Current Concepts in Concussion Care

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

2. Disclosures • No industry-related financial disclosures

3. 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

4. To identify mild Traumatic Brain Injury in children • Symptoms • Epidemiology

5. 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

6. Common symptoms of concussion Thinking Symptoms Feeling mentally foggy Problems concentrating Problems remembering Feeling more slowed down Preschoolers (Rane et al.) Enuresis Behavioral changes Nightmares Stomachaches Physical Symptoms Headaches Nausea Fatigue Visual problems Balance problems Sensitivity to light Sensitivity to noise Numbness/tingling Vomiting Dizziness Concussion Sleep Symptoms Drowsiness Sleeping more than usual Sleeping less than usual Trouble falling asleep Emotional Symptoms Irritability Sadness Feeling more emotional Nervousness

7. Classification of Severity of Pediatric TBI *In presence of intracranial neuroimaging findings = mild complicated or moderate TBI

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

9. 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 Bakhoset al., Pediatrics, 2010

10. Increasing diagnosis of concussion Concussion is diagnosed in 1:160 children seen in pediatric hospital EDs

11. 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 • “ZackeryLystedt Law” Washington State, 2009 • 40+ states now have similar legislation • Maryland’s law was signed on May 19th, 2011

12. TYPICAL RECOVERY

13. Typical symptoms resolution N=186 8-15 y/o 21% 15% 64% Yeates et al., Pediatrics, 2009

14. Days from injury to dischargefrom Concussion Clinic N=105 6-12 years 15 children reporting symptoms at discharge Proportion discharged from clinic Risen et al., in preparation

15. Evaluation and Management

16. 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

17. KKI: NeuroRehabilitation Concussion ClinicMulti-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

18. 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

19. 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

20. 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

21. 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

22. First Line ApproachBehavioral Strategies • HYDRATION!!! • 3 meals, small snacks in between • Consistent and appropriate SLEEP • Avoid Medication Overuse • Stress Management

23. First Line ApproachMedical Strategies • Fish Oil • Melatonin

24. 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?

25. 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… Halstead et al., Pediatrics, 2013

26. School Modifications

27. 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

28. Gradual Return to Play

29. Approaches to Complex Issues

30. When a mild TBI is not mild: Persistent Symptoms N=186 8-15 y/o 9% 12% 15% 64% Yeates et al., Pediatrics, 2009

31. Other contributors to persistent symptoms? Yeates et al., Pediatrics, 2009

32. Factors that influence recovery Factors that influence recovery Yeates and Taylor, 2005

33. 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)

34. 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

35. The Balance of Rest and Activity Too little activity Too much activity Optimal function

36. Other resources available in KKI Continuum of Care • Behavioral Psychology • Physical Therapy • Education • Speech Therapy • Neuropsychology • Specialty Medical Care

37. 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

38. 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

39. 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

40. 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

41. Specialized Transition Program • School-based day rehabilitation program • Provides daily PT/OT/Speech, neuropsychology, education. • Physician involvement • Appropriate for children with significant functional impairments

42. 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

43. 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

44. 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

45. Recovery or Compensation? Areas of increased connectivity with attention network in children with TBI Risen et al., in preparation

46. 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.

47. NAA 3.0 2.0 PPM 4.0 1.0 Research Goals Cr Cho Glu • 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?

48. 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)

49. Potential long-term consequences

50. 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) McKee et al., Brain, 2013