1

POST-CONCUSSION SYNDROMEand RETURN TO SCHOOL

CSMS Conference April 28, 2015

Michael A. Lee, MDStaff Physician; Connecticut Children’s Medical CenterAttending Physician Pediatrics; Yale University

CCMC – Fairfield Satellite Office Member, Connecticut Concussion Task ForceCharter Member, AMSSMMember, AAP-COSMF, Former Chairman, CSMS Committee on Medical Aspects of Sports Former Editor, SPORTSMed Newsletter

2

OverviewPost-concussion Syndrome – signs, symptoms,

physical findings and managementRecovery process (as affects school) and different

adjustmentsFemale concussionsADD

Disclaimers: I have had one concussion I have no financial disclosures I will not discuss unapproved or off label products or their uses

3

4

Concussions:

They are a part of playing sports at all levels and also occur in non-sports activities and MVAs.

One of the most discussed problems in US sports media coverage today

Very difficult to manage especially when the symptoms are prolonged.

5

A Decade of Change…

“Congress draws needed attention to concussions” Hearings put pressure on NFL to act

Former NFL Players Call for Concussion Education: Congressional Hearing Reveals Education Needed at all Levels

FEMALE CONCUSSIONS

Girls have a higher rate of concussion

than boys, particularly in similar sports

Lincoln, et.al., Am J Sports Med 2011; Giza, Kutcher, et al., Neurol 2013

FEMALE CONCUSSIONSTend to be worse and last longer

Likely related to weaker neck muscles

Related to more migraine headaches

Females have, compared to males:

25% less head neck segment mass

5% less head-neck segment length

12% less neck girth

50% less isometric neck flexor strength

53% less isometric neck extensor strength

44% greater head acceleration after contact

CHEERLEADINGOften is not considered a sport, YET

50% of deaths in college woman’s sports

Seem to have more PCS and are more difficult to manage in my experience

THE

HIDDEN EPIDEMIC

In Pediatrics

Average High School in CT may have 50-70/year

ISSUES IN CONCUSSION CARE

Focus has been on return to play (sports)

Schools don’t understand the need for assistance to students after a concussion

It is not a visual diagnosis Lack of understanding by health care

professionals on what are the best ways to assist a student following a concussion

13

The Good News…

80% of concussions

resolve in 1-2 weeks

How long does it take to recover from a

concussion?

Less than a week? AAP CT 2-3 days?Sports authorities say less than a week

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 Concussed High School Football Players

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

40%RECOVERED

60%RECOVERED

80%RECOVERED

Collins et al., 2006, Neurosurgery

3 Year Prospective Study of 17 High School Football Teams N=2,141

Individual Recovery From Football-Related mTBI: How Long Does it Take?

16

Recovery: fMRI Subsample (UPMC Program)Lovell et al;

Mean Age: 16.2 yrs

Gender: 78% male

Days to Recover

Range: 4 – 211 days

Mean = 26.2 days

Cumulative Percent Recovery

15 days – 25%

26 days – 50%

45 days – 75%

92 Days – 90%N = 208

Will now focus on the 20% who do not recover rapidly and review how their

concussion impacts their school performance.

Students who cover quickly usually do not require the many adjustments PCS

students need

Definition of Post-Concussion Syndrome

Concussion symptoms lasting more than 3 weeks

This is the time when treatment is usually started

19

Symptoms of PCS Headache Foggy and slowed down Dizziness (spinning) Ocular problems Balance Problems Concentration Memory Sleep Psych symptoms Neck symptoms

20

Headache Most common sx of concussion & PCS Initially constant, steady “pressure feeling” Then headache comes and goes, is dull/achy

at rest and becomes throbbing with activity Doing cognitive/physical activity for more than

10-20 minutes increases headache. Need to take breaks every 10-20 minutes History of migraines increases risk of

prolonged recovery

21

Feeling Foggy and Slowed Down

Hard to define Brain feels like computer with a virus

like your head is under water like a regular TV and not HD TV like your head is in a cloud

When this resolves patient often wakes up one morning and says “Wow, I am better”

Headache usually resolves within 1-2 days after this symptom resolves

Dizziness Spinning when stand up (room

around patient or patient around room)This is different than just lightheadedness

Difficulty with heights, moving crowds, stores, spiral staircases & busy patterns

Heights cause dizziness Incr. awareness of normal motion Bothered by busy patterns

Suggestive of vestibular problems22

Ocular Problems

Blurry, foggy vision Light sensitivity (fluorescent light

bother them) this sometimes is last sx to resolve.

Difficulty reading, depth perception off

Seeing double (suggestive of an eye convergence problem)

24

Balance Problems

Difficulty with balance

in a dark room Hard to maintain balance

on stairs Bang into walls

Concentration and Memory Difficulty focusing and can only read or be

on the computer 10-15 minutes before symptoms increase

Can’t remember what they hear or read and have difficulty learning school work.

Repeat themselves, lose their train of thought, forget what they say

in conversation.

27

Sleep Symptoms Altered sleep will delay recovery. Have trouble falling

asleep or staying asleep Do not allow to sleep all the time after the first one to

two days No naps after the first two days Maintain sleep pattern present prior to the concussion

(same wake-up and bedtime schedule). Blue Light Blocking Glasses (orange-tinted glasses) No LED screens (TV, smart phone computer monitor, tablets)

Psychiatric Symptoms

Irritability is usually present early on If psychiatric symptoms were present pre-

concussion, they often become worse. Depression due to pre-existing condition or

not being able to attend school or sports. Anxiety is common. (Will I ever recover?) (especially with vestibular issues)

Neck Pain and Spasm Need to examine the neck in

any patient with a concussion.

Prolonged concussion headaches may be related to neck pathology.

Tingling or numbness in extremities may be an indication of neck pathology

START NECK PT ASAP29

Physical Findings of PCSLightheadedness with rapid lateral and

horizontal eye movements

Diagnostic of concussionDisappears around the time when the feeling

foggy and slowed down resolves

Physical Findings of PCS

Vestibular findings

Vestibular System Overview

• Peripheral Vestibular System • Semicircular Canals

• Otoliths: Utricle and Saccule • Vestibular Ganglia • Vestibular Nerve

• Central Vestibular Projections • Vestibular Nuclei

• Cerebellum • Autonomic Nervous System

• Thalamus • Cerebral Cortex

Function of Vestibular SystemSTABILIZE VISION WHILE HEAD MOVES

Normal VOR:Able to maintain focus on stationary object

while moving head without loss of visual focus or dizziness

Physical Findings of PCS

Eye convergence difficulty Near point of conversion should be less

than 6 cm (normal is 0-6 cm.) Usually resolves on its own Sometimes may need exercises or prism

glasses if persists greater than 3-4 weeks (can be cause of persistent headaches

when reading).

Physical Findings of PCS

Abnormal balance findings Difficult to assess without a baseline Most helpful to use at time of the injury for

making the diagnosis of a concussion Appears to resolve more quickly than other symptoms following a concussion. (Catena 2011, Guskiewicz 2003)

TOOLS USED TO ASSESS PCS

Neurocognitive testing (ImPACT)

MRI of head sometimes needed

Full neuro-cognitive testing by a neuropsychologist (expensive, often not covered by insurance)

37

Neurocognitive/psych testing Zurich conference emphasized role of testing

“In the absence of NP and other (e.g. formal balance assessment) testing, a more conservative return to play approach may be appropriate.”

“Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance”

38

VALUE OF ImPACT CLINICALLYFinds patients with extremely low scores (low single digits on all parameters) who

are more likely to develop Post-Concussion Syndrome

Shows when patients are not following activity restrictions because the scores

decrease on serial testing

Tells how long it takes to have cognitive fatigue and later finds patients with memory loss or overdoing activity

Predicting Who Will Develop PCS Patients with Vestibular findings Multiple blows at time of or around injury Extremely low scores on neuro-cog testing Previous Post-concussion Syndrome History of migraine headaches Motor Vehicle Accidents (especially females) History of ADD Compulsive, type A excellent student

Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players

Lau, Kontos, Collins, AJSM 2011

On-Field Marker N Chi2 P Odds Ratio

95% Confidence Interval

Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42

Retrograde Amnesia 97 .120 0.729 1.179 0.46-3.00

Confusion 98 .114 0.736 1.164 0.48-2.82

LOC 95 2.73 0.100 0.284 0.06-1.37

On-Field Symptom N Chi2 P Odds Ratio

95% Confidence Interval

Dizziness** 98 6.97 0.008 6.422 1.39-29.7

Headache 98 0.64 0.43 2.422 0.26-22.4

Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63

Visual Problems 97 0.62 0.43 1.400 0.61-3.22

Fatigue 97

0.04 0.85 1.080 0.48-2.47

Balance Problems 98 0.28 0.59 0.800 0.35-1.83

Personality Change 8 0.86 0.35 0.630 .023-1.69

Vomiting 97 0.68 0.41 0.600 0.18-2.04

The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.

**p<.01

41

SECOND BLOWS TO THE HEAD

37 athletes had a second blow to the head within 2 weeks of the first blow. No case of Second Impact Syndrome occurred.

25 Males and 13 developed PCS (52%) 12 Females and 8 developed PCS (67%)

Lee and Fine. CT Medicine 2010

Since most concussion symptoms usually will resolve

by 3 weeks, no treatment is usually necessary prior to that

time (except for neck PT)

Every patient’s treatment needs to be individualized

IT TAKES A VILLAGE TO HELP SOME PATIENTS RECOVER FROM THEIR CONCUSSION

PT neckVestibularSCHOOL FAMILY OCULAR PSYCHNEURO-PSYCH

44

Post-concussion Syndrome(Patterns possibly requiring medication)

Emotional IssuesDepressionIrritability

More emotionalNervousness Thinking issues

Attention problemsDifficulty with memory

“Fogginess”Cognitive Slowing

Fatigue

Physical IssuesHeadachesDizziness

Balance difficultiesLight and noise Sensitivity

Visual problems Nausea Sleep Issues

Difficulty falling asleepSleeping less than usual

45

Post-concussion Syndrome

Emotional IssuesSSRI: LexaproZoloft/Prozac

XanaxKlonopinTherapy

Thinking IssuesNeurostimulants

Amantadine Amphetamines

MehytlphenidateStrattera

Physical IssuesAmitryptaline (Elavil)

NortryptalineTopamax/DepakoteVestibular therapy?

GabapentinPropanalol (?NCAA)

Sleep IssuesMelatoninTrazedone

46

Headache ManagementKeep the dull and achy headache from

becoming pounding and throbbing.

Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache.

Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms

Tylenol as needed (Ibuprofen after a few days)

Pulled muscle analogy

48

Headache ManagementKeep the dull and achy headache from

becoming pounding and throbbing.

Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache.

Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms

Tylenol as needed (Ibuprofen after a few days)

EXERCISE

May start to exercise lightly after 2-3 weeks even with mild headaches.

No impact activities, limit head movement (elliptical or exercise bike initially) Start off very slowly (few minutes) and gradually

increase. Can do multiple times a day. Leddy et al, Exercise treatment for PCS J Head Trauma Rehabil. 2013 Jul-Aug;28(4):

SCHOOL

Students recover quickly during Christmas, Spring and Summer vacations

Need to remember (remind parents) the first priority is to get kids back to school ASAP. Sports is a secondary priority!

Different than other medical conditions causing school absence

Can’t see the problem

Only condition where you are unable to perform cognitive functioning needed to do school work

The return to school is a very critical time. If cognitive work is overdone, or

increases inappropriately, the concussion symptoms will return,

sometimes almost as much as right after the injury.

Sady, Phys Med Rehab Clin N Am 2011: Howell, MSSE, 2013

SCHOOL ADJUSTMENTS(when they return to school)

X + X = 2XExcuse all non-essential school workNo double workload – make-up work and new work

.

SCHOOL ADJUSTMENTS

Goal: Get the most out of the school day without worsening the symptoms.

Optimize learning without creating quick fatigue.

55

SCHOOL (initial return)Sleep in, Leave early

Alternate AM and PM classes to cover all(? Initially avoid Math, Chemistry, Foreign Language)

Need to be driven to school initially(should not ride the school bus)

Elevator passes if stairs (unless this makes them “dizzy”)

Rest periods after 30-45 minutesDon’t let student go to all “hard” classes!

Some classes easier than others – ask!No gym class or exercising initially

(are not to be allowed in P.E. class)

56

Trial and error needed (balancing act)

1 period, ½ day, full day

Go to nurse’s office when HA increases

Frequent breaks with rest periods

Alternate class with rest period

Gradually increase hours

No extra-curricular activities or job

57

SCHOOL (initial return)No note taking (may need scribes)

Pre-printed class notes helpful

(should be sent home while not in school)

Listen to lectures only

Audio books helpful

Limit computer time

Avoid videos in class

Tutoring may be needed to help catch up

SCHOOL (initial return)

Workload may need to be reduced 50-75%

Progress to homework when no symptoms

Homework less than 1-2 hours a night

Frequent breaks while doing homework

Term papers postponed or forgiven

It is imperative that the student advocate for his/her needs. If an increasing headache develops

they should not stay in class but should go to the nurse’s office.

They can rest there (skip a period and try another class if the

headache resolves). If it returns they need to go home.

HEADACHE

Most common symptom of concussion Can distract student from concentration Can vary throughout the day and may be

triggered by various exposures, such as fluorescent lighting, loud noises, reading, focusing or tasks

Math, Chemistry Foreign Language seem to cause headaches to occur more than other subjects

HEADACHE ADJUSTMENTS

Identify triggers and reduce their exposure Frequent breaks Rests, planned or as needed in nurse’s

office or other quiet area Give student class notes Allow student to put head down in class

62

NOISE SENSITIVITY AT SCHOOL: Hallways Lunch room Music classes (band/choir) P.E. classes Shop classes, Organized sports practices

Should not listen to loud music (especially in cars or on I-pods)

Should avoid attending dances, parties, music concerts and sports events until symptoms are gone

NOISE ADJUSTMENTS

Allow use of ear plugs as needed Leave class 5 minutes early to avoid hall

noise Quiet area to do work Lunch in a quiet area with a classmate Avoid/limit music, shop and P.E class Avoid noisy gym and team/sports practice

64

VISUAL PROBLEMS LIGHT SENSITIVITY, BLURRY/DOUBLE VISION

AT SCHOOL: Artificial lighting Smart boards, slide presentations Computers, Handheld computer tablets Movies

Sunglasses may be necessary if photophobia is present (outdoors and sometimes indoors)

Avoidance of bright sunlight and exposure to flashing lights (strobe/computer games)

No movie theaters (loud noise and bright flashing lights)

VISUAL ADJUSTMENTS

Allow sunglasses to be worn in school Reduce exposure to computers, smart

boards and videos Reduce brightness on screens Turn off fluorescent lights as needed Consider use of audiotapes of books

CONCENTRATION and MEMORY ISSUES

Difficulty learning new tasks and comprehending new material

Difficulty with recalling and applying previous learned material

Difficulty with focusing and attention Problems with test taking, especially

longer more standardized tests

67

SCHOOL TESTS IS TESTING IN A BRAIN INJURED STUDENT VALID?

Quizzes, tests, PSAT/SAT, ACT tests, mid-terms, final exams may need to be delayed/postponed.

TESTS ONLY AFTER STUDENTS CATCH UP ON SCHOOL WORK!!Tutoring in school may be needed to help catch up

Extra time (un-timed tests) may be necessary when test taking is resumed. May need to take breaks. Tests

may need to be taken over multiple sessions.

No more than one test a day when test taking resumed.

Initially, if test results are poor, they should be voided or retaken.

SCHOOL TESTS (cont.)

If significant concentration and memory problems are present:

May need reader for exams

Oral exams may be necessary (or if students develop headaches taking written tests).

Consider having students do take home tests so they can catch up quicker.

Open book tests may be needed for some students (especially if memory issues are present)

PROLONGED SCHOOL ABSENCE

After 2-3 weeks of missing school it is important to let students go to school for a brief period in order to see their friends, even if they are unable to do any school work.

(Should do no cognitive work)

Very Prolonged PCS School Issues

What if student can’t attend school and has to stay home and both parents work, who takes care of the student?

If home tutoring is needed will the school allow it to be done in blocks of time followed by a break?

Some schools may require tutoring to be done in school only.

If go to school for one period do you lose home tutoring?

Very Prolonged PCS School IssuesIsolation - Students need to see friends (Will the school allow brief visits to school-one period a day?) How to manage school with multiple rehab/physician visits.

Taking students out of honors/AP classes

Who pays for needed neuro-cognitive testing?

72

No spinning carnival rides and no boating in rough seas until concussion is completely

resolved.

Recommendation: No carnival rides for 3 months (perhaps never if vestibular findings)

No chiropractic adjustments

ADHD AND CONCUSSIONS

75

ADHD Prevalence is Up Among Older Children

Among youth aged 12-17 years ADHD increased by 4% annually from1997-2006.

No increase in those aged 6-11 years.

Thought to be due to a greater awareness of clinicians in diagnosing this condition

Audrey Kubetin, Pediatric News, August 2008, Vol. 42 Issue 8

ADHD Related to Longer Lasting Head Injury?

ADHD patients compared with non-ADHD patients after a concussion.

25% had moderate disability and 56% recovered after 6 months

vs

2% in normal group had moderate disability and 84% recovered after 7 weeks

Stephanie Greene, M.D, Journal Neurosurgery:Pediatrics 6/25/13

Although not statistically significant, youth athletes with ADHD took on average 3 days longer to return to baseline neurocognitive testing

compared with a control group without ADHD.Mautner,et al., Cliniclal Journal Sports Medicine Nov. 2014

DILEMMAShould an athlete who never had ADD

symptoms prior to a concussion be allowed to continue to play contact sports if ADD symptoms develop and persist after

the concussion?

Are undiagnosed concussions one cause of ADHD in children

Issue for schools and sports

How many concussions are

too many?

NO EASY ANSWER

Each athlete needs to be evaluated individually.

There is no magic number as to how many concussions are too many.

Return to play should probably be guided by symptoms and neuro-psych testing regardless of the number of concussions.

If it takes exceedingly longer to recover from each concussion or PCS occurs, perhaps it may be time to do a non-contact sport.

Do you allow fewer concussions in youngsters

( What if 3 or 4 concussions before age 12?)

CONTACT INFORMATION

Michael A. Lee, M.DConnecticut Children’s Medical Center95 Reef RoadFairfield, CT 06824Office (203) 452-8322Fax (203) 254-0358www.concussionmd.com