Complexity and Challenges of Return to Play After a Mild Traumatic Brain Injury

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Betty Clarke
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1 Complexity and Challenges of Return to Play After a Mild Traumatic Brain Injury Kristina Wilson, MD, MPH, CAQSM, FAAP Medical Director, Pediatric and Adolescent Sports Medicine and Sports Physical Thearpy Phoenix Children's Hospital, Department of Orthopedics and Sports Medicine Medical Director, Brain Injury and Concussion Program Barrow Neurologic Institute at Phoenix Children's Hospital Clinical Assistant Professor, Department of Child Health University of Arizona School of Medicine What are we talking about? Mild traumatic brain injury (mtbi) Acute brain injury resulting from mechanical energy to the head from external physical forces including 1. 1 or more of the following Confusion or disorientation Loss of consciousness for 30 minutes or less Post-traumatic amnesia for less than 24 hours AND/OR other transient neurological abnormalities Focal signs or symptoms Seizure 2. Galsgow Coma Scale sore (GCS) of after 30 minutes post-injury or later upon presentation for healthcare Most children (70-80%) with mtbi do not show significant difficulties that last more than 1 to 3 months after injury Each child s recovery from mtbi is unique and will follow its own trajectory 1. Predictive factors for more severe symptoms or delayed recovery Previous history of head injury and/or concussion Lower cognitive ability (IC lesions) Neurologic or psychiatric disorder (anxiety, depression) Learning difficulties (i.e. dyslexia, ADD, ADHD) Increased preinjury symptoms (migraine/headache disorders) Family and social stressors 2. Factors associated with increased risk of long-term sequelae (> 1 year) Age at injury (older children and adolescents) Cognitive ability Extracranial injury Injury severity Intracranial lesion Preinjury psychiatric status Pre/post injury child functioning Pre/post injury family functioning Socioeconomic status (lower) Demographics Genetics (Hispanic race/ethnicity) Headaches persist longer in girls

2 Assessment Tools Interventions 1. Combination of tools should be used to assess recovery in children with mtbi a. Validated symptom scales b. Validated cognitive testing (including reaction time) when available c. Balance testing when available for adolescents 2. No single tool is strongly predictive of outcome, but above tools have the strongest evidence in terms of their contribution to predicting outcomes and assessing recovery 1. Referral should be made for appropriate assessments and/or interventions in children with mtbi whose symptoms do not resolve as expected in 4-6 weeks Treatments demonstrating improved outcomes 2. Education and reassurance to the family a. b. Warning signs for more serious injury c. Description of injury and expected course of symptoms d. Prevention of further injury e. Management of cognitive and physical activity/rest f. Instructions regarding return to play/recreation and school g. Clear clinician follow-up instructions 3. Scientific evidence supporting the timing, duration, and efficacy of rest is LIMITED a. Counsel patients and families to observe more restrictive physical and cognitive activity during first 2-3 days particularly if patient is having symptoms b. Cognitive/physical rest periods longer than 3 days for MOST children may worsen their self-reported symptoms c. Children with prolonged symptoms beyond 4 weeks demonstrate that physical exercise, performed below symptom exacerbation, reduce postconcussive symptoms in active rehabilitation models d. No specific time frame individualized by symptom severity and symptom burden. 4. Gradual return to activity should resume after first 2-3 days with close monitoring of symptom expression (number and severity symptom scale) to ensure no overall exacerbation a. Identify symptom triggers and provide strategies to avoid or minimize symptom exacerbation b. Return to learn plan i. Encourage prompt return to school ii. Avoid deleterious effects of prolonged school absence iii. Academic adjustments iv. Academic modifications v. Collaboration between medical, school, and family systems is paramount c. Return to activity active rehabilitation program

3 Stategies to Control Symptoms i. Stepwise progression ii. Leddy protocol gradual increase of aerobic exercise monitoring HR and BP iii. Minimize additional injury no contact d. Return to play i. no same day return ii. Full integration into school without adjustments iii. Complete resolution of symptoms 1. Headaches a. Frequent breaks b. Identify aggravators c. Reduce exposure d. Rest periods e. Quiet environment 2. Dizziness a. Put head down b. Early dismissal c. Avoid crowded hallways 3. Visual symptoms a. Reduce exposure to screens b. Reduce brightness to screens c. Permit hat/sunglasses d. Audiotapes of books e. Turn off fluorescent lights f. Seat in center of classroom 4. Noise a. Lunch in quite area with one classmate b. Avoid choir, band, shop classes c. Avoid gym d. Ear plugs e. Early dismissal 5. Noise a. Lunch in quite area with one classmate b. Avoid choir, band, shop classes c. Avoid gym d. Ear plugs e. Early dismissal 6. Sleep disturbance a. Late start b. Shortened school day c. Rest breaks Medical Treatment of Symptoms

4 1. Headaches a. Nonopiod analgesia should be offered to children with painful headache after acute mtbi but also provide counseling to the family regarding the risks of analgesic overuse, including rebound headache b. Chronic headache after mtbi is likely to be multifactorial; therefore, children with chronic headache after mtbi should be referred for multidisciplinary evaluation and treatment, with consideration of analgesic overuse as a contributory factor 2. Vestibulo-Oculomotor Dysfunction 3. Sleep a. Children with subjective or objective evidence of persistent vestibulooculomotor dysfunction after mtbi may be referred to a program of vestibular rehabilitation a. Guidance should be provided on proper sleep hygiene methods to facilitate recovery from pediatric mtbi i. Consistent sleep and wake time ii. No screens 1 hour prior to bedtime iii. No physical activity 1 hour prior to bedtime iv. No caffeine after 2 pm v. No activities other than sleep in bed b. If sleep problems emerge or continue despite appropriate sleep hygiene measures, health care professionals may refer children with mtbi to sleep disorder specialist for further assessment 4. Cognitive Impairment a. Children with persisting problems related to cognitive function may be referred for a formal neuropsychological evaluation to assist in determining the etiology and recommending targeted treatment b. Treatment should be recommended for cognitive dysfunction that reflects its presumed etiology i. Attention ii. Memory and learning iii. Response speed When is too many concussions too many? iv. Aspects of executive functions

5 1. Lesional brain injury a. Findings on neuroimaging that don t resolve b. History of multiple concussions c. Prolonged recovery

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children September 2018

Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children September 2018 Nothing to Disclose CDC Guidelines- Objective Question-