Transcript Kennedy Krieger Institute Family Center

Current Concepts in Concussion Care
Stacy Suskauer, M.D.
Pediatric Physiatrist
Beth Slomine, Ph.D., ABPP
Neuropsychologist
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
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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
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Consensus statement, 4th International Conference on Concussion
in Sport, 2012
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Common symptoms of concussion
Physical Symptoms
Headaches
Nausea
Fatigue
Visual problems
Balance problems
Sensitivity to light
Sensitivity to noise
Numbness/tingling
Vomiting
Dizziness
Thinking Symptoms
Feeling mentally foggy
Problems concentrating
Problems remembering
Feeling more slowed down
Concussion
Emotional Symptoms
Irritability
Sadness
Feeling more emotional
Nervousness
Preschoolers (Rane et al.)
Enuresis
Behavioral changes
Nightmares
Stomachaches
Sleep Symptoms
Drowsiness
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep
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Classification of Severity of Pediatric TBI
Severity
Glasgow
Coma
Scale
Time to Follow
Commands
Duration of PostTraumatic
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
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Average Annual Rates of TBI-related Emergency
Department Visits, Hospitalizations, and Deaths,
2002-2006
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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
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Increasing diagnosis of concussion
Concussion is diagnosed in 1:160 children seen in pediatric hospital EDs
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Concussion identification:
A public health approach to a public health problem
• Legislation mandating
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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
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TYPICAL RECOVERY
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Typical symptoms resolution
N=186
8-15 y/o
21%
64%
Yeates et al., Pediatrics, 2009
15%
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Days from injury to discharge from
Concussion Clinic
N=105
Proportion discharged from clinic
6-12 years
Risen et al., in preparation
15 children reporting
symptoms at discharge
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Evaluation and Management
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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
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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
Ponsford et al., Pediatrics, 2002
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Sources for Education
• www.cdc.gov/concussion
– “Heads-Up” Tool Kits
• Physicians
• School
– Pamphlet: “Facts about concussion
and brain injury”
– ACE Office Version:
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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:
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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 Approach
Behavioral Strategies
• HYDRATION!!!
• 3 meals, small snacks in between
• Consistent and appropriate SLEEP
• Avoid Medication Overuse
• Stress Management
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First Line Approach
Medical Strategies
• Fish Oil
• Melatonin
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Cognitive Modifications:
How much is enough?
• Which activities?
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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 Report
Returning 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…
Halstead et al., Pediatrics, 2013
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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
N=186
8-15 y/o
9%
12%
64%
Yeates et al., Pediatrics, 2009
15%
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Other contributors to persistent
symptoms?
Yeates et al., Pediatrics, 2009
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Factors that influence recovery
Factors that influence recovery
Yeates and Taylor, 2005
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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
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McNally et al. Neuropsychology, 2013
• Premorbid parent anxiety, child’s pre-injury concussive
symptoms, child’s health-related quality of life
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Olsson et al. Brain Injury, 2013
• Repeat concussions increase risk of more severe concussion
and slower or incomplete recovery
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The Balance of Rest and Activity
Sleep
difficulty
Increased
worry and
mood
symptoms
Increased
worry and
mood
symptoms
Decreased
school
performance
Decreased
school
performance
Increased
headache
and
dizziness
Sleep
difficulty
Too little activity
Increased
headache
and
dizziness
Too much activity
Optimal
function
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Other resources available in KKI Continuum
of Care
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Behavioral Psychology
Physical Therapy
Education
Speech Therapy
Neuropsychology
Specialty Medical Care
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Behavior Psychology
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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?
Areas of increased connectivity
with attention network in children with TBI
Risen et al., in preparation
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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
• Understand early (<1 week post-injury)
and late changes related to concussion
– Diagnosis of injury and recovery
NAA
Cho
• Understand whether changes in imaging or
cellular connectivity persist after a child
clinically appears to be back to baseline
Cr
Glu
PPM 4.0
3.0
2.0
1.0
– Risk factors for future injuries?
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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 (ALSlike)
McKee et al., Brain, 2013
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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
Baugh et al., Brain Imaging and Behavior, 2012 51
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KKI Concussion Program
Longer 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???
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