mtbi/concussion in Children, Adolescents & Young Adults: What it is and Why we should be Concerned Ronald C. Savage, Ed.D.

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1 mtbi/concussion in Children, Adolescents & Young Adults: What it is and Why we should be Concerned Ronald C. Savage, Ed.D. 1

How Common Are mtbi/concussions? CDC reports indicate that between 1.6 and 3.

estimates of between 20% and 40% of the nearly two million military personnel

which are now associated with increased likelihood of poor outcomes, are a

amongst this group This is a particularly important concern given the numbers

high concussion-risk sports like boxing, football, soccer, and ice hockey and

2 How Common Are mtbi/concussions? CDC reports indicate that between 1.6 and 3.8 million sports and recreation related concussions occur each year DOD estimates of between 20% and 40% of the nearly two million military personnel returning from war service will have sustained a TBI Repeat concussions, which are now associated with increased likelihood of poor outcomes, are a frequent occurrence often because initial injuries often go unreported amongst this group This is a particularly important concern given the numbers of children and youth between the ages of 5 and 24 years who are involved in high concussion-risk sports like boxing, football, soccer, and ice hockey and the potential impact this has on their future education, employment and independent living. 2

mcycle bcycle atv/rv pedestrian gsw stab beating sport struck animal machine caught fall other Defining Concussion Centers for Disease Control and Prevention (CDC, 2005) Mild traumatic brain injury

3 % of normal National Pediatric Trauma Registry (Savage et al., 2000) Mechanism of Injury for mtbi (B-19 years) N = % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% m.v. mcycle bcycle atv/rv pedestrian gsw stab beating sport struck animal machine caught fall other Defining Concussion Centers for Disease Control and Prevention (CDC, 2005) Mild traumatic brain injury (mtbi) or concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. This disturbance of brain functioning is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). Mild TBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Concussion in Sports CDC Fast Facts: A concussion is a brain injury and all are serious. Most concussions occur without loss of consciousness. Recognition and proper response to concussions when they first occur can help prevent further injury or even death. Neurometabolic Cascade Following Cerebral Concussion/MTBI 500 (Giza & Hovda, 2001) 400 Calcium 300 K+ Glutamate Glucose minutes hours days Cerebral Blood Flow UCLA Brain Injury Research Center 3

Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution Lovell et al.

College Paper and 5-7 days 7 days Pencil NP 29 College Paper and Pencil 3 days 3 days NP 94 College Balance 3-5 Days 7 Days BESS

7-10 Days 208 High School Computer 26 days 17 Days 72 High School Computer 21 days 7 Days 100 90 80 70 60 50 40 30 20 10 0 WEEK 1

17 19 21 23 25 27 29 31 33 35 37 38 40+ All Athletes No Previous Concussions 1 or More Previous Concussions Maugans et al 2011 12

4 Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution Lovell et al McCrea et al McCrea et al Echemendia 2001 Guskiewicz et al Bleiberg et al Iverson et al McClincy et al Lovell, Collins et al 2008 Covassin et al Pro (NFL) Paper and Pencil NP 1 day 1 day 94 College SAC <1 Day 7 days 94 College Paper and 5-7 days 7 days Pencil NP 29 College Paper and Pencil 3 days 3 days NP 94 College Balance 3-5 Days 7 Days BESS 64 College Computer 3-7 days Did Not NP (ANAM) Evaluate 30 High School Computer 10 days 7 Days 104 High School Computer 14 days 7-10 Days 208 High School Computer 26 days 17 Days 72 High School Computer 21 days 7 Days WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED N=134 High School Male Football Athletes All Athletes No Previous Concussions 1 or More Previous Concussions Maugans et al Ages Computer 30 days 14 Days Other Factors to consider Age of the child younger is not always better Symptoms that persist for longer than 6-8 weeks Cumulative effects of multiple concussions CNN Video National Youth Sports Concussion Tour (43 states in 6 months) 4

5 Follow-up for a Sprained Ankle Ice to reduce swelling No or limited weight bearing Elevate and rest Use of crutches, bracing, wrapping Lessen activities / modify environment Slow return to activity Rebuild strength Follow-up for Sprained Brain Allow time for swelling to reside No or limited cognitive activities Rest and more rest Use of modifications, compensatory strategies Lessen activities / modify environment Slow return to activity Rebuild strength 5

concussion history When Can an Athlete Return to Play?

6 Adoption of NeuroCognitive Testing for mtbi/concussion 1. ImPACT 2. SCAT 3. CogState 4. Headminders 5. ANAM Baseline Testing Provides comparison based on pre- and post-concussion scores Provides Physicians/Clinicians/AT s with a key tool to determine safe return to play Documents an athlete s concussion history When Can an Athlete Return to Play? When medically cleared No activity of any kind while still symptomatic, including headaches Check on academic performance Start out with light activity If symptom free with light activity, progress to increased activity Always respect the brain and the time it needs to heal When Can a Student-Athlete Return to School? Pars opercularis Motor cortex Somatosensory cortex Sensory associative cortex Visual associative cortex Broca s area Visual cortex Primary Auditory cortex Wernicke s area 6

Learning/Thinking Changes Confused, foggy Mixed up about time and place Can t attend or concentrate Forgetful, trouble remembering

Changes Restless, irritable or fussy Acts without thinking Becomes easily upset, angry or loses temper Sad, depressed or withdrawn

lightheaded Vomits or feels sick Parts of body tingle or feel numb Loses balance, trips or stumbles a lot Feels worn out or exhausted

7 Learning/Thinking Changes Confused, foggy Mixed up about time and place Can t attend or concentrate Forgetful, trouble remembering things Difficulty organizing words or thoughts Misunderstands things Slow processing Takes longer to do homework Behavioral/Emotional Changes Restless, irritable or fussy Acts without thinking Becomes easily upset, angry or loses temper Sad, depressed or withdrawn Anxious or nervous Gets into arguments with friends / peers Cries easily or for no reason Physical Changes Has headache, is dizzy or lightheaded Vomits or feels sick Parts of body tingle or feel numb Loses balance, trips or stumbles a lot Feels worn out or exhausted Tires easily Drowsy or sleepy Needs extra sleep Hard to fall and stay asleep Sensitive to light and noise Blurry vision Ringing in ears 7

physician and a Neuro-Vestibular PT. The team can also include an athletic coach/trainer, neuro-otologist, neuroophthalmologist, psychologist and cognitive therapist.

malls/parties, migraine prevention education and/or medication.

8 How Can a Physical Therapist Help? The Physical Therapist's examination is essential to assess an individual s symptoms and limitations Post-Concussion Management is best done with a team approach, including a neuropsychologist, a physician and a Neuro-Vestibular PT. The team can also include an athletic coach/trainer, neuro-otologist, neuroophthalmologist, psychologist and cognitive therapist. Standard interventions include removal from play/activity, minimized cognitive exertion, academic accommodations/decreased work load, limited reading, no video games or outside activities like malls/parties, migraine prevention education and/or medication. Physical Sensory Variables Dizziness Balance problems Visual problems Vestibular Vestibular Vestibular Impairments in Vestibular System can arise from multiple areas Concussion to the labyrinth of the inner ear Post-traumatic paroxysmal positional vertigo Post-traumatic migraine Concussion to the brain stem Post-traumatic endolymphatic hydrops Perilymphatic fistula 2010) (Furman et al., NeuroVestibular Expert Tests for and treat balance and ocular problems Uses techniques that help retrain the brain to understand complex environments that include space, motion, and head/eye movements, with exercises that focus on: Vision Balance Motion Gait When vestibular and headache symptoms pass, or if you quickly recover from cognitive symptoms, your doctor may clear you for certain controlled physical activities. Excertion Training Reintroduce the vestibular system to dynamic activity in a careful and deliberate way. Safely increase your heart rate through a variety of regimens, such as: Cardiovascular exercise Strength training Agility drills Plyometrics No head injury is too severe to despair of, nor too trivial to ignore Hippocrates, 4 th Century, B.C. 8

Brain Injury Magazine www.nabis.org HTTP://ISSUU.

9 Brain Injury Magazine P30 P13 9

Seth Smith MD, PharmD. Thank You!

Seth Smith MD, PharmD. Thank You! Seth Smith MD, PharmD Thank You! Concussion Headlines!!! Concussion Headlines!!! Concussion rules put kids health before winning games The Miami Herald 8/21/12 FHSAA's implementation of legislation goes