Safe Return to Activity (RTA) After Mild Traumatic Brain Injury ( mTBI )

1. Safe Return to Activity (RTA) After Mild Traumatic Brain Injury (mTBI)

2. OBJECTIVES • Review what is a mild Traumatic Brain Injury including causes and symptoms associated with concussion. • Discussion on assessment of concussions and implications • Management of concussions including school accommodations • Role of Physical Therapy to allow your student/athlete to safely return to play.

3. New Minnesota Law CHAPTER 90--S.F.No. 612. • Effective September 1, 2011 • Minnesota State Law requires coaches and/or officials • To remove youth athletes from participating in any youth athletic activity when the youth athlete exhibits signs, symptoms, or behaviors consistent with a concussion; or is suspected of sustaining a concussion. • In order to return to activity the youth must be symptom free & evaluated by a provider trained and experienced in evaluating & managing concussions • Coaches and officials must complete an online training every 3 years • https://www.revisor.mn.gov/laws/?id=90&year=2011&type=0

4. History of the Neurotrauma clinic at Gillette

5. Gillette Children’s Neurotrauma Clinic • Began May 2007 • Children between 0-21 years • Mild to moderate injury • Patient Seen -over 1700 • Mechanisms of Injury • Sports • MVA • Car vs bike • Car vs pedestrian • Falls • Assault • Brain Injuries • Fractures and Bleeds • Spine Injuries • Cervical strains • Fractures • Compression fracture • SCIWORA

6. REVIEW OF MILD TBI’S

7. Traumatic Brain Injury “Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.” http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf

8. Concussion - Definition • Complex process affecting the brain • Induced by traumatic forces • Direct or Indirect • Functional Disturbance rather than Structural Injury • No abnormality on standard structural neuroimaging • Have seen students/athletes after concussion who have had an MRI and because it is normal they are told to return to activity.

9. Acceleration/Deceleration Brain moves forward in skull Frontal lobes strike inside of skull Rebound contre coup injury to the occipital lobe

10. Rotational Injury • Brain rotates on axis causing stretching/tearing of axon • Stretching and tearing of blood vessels results in hematoma • Brain strikes skull causing contusion

11. Causes of TBI Sports-Related Head Injuries: 300,000 per year in U. S. Recreation TBI Deaths: > 500 per year MVA Other Assaults Sports Centers for Disease Control and Prevention 2000

12. Mild Traumatic Brain Injury • Results in a graded set of clinical syndromes that may or may not involve loss of consciousness. • Resolution of the clinical and cognitive symptoms typically follows a sequential course • Typically associated with grossly normal neuroimaging studies • Acute clinical symptoms reflect a functional disturbance rather than structural injury

13. Mild Traumatic Brain Injury Mild TBI can cause functional changes, which are interactive: • Cognition (learning, memory and reasoning) • Sensation • Language (communication, expression, and understanding) • Emotion (depression, anxiety, personality changes, aggression, acting out, social inappropriateness)

14. 500 K+ 10 2 6 12 20 30 6 24 3 6 Glucose Calcium Glutamate hours days minutes 400 Cerebral Blood Flow 300 % of normal 200 100 50 0 (Giza & Hovda, 2001) UCLA Brain Injury Research Center

15. Guidelines for Return to Play • Guidelines for return to play have been created with this data in mind, avoiding a time period where the brain is more vulnerable to injury due to the energy crisis of the brain • Difficult to definitively define the period of vulnerability following TBI, each injury is different with varied effect on the cascade

16. ASSESSMENT OF MILD TBI

17. Assessment • Physical exam to rule out bleed, neck injury, spine injury • Neurocognitive screening/developmental screening • CT scans and MRIs of the head are usually normal and are not necessary unless the patient has increasing symptoms of concern

18. Asking about symptoms • Specific yes/no questions about the more subtle symptoms is more effective than asking open ended questions. • “Asymptomatic” is not an easily defined term, though is at the core of proper concussion management

19. Symptoms may be delayed or recurrent • Many athletes may seemingly “normalize” within minutes of an injury, but then have a recurrence and potential worsening minutes to hours later • IMPLICATION: very rare same-day return to play

20. Signs and Symptoms Somatic: • Headache, pressure, neck pain, n/v, vision changes, balance problems, light or noise sensitivity, “don’t feel right” Cognitive: • Feeling “In a Fog”, difficulty concentrating or remembering, confusion Emotional: • more emotional, sadness

21. Signs and Symptoms • Physical Signs • Loss of Consciousness, Amnesia, motor/sensory deficits • Behavioral Changes • Irritable, nervous • Cognitive Impairment • Slowed reaction times, memory or concentration deficits • Sleep Disturbance • Drowsiness, difficulty falling asleep

22. PCS Assessment/Referral PHQ-9 GAD-7 Pediatric Symptom Checklist Psychotherapy Psychology Psychiatry Pediatric, Adolescent, Adult Medicine Social Work Mood Disruption Emotional, Sadness, Nervousness, Irritability Somatic Symptoms Migraine, Headaches, Visual problems Dizziness/balance disturbance Noise/Light sensitivity Nausea Neck Pain/Spine Pain Cognitive Symptoms Attention problems, Memory dysfunction, “Fogginess”, Fatigue, Cognitive Slowing Headache Log Vestibular Therapy Physical Therapy Relaxation techniques Guided Imagery Integrative Medicine Clinic Neurology Ophthalmology ImPACT Testing Pediatric Symptom Checklist Vanderbilt ADHD Scale Driving Evaluation Speech Therapy Occupational Therapy Psychology Psychiatry Neuropsychology Sleep Alterations Difficulty falling asleep Sleeping less than usual Sleep Log Sleep Specialist

23. Neuropsychological Testing • Objective evaluation of function • Baseline testing may be helpful • Allows comparison of baseline to post-injury tests • If baseline testing is not available, compare to age-matched controls and a percentile generated

24. Facts for Physicians booklet   Acute Concussion Evaluation (ACE) form    ACE Care Plan Work version  School version   Concussion in Sports palm card   CDCHeads Up – Brain Injury in your Practice

25. MANAGEMENT OF MILD TBI’S

26. Goals of post injury management • Prevent against Second Impact Syndrome • Prevent against cumulative effects of injury • Prevent presence of Post-Concussion Syndrome • Determination of asymptomatic status essential for reducing repetitive and chronic morbidity of injury • Post injury: cellular metabolism is over worked, thus the cells are more vulnerable to further insults and injuries.

27. Management • Physical rest • “Cognitive” rest • Child needs to limit exertion with activities of daily living and limit scholastic activity while symptomatic • Repeated injury or overstimulation during the energy crisis of acute brain injury could lead to cell death • Pharmacology • Management of specific symptoms Giza, Hovda. The Neurometabolic Cascade of Concussion. J Athl Train. Vol 36, p 228-235, 2001.

28. What is Cognitive Rest? • Cognitive rest may also be called “brain rest” • After a MTBI, we need to limit the activities that use “brain energy” so that the brain can function on the limited amount of energy it is creating. • To help the brain heal and recover, some cognitive activities need to be limited temporarily.

29. What is Cognitive Rest? • Some symptoms may worsen when engaging in cognitive and physical activities. This is the body’s way of indicating it is not able to make the amount the energy being demanded, activity should be stopped to allow body to rest.

30. What can be done on cognitive rest? • OK to watch TV, watch movies, and listen to music. The volume should be low. • Go to school and do homework; however if school and school work increases symptoms you may need accommodations at school, shortened school days or to stay home.

31. What is not allowed while on cognitive rest? • No computer activities • No video games • No recreational reading • No board games • No card games • No text messaging • No computer activities • No practicing musical instruments

32. What is physical rest? • Physical rest is limiting the amount of energy spent in physical activity to allow the brain to use that energy to heal.

33. What can be done on physical rest? • Walk with feet on the ground at a casual pace. • Attend to school (no phy ed, gym class or recess).

34. What is not allowed while on physical rest? No sports No games No practices No gym/recess/exercise No strenuous activity No physical labor/work No amusement park rides No biking/skating/sledding/skiing No jumping

35. School Accommodations • Approve dismissal for medical appointments related to this injury • Reduced homework load. Limit to two hours maximum for all subjects per night. • Limit computer time and reading requirements as needed • Early dismissal/late arrival as needed • Extended time for testing, homework etc

36. School Accommodations • Eliminate non-essential work • Rest period in Health Office during day as needed • Wear hat or sunglasses for light sensitivity • Preprinted class notes • Utilize tools that address learning style: audio/video recorders, computers, etc

37. How can your student receive accommodations at school? • First identify the contact person at your school: advisor, dean, principal. • Alert the school and teachers of the injury as soon as possible. • Arrange a meeting with the school to discuss school accommodations, bring in medical documentation.

38. Symptom Treatment • REST!... the only known effective treatment for a concussion • Encourage frequent breaks from studying • Encourage good hydration and regular meals to avoid dehydration and hypoglycemic-related headaches

39. Student Athlete Management • COGNITIVE REST • If symptoms recur with cognitive activity, time off school may be needed • Involve teacher, school nurse, principal, coach

40. PCS Management Antidepressants Anxiolytics Psychotherapy Mood Disruption Emotional, Sadness, Nervousness, Irritability Somatic Symptoms Migraine, Headaches, Visual problems Dizziness/balance disturbance Noise/Light sensitivity Nausea Neck Pain/Spine Pain Cognitive Symptoms Attention problems, Memory dysfunction, “Fogginess”, Fatigue, Cognitive Slowing Non-Pharm Headache Management OTC: NSAIDs Triptans Beta Blockers CCB Antiepileptics Antidepressants Flexeril Valium Amitriptyline Amantadine* (off label) Neurostimulants* (off label) Sleep Alterations Difficulty falling asleep Sleeping less than usual Behavioral: Sleep hygiene education, relaxation therapies, sleep schedule Pharmacologic: melatonin, amitriptyline, trazadone, short-term use of nonbenzodiazepines

41. Pediatric Athletes (<18) American Academy of Pediatrics (AAP) recommends “conservative” management: • NO return to play on same day • Seriously, NO return to play on same day • When in Doubt, Sit them OUT!

42. High school athletes’ and their recovery from concussion Collins M, et al. Neurosurg 2006

43. Return to Play • Normal imaging • Normal physical exam • Normal cognitive screen • Symptom free - Medication free (without activity)

44. Role of Physical Therapy for Return to Activity • Determine readiness to return • Balance and vestibular assessments • Stages for return to activity

45. Determining Readiness to Return to Activity

46. Readiness for Return to Activity • No adolescent with a concussion should continue to play or return to a game after sustaining a concussion. • Immediate Evaluation and Exam after a Concussion • An individual sustaining a concussion should cease doing any activity that causes the symptoms of a concussion to increase (e.g. headaches, dizziness, nausea, etc.).

47. Readiness for Return to Activity • If patients develop increased symptoms while doing a specific activity, that activity should be discontinued. • Continuing activities, or exercise that increases symptoms, can delay the recovery from the concussion.

48. What are the risks of returning to activity before an injury is healed? • Symptoms may last longer and become more intense. • New symptoms may occur. • Risk of repeat injury and risk of Second Impact Syndrome.

49. Explain Risks of Premature RTP before full recovery • 2nd impact syndrome • Death • Higher risk in young athletes • 2nd concussion, more severe • Prolonged symptoms

50. Second Impact Syndrome • In September of 2008, Jaquan Waller, 16, suffered a concussion during football practice at J.H. Rose High School in Greenville, N.C. • A certified athletic trainer educated in concussion management wasn't onsite, and the school's first responder who examined Waller cleared him to play in a game two days later. • During that game, Waller was tackled. Moments later, he collapsed on the sidelines. • He died the next day.