Heather Funkhouser Board, MPH Injury Prevention Program Office of Family Health Services

1. Heather Funkhouser Board, MPH Injury Prevention Program Office of Family Health Services New Information on the Effects of Concussion on the Young Brain and the Prevention of Related Injuries

2. “No head injury is too severe to despair of, not too trivial to ignore” Hippocrates 4th Century BC

3. Leading Causes of Injury • Children < 1 • Death: Suffocation, Drowning = Motor Vehicle • Hospitalization: Fall, Poisoning, Burn • Children 1-4 • Death: Motor Vehicle, Drowning and Suffocation • Hospitalization: Fall, Poisoning, Burns • Children 5-9 • Death: Motor Vehicle, Drowning and Firearm=Pedestrian • Hospitalization: Fall, Bites/stings, Struck by/against

4. What is a Concussion? A complex vascular and neurochemical process affecting the brain, induced by direct or indirect traumatic forces to the head. Brain goes into panic mode after it gets jostled around

5. Axonal Injury • Axons stretch unnaturally • Structural damage to the myelin sheath • Outflow of potassium and an influx of calcium • Calcium shuts down the mitochondria

6. Axonal Injury • Brain tries to bring back the potassium • Energy use increases 150% • Energy production decreases 50% • Neuronal energy crisis • Progressive damage

7. What is a Concussion? • Changes that occur are a process not an event • Concussion is a chemical mismatch that results in a functional problem, not a structural problem • This means… A normal CT or MRI DOES NOT mean there is no concussion

8. Increased Susceptibility of Children • Brain Development • Recognition

9. Brain Development • Development of the brain occurs from back to front • Basic brain centers develop first with higher-order centers developing later

10. Brain Development • Neurons become mylenated with learning and development-disappearance of gray matter • “Myelination" of the prefrontal cortex is especially slow – not beginning until the ninth prenatal month, and continuing as late as the mid-twenties

11. Time-Lapse Imaging of Brain Development • 13 healthy children and teens • MRI scans every 2 years for 10 years as they grew • Looked at scans using an intricate set of anatomical landmarks • Saw the waves of grey matter changes from ages 5-20

12. Brain Development

13. Brain Development

14. Brain Development • There is a great deal of risk if there is damage to the brain during myelination • Damage most commonly occurs in the frontal cortex • This can impair the ability to control emotions and inhibit inappropriate behavior

15. Childhood TBI Research • Children tested 5 years after a TBI experienced a slowed growth curve in academic achievement. The younger the child at the time of injury, the more pronounced the deficit, even with only mild or moderate TBI • Head Games: Football’s Concussion Crisis, 2007

16. Childhood TBI Research • 43% of children 5-15 years tested >2yrs after a MTBI had behavioral or learning problems that led to their being described as having a “moderate disability”. 21% were noted as having personality changes by parents • Head Games: Football’s Concussion Crisis, 2007

17. Childhood TBI Research • 48% of children 6-15 years 1year after TBI still suffered from psychiatric disorders that appeared after the injury • Head Games: Football’s Concussion Crisis, 2007

18. Other Risks • Less developed neck/shoulder muscles don’t transfer energy to the rest of the body well • Less proficient at assessing risk, less coordination, slower reaction time • Greater head-to-body ratio • Thinner cranial bones

19. The vast majority of concussions heal and result in a complete recovery … If the initial injury is recognized and managed properly

20. Recognition Challenges

21. Recognition Challenges • Loss of consciousness is seen in less then 10% of concussions • Symptoms may appear minutes to hours or days after the initial impact • Functional disruption not structural disruption • MRI and CT scan will not detect a concussion • Batten, C. Sports Related Concussion

22. Signs and Symptoms • Physical • Headache • Nausea • Dizziness • Balance problems • Visual problems • Cognitive • Confusion • Difficulty concentrating • Feeling mentally “foggy” • Feeling slowed down • Emotional • Irritable • Sadness • More emotional than usual • Nervousness • Sleep • Drowsiness • Sleeping too much • Sleeping too little • Trouble falling asleep

23. Additional Symptoms Young children may also exhibit: Lack of interest in their usual activities or favorite toys Loss of new skills, such as toilet training Loss of balance and trouble walking Not being able to pay attention • More crying than usual • Changes in the way they play or act • Changes in the way they nurse, eat, or sleep • Being upset easily or having more temper tantrums • A sad mood

24. Could it be More than a Concussion? • Warning signs of increased intracranial pressure: • Loss of consciousness > 30 seconds • Convulsions/seizures • Deteriorating level of consciousness or behavior • Headache that is getting worse • Late onset or persistent vomiting • Late onset or worsening amnesia or short term memory loss • Focal neurological signs (motor function, vision, speech)

25. Challenges • Signs and symptoms vary from person to person • No two concussions “look” the same, even in the same person • Must take the necessary steps to manage concussion appropriately at earliest opportunity

26. Self Report Challenges • Lack of reliability/validity • Lack of knowledge • McCrea et al. found about 50% of athletes didn’t report symptoms because the athlete didn’t think the injury was serious enough • Logan et al. found 60% of soccer and football players reported having symptoms but only 20% actually realized they had suffered a concussion

28. Neurobehavioral Test • Standardized means of objectively documenting the presence and severity of neurocognitive impairment • Standardized Assessment of Concussion (SAC) • Balance Error Scoring System (BESS) • ImPACT • Sideline Concussion Assessment Tool 2 (SCAT 2) • The results are then compared to a baseline score or to normative scores if a baseline test was not done.

29. Concussion Treatment: Cognitive and Physical Rest • Goal is to reduce the amount of stress on the brain • Adequate rest enhances healing process • The return of the chemical balance requires energy • Gradual increase in cognitive and physical activities • Prevents flare up as concussion finishes healing

30. Post-Concussion • The cells are in an extreme state of vulnerability • Failure to recognize or treat the concussion: • Second Impact Syndrome • Post-Concussion Syndrome

31. Second Impact Syndrome • Catastrophic brain injury following minor impact in contact sports • While the athlete is still symptomatic from the initial head injury • Both the initial and second impacts can occur on the same day • Reinforces never allowing an athlete with a significant head injury to return to play until cleared by a physician

32. Second Impact Syndrome • Except for boxing, all cases reported occur to those <20 years of age • 2nd injury is often minor and goes unnoticed • Progression of symptoms occurs over seconds to minutes • Little can be done • 50% result in death • Nearly all that survive sustain permanent brain damage

33. Second Impact Syndrome Early recognition of the initial head injury and prevention of a second injury is the ONLYpreventative measure

34. Post-Concussion Syndrome • Symptoms lasting more than 6 weeks • Indicator of a significant head injury • Needs treatment by an experienced physician • Approximately 10% take more than 7 days to recover • Academic performance and social interactions are impacted

35. Sport-Related Concussions • 60% of high school students participate in organized sports • Numbers are increasing and age is decreasing • Annually >300,000 sport-related mild-to-moderate TBIs • Kirkwood, M.W., Yeates, K.O., Wilson, P.E., Pediatrics, 117(4), 2006.

36. Prevention: Helmets • Head injury is the leading cause of bicycle related death. • 75% of all bike related fatalities could be prevented with a helmet. • Helmets reduce the risk of head injury and brain injury by 85 and 88% respectively.

37. Prevention: Falls

39. Prevention: Playground Surfacing • Nearly 70% of all playground injuries are due to falls to surface • Inadequate surfacing is the most persistent and dangerous hazard • Recent studies have found that about 80% of playgrounds have unsuitable surfaces

40. Prevention: Child Restraints • Prevent ejection • Distribute forces to the strongest parts of the skeleton • Spread crash forces over a broad area • Provide “ride down” • Protect head, neck and spinal cord by preventing contact with hard surfaces • Allows children to ride in the safer rear-facing position

41. CDC Resources • Heads Up: • Concussion Prevention • Toolkits • http://www.cdc.gov/concussion

42. Contact Information • Heather Board, MPH • Injury Prevention Program Supervisor • 804-864-7738 • Heather.Board@vdh.virginia.gov