the return to learn and return to play decision-making process
Ding Got his/her bell rung Saw Stars Just a Concussion
3.9 million activity/sports related concussions per year (CDC)
Falls, accidents and assault Media attention- professional sports, legislation
Nearly all states now have legislation regarding sports concussions
Washington was the first state to have such a lawNo athlete may return to sports if concussion
suspectedFurther evaluation by licensed professional
Complex pathophysiological process effecting the brain induced by traumatic biomechanical forces.
May be caused by direct blow to head, face or neck, or elsewhere on body with “impulsive forces” transmitted to head.
Typically involves rapid onset of short-lived impairment of neurological function that resolves spontaneously.
Clinical symptoms largely reflect functional disturbance rather than structural injury.
Results in graded set of clinical symptoms that may or may not involve LOC.
No abnormality evident on standard neuroimaging.
PECARN
CT scan rate 35.3%Traumatic Brain Injury 5.2%ciTBI 0.9%Neurosurgical intervention 0.1%
8
Removal from field if concussion sustained SCAT3 work group developed to improve
SCAT2 Validating SCAT for pediatric pts < 8 yo Evolving condition, reassessments needed “Bell ringers” = transient dysfunction of
neurological function (mgmt ???) Injury2 days rest (> 10 days possibly
harmful)graded exercise even if sxs persist
Physical Cognitive Emotional Sleep
headache nausea/vomiting imbalance (ataxia), motor problems excessive drowsiness, fatigue photosensitivity auditory sensitivity numbness, tingling blurry or double vision (diploplia)
Intelligence General language functioning Knowledge base (long term memory)
Awareness/Orientation Attention Mental Flexibility Working Memory Executive Functioning Processing Speed Reaction Time
Core deficits seen in concussion have functional effect on other skills
Trends may be subtle but significant
Day to day work, play, relationships and life impacted by key challenge areas.
Disinhibition Emotional Lability Irritability/Reactivity Anxiety Depression Frustration Hopelessness Downplaying impact
Confusion, disorientation Retro/anterograde amnesia Headache Nausea, vomiting Motor weakness, incoordination Dizziness, imbalance Sensory sensitivity (light, sound) Fatigue, increased need for sleep
Decreased processing speed Short-term memory impairment Difficulty retaining new information Irritability, depression, anxiety Fatigue, sleep disturbance “Foggy” feeling Frustration
High risk age groups:
Children aged 0 to 4 years
Adolescents 15 to 19 years
TBI rates higher for females > males in similar sports› Girls 1.7/10,000 AE > Boys 1.0/10,000
Boys 0 to 4 years = highest rates of TBI-related ED visits, hospitalizations, and deaths
Football: 47.1% Girls’ soccer: 8.2% Boys’ wrestling: 5.8% Girls’ basketball: 5.5%
Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).
Player to player contact: 70.3% of incidents
Player to playing surface: 17.2%
Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).
22% of all hockey injuries are concussion
Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).
Struck By/Against Events
Includes colliding with a moving or stationary object, as in sports
Cause of 25% of TBI’s in children 0-14 years
Broglio, Univ. of Michigan, 2010
study cohort linear acceleration
Pellman(2003)
Professional(75% injury risk)
98g
Guskiewicz(2007)
Collegiate(mean of 13 concussions)
102.8g
Broglio(2010)
High school(CART of 13 concussions)
96.1g
Metabolic Cascade(hours to days)
Developing brain(neuroplasticity vs. increased
vulnerability)
Overuse(implications to exertion)
Neuroanatomical involvement
Neuroplasticity: younger brains are still developing and thus are more resilient to trauma due to brain’s ability to form alternate neural connections for function.
Vulnerability: higher mortality rate seen with TBI in younger children likely due to higher rate of cerebral edema.
Animal models support both factors.
Unilateral cortical lesions.
Recovery of function associated with increased dendritic growth within uninjured cortex dependent upon use of the intact forelimb.
Restraint of uninjured forelimb with overuse of the injured limb results in failed dentritic enhancement, increased lesion size in injured cortex, and longer behavioral deficits.
Some mitigation with delayed use: no lesion increase but functional recovery still delayed.
Considerations Regarding Resumption of ‘Activity’
(Silverberg, N. and Iverson, G., 2012. Jnl Head Trauma RehabThomas, D., Apps, J., Hoffmann, R., McCrea, M., Hammeke, T. 2015. Pediatrics)
Complete rest beyond 3 days probably not helpful in most cases (not all)
Gradual resumption of preinjury, non impact activities should begin as soon as tolerated
Supervised exercise of benefit to patients with persistent symptoms both physically and emotionally
Caution re early restrictions establishing a “mindset” for recovery expectations
Physical symptoms and altered mental status usually first noted
Physical symptoms often improve before cognitive.
Cognitive symptoms may worsen during first 48-72 hours due to cellular and metabolic changes.
Majority of pediatric cases with mild injury are back to baseline at ???
Physical Cognitive Emotional Sleep
Acute Phase (Injury – 3 days)
Post Acute (3 days-3 months)
Prolonged (PPCS) (> 3 months)
Activity restriction determined by extent of current injury, history of previous injuries, functional presentation of patient
Ongoing evaluation to inform treatment needs and monitor recovery trends
Rest Reduction of Stimulation Reduction of Exertion
› Physical, emotional & cognitive Modified Expectations
› Assessment of rehab needs› Education re care provider roles› Brief directed cognitive assessment
(EF, working memory, stim tolerance, endurance)
› Set and monitor activity restrictions› Support adjustment to activity limitations› Facilitate return to activity (and
stimulation)› Reintegration to school
What is Head Injury
Recovery Course and What to Expect
Symptoms & Management
Resources
Cognitive Rest Limit stimulation Time off from
school Reduction in work Educational
Accommodations (504,IEP)
Don’t panic 10-20% of pediatric concussions can
take 3 weeks or more HS athletes take twice as long as
college/professional athletes to recover (10-14 days vs. 3-7 days)
Younger kids take longer They will get better, even if it takes a
while
Psychosocial stress Bright kids Anxiety Depression Chronic medical
illness Difficulties at home
Learning disabilities ADHD Dyslexia
Previous history Concussions Headaches Family hx of HA
Sleep problems
Prior high standard of academic performance “Overnight” changes to functioning More time needed for homework/studying Frustration with current deficits Increased cognitive exertion exacerbates
symptoms Teachers/peers not aware b/c student at
grade level Student feels unsupported/deficits minimized At risk for depression/anxiety/pessimism re:
future
Headache- most common Makes concentration difficult Avoid triggers (e.g. lights, noises, subjects
(math, high level science, foreign language) Is this present at baseline Limit NSAIDs Focus on sleep Riboflavin, magnesium, fish oil Occasionally consider amitriptyline or neuro
referral
Dizziness/lightheadedness Vestibular system/sensory organization problem
Usually worsened by quick movements, video or hallwaysVestibular therapy
Lightheaded- sense that they may pass out with position changeMore problematic because of limited cerebral perfusion Light aerobic activity or exercise in lying positionCareful position changes
NauseaZofran
Neck strain- often present with head injurySometime can drive symptoms, even
cause dizzinessTreat with heat, PT, massage, even muscle
relaxers at times
Sleep disturbance – makes most symptoms worseCan’t fall asleep, wake up at night,
excessive nappingAffects ability to attend and focus, new
learning is difficult If you don’t sleep you can’t do anything
well, even without a head injuryTreat aggressively- sleep hygiene,
melatonin, sometimes other meds
Mental health Head injuries have a way of unmasking underlying
problems Depression, anxiety, conversion disorder Concussed kids lose coping strategies (high
performance in sports or school, exercise for stress relief, social interaction, video games)
Address and normalize what they are going through
Psychology referral when necessary
Difficulty with concentration and short term memoryOften most persistent symptomsSchool accommodationsPatience (often take months, reassuring
when there is a trend toward improvement)Often pre-existing learning issuesStimulants on occasionCognitive rehabilitationNeuropsychology referral
Need for education re management Presence of preinjury risk factors:
learning, attention, psychosocial Cognitive challenges School issues Change in behavior, mood, personality Undue parental, coach pressure re RTP Need for cognitive clearance for RTP
Collaborative effort between student, parents, educators, coaches, and health care professionals
Careful plan to facilitate transition/reduce risk of failure
Focus on individual student needs (current functional deficits, pre-existing risk factors, academic status)
Set clear goals with student
Close monitoring and feedback to student/parents
Adjust plan with recovery
Modifying the school schedule (reduced endurance, fatigue, processing)
› Reduced school day/late arrival
› More frequent breaks in school day
› Additional study period/study skills class
› Drop classes with significant new learning: foreign language, higher-level math and science classes (e.g., calculus, physics, chemistry)
Safety precautions(increased vulnerability,Increased distractibility)
› No PE
› No activities in gym or on playground
› No woodshop, auto mechanics, any class with risk of injury
› Early dismissal from class to avoid crowded hallways
Environmental accommodations (inattention, sensory sensitivity)
› Preferential seating
› Reduction of distractions
› Testing in a quiet environment
› Avoid noisy environments (e.g., cafeteria, assemblies)
› Rest periods in nurse’s office if headaches/fatigue
Adjusting requirements/grading (reduced cognitive resource, fatigue,
slowed processing)
› Forgive missed work
› Grades based on completed/representative work
› “Freeze” grades
› Assign incompletes
› Use pass/fail option
Modifying assignments (processing, attention, memory, learning)
› Decrease work load (e.g., length of spelling/ vocabulary word list, even or odd math problems)
› Use aides: calculators, computers, “cheat sheets”
› Assign peer note-taker
Modifying tests (processing speed, retrieval)
› Untimed testing option
› Open book, “cheat sheets,” note cards
› Recognition tests (multiple-choice, T/F)
› Assistance with first few steps/problems
Support for new learning
› Review of previously learned academics› New material/concepts presented in context of
familiar or already-acquired knowledge› New material/concepts broken down into small
chunks› Multimodal instruction› Repeated exposure to novel information› Frequent review of new material
Implement schedules, calendars, to do lists Maintain pictures/lists of assignments Break down large tasks Frequent reinforcement Provide concrete time limits and
communicate them directly (verbal, written, timer, task-based)
Frequent feedback, and redirection if needed
› Approximately 24 hours (or longer) in between each step› If symptoms, stop activity, rest until symptom-free 24 hours, return to previous
step› If symptoms increase, seek medical attention
1. Light General Conditioning Exercises (Goal: Increase HR)
2. Moderate General Conditioning and Sport Specific Skill Work Individually (Goal: Add Movement, individual skill work)
3. Heavy General conditioning, skill work individually and with teammate. NO CONTACT (Goal: Add Movement, teammate skill work)
4. Heavy General conditioning, skill work, and team drills. No live scrimmages. VERY LIGHT CONTACT. (Goal: Team skill work, light static contact)
5. Full Team Practice with Body Contact
Quick to administer Administration “standardized” Randomized forms Serial tracking of recovery with less
chance for practice effect Available to non-NP providers and can be
given in schools and office. Some higher measurement sensitivity.
What are we truly measuring?
Does less data lead to less ability to generalize findings?
Response type constrained by computer
Requires careful oversight of administration.
Athletes “dumbing down” baseline screens.
Increased risk for another TBI with more severe symptom presentation
Cumulative effects of repeated injuries
Potential catastrophic or fatal outcomes of repeated injuries within short time period
Increased risk of sustaining concussion
Longer recovery period from concussion
Rapid early recovery from moderate/severe TBI but…
Increased risk for
Alzheimer’s disease
Parkinson’s disease
Other brain disorders associated w/ aging
http://www.cdc.gov/concussion
Concussion is a multifaceted and complex functional injury.
Neurocognitive symptoms may be present which are not immediately evident during the first few days of evaluation.
Recovery course from concussion is variable with outcomes determined by previous risk factors, injury severity, past concussions and management.
Caution is warranted with all concussions and return to activity remains a medical decision which should be informed by ongoing attention to physical, cognitive, and emotional factors.