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Current Concepts in Concussion Care. Stacy Suskauer, M.D. Pediatric Physiatrist Beth Slomine, Ph.D., ABPP Neuropsychologist. Disclosures. No industry-related financial disclosures. Objectives. To identify mild Traumatic Brain Injury in children Symptoms E pidemiology

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Current concepts in concussion care

Current Concepts in Concussion Care

Stacy Suskauer, M.D.

Pediatric Physiatrist

Beth Slomine, Ph.D., ABPP

Neuropsychologist


Disclosures
Disclosures

  • No industry-related financial disclosures


Objectives
Objectives

  • To identify mild Traumatic Brain Injury in children

    • Symptoms

    • Epidemiology

  • To understand typical course of recovery and approaches to early management

    • Cognitive rest

    • Active treatment strategies

  • To understand approaches to complex issues

    • Prolonged symptoms

    • Short-term sequelae of repetitive injuries


  • To identify mild Traumatic Brain Injury in children

    • Symptoms

    • Epidemiology


Concussion mild traumatic brain injury mtbi
Concussion = mild Traumatic Brain Injury (mTBI)

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

  • May be caused by blow to head, neck, face, or blow elsewhere on body with forces transmitted to head

  • Typically results in rapid onset of short-lived impairment of neurologic function that resolves spontaneously

    • Symptoms and signs may evolve over minutes to hours

  • May result in neuropathological changes, but acute symptoms reflect physiological, not structural changes

    • Standard neuroimaging is normal

  • Graded set of clinical symptoms

    • May or may not involve loss of consciousness

    • Symptoms may be prolonged

Consensus statement, 4th International Conference on Concussion in Sport, 2012


Common symptoms of concussion
Common symptoms of concussion

Thinking Symptoms

Feeling mentally foggy

Problems concentrating

Problems remembering

Feeling more slowed down

Preschoolers (Rane et al.)

Enuresis

Behavioral changes

Nightmares

Stomachaches

Physical Symptoms

Headaches

Nausea

Fatigue

Visual problems

Balance problems

Sensitivity to light

Sensitivity to noise

Numbness/tingling

Vomiting

Dizziness

Concussion

Sleep Symptoms

Drowsiness

Sleeping more than usual

Sleeping less than usual

Trouble falling asleep

Emotional Symptoms

Irritability

Sadness

Feeling more emotional

Nervousness


Classification of severity of pediatric tbi
Classification of Severity of Pediatric TBI

*In presence of intracranial neuroimaging findings = mild complicated or moderate TBI


Average Annual Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006


A public health problem
A public health problem Visits, Hospitalizations, and Deaths, 2002-2006

  • Millions of concussions are estimated to occur in the U.S. annually

    • Range 1.2 – 3.8 million

    • Athletic trainer, pediatrician, urgent care, school nurse

  • The number of children receiving care for concussion is increasing

    • Increased mTBI diagnosis in ED over 10 years

      • > 200% in children in 14-19 y/o

      • Doubled in 8-13 y/o

Bakhoset al., Pediatrics, 2010


Increasing diagnosis of concussion
Increasing diagnosis of concussion Visits, Hospitalizations, and Deaths, 2002-2006

Concussion is diagnosed in 1:160 children seen in pediatric hospital EDs


Concussion identification a public health approach to a public health problem
Concussion identification: Visits, Hospitalizations, and Deaths, 2002-2006A public health approach to a public health problem

  • Legislation mandating

    • Education of coaches, athletes, and parents

    • Removal from play if concussion is suspected

    • No same-day return to play

    • Written clearance for return to play from a medical professional with expertise in brain injury

  • “ZackeryLystedt Law” Washington State, 2009

  • 40+ states now have similar legislation

  • Maryland’s law was signed on May 19th, 2011


TYPICAL RECOVERY Visits, Hospitalizations, and Deaths, 2002-2006


Typical symptoms resolution
Typical Visits, Hospitalizations, and Deaths, 2002-2006symptoms resolution

N=186

8-15 y/o

21%

15%

64%

Yeates et al., Pediatrics, 2009


Days from injury to discharge from concussion clinic
Days from injury to Visits, Hospitalizations, and Deaths, 2002-2006dischargefrom Concussion Clinic

N=105

6-12 years

15 children reporting symptoms at discharge

Proportion discharged from clinic

Risen et al., in preparation


Evaluation and Management Visits, Hospitalizations, and Deaths, 2002-2006


Evaluating concussion and recovery
Evaluating Concussion and Recovery Visits, Hospitalizations, and Deaths, 2002-2006

  • Currently no objective measure of brain physiology in clinical use for evaluating the presence of and recovery from concussion

  • Evaluation and management of concussion is based on symptoms


Kki neurorehabilitation concussion clinic multi disciplinary evaluation
KKI: Visits, Hospitalizations, and Deaths, 2002-2006NeuroRehabilitation Concussion ClinicMulti-disciplinary Evaluation

  • Neuropsychology: Screening cognitive function in areas expected to be affected by concussion

    • Age-based assessment, ~ 45 minutes

    • Computer Testing (IMPACT)

    • Pencil and paper cognitive testing

    • Timed motor movements

  • Physician: Neurology or Rehabilitation

    • Complete neurological exam

    • Includes balance testing

  • Other disciplines associated with our clinic

    • Behavioral Psychology

    • Physical Therapy


Early education and recovery
Early Education and Recovery Visits, Hospitalizations, and Deaths, 2002-2006

  • mTBI: 119 children ages 6-15 years

  • Controls: Orthopedic injuries

  • Intervention: Educational Pamphlet at evaluation 1 week post-injury

    • Common symptoms

    • Expected course recovery

    • Coping strategies

  • 3 months post-injury:

    • Pamphlet  Fewer symptoms and less stress

Ponsford et al., Pediatrics, 2002


Sources for education
Sources for Education Visits, Hospitalizations, and Deaths, 2002-2006

  • www.cdc.gov/concussion

    • “Heads-Up” Tool Kits

      • Physicians

      • School

    • Pamphlet: “Facts about concussion and brain injury”

    • ACE Office Version:

      • Injury Characteristics

      • Symptoms Checklist

      • Risk Factors

      • Red Flags


Modifications conceptual background
Modifications: Conceptual background Visits, Hospitalizations, and Deaths, 2002-2006

  • Recommendations for rest are based on “metabolic mismatch” of mTBI.

  • In the initial days after injury, cerebral energy demands are increased but glucose delivery decreased

  • Restricting activity modulates metabolic demands


Do s and don t for the first few days
Do’s and Don’t for the first few days Visits, Hospitalizations, and Deaths, 2002-2006

  • Do:

    • Rest as needed

    • Sleep as needed

    • Return to daily activities as tolerated

    • Return to school as tolerated

    • Obtain guidance from medical/school personnel

  • Don’t:

    • Persist in activities if symptoms worsen

    • Participate in PE, physical activity in recess, or contact sports/high risk activities until cleared by healthcare professional


First line approach behavioral strategies
First Line Approach Visits, Hospitalizations, and Deaths, 2002-2006Behavioral Strategies

  • HYDRATION!!!

  • 3 meals, small snacks in between

  • Consistent and appropriate SLEEP

  • Avoid Medication Overuse

  • Stress Management


First line approach medical strategies
First Line Approach Visits, Hospitalizations, and Deaths, 2002-2006Medical Strategies

  • Fish Oil

  • Melatonin


Cognitive modifications how much is enough
Cognitive Modifications: Visits, Hospitalizations, and Deaths, 2002-2006How much is enough?

  • Which activities?

    • Attending school

    • Homework

    • Texting

    • Computer use

    • TV

    • Video games

  • For how long?

    • 1 week?

    • Until symptom free?

    • Symptom-based?


Aap clinical report returning to learning following a concussion
AAP Clinical Report Visits, Hospitalizations, and Deaths, 2002-2006Returning to Learning Following a Concussion

  • …adding additional restrictions that may not be needed has the potential to create further emotional stress during the recovery.

  • There is insufficient research…although recent research suggests benefit to the concept of cognitive rest…

  • This calls for an individualized approach…

Halstead et al., Pediatrics, 2013


School modifications
School Modifications Visits, Hospitalizations, and Deaths, 2002-2006


Physical modifications when in doubt sit it out
Physical Modifications: Visits, Hospitalizations, and Deaths, 2002-2006WHEN IN DOUBT, SIT IT OUT

  • “Second Hit Syndrome/Second Impact Syndrome”

    • Specific to children and teenagers

    • Occurs when a second, even mild injury, occurs in the setting of a healing brain

    • Explosive swelling

    • Results in death or severe disability

  • Even in absence of catastrophic injury, symptoms typically worsen/are prolonged after a second hit at any stage of recovery

  • An athlete should never return to play if symptomatic


Gradual return to play
Gradual Return to Play Visits, Hospitalizations, and Deaths, 2002-2006


Approaches to complex issues
Approaches to Complex Visits, Hospitalizations, and Deaths, 2002-2006Issues


When a mild tbi is not mild persistent symptoms
When a mild TBI is not mild: Visits, Hospitalizations, and Deaths, 2002-2006Persistent Symptoms

N=186

8-15 y/o

9%

12%

15%

64%

Yeates et al., Pediatrics, 2009


Other contributors to persistent symptoms
Other contributors to persistent symptoms? Visits, Hospitalizations, and Deaths, 2002-2006

Yeates et al., Pediatrics, 2009


Factors that influence recovery
Factors that influence recovery Visits, Hospitalizations, and Deaths, 2002-2006

Factors that influence recovery

Yeates and Taylor, 2005


Prolonged symptoms injury related factors
Prolonged Symptoms: Visits, Hospitalizations, and Deaths, 2002-2006Injury related factors

  • Post-traumatic amnesia (PTA), LOC, and increased symptoms predicted prolonged recovery (> 7 days) (McCrea 2013)

  • MVA, LOC, Neuroimaging abnormalities and hospitalization were associated with higher levels of prolonged post-concussive symptoms (Taylor et al 2010)


Prolonged symptoms pre and post injury child and family factors
Prolonged Symptoms: Visits, Hospitalizations, and Deaths, 2002-2006Pre and Post-injury child and family factors

  • Injury severity factors important early predictors

  • Child/Family factors important later predictors

    • McNally et al. Neuropsychology, 2013

  • Premorbid parent anxiety, child’s pre-injury concussive symptoms, child’s health-related quality of life

    • Olsson et al. Brain Injury, 2013

  • Repeat concussions increase risk of more severe concussion and slower or incomplete recovery


The balance of rest and activity
The Balance of Rest and Activity Visits, Hospitalizations, and Deaths, 2002-2006

Too little activity

Too much activity

Optimal

function


Other resources available in kki continuum of care
Other resources available in KKI Continuum of Care Visits, Hospitalizations, and Deaths, 2002-2006

  • Behavioral Psychology

  • Physical Therapy

  • Education

  • Speech Therapy

  • Neuropsychology

  • Specialty Medical Care


Behavior psychology
Behavior Psychology Visits, Hospitalizations, and Deaths, 2002-2006

  • Cognitive – Behavior Approach

  • Pain Management techniques

  • Sleep Hygiene

  • Stress Management

    • Activity Restrictions

    • School Problems

    • Social Issues

  • Longstanding psychosocial issues

  • Special appointment slots designated for quick access for concussion patients


Physical therapy
Physical Therapy Visits, Hospitalizations, and Deaths, 2002-2006

  • Subsymptom Aerobic Training Program

    • Aerobic training advocated for pediatric patients 4 to 6 weeks post injury (Vidal et al., Pediatric Annals, 2012; Gagnon et al., Brain Injury, 2009)

    • Benefit of exercise may relate to improved cerebral blood flow (Leddy et al., JHTR, 2012)

  • Manual Therapy to address pain and restricted range of Motion

  • Vestibular Therapy


Educational specialists
Educational Specialists Visits, Hospitalizations, and Deaths, 2002-2006

  • Provide advocacy for children/families

  • Work with the school to develop appropriate supports

  • Grant funding for education of school personnel regarding medical disorders


Neuropsychology
Neuropsychology Visits, Hospitalizations, and Deaths, 2002-2006

  • Comprehensive Evaluation

    • Suspected pre-injury concerns (e.g., LD/ADHD)

    • Ongoing cognitive concerns post-injury that are not resolving as expected

    • Better characterize cognitive, emotional, behavioral concerns and their etiology

    • If more formalized school services are needed


Specialized transition program
Specialized Transition Program Visits, Hospitalizations, and Deaths, 2002-2006

  • School-based day rehabilitation program

  • Provides daily PT/OT/Speech, neuropsychology, education.

  • Physician involvement

  • Appropriate for children with significant functional impairments


Neurology
Neurology Visits, Hospitalizations, and Deaths, 2002-2006

  • Medication management for headaches initiated in concussion clinic

  • Patients with prior history of headache or headaches that are not resolving with months of post-injury care are referred for longer term follow up


Rehabilitation follow up clinic
Rehabilitation Follow Up Clinic Visits, Hospitalizations, and Deaths, 2002-2006

  • Interdisciplinary rehabilitation management clinic including physiatry, neuropsychology, education, and behavioral psychology.

  • Transition to this clinic initiated for children we expect will have ongoing concerns that warrant interdisciplinary perspective


Concussion research at kennedy krieger
Concussion Research at Kennedy Krieger Visits, Hospitalizations, and Deaths, 2002-2006

  • Clinical research efforts are designed to add to our understanding of recovery and optimize evaluation and treatment of concussion with concussion

  • Use of data generated through review of clinical notes (data de-identified)

    • Pre-school symptom data

    • Trajectory of recovery in younger children

  • Prospective research studies

    • Children do not have to receive clinical care at KKI to participate


Recovery or compensation
Recovery or Compensation? Visits, Hospitalizations, and Deaths, 2002-2006

Areas of increased connectivity

with attention network in children with TBI

Risen et al., in preparation


A portable means of evaluating brain connectivity
A portable means of evaluating brain connectivity? Visits, Hospitalizations, and Deaths, 2002-2006

  • Vibrations are applied to the fingertips.

  • The ability of the child to sense the vibrations provides information about how brain cells communicate with each other.

  • Portable technology lends itself to use in schools and at athletic events.


Research goals

NAA Visits, Hospitalizations, and Deaths, 2002-2006

3.0

2.0

PPM

4.0

1.0

Research Goals

Cr

Cho

Glu

  • Understand early (<1 week post-injury) and late changes related to concussion

    • Diagnosis of injury and recovery

  • Understand whether changes in imaging or cellular connectivity persist after a child clinically appears to be back to baseline

    • Risk factors for future injuries?


Effects of repetitive concussion in children
Effects of Repetitive Concussion in Children Visits, Hospitalizations, and Deaths, 2002-2006

  • Higher level of reported symptoms at baseline (Schatz et al 2011)

  • More severe “on field” presentation of concussion if history of 3 or more prior concussions (Collins et al 2002)


Potential long term consequences
Potential long-term consequences Visits, Hospitalizations, and Deaths, 2002-2006


Chronic traumatic encephalopathy cte
Chronic Traumatic Encephalopathy (CTE) Visits, Hospitalizations, and Deaths, 2002-2006

  • Late neurodegenerative process distinct from persistent post-concussive symptoms

  • Recognized in boxers in 1928 (“dementia pugilistica”)

  • Symptoms:

    • Early: impulsivity, irritability, mood disorder, short-term memory loss

    • Late: dementia, gait and speech abnormalities, parkinsonism

  • Recent case report of CTE and motor neuron disease (ALS-like)

McKee et al., Brain, 2013


Chronic traumatic encephalopathy cte1
Chronic Traumatic Encephalopathy (CTE) Visits, Hospitalizations, and Deaths, 2002-2006

  • Post-mortem diagnosis (Neuropathology)

    • Hyperphosphorylated tau protein deposits distinct from Alzheimer’s disease

    • Diagnosis also in asymptomatic athletes (early pathologic stages) and football players without clinical concussions

  • Other contributing factors not yet clear

    • Genetics

    • Age at initial exposure to repetitive trauma

    • Other environmental factors

  • Cohort studies are needed to better understand epidemiology, etiology, and risk factors

Baugh et al., Brain Imaging and Behavior, 2012


Kki concussion program longer term research goals
KKI Concussion Program Visits, Hospitalizations, and Deaths, 2002-2006Longer Term Research Goals

  • Epidemiological study of large groups of children and teens with concussion

    • Long term follow-up

    • Understand rate of lasting and later effects of injury

    • Understand risk factors for lasting and later effects


Questions
Questions??? Visits, Hospitalizations, and Deaths, 2002-2006


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