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Pediatric Concussion

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  1. Pediatric Concussion William Storo, MD, FAAP Dartmouth Hitchcock Concord Pediatric Chair NH Pediatric Society Vice President NH State Advisory Council on Sports-Related Concussion Brain Injury Association of NH Board Member

  2. What is a TBI:A rose by any other name… • Traumatic brain injury (TBI) • Concussion • Acquired brain injury (ABI) • Closed head injury (CHI) • Head injury

  3. TBI Definitions • No “gold standard” definition used across disciplines: • American Congress of Rehabilitation Definition (ACRM) • Individuals with Disabilities Education Act (IDEA) • American Academy of Neurology (AAN) …a traumatically induced alteration in mental status that may or may not involve a loss of consciousness. Confusion and amnesia are hallmarks…

  4. ACRM Definition • An injury caused by an external force (or medical condition resulting in brain damage) • Event results in a definitive loss of consciousness or a period of feeling dazed or confused • Changes in physical, cognitive and emotional/behavioral functioning secondary to the event

  5. IDEA Definition • …open or closed head injuries resulting in impairments in one or more areas: cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-social behavior; physical functions; information processing; and speech. • …does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma.”

  6. TBI is a biological event within the brain • Tissue damage • Bleeding • Swelling

  7. Mechanism of Damage • Brain = consistency of “jello” • Skull encases and protects the brain • Three mechanism of damage: • Bruising of the brain due to forward/backward movement against skull • Stretching of nerve fibers due to twisting of brain within skull = temporary alteration in function • Nerve fibers are broken = permanent alteration in function • Onset of physical, cognitive and behavioral changes after the TBI reflect impaired functioning due to these broken or stretched nerve fibers

  8. Two classifications of TBI Type of injuries • Closed head injury • - Open head injury • Impact • Coup • Contrecoup • Inertial • Diffuse shearing

  9. Coup Injury Stoller & Hill (1998)

  10. Contre-coup Injury Stoller & Hill (1998)

  11. Shearing Injury Stoller & Hill (1998)

  12. Primary Damage to the brain 2o to impact force Secondary Edema Infection Ischemia Bleeding Seizures Neuropathological effects

  13. In TBI, there is preferentially greater damage to the frontal and temporal lobes of the brain

  14. Frontal Lobe Functions • Planning/anticipation/initiation • Problem solving/judgement • Awareness • Mental flexibility • Ability to inhibit responses • Personality/ emotions

  15. Temporal Lobe Functions • Memory and learning • Organizing and sequencing • Hearing • Understanding language

  16. Measures of TBI severity • Length of loss of consciousness • Length of post traumatic amnesia • Glasgow Coma Scale Score • Note: Reflection of severity of injury, NOT severity of consequences

  17. TBI Severity • Mild 85% • Seen in ER or MD office • Often unreported or undiagnosed • Moderate/Severe 15% • Hospitalized • Rehabilitation

  18. “At Risk” Population for TBI • Males > Females • Predominantly 2nd and 3rd decades of life • Have higher rates of premorbid learning disabilities • Higher rates of alcohol and substance abuse: 30 – 60% intoxicated at time of injury • Personality styles: impulsivity, hyperactivity, and risk taking

  19. TBI causes behavior problems • Behavior may be conceptualized in terms of 3 functional systems: • cognition: information-handling aspects • emotionality: feelings and motivation • executive functions: how behavior is expressed • Brain damage rarely affects just one of these systems • Neuropsychology is interested in all 3 aspects, but particular attention is paid to cognitive and executive functions.

  20. TBI Produces Cognitive, Emotional, Behavioral, and Physical Disturbances • Physical: • seizures, headaches, dizziness, balance and coordination problems, visual disturbances, hearing impairments, weakness or paralysis, sensory impairments • Cognitive: • impaired attention, memory, language skills, and complex cognition (judgment, insight, problem solving) • Emotional and Behavioral: • depression, anxiety, mania, irritability, affective lability, rage/aggressio • diminished motivation (apathy), • impulsivity, perseveration, psychosis

  21. What happens in a TBI? • Mechanisms: Contact and Acceleration/Deceleration • Contact mechanisms • result in damage to scalp, skull, and brain surface (eg contusions, lacerations, intracerebral hematomas) • Inertial (Acceleration/Deceleration) Mechanisms • Differential movement of partially tethered brain within the skull which result in stretching and twisting of nerve axons

  22. Inertial (Acceleration/Deceleration) Forces: Diffuse Axonal Injury Pre-Injury Acute Injury

  23. Distribution of Diffuse Axonal Injury(DAI) • Although it is diffuse, DAI particularly effects: • Sub-cortical white matter • Corpus callosum

  24. Injury from both contact and acceleration/deceleration mechanisms • Occurs immediately - Primary injury • Direct result of the force applied to the brain • Contusions • Hemorrhages • Diffuse Axonal Injury (DAI) • Evolves over time - Secondary injury • Results from: • massive release of neurotransmitters • Cerebral edema • Hypoxia/ischemia • Increased intracranial pressure • subsequent triggering of excitotoxic injury cascades

  25. Neuropathology of TBI • Combination of: • Diffuse and focal • Primary and secondary • Immediate injury and evolution of damage over time • Non-random geographic distribution of injury burden within the brain

  26. Regional Cortical (Structural) Vulnerability to TBI Predicts Neuropsychiatric Sequelae Dorsolateral prefrontal cortex (executive function, including sustained and complex attention, memory retrieval, abstraction, judgement, insight, problem solving) Orbitofrontal cortex (emotional and social responding) Anterior temporal cortex (memory retrieval, face recognition, language) Amygdala (emotional learning and conditioning, including fear/anxiety) Ventral brainstem (arousal, ascending activation of diencephalic, subcortical, and cortical structures) Hippocampus (only partially visible in this view - declarative memory)

  27. Neurochemical Vulnerability • Evidence for massive release and subsequent dysregulation of several neurotransmitter systems that modulate key neurobehavioral functions: • Cholinergic • Catecholaminergic • Glutamatergic • Serotonergic

  28. What is a Concussion? CDC Definition • A type of brain injury that changes the way the brain normally works. • Caused by a bump, blow, or jolt to the head that causes the head and brain to move rapidly back and forth. • Children and adolescents are among those at greatest risk for concussion

  29. Concussion Epidemiology • 7 million teens participate in high school sports • Published estimates • CDC: 100,000 annual HS concussions (300,000 in all children/adolescent) [data WITH LOC!] • Account for 9% of high school sports injuries • Account for 19.3% high school football injuries! • Only MVAs cause more TBI in 15-24 age group • HS football alone accounts for over 250,000 brain injuries/year (1/20 players/season) • Concussions Underreported (< 1/3)

  30. Epidemiology [MMWR 10/07/11]

  31. Concussion by Activity [MMWR 10/07/11]

  32. Concussion by Activity [MMWR 10/07/11]

  33. Not just football? • % of NH high school* athletes sustaining a concussion during sports season • Football 16 • Rugby 10 • Boys Ice Hockey 9 • Girls Soccer9 • Cheerleading8 • Girls Basketball 7 • Girls Ice Hockey 6 • Boys basketball 5 • Boys Soccer 4 • Boys & Girls Lacrosse 4 • Field Hockey 3 • Skiing/Snowboarding 3 • Baseball 2 (Unpublished, Dr. Maerlender communication 08/11) * Schools in NH Concussion pilot project 2010-2011 school year

  34. Not just football! • Injury rate per 100,000 player games in high school athletes • [Hockey* 72] • Football (**) 47 (60) • Girls soccer 36 • Boys soccer 22 • Girls basketball 21 • Wrestling 18 • Boys basketball 7 • Softball 7 • (Cheerleading** 6) Data from HS RIO, JAT, 2007 [*from Agel, Can J Surg, 2010] (**from Lincoln 2011)

  35. Why the sudden interest? • Catastrophic injuries in young children • Local and national news • State laws named for injured players: Zack Lystedt – Jr. HS football player, Washington State sustained concussion 11/06, Zack’s Law 5/09, requires: • School districts/WIAA develop concussion guidelines • Parents sign informed consent of concussion risks • Suspected concussed athletes are removed from play • Medical clearance required for concussed athletes to return to play

  36. Consensus Highlights • LOC/Amnesia not required for diagnosis • No grading systems – individual monitoring • Youth have more concussions/problems • Academic performance may suffer – monitoring required • Complete resolution=safe management • Multiple concussions warrant more conservative management.

  37. Consensus Highlights • Baseline testing of contact/collision kids • New baseline at least every 2 years • Baselines should be screened/validated • RTP after return to baseline and graduated progression without symptoms • Most conservative opinion takes precedence • School personnel involved to advocate for appropriate accommodations

  38. Consensus Highlights • High schools should have certified athletic trainers • Team physicians with sports med training • Involvement and training of school nurse • Neuropsychologists should review/supervise neurocognitive tests • All concerned should receive education to recognize concussion

  39. Acute Management • Worsening headaches • Repeated vomiting • Seizures • Change in state of • consciousness • Looks very drowsy/can’t • be awakened • Increasing confusion or • irritability • Can’t recognize people or • places • Unusual behavioral change • Focal neurologic signs • Slurred speech • Weakness or numbness in • arms/legs • Significant neck • pain/injury • Concerns of skull fracture • (excessive scalp swelling • or bleeding) Symptoms requiring urgent evaluation:

  40. Treatment • Cornerstone: Physical & Cognitive Rest • Physical Rest – NO activity: • No gym class • No bike riding • No weightlifting • No sports – games or practice • Controversy – light activity? • Sub-symptom activity

  41. Treatment • Cornerstone: Physical & Cognitive Rest • Cognitive Rest: NO or reduced activity: • School limitations • No school? Reduced schedule? • No [standardized] tests • Reduced load – assignments, homework, etc • Home/social limitations • TV, computer, videogames • Reading -- IM/texting • ? Sub-symptom cognitive activity

  42. Concussion Return to School Considerations • “Accommodations”, 504 Plan, IEP, something else? • School nurse monitoring: symptom score, need for breaks, need to go home • Guidance counselor monitoring: Academic performance, “burden” of accumulated missed work, cognitive deficits, catch-up plan • Rectifying discordant recommendations/plans – physician, teacher, guidance counselor • Reducing, pro-rating, excusing from make-up work • Plan for grades, exams, credit, need for “remedial” work (summer school, repeating courses)

  43. Concussion Consultation Recommendations • Prolonged (> 3 week) duration of symptoms • Profound post-concussive symptoms (unable to attend school, difficulty with daily functioning) • Desire/need for neurocognitive/ImPACT testing • Recurrent concussions: • 2nd in same sports season • 3rd in same year/ever? • With less provocation • With more prolonged recovery • More authoritative or 2nd opinion desired

  44. Concussion Resources • Brain Injury Association of New Hampshire (BIANH) NH Concussion in Sports Consensus Statement http://www.bianh.org/concussion.asp • CDC Concussion in Sports http://www.cdc.gov/concussion/sports/index.html • CDC TBI/Concussion Guidelines Physician Booklet http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf • Clinician Concussion Training www.preventingconcussions.org

  45. Concussion Resources • CDC Clinician Concussion in Sports School Toolkit (ACE) http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html • CDC Concussion in Sports School Resources http://www.cdc.gov/concussion/HeadsUp/schools.html • CDC Concussion in Sports Resource Orderinghttp://www.cdc.gov/concussion/sports/resources.html • Concussion Information, Resources, Tools http://www.knowconcussion.org/

  46. Concussion Resources • NFL Concussion Education http://nflhealthandsafety.com/ • CBS Zack Lystedt/Preventing Concussion 01/10 http://www.youtube.com/watch?v=llLLz6AG_-s • Impact of Concussion in Youth Sports - Dr. Cantu (10/11), Chris Nowinski (10/11), Anne McKee (10/09) http://www.youtube.com/watch?v=DcHERVcoHTM http://www.youtube.com/watch?v=mhksd34WwYQ&feature=results_video&playnext=1&list=PL79800A3318631CB4http://www.youtube.com/watch?v=uoKkpLL10xw&feature=results_video&playnext=1&list=PL074A6174900A06AB