Pediatric Concussion update

Transcription

1 Pediatric Concussion update OCTOBER 14, 2016 NANAIMO BRAIN INJURY SOCIETY DR. JACQUELINE PURTZKI CLIN. ASSIST. PROFESSOR, UBC, DIV. OF PHYSICAL MEDICINE & REHABILITATION GF STRONG REHAB, CENTRE ADOLESCENT COMPLEX CONCUSSION CLINIC BCCH, SHHCC DIV. OF DEVELOPMENTAL PEDIATRICS

2 Objectives To provide an update of our current understanding of pediatric and adolescent concussions To understand the background of current pediatric return to sport guidelines To gain knowledge about symptoms management, rehab strategies, return to learn and return to sports. Take home some useful resources

3 Distribution of TBI A. McKinley 2009

4 Definition and Pathophysiology of concussion

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6 Mild Traumatic Brain Injury (American Congress of Rehabilitation Medicine) 6 At least ONE or MORE of the following: Loss of consciousness (LOC) Loss of memory for events immediately before or after the accident Any alteration in mental state Focal neurological deficit Exclusion: Loss of consciousness >30 mins. Glasgow Coma Scale < 13 after 30 mins. Post-traumatic amnesia >24 hrs. May be due to direct blow to the head, face, or neck or by a blow to somewhere else on the body that transmits an impulsive force to the head. You do not need to lose consciousness to sustain a concussion/mtbi. 90% of concussions do not involve LOC!

7 Concussion/Brain Injury- Diffuse axonal injury 7

8 Regions of the Brain Parietal Lobe Intellect Sense of Touch Differentiation of size, shape & colour Spatial perception Visual perception Muscle tone, strength & sensation Occipital Lobe Vision Cerebellum Balance Coordination Brain Stem Breathing Heart Rate Blood Pressure Movement & sensation for head, neck, eyes, hearing Frontal Lobe Initiation Planning/Anticipation Follow-through Impulsivity Judgement Reasoning Abstract Thinking Smell Motor Planning Personality Emotionality Speaking Integration of thought and emotion Self-monitoring Temporal Lobe Memory Hearing Understanding Language Relays messages for other movements and sensations 8

9 Modern view: Neural networks 248 E.A. Wilde et al. / Pediatric traumatic brain injury: Neuroimaging and neurorehabilitation outcome Fig. 3. Neuroimaging methods now permit the identification of networks, including important hubs that represent important points where network information passes through and/or is relayed to other brain regions. This illustration demonstrates the high-resolution connectome (C) derived from DTI showing with red circles where hubs were located, where the size of the colored circle represents the size of the hub. Color also

10 Diffuse axonal injury

11 Secondary injury mechanisms from Zasler et al, Brain Injury Medicine

12 Rat model

13 Brain injury can cause symptoms and dysfunction Slide adapted from Dr. Giza

14 14 Concussion Statistics for Children and Adolescents

15 Estimated annual incidence million concussions. (Grady, M, 2010) US-Concussion Statistics Children and Adolescents 15 In the United States, concussion/mild traumatic brain injury occurs in 692 of 100,000 children younger than 15 years. (Barlow, K. et al, 2010) True incidence unknown: (Zemek, R et al., 2013; Halstead, M, 2010)

16 Data from Vancouver Coastal Health, Fraser Health, BC Children s Hospital examined. 9,027 children and youth ages 0-19 years seen at BCCH with concussion during Significant increase from 2001 to Recommendations: Need for a provincial concussion program for children and youth. Active and timely rehabilitation essential for concussed children and youth who remain symptomatic > 6 weeks. The Burden of Concussion in British 16 Columbia Report BC Injury Research and Prevention Unit and Child Health BC (Rajabali, Ibrahimova, Turcotte and Babul, 2012) BC Injury Research and Prevention Unit and Child Health BC (October 2012)

17 Sports and Recreation Related Concussion 17 Statistics Children under 10 years concussions mainly due to non-sports-related falls (home, school, playground)(karlin, A, 2011) Children over 10 years concussions mainly due to sports-related injuries.(karlin, A, 2011) 5 main causes of concussion due to sports and recreation in children aged 5 to 18 years: bicycling, football, basketball, playground activities, and soccer.

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19 What do we know and think we know about concussions in youth

20 What we know about concussions

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25 #6 Concussions are Cumulative 26 History of one or two previous concussions elevates concussion risk. Sustaining multiple concussions places high school athletes at greater risk for worse neurobehavioral outcomes. (Collins, M. et al, 2008) After 1 concussion, the individual is 3 times likely to get another concussion. In some athletes with multiple concussions, there is the possibility of long-term neuropsychiatric effects which include psychiatric (mood disorders, addictions, psychosis etc.), physical (sleep disturbance etc.) and cognitive impairment. (Laker, S. 2011) No standards exist for how many concussions are too many. (Apps, J., 2012)

26 C.Giza, BIS 2015

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32 Synapses (connections between neurons)in the gray matter (outer layer of the brain) are overproduced during early adolescence. 33 The growth is followed by pruning of the synapses. Synapses exercised by experience are strengthened (e.g. learning a new language, learning a new sport) while others wither away if not used. Brain becomes more efficient. Frontal lobes are responsible for more "top-down" control, controlling impulses, and planning ahead (hallmarks of adult behavior) and are among the last regions of the brain to mature (mid-20s and onwards). (

33 Brain Development Milestones: Brain development ages 0 to 3 The most rapid postnatal brain growth occurs in the first three gyears of life By ah e 3, a c ild s brain o has f rmed 1,000 trillion connections, twice as many as adults have By early adolescence, the brain is eliminating more synapses than it is producing By late adolescence, half of the synapses have been discarded, leaving 500 trillion. This number remains fairly constant through the rest of the life cycle.

34 Maturation process Gray matter maturation Gogtay, Giedd et al PNAS N = 13 (7 male, 6 female) typical subjects

35 Once a concussion occurred

36 Acute management of concussion at school Important to suspect a concussion if a student experienced a blow to the head If in doubt: call Red flags: loss of consciousness Seizures Potential spine injury Unwitnessed High impact

37 Return to Activity Return to learn before return to sports is premature especially if return to contact sports Return to activity after initial rest period is likely safe and beneficial

38 Simple Complex RECOVERY

39 Road of recovery COMPLEX In majority of kids and adolescents: 85% Symptom free by 4 weeks No risk factors for slow recovery Progressive improvement No mental health or LD No drug or alcohol use history % will have persistent sx by 3 months and 2% by one year. (Barlow,K. 2010) Anticipate prolonged recovery if risk factors present concussion was actually a more severe injury Concussion and mental health Concussion and chronic headaches Always ask why is my student not recovering as expected

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41 Adapted from Dr. D. Arciniegas, BIS

42 Adapted from Dr. D. Arciniegas, BIS 2015

43 K.Barlow et al, Pediatrics,2010

44 REHABILITATION

45 Focus on Healthy Lifestyle Improves sleep Mood Sense of well-being Concentration Brain healing

46 Effect of prolonged rest Social consequences Isolation from friends Loss of social engagement with team mates Loss of self esteem Physical consequences Deconditioning Weight gain Tachycardia and orthostatic hypotension Insomnia due to inactivity and worry Poor concentration exercise improves attention Emotional consequences Loneliness Isolation Anxiety about school and friends Worry about brain injury

47 Active Rehab versus Rest

48 Return to School Guidelines for Concussion Management 50 Concussion is a medical event and the recovery spans the home and school setting for 3 or more weeks. THUS, Communication and collaboration between student, parents, educators and health care providers is vital. (McAvoy, K., 2009)

49 Why Is The Student So Tired? Energy Crisis in the Brain Neurometabolic Cascade following TBI (Giza & Hovda, 2001) 51 Unsafe to return to sport until brain activity has returned to normal Period between concussion and recovery: window of vulnerability (return to play during this time could cause more severe or even catastrophic brain injury.)

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51 Colorado Dept. of Education: Concussion Management Guidelines, 2012 Authors: Karen McAvoy, PsyD and Kristina Werther, LCSW Symptom Wheel (Colorado Dept. of Education Concussion Management Guidelines) 53

52 Emotional Changes 54 Irritability/easily angered Frustration/impatience Anxiety Depression (can impact cognition) May be related to poor sleep and/or pain May be difficult for parents and teachers to differentiate between adolescent behavior and concussion behavior (is the behavior different from prior to the concussion?)

53 Cognitive (Thinking) Changes (Returning to School After A Concussion: A Fact Sheet for School Professionals, Centers for Disease Control and Prevention) 55 Attention/Concentration Memory Slower thought processing speed Reaction times (slower, more sluggish) May be affected by Sleep, Mood and/or Pain

54 Physical Symptoms (immediate or delayed) 56 Headaches (most frequently reported) Fatigue Sleep disturbance Dizziness/nausea Sensitivity to noise or light Visual changes

55 RESOURCES

56 Tiers of Service Tier 4 subspecialty provincial service Tier 3 local regional service Tier 2 Pediatrician, local community providers, BIS, OT, PT, Tier 1 family doctor, ER, nurse practioners

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58 Berlin: 5 th International conference on concussion in sport: October 27-28, 2016 GF Strong AC3 referrals for complex concussions: