1

Diagnosis, Management &

Treatment of Mild Traumatic Brain Injuries

Kody Moffatt, MD, FACSM, ATCAssociate Professor of Pediatrics: Creighton University

Lori Terryberry-Spohr, Ph.D., ABPPStaff Psychologist, Brain Injury Program Manager:

Madonna Rehabilitation Hospital

Presenter Disclosures

Consultant/

Speakers bureaus

No Disclosures.

Research funding No Disclosures.

Stock

ownership/Corporate boards-employment

No Disclosures.

Off-label uses No Disclosures.

Objectives

Review the mechanisms and pathophysiology of concussions

Discuss the evaluation and diagnosis of concussion

Concussion

Recent explosion of information–AMSSM Position Statement 1/13

– International Consensus Statement 3/13

–AAN Position Statement 3/13

TBI/ MTBI

Return to play recommendations

Return to learn

Physiology

Animal Models

Chaotic-Metabolic Crisis –4-6 days post-concussion

–K+ efflux/ Ca+2 influx

–Na+/K+ pump in disarray

–Decreased ATP

–Decreased cerebral blood flow

–4-6 days of metabolic mismatch

No cell death if no secondary insult

12

34

5

6

2

Second Impact Syndrome

Pediatric Problem

Hypotension

Increased ICP

Anoxia/ ischemia

Decreased autoregulation

Cell death

Permanent neurological impairment

~ 100% morbidity/ recovery is rare

Risk Factors

History of concussion

Number, severity & Sx duration

Female

Pre-injury

–Mood Disorder

–ADHD

–Learning Disorders

–Migraine HA

Style of play

Mechanism

Poor technique

FB, hockey, rugby, soccer, basketball

Helmet fitted & fixed to head

Neck muscles

–F=ma

Hydration, genetics, luck

Evaluation

Onsite eval (MD/DO, ATC, etc.)

–C-spine

–Pocket Concussion Recognition Tool

Remove from play & not left alone

–No same day return to play

Eval by professional

–Specific expertise

Symptoms

Difficulty thinking clearly (cloudy)

Difficulty concentrating

Feeling slow

Difficulty remembering

– New Information

Balance difficulty

Headache

Blurry vision

Nausea/ Dizzy

Light/ noise issues

Tired/ Sleep issues

Irritable

Sad

Emotional

Nervous/ anxious

3

“The look in the eye”

Symptoms

Graded symptom check list

–SCAT 3

–Child SCAT 3 (5-12 years)

ImPACT

Hematoma

Subdural

High impact trauma

High speed collisions

Venous structures

With skull Fx

– Sx in minutes

W/O skull Fx

– Sx over days

LOC at some point

Significant morbidity

Epidural

Temporal skull Fx

Middle meningeal art

High impact event

– Struck by baseball

Lucid period followed by severe headache

Trauma center

Old Classifications

4

New Classification

Simple vs. Complex

Simple: progressively resolves without

complication over 7-10 days, mental status

screening, no formal neuropsychological screening

For clinicians: most will recover within hours to 5-7 days

Specific Points

Helmets

Mouthpieces

Neck strengthening

Rule changes and enforcement

–Proper tackling, sliding, sticking rules

Role of the Healthcare Provider-

Education and Early Intervention–positive expectations for recovery

–why specific symptoms are present

–how to adjust behavior accordingly

–specific guidelines for daily activity including facilitating return to activity

–closely monitor symptoms and refer for further assessment if not resolving as anticipated

Return to Activity

Return to Activity

–Return to Learning

–Return to Play

Returning to learning (academics) should precede return to play

–Get them back in school and tolerating that well first and then add in the additional demands and risks of athletics

Collaborate and Communicate

Best to have communication between the health care provider and the school prior to a student returning to the classroom—get releases in place before they leave the office

–Sets student up for success

–Allows for increased understanding and early accommodations

Nebraska’s Status

In Nebraska, return to play is partially legislated for those 18 and below in age

Return to learn is still in development and not yet standardized although recommendations do exist

5

ManagementRest, Rest, Rest for the short term

• Although there is general consensus that rest in the short term is beneficial, more research is needed to determine the optimal length of time that complete rest is needed• Some research suggests it may shorten recovery time to rest for the first couple of days following the injury

• Managing physical and cognitive activity• Risk for increase or re-emergence of post-concussion symptoms following significant exertional activity

• Managing school demands and physical activities

Physical Rest?• No sports• No exercise

• No weightlifting• No PE• Minimize exertion with Activities of Daily Living

REST = ABSOLUTE REST for a few days and then ease back into activities, backing off if symptoms recur or

exacerbate

Mental/ Cognitive Rest?• No prolonged concentration• No prolonged homework

• No prolonged classes (block scheduling)• No prolonged days• Limit screen time-most say none for the first couple of days

• Limit cell time-most say none for the first couple of days

REST = ABSOLUTE REST at least for the first couple of days and then

ease back in as tolerated

Chronic Brain Injury

Can result from multiple concussions

Results in lower neuropsychological test scores

Learning Disabilities

Slower speed of information processing

Slow reaction time

Return to LearnStep 1: Home with total rest

Step 2: Home with light mental activity

Step 3: Attend School Part Time with built in breaks, no testing, and modification of assignments

Step 4: Attend School Part Time with some accommodations

Step 5: Attend School Full Time, no standardized tests but routine tests OK, some minor accommodations

Step 6: Attend School Full Time, no accommodations

Brain Injury Regional School

Support Teams (BIRSST)

All schools in Nebraska have access to BIRSST

Contact a BIRSST team member when you have a student who needs assistance transitioning into the classroom after a brain injury

Team members can help identify strategies to support student success– Training and consultation for Concussion Management and SAT

teams

– Information on brain injury and resources

– Methods to reintegrate students with peers

– Support for students struggling with new identities

6

BIRSST Region Contacts

Western Region: Marg Dredla at ESU13 (mdredla@esu13.org)

Central Region: Patrice Fellers at ESU10 (pfellers@esu10.org)

Northeast Region: Cathy Schroeder at ESU1 (cschroeder@esu1.org)

Southeast Region: Cindy Brunken at Lincoln Public Schools (cbrunk@lps.org)

Metro Region: Andrea McDonald at Bellevue Public Schools (andrea.mcdonald@bpsne.net)

For more info: Rose Dymacek, Brain Injury Advisory Council (rose.dymacek@nebraska.gov)

Legislating Return to Play—Rapid

Changes Nationally

State laws in WA and OR in 2009 legislating no return to play same day for athletes below the age of 19

– 48 states have passed legislation on this issue. LB260 was enacted in Nebraska on July 1, 2012.

What does the law (Nebraska LB260) say?

Mandatory coach and parent/athlete education

Player must be removed from play if “exhibits signs, symptoms, or behaviors consistent with a concussion”

Cannot return to play that day

Cannot return to play until asymptomatic and cleared to return by a trained “health care professional”

Gradual Return to Play�Rest until symptom free, may be appropriate to stay home from school for a few days and limit assignments

�Return to School

�Light exercise

�Running

�Non-contact drills

�Full contact practice or training

�Play in Game

�If post-concussion symptoms occur at any step, activity must stop

Nebraska HHS Approved CoursesCDC – Centers for Disease Control

Heads UP Concussions in Youth Sports(Training for coaches, parents and others helping to keep athletes

safe from conclusions)

Heads Up Clinicians: Addressing Concussion in Sports Among Kids

and Teens(Training for healthcare professionals)

NFHS - National Federation of High Schools

Concussion in Sports - What You Need to Know

Sports Safety International

ConcussionWise (Courses for Coaches, Athletes, and Parents are free. There is a fee for courses for Athletic Trainers, Physicians,

and Nurses.)

Oregon Center for Applied Science

ACTive™Athletic Concussion Training for Coaches

Reports

Traumatic Brain Injury Fact Sheet in 2004-2008

Childhood Sports Related Injuries

Computerized Testing

Neuropsychological Tests used for baseline and post-injury assessment

–ImPACT

–Headminders

–CogSport

–ANAM

7

Benefits/ConcernsCan be useful as a supplement to solid clinical assessment

Baseline vs. Normative comparisons

A test informs the user but cannot be used as a red light/green light measure

Test results can be influenced by other factors

–Distractibility in the environment

–Learning issues

–Motivation

Problems for Athletes-

Post-Concussion Syndrome

85-90% of concussed young athletes will recover within 1 to 2 weeks

The remainder may have symptoms lasting from weeks to months interfering with school and daily life

Subtle deficits may persist a lifetime, primarily with those with multiple injuries

So what if they don’t recover as expected?

What if there are still symptoms after 10-14 days? The bigger picture….

–When post-concussion symptoms persist, it often signals the presence of undiagnosed or undertreated co-morbid conditions.

–Delaying appropriate identification and treatment can lead to the development of dysfunctional patterns such as fear of failure, chronic headaches, overlying anxiety/depression, etc.

–A typical patient presents to our clinic with four or more comorbidities… 39

Barriers to recovery…

Common comorbidities

1. Post traumatic headache

2. Balance / vestibular disorders

3. Post traumatic vision syndromes

4. Whiplash

5. Orthopedic pain

6. Disrupted sleep / wake cycle

7. Depression / anxiety

8. Undiagnosed Premorbid Learning Difficulties

40

Everyday Functional Effects

• Home– Difficulty completing tasks at home

– Reduced play/ activity

– Irritability with challenges

• School– Concentration

– Remembering directions

– Disorganized

– Difficulty with completing assignments

– Fatigue

– Fall behind, fail tests, reduced grades

Typical Complaints of

Adolescents and Adults

“I’m having difficulty concentrating.”

“I don’t feel organized.”

“I can’t seem to complete anything I start.”

“I lose my train of thought.”

8

•Given this complex picture, is it surprising that assessment and interventions focusing on a single problem have limited effectiveness, particularly once problems become chronic?

•This is the strength of the multidisciplinary team….

43

The Team

MD - Physiatry

Physical therapy

Occupational therapy

Speech therapy

Neuropsychology

Neuro-optometry on site

Educational Specialist

Case Manager44

Mild TBI Assessment ClinicMadonna Rehabilitation Hospital

WHAT

–Since 1998 we have offered a weekly comprehensive outpatient assessment clinic focusing on the rehabilitation needs of individuals of all ages who have experienced a recent head trauma with suspected mild brain injury.

Mild TBI Assessment ClinicWHY

–minimize long term disability through comprehensive early assessment and intervention

–more effectively meet needs of an under-diagnosed and under-served population

Recovery +Adaptation

• Sometimes not all deficits can be erased, particularly if it has been a long time since the injury

• Compensatory skills

• Acceptance– redefine goals

– adjustment to new self

Case ExampleJamie– 14 year old female injured in basketball game in June

– Referred to me by PCP for evaluation of possible PCS at 22 days post injury

– Presents to my office with headache (4/6), fatigue, difficulty concentrating and remembering, mild complaints of nausea, balance issues, dizziness, nervousness and trouble falling asleep

– Results of ImPACT testing indicated significant impairment in all areas (or invalidity)

9

Case Example

No contact play or major exertion until symptom resolution and re-evaluation

Referred to the rest of the Mild TBI team for evaluation and addressing of symptoms

PT for dizziness/headaches

OT to rule out any visual disturbances that may be contributing to the cognitive complaints or headaches

CD/ST to address cognitive/communication issues

Psych for strategies to minimize anxiety

Summer time so held on involving educational specialist

Case ExamplePT made good progress on reducing headaches but noticed report of symptom resumption when friend was in a car accident in August.

OT did not identify any significant visual disturbances at this time

CD worked on compensatory strategies and then involved Education towards end of summer to provide support as student transitioned back to school

Case Example

Psych interventions helped Jamie to learn that many of her symptoms were quickly exacerbated when she was anxious because it increased the muscular tension in her shoulders and neck, worked on relaxation training and other positive coping skills

Re-evaluation at 3 months, 12 days post injury indicated resolution of headaches except when under stress

Case Example

ImPACT Testing

Scores Post Injury 122 days

Post Injury 23 months, 12

days

Verbal Memory <1st Percentile 20th Percentile

Visual Memory <1st Percentile 32nd Percentile

Visual MotorSpeed

<1st Percentile 38th Percentile

Reaction Time <1st Percentile 38th Percentile

Impulse Control 4 1

Symptom Score 15 2

Case ExampleRecommended cautious return to playing volleyball, no basketball yet, with slow progression (over the course of 2-3 weeks)

Returned to conditioning and subsequently playing with volleyball team with no increase of symptoms, played basketball this winter without difficulties

School provided minimal supports during fall with phasing out by semester end

� We know a lot about injuries to the brain

� We have systems that can be put in place to

� Safeguard the student-athletes

� Facilitate speedy but safe return to play

� Reduce risk/ liability to the athletic system

� Improve overall athletic system performance

Wrapping It UpWrapping It Up

10

Summary:

Collaborate and Educate Students, Parents, Coaches and Professionals

Teach “fair play”

Detection of Injury

Learn to recognize the clinical features

Put in place proper assessment strategies

Follow the RTP principles

Refer for further evaluation if symptoms don’t resolve as expected

Finally……...

The best treatment for MildTBI is

PREVENTION!

References

ACTive: Athletic Concussion Training™ http://activecoach.orcasinc.com

Consensus Statement on Concussion in Sport, 4th International Conference on Concussion in Sport, Zurich, November 2012.

Gioia, G.A. (2009). Concussion Management on the Field and Return to Play Decisions: A New Approach. Presentation.

Brain Injury Assoc. of Nebraska

– 800-444-6443

– www.biane.org

Brain Injury Advisory Council

– 308-865-5012

– www.braininjury.ne.gov

Nebraska Department of Education Hotline for Disabilities

– 1-800-742-7594 (V/TT)

– www.cap.state.ne.us

Brain Injury Resources

Brainline.org

–http://brainline.org/

Centers for Disease Control (CDC)

–http://www.cdc.gov/TraumaticBrainInjury/

Brain Injury Websites