Pediatric Concussion update OCTOBER 14, 2016 NANAIMO BRAIN INJURY SOCIETY DR. JACQUELINE PURTZKI CLIN. ASSIST. PROFESSOR, UBC, DIV. OF PHYSICAL MEDICINE & REHABILITATION GF STRONG REHAB, CENTRE ADOLESCENT COMPLEX CONCUSSION CLINIC BCCH, SHHCC DIV. OF DEVELOPMENTAL PEDIATRICS
Objectives To provide an update of our current understanding of pediatric and adolescent concussions To understand the background of current pediatric ‘return to sport’ guidelines To gain knowledge about symptoms management, rehab strategies , return to learn and return to sports. Take home some useful resources
Distribution of TBI A. McKinley 2009
Definition and Pathophysiology of concussion
6 Mild Traumatic Brain Injury (American Congress of Rehabilitation Medicine) At least ONE or MORE of the Exclusion: following: Loss of consciousness >30 Loss of consciousness (LOC) mins. Loss of memory for events Glasgow Coma Scale < 13 immediately before or after after 30 mins. the accident Post-traumatic amnesia >24 Any alteration in mental state hrs . Focal neurological deficit • May be due to direct blow to the head, face, or neck or by a blow to somewhere else on the body that transmits an impulsive force to the head. • You do not need to lose consciousness to sustain a concussion/mTBI. • 90% of concussions do not involve LOC!
Concussion/Brain Injury- 7 Diffuse axonal injury
Parietal Lobe Frontal Lobe Initiation Intellect Regions of the Planning/Anticipation 8 Follow-through Sense of Touch Impulsivity Brain Differentiation of Judgement size, shape & colour Reasoning Spatial perception Abstract Thinking Smell Visual perception Motor Planning Muscle tone, Personality strength & Emotionality Speaking sensation Integration of thought and emotion Self-monitoring Occipital Lobe Temporal Lobe Memory Vision Hearing Cerebellum Understanding Balance Language Coordination Brain Stem Breathing Relays Heart Rate messages for Blood Pressure other movements Movement & sensation and sensations for head, neck, eyes, hearing
Modern view: Neural networks E.A. Wilde et al. / Pediatric traumatic brain injury: Neuroimaging and neurorehabilitation outcome 248 “ ”
Diffuse axonal injury
Secondary injury mechanisms from Zasler et al, Brain Injury Medicine
Rat model
Brain injury can cause symptoms and dysfunction Slide adapted from Dr. Giza
14 Concussion Statistics for Children and Adolescents
US-Concussion Statistics 15 Children and Adolescents ‘ Estimated annual incidence 1.6-3.8 million concussions. ( Grady, M, 2010) In the United States, concussion/mild traumatic brain injury occurs in 692 of 100,000 children younger than 15 years . (Barlow, K. et al, 2010) True incidence unknown: (Zemek, R et al., 2013; Halstead, M, 2010)
‘ The Burden of Concussion in British 16 Columbia ’ Report ’ Data from Vancouver Coastal Health, Fraser Health, BC Children’s Hospital examined. 9,027 children and youth ages 0 -19 years seen at BCCH with concussion during 2001 – 2009. Significant increase from 2001 to 2009. Recommendations : Need for a provincial concussion program for children and youth. Active and timely rehabilitation essential for concussed children and youth who remain symptomatic > 6 weeks. BC Injury Research and Prevention Unit and Child Health BC (Rajabali, Ibrahimova, Turcotte and Babul, 2012) BC Injury Research and Prevention Unit and Child Health BC (October 2012)
Sports and Recreation Related Concussion 17 Statistics Children under 10 years – concussions mainly due to non-sports-related falls (home, school, playground) (Karlin, A, 2011) Children over 10 years – concussions mainly due to sports-related injuries. (Karlin, A, 2011) 5 main causes of concussion due to sports and recreation in children aged 5 to 18 years: bicycling, football, basketball, playground activities, and soccer.
19 http://www.ncaa.org/health-and-safety/medical- conditions/ssi-task-force-explores-issues-challenges-around- concussions
What do we know and think we know about concussions in youth
What we know about concussions
#6 Concussions are Cumulative 26 History of one or two previous concussions elevates concussion risk. Sustaining multiple concussions places high school athletes at greater risk for worse neurobehavioral outcomes . (Collins, M. et al, 2008) After 1 concussion, the individual is 3 times likely to get another concussion. In some athletes with multiple concussions, there is the possibility of long-term neuropsychiatric effects which include psychiatric (mood disorders, addictions, psychosis etc.), physical (sleep disturbance etc.) and cognitive impairment. (Laker, S. 2011) ‘No standards exist for how many concussions are too many.’ (Apps, J., 2012)
C.Giza, BIS 2015
• Synapses (connections between neurons)in the gray matter (outer layer of the brain) are overproduced during early 33 adolescence. • The growth is followed by ‘pruning’ of the synapses. • Synapses ‘exercised’ by experience are strengthened (e.g. learning a new language, learning a new sport) while others wither away if not used. Brain becomes more efficient. Frontal lobes are responsible for more • "top-down" control, controlling impulses, and planning ahead (hallmarks of adult behavior) — and are among the last regions of the brain to mature (mid-20s and onwards). (http://www.nimh.nih.gov/health/publications/the-teen-brain-still- under-construction/the-changing-brain-and-behavior-in-teens.shtml)
Brain development ages 0 to 3 The most rapid postnatal brain growth occurs in the first three years of life g By a e 3 a c ild ’ s brain has f rmed 1,000 trillion h , o connections, twice as many as adults have By early adolescence, the brain is eliminating more synapses than it is producing By late adolescence, half of the synapses have been discarded, leaving 500 trillion. This number remains fairly constant through the rest of the life cycle.
Maturation process Gogtay, Giedd et al PNAS 2004. N = 13 (7 male, 6 female) typical subjects
Once a concussion occurred…
Acute management of concussion at school Important to suspect a concussion if a student experienced a blow to the head If in doubt: call 9-1-1 Red flags: loss of consciousness Seizures Potential spine injury Unwitnessed High impact
Return to Activity Return to learn before return to sports – especially if return to contact sports is premature Return to activity after initial rest period is likely safe and beneficial
Simple Complex RECOVERY
Road of recovery COMPLEX 13-15 % will have persistent sx by 3 months and In majority of kids and adolescents: 2% by one year . (Barlow,K. 2010) 85% Symptom free by 4 weeks Anticipate prolonged recovery if risk factors present No risk factors for slow recovery ‘concussion was actually a more severe injury Progressive improvement Concussion and mental health No mental health or LD Concussion and chronic headaches No drug or alcohol use history Always ask why is my student not recoVering as expected
Adapted from Dr. D. Arciniegas, BIS 2015
Adapted from Dr. D. Arciniegas, BIS 2015
K.Barlow et al, Pediatrics,2010
REHABILITATION
Focus on Healthy Lifestyle Improves sleep Mood Sense of well-being Concentration Brain healing
Effect of prolonged rest Physical consequences Social Emotional consequences consequences Deconditioning Weight gain • Isolation from friends • Loneliness Tachycardia and orthostatic • Loss of social engagement • Isolation hypotension with team mates • Anxiety about school and Insomnia due to inactivity and • Loss of self esteem worry friends Poor concentration – exercise • Worry about brain injury improves attention
Active Rehab versus Rest
50 Return to School Guidelines for Concussion Management ‘Concussion is a medical event and the recovery spans the home and school setting for 3 or more weeks.’ THUS, ‘Communication and collaboration between student, parents, educators and health care providers is vital.’ (McAvoy, K., 2009)
Why Is The Student So Tired? 51 Energy Crisis in the Brain Neurometabolic Cascade following TBI (Giza & Hovda, 2001) Unsafe to return to sport until brain activity has returned to normal Period between concussion and recovery: “ window of vulnerability ” (return to play during this time could cause more severe or even catastrophic brain injury.)
Symptom Wheel (Colorado Dept. of Education Concussion Management Guidelines) 53 Colorado Dept. of Education: Concussion Management Guidelines, 2012 Authors: Karen McAvoy, PsyD and Kristina Werther, LCSW
Recommend
More recommend
