Disclosures. Pediatric Mild TBI. Mild TBI vs. Concussion. Objectives. Concussion Common Features. Concussion 6/7/2015. None. Understand concussion:

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1 Pediatric Mild TBI None Disclosures Big Heads, Big Follow-Up Harmony Sierens, MD, FAAPMR, MPT Pediatric Physical Medicine and Rehabilitation Understand concussion: Definition Epidemiology Outcomes Management Concussion law Objectives Mild TBI vs. Concussion Previously used interchangeably Concussion in Sports group (Zurich 2008, 2012) defines the above as different injury constructs and should not be used interchangeably Understand Mild TBI: Definition Management Concussion Concussion is the historical term representing low velocity injuries that cause brain shaking resulting in clinical symptoms and which are not necessarily related to a pathological injury A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces Concussion Common Features May be caused by a direct blow to head, neck, face or elsewhere on the body with an impulsive force transmitted to the head Results in rapid onset of short-lived impairment of neurologic function that resolves spontaneously May have neuropathologic changes, but acute clinical symptoms reflect a functional disturbance rather than a structural injury Graded set of clinical symptoms that may or may not include LOC No abnormalities on neuroimaging seen in concussion 1

2 Concussion Symptoms Somatic symptoms such as headache Cognitive symptoms such as feeling in a fog Emotional symptoms such as lability Physical signs such as LOC and amnesia Behavioral changes such as irritability Cognitive impairment such as slowed reaction times Sleep disturbances/drowsiness Concussion Epidemiology million children and adolescents participate in nonscholastic organized sports in the U.S. Some children participate as early as 3-4 years of age More than 7.6 million U.S. adolescents participate in high school athletics Football has an estimated 1.1 million high school participants CDC estimates that 1.7 million children and adults sustain a concussion each year 20% are sports related Large majority of these are children Concussion Epidemiology Before age 10 children tend to sustain concussions primarily from non-sports related falls After age 10, children sustain majority of concussions from sports-related injuries Younger children tend to be injured at home, school or the playground Pediatric concussion is likely under-estimated due to lack of recognition, lack of follow up and failure to report symptoms Concussion Outcomes 80-90% of concussions resolve in 7-10 days Recovery may take longer in children and adolescents Return to neurocognitive baseline is high school athletes is days; collegiate athletes in 5-7 days and professional athletes in 3-5 days 26% of athletes with concussion reported being symptom free and ready for RTP has persisting neurocognitive deficits Small percentage of cases may have prolonged postconcussive symptoms Concussion Outcomes Children younger than age 7 at time of head injury fared worse in age adjusted performance on neurocognitive testing than those older than age 7 at time of head injury Long-Term Consequences of Youth Concussion Single concussion is generally thought to have limited long-term consequences if any Effects of multiple concussions appear to be cumulative, however how this may affect children later in life is not known Athletes with 2 or more concussions exhibit lower GPAs than matched students with no concussion history 2

3 Retirement From Youth Athletics No consensus on number of concussions that is thought to be too many Make decisions on individual basis Consider removal when time period between concussions is decreasing, symptoms are more severe and/or prolonged, and concussions occur with less force Pediatric Outcome Concerns Immaturity of developing CNS/incomplete myelination Thinner cranial bones Larger subarachnoid space in which the brain can move freely Larger head to body ratio Reduced development of neck and shoulder musculature contributes to the inability to efficiently dissipate the energy from head impact to the rest of the body Gains in weight and mass during adolescence increase the force and momentum during collision without gains in neck strength Pathophysiologic Pediatric Outcome Concerns More widespread and prolonged cerebral swelling with TBI in pediatrics versus adults (higher water content of brain) Injured brain s natural timeline of neuronal maturation may be altered by disturbances caused by trauma High plasticity of developing brain could have negative impact on outcome due to apoptotic death of neurons Pathophysiologic Pediatric Outcome Concerns Metabolic cascade of concussion Increased diffusion of excitotoxic neurotransmitters in immature brain Sensitivity of glutamate and NMDA is estimated to be up to 60% higher in the developing brain Increased inflammatory response in developing brain Increased blood-brain barrier permeability after injury Second Impact Syndrome Occurs when a youth athlete sustains a second concussion before the initial concussion heals Disruption of autoregulation of cerebral blood flow, leading to severe vascular congestion, diffuse brain swelling and increased ICP Brain herniation, coma, and death All cases in athletes younger than 20 years Concussion Management Cornerstone of management is physical and cognitive rest until symptoms resolve and then a graded program of exertion to eventual return to play Sensible approach to gradual return to cognitive and physical activities prior to return to contact sports, avoiding exacerbation of symptoms 3

4 Rest is Best??? Controversy in literature for more than 80 years Symonds 1928 (Bedrest, no visitors) Pilkington 1937 (Strict rest, no mental work) Watt 1938 (If unconscious then bed rest at least 3 weeks) Asher 1947 (Dangers of Going to Bed) Merloo 1949 (Too long of rest may lead to secondary neurotic syndrome) Voris 1950 (Rest is best but must not be prolonged) Rest is Best??? A clinical trial Andreasson et al Found that reassurance, early mobilization and advice to return to activities immediately led to quickest recovery with least sequelae Rest is Best??? Systematic Review Schneider et al 2013 Sparse evidence about effects of rest after concussion Initial period of rest may be beneficial but more research needed about long-term effects of rest and optimal amount and type of rest Rest is Best??? Randomized Controlled Trial de Kruijk et al 2002 No clear effect from bed rest; palliated symptoms in first 2 weeks but positive effects disappeared or reversed in the long-term Non-randomized Controlled Trial Gibson et al 2013 Rest associated with slower symptom resolution on univariate but not multivariate analysis More research is needed Rest is Best??? Probably best in first hours Inconclusive evidence after that RECOMMEND sensible approach to activity resumption Consider iatrogenic effects of strict bedrest Initial Assessment Youth athletics are less likely to have trained medical professionals or athletic trainers on the field Youth athletics more likely to be staffed by volunteer coaches and officials More likely to have reduced or delayed identification of concussion 4

ED Visit Must have follow up with medical provider after ED evaluation Must be given activity restrictions emphasizing cognitive and physical rest Explain expected symptoms and reason to return

$deficits, and no evidence of skull fracture then risk of finding intracranial pathology is as low as 0.$

5 ED Visit Must have follow up with medical provider after ED evaluation Must be given activity restrictions emphasizing cognitive and physical rest Explain expected symptoms and reason to return Consider removal from school until further OP evaluation can be done Neuroimaging Concussion is a metabolic and functional disturbance not structural If normal mental status, no focal neurologic deficits, and no evidence of skull fracture then risk of finding intracranial pathology is as low as 0.02% Avoid CT if possible due to concerns for malignancy due to radiation exposure fmri show activation patterns that correlate with symptom severity but only for research settings at this time Outpatient Clinic Visit Mainstay of concussion management Can be in the pediatrician office Best managed in a multidisciplinary concussion clinic setting with a physician as the medical decision maker Physician needs to be well versed in management of concussion and return to play guidelines Requires a comprehensive history and physical exam including a complete neurologic exam Concussion Modifiers Requiring Further Consideration Frequency of previous concussions including timing Symptoms including number, severity and duration (>10days) Prolonged LOC (>1 min) and amnesia Concussive convulsions Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Children and adolescents 5

6 Concussion Modifiers Requiring Further Consideration Co-morbid migraine, depression, or other mental health disorders, ADHD, learning disabilities or sleep disorders Psychoactive drugs, anticoagulants Dangerous style of play High-risk activity, contact or collision sport, high sporting level Clinical Management Reassurance and education Physical and cognitive rest until symptom free provide family with symptom inventory to track symptoms SCAT3 Form can be used for this Difficulties with Rest for the Pediatric Patient Physical rest requires removal from all activities that can lead to re-injury such as physical education, recess or horseplay with siblings Postpone return to all the above until cleared for full return to play All visits need to emphasize importance of refraining from all activities that may lead to subsequent head injury Difficulties with Rest for Pediatric Patient Cognitive rest includes reduction or discontinuation of activities such as watching TV, reading, computer usage, video gaming, texting, homework or talking on the phone Monitor for any exacerbation of symptoms Use common sense School Concussion symptoms may lead to adverse effects on reading comprehension, recall of new and previously learned materials, and decreased ability to complete test or homework on time Attending school may lead to worsening of symptoms Restricting school attendance may be needed for more complete cognitive rest School Repercussions of missing school Psychosocial development Changes relationships with peers/perception of reduced social acceptance Feelings of isolation Development of symptoms of anxiety and/or depression Make-up work and postponed testing accumulate increasing stress Absences/risk of repeating semester 6

School Consider half-days Postpone standardized testing Communicate with teachers/school administration Informal accommodations for short term Consider 504 plan or IEP for prolonged recovery CDC s

7 School Consider half-days Postpone standardized testing Communicate with teachers/school administration Informal accommodations for short term Consider 504 plan or IEP for prolonged recovery CDC s Heads Up initiative provides educational fact sheets Pharmacologic Therapy Management of specific prolonged symptoms Nausea Headache Anxiety Insomnia Depression When considering return to play, the athlete should be symptom free and off all medications that may mask or modify symptoms Careful consideration must be taken Role of Neuropsychological Testing Clinical value and contribution of NP testing In children may be helpful to test when symptomatic to provide guidance about school reintegration RECOMMEND to be given by trained neuropsychologist especially with co-morbid learning disabilities, behavior disorders or ADHD Must be developmentally sensitive and take into account expected performance improvements that occur with maturation Role of Neuropsychological Testing Cognitive recovery largely overlaps with symptom resolution NP testing should not be sole basis of decision making for RTP; should be an aid to clinical decision making RTP should remain a medical decision Graduated Return to Play Protocol Rehabilitation stage 1. No activity 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills 5. Full contact practice Functional exercise at each stage of rehabilitation Symptom limited physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% maximum permitted heart rate. No resistance training Skating drills in ice hockey, running drills in soccer. No head impact activities Progression to more complex training drills, e.g. passing drills in football and ice hockey. May start progressive resistance training Following medical clearance participate in normal training activities Objective of each stage Recovery Increase HR Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff 6. Return to play Normal game play 7

Differences in Pediatric Population General concussion management recommendations apply to children and adolescents to age 10 Younger children may present with different symptoms Parent input is

interpret information Children with learning disabilities or ADHD need more sophisticated assessment strategies Differences in Pediatric Population Children cannot be returned to play or practice

modified or attendance limited Differences in Pediatric Population Children and adolescents have different physiologic responses after concussion/head trauma More conservative return to play is

length of time of asymptomatic rest and graded exertion Never appropriate for a child to return to play on day of injury Michigan Concussion Law Requires all coaches, employees, volunteers, and other

8 Differences in Pediatric Population General concussion management recommendations apply to children and adolescents to age 10 Younger children may present with different symptoms Parent input is crucial; as well as teacher and school input when appropriate Neuropsychological testing must be age appropriate until late teen years; more important to use a trained neuropsychologist to test and interpret information Children with learning disabilities or ADHD need more sophisticated assessment strategies Differences in Pediatric Population Children cannot be returned to play or practice until completely symptom free Children may require longer period of time to recover than adults Children need to limit scholastic and other cognitive stressors while symptomatic School may need to be modified or attendance limited Differences in Pediatric Population Children and adolescents have different physiologic responses after concussion/head trauma More conservative return to play is recommended State of Michigan Concussion Law Michigan is the 39 th state to enact a law to regulate sports concussion and return to athletic activity Law went into full effect on June 30, 2013 Extend length of time of asymptomatic rest and graded exertion Never appropriate for a child to return to play on day of injury Michigan Concussion Law Requires all coaches, employees, volunteers, and other adults involved with a youth athletic activity to complete a concussion awareness on-line training program Sports Organizations Rules All amateur sports organizations adopted programs to meet the guidelines of the Michigan Concussion Law The organizing entity must provide educational materials on the signs/symptoms and consequences of concussions to each youth athlete and their parents/guardians and obtain a signed statement acknowledging receipt of information The law also requires immediate removal of an athlete from physical participation in an athletic activity who is suspected of sustaining a concussion The student athlete must then receive written clearance from an appropriate health professional before returning to activity 8

9 Mild Traumatic Brain Injury Both a structural and functional injury Will show changes on neuro-imaging studies Case Study 1 14 year old male peds vs MVA, car travelling mph with front hood damage Positive LOC on scene; upon presentation GCS 15 and patient was alert and conversing appropriately Injuries: Open right tib-fib fracture and left tibial plateau fracture C-spine, CXR and PXR negative Head CT Negative for any intracranial injury Comminuted and laterally displaced fracture of right nasal bone Case Study 1 Did well on Inpatient Rehab Had speech and language evaluation no obvious deficits Upon discharge started homebound schooling Dad and teachers reports patient doing well with homework Patient denies any difficulties with homework Cleared to return to school with accommodations 6 weeks after injury Recommended NP evaluation Case Study 1 At follow up visit 3 months later patient reports difficulty in school and poor grades Completed NPE that revealed: Mild neurocognitive disorder due to TBI Adjustment reaction with anxiety REC further school accommodations, OT and SLP treatment to promote recovery MRI brain ordered MRI Brain A few nonspecific T2/flair hyperintensities in the frontal subcortical white matter as well as the left subinsular region 9

10 Case Study 1 Continues to follow with PMR Receives outpatient brain injury rehabilitation including speech and language pathology Currently doing well in school Mild TBI Management Similar approach as outlined for concussion Regular close follow ups to manage symptoms and evaluate recovery Even if patient is not showing obvious deficits initially, important to follow up to further monitor for abnormalities Especially once returning to school Mild TBI Outcomes 14% of children aged 6-18 years with mtbi remained symptomatic 3 months after injury 2.3% of children 0-18 years were symptomatic at 1 year after injury Difference in Mild TBI Management Much more conservative with return to play Less likely to ever allow return to contact sports Children aged 0-10 who sustained a mtbi that resulted in hospital admission were statistically more likely to exhibit adverse behavioral outcomes such as inattention, hyperactivity and conduct disordered behavior by age Even more likely if injury prior to age 5 Case Study #2 16 year old male with confusion, headache and neck pain after head to head football contact No LOC Head CT revealed subdural hematoma along tentorium on right side MRI brain revealed: T1 hyperintense subdural hemorrhage along right tentorium; Trace amount of subdural hematoma along cerebral convexities; No intracerebral hemorrhage, mass effects or midline shift. No evidence of diffuse axonal injury Case Study #2 Pre-morbid ADHD and learning disabilities Worsened performance in school Development of anxiety/depression since restrictions placed (no physical activity or contact sports) Allowed return to exercise with some improvements in mood Continued difficulties since no longer part of football team (rejection from peers and coaches) 10

11 Case Study #2 2 years post injury: Continued headaches but manageable Mood improved with counseling Improved school performance with stimulant medications to control ADHD References McCrory, P, et al. Consensus statement on Concussion in Sport The 4th International Conference on Concussion in Sport held in Zurich, November Br J Sports Med Apr;47(5): McCrory, P, et al. Consensus statement on Concussion in Sport The 3rd International Conference on Concussion in Sport held in Zurich, November Journal of Athletic Training 2009; 44(4): Karlin, AM. Concussion in the Pediatric and Adolescent Population: Different Population, Different Concerns. PMR 2011;3:S369-S379. Thank You 11

Director of Athletics

3341-8-1 Concussion Management Policy. Applicability Intercollegiate Athletics Responsible Unit Policy Administrator Intercollegiate Athletics/Director of Athletics Director of Athletics (A) Policy Purpose