Current Concepts in Concussion Care Stacy Suskauer, M.D. Pediatric Physiatrist Beth Slomine, Ph.D., ABPP Neuropsychologist

Current Concepts in Concussion Care

Stacy Suskauer, M.D.Pediatric Physiatrist

Beth Slomine, Ph.D., ABPPNeuropsychologist

www.kennedykrieger.org

Disclosures

• No industry-related financial disclosures

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Objectives

• To identify mild Traumatic Brain Injury in children– Symptoms – Epidemiology

• To understand typical course of recovery and approaches to early management• Cognitive rest• Active treatment strategies

• To understand approaches to complex issues– Prolonged symptoms– Short-term sequelae of repetitive injuries

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• To identify mild Traumatic Brain Injury in children– Symptoms – Epidemiology

44


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Concussion = mild Traumatic Brain Injury (mTBI)

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

May be caused by blow to head, neck, face, or blow elsewhere on body with forces transmitted to head

Typically results in rapid onset of short-lived impairment of neurologic function that resolves spontaneously• Symptoms and signs may evolve over minutes to

hours

May result in neuropathological changes, but acute symptoms reflect physiological, not structural changes• Standard neuroimaging is normal

Graded set of clinical symptoms• May or may not involve loss of consciousness• Symptoms may be prolonged

Consensus statement, 4th International Conference on Concussion in Sport, 2012


Common symptoms of concussion

Physical SymptomsHeadachesNauseaFatigueVisual problemsBalance problemsSensitivity to lightSensitivity to noiseNumbness/tinglingVomitingDizziness

Thinking SymptomsFeeling mentally foggyProblems concentratingProblems rememberingFeeling more slowed down

Emotional SymptomsIrritabilitySadnessFeeling more emotionalNervousness

Sleep SymptomsDrowsinessSleeping more than usualSleeping less than usualTrouble falling asleep

Concussion

Preschoolers (Rane et al.)EnuresisBehavioral changesNightmaresStomachaches


Classification of Severity of Pediatric TBI

Severity

Glasgow Coma Scale

Time to Follow Commands

Duration of Post-Traumatic

Amnesia

Mild * 13-15 <30 minutes < 24 Hours

Moderate

9-12 1-6 Hours 1-7 Days

Severe 3-8 > 6 Hours > 7 Days

*In presence of intracranial neuroimaging findings = mild complicated or moderate TBI


Average Annual Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006

8


A public health problem

• Millions of concussions are estimated to occur in the U.S. annually– Range 1.2 – 3.8 million– Athletic trainer, pediatrician, urgent care, school

nurse

• The number of children receiving care for concussion is increasing – Increased mTBI diagnosis in ED over 10 years

• > 200% in children in 14-19 y/o• Doubled in 8-13 y/o

Bakhos et al., Pediatrics, 2010


Increasing diagnosis of concussion

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Concussion is diagnosed in 1:160 children seen in pediatric hospital EDs


Concussion identification: A public health approach to a public health problem

• Legislation mandating – Education of coaches, athletes, and parents– Removal from play if concussion is suspected– No same-day return to play– Written clearance for return to play

from a medical professional with expertise in brain injury

• “Zackery Lystedt Law” Washington State, 2009

• 40+ states now have similar legislation

• Maryland’s law was signed on May 19th, 2011


TYPICAL RECOVERY

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Typical symptoms resolution

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N=1868-15 y/o

Yeates et al., Pediatrics, 2009

64% 15%

21%

Beth Slomine

add age range


Days from injury to discharge from Concussion Clinic

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N=105

6-12 years

15 children reporting symptoms at discharge

Risen et al., in preparation

Pro

port

ion

disc

harg

ed f

rom

clin

ic


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Evaluation and Management


Evaluating Concussion and Recovery

• Currently no objective measure of brain physiology in clinical use for evaluating the presence of and recovery from concussion

• Evaluation and management of concussion is based on symptoms

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KKI: NeuroRehabilitation Concussion Clinic

Multi-disciplinary Evaluation

• Neuropsychology: Screening cognitive function in areas expected to be affected by concussion– Age-based assessment, ~ 45 minutes– Computer Testing (IMPACT)– Pencil and paper cognitive testing– Timed motor movements

• Physician: Neurology or Rehabilitation– Complete neurological exam– Includes balance testing

• Other disciplines associated with our clinic– Behavioral Psychology– Physical Therapy

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Early Education and Recovery

• mTBI: 119 children ages 6-15 years• Controls: Orthopedic injuries

• Intervention: Educational Pamphlet at evaluation 1 week post-injury– Common symptoms– Expected course recovery– Coping strategies

• 3 months post-injury:– Pamphlet Fewer symptoms and less

stress

1818Ponsford et al., Pediatrics, 2002


Sources for Education

• www.cdc.gov/concussion– “Heads-Up” Tool Kits

• Physicians• School

– Pamphlet: “Facts about concussion and brain injury”

– ACE Office Version:• Injury Characteristics• Symptoms Checklist• Risk Factors• Red Flags

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Modifications: Conceptual background

• Recommendations for rest are based on “metabolic mismatch” of mTBI.

• In the initial days after injury, cerebral energy demands are increased but glucose delivery decreased

• Restricting activity modulates metabolic demands

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Do’s and Don’t for the first few days

• Do:– Rest as needed– Sleep as needed– Return to daily activities as tolerated– Return to school as tolerated– Obtain guidance from medical/school personnel

• Don’t:– Persist in activities if symptoms worsen– Participate in PE, physical activity in recess, or

contact sports/high risk activities until cleared by healthcare professional

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First Line ApproachBehavioral Strategies

• HYDRATION!!!

• 3 meals, small snacks in between

• Consistent and appropriate SLEEP

• Avoid Medication Overuse

• Stress Management


First Line ApproachMedical Strategies

• Fish Oil

• Melatonin

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Cognitive Modifications:How much is enough?

• Which activities?– Attending school– Homework– Texting– Computer use– TV– Video games

• For how long?– 1 week?– Until symptom free?– Symptom-based?

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AAP Clinical ReportReturning to Learning Following a Concussion

• …adding additional restrictions that may not be needed has the potential to create further emotional stress during the recovery.

• There is insufficient research…although recent research suggests benefit to the concept of cognitive rest…

• This calls for an individualized approach…

2525Halstead et al., Pediatrics, 2013


School Modifications

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Physical Modifications:WHEN IN DOUBT, SIT IT OUT

• “Second Hit Syndrome/Second Impact Syndrome”– Specific to children and teenagers– Occurs when a second, even mild injury, occurs in the

setting of a healing brain– Explosive swelling– Results in death or severe disability

• Even in absence of catastrophic injury, symptoms typically worsen/are prolonged after a second hit at any stage of recovery

• An athlete should never return to play if symptomatic

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Gradual Return to Play

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Approaches to Complex Issues

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When a mild TBI is not mild: Persistent Symptoms

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N=1868-15 y/o


64% 15%

9%

12%

Beth Slomine

add age range


Other contributors to persistent symptoms?



Factors that influence recovery

Factors that influence recovery

Yeates and Taylor, 2005


Prolonged Symptoms: Injury related factors

• Post-traumatic amnesia (PTA), LOC, and increased symptoms predicted prolonged recovery (> 7 days) (McCrea 2013)

• MVA, LOC, Neuroimaging abnormalities and hospitalization were associated with higher levels of prolonged post-concussive symptoms (Taylor et al 2010)

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Prolonged Symptoms: Pre and Post-injury child and family factors

• Injury severity factors important early predictors• Child/Family factors important later predictors

– McNally et al. Neuropsychology, 2013

• Premorbid parent anxiety, child’s pre-injury concussive symptoms, child’s health-related quality of life– Olsson et al. Brain Injury, 2013

• Repeat concussions increase risk of more severe concussion and slower or incomplete recovery


The Balance of Rest and Activity

Increased worry and

mood symptoms

Sleep difficulty

Decreased school

performance

Increased headache

and dizziness

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Optimal function

Increased worry and

mood symptoms

Sleep difficulty

Decreased school

performance

Increased headache

and dizziness

Too little activity Too much activity


Other resources available in KKI Continuum of Care

• Behavioral Psychology• Physical Therapy• Education• Speech Therapy• Neuropsychology• Specialty Medical Care

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Behavior Psychology

• Cognitive – Behavior Approach• Pain Management techniques• Sleep Hygiene• Stress Management

– Activity Restrictions– School Problems– Social Issues

• Longstanding psychosocial issues

• Special appointment slots designated for quick access for concussion patients

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Physical Therapy

• Subsymptom Aerobic Training Program– Aerobic training advocated for pediatric patients 4 to

6 weeks post injury (Vidal et al., Pediatric Annals, 2012; Gagnon et al.,

Brain Injury, 2009) – Benefit of exercise may relate to improved cerebral

blood flow (Leddy et al., JHTR, 2012)

• Manual Therapy to address pain and restricted range of Motion

• Vestibular Therapy

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Educational Specialists

• Provide advocacy for children/families

• Work with the school to develop appropriate supports

• Grant funding for education of school personnel regarding medical disorders

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Neuropsychology

• Comprehensive Evaluation– Suspected pre-injury concerns (e.g.,

LD/ADHD)

– Ongoing cognitive concerns post-injury that are not resolving as expected

– Better characterize cognitive, emotional, behavioral concerns and their etiology

– If more formalized school services are needed

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Specialized Transition Program

• School-based day rehabilitation program

• Provides daily PT/OT/Speech, neuropsychology, education.

• Physician involvement

• Appropriate for children with significant functional impairments

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Neurology

• Medication management for headaches initiated in concussion clinic

• Patients with prior history of headache or headaches that are not resolving with months of post-injury care are referred for longer term follow up

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Rehabilitation Follow Up Clinic

• Interdisciplinary rehabilitation management clinic including physiatry, neuropsychology, education, and behavioral psychology.

• Transition to this clinic initiated for children we expect will have ongoing concerns that warrant interdisciplinary perspective

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Concussion Research at Kennedy Krieger

• Clinical research efforts are designed to add to our understanding of recovery and optimize evaluation and treatment of concussion with concussion

• Use of data generated through review of clinical notes (data de-identified)– Pre-school symptom data– Trajectory of recovery in younger children

• Prospective research studies– Children do not have to receive clinical care at KKI to

participate

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Recovery or Compensation?

4545Risen et al., in preparation

Areas of increased connectivitywith attention network in children with TBI


A portable means of evaluating brain connectivity?

• Vibrations are applied to the fingertips.

• The ability of the child to sense the vibrations provides information about how brain cells communicate with each other.

• Portable technology lends itself to use in schools and at athletic events.

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Research Goals

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• Understand early (<1 week post-injury) and late changes related to concussion– Diagnosis of injury and recovery

• Understand whether changes in imaging or cellular connectivity persist after a child clinically appears to be back to baseline– Risk factors for future injuries?


Effects of Repetitive Concussion in Children

• Higher level of reported symptoms at baseline (Schatz et al 2011)

• More severe “on field” presentation of concussion if history of 3 or more prior concussions (Collins et al 2002)

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Potential long-term consequences

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Chronic Traumatic Encephalopathy (CTE)

• Late neurodegenerative process distinct from persistent post-concussive symptoms

• Recognized in boxers in 1928 (“dementia pugilistica”)

• Symptoms: – Early: impulsivity, irritability, mood disorder, short-term

memory loss– Late: dementia, gait and speech abnormalities,

parkinsonism

• Recent case report of CTE and motor neuron disease (ALS-like)

5050McKee et al., Brain, 2013


Chronic Traumatic Encephalopathy (CTE)

• Post-mortem diagnosis (Neuropathology) – Hyperphosphorylated tau protein deposits distinct from

Alzheimer’s disease – Diagnosis also in asymptomatic athletes (early

pathologic stages) and football players without clinical concussions

• Other contributing factors not yet clear– Genetics– Age at initial exposure to repetitive trauma– Other environmental factors

• Cohort studies are needed to better understand epidemiology, etiology, and risk factors

5151Baugh et al., Brain Imaging and Behavior, 2012

Windows User

wondering our lead in to CTE... I guess : we have just discussed more complex issues including repetitive injuries, common concern is long term effects of these injuries.


KKI Concussion ProgramLonger Term Research Goals

• Epidemiological study of large groups of children and teens with concussion– Long term follow-up – Understand rate of lasting and later effects of injury– Understand risk factors for lasting and later effects

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Questions???

Documents

Current Concepts in Concussion Care Stacy Suskauer, M.D. Pediatric Physiatrist Beth Slomine, Ph.D., ABPP Neuropsychologist