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

Mild Traumatic Brain Injury (American Congress of Rehabilitation Medicine)

At least ONE or MORE of the

following:

Loss of consciousness (LOC)

Loss of memory for events

immediately before or after

the accident

Any alteration in mental state

Focal neurological deficit

Exclusion:

Loss of consciousness >30

mins.

Glasgow Coma Scale < 13

after 30 mins.

Post-traumatic amnesia >24

hrs.

6

•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-

Diffuse axonal injury 7

8

Parietal Lobe Frontal Lobe

Intellect

Sense of Touch

Differentiation of

size, shape & colour

Spatial perception

Visual perception

Muscle tone,

strength &

sensation

Occipital Lobe

Vision

Cerebellum

Balance

Coordination

Initiation

Planning/Anticipation

Follow-through

Impulsivity

Judgement

Reasoning

Abstract Thinking

Smell

Motor Planning

Personality

Emotionality

Speaking

Integration of thought

and emotion

Self-monitoring

Temporal Lobe

Memory

Hearing

Understanding

Language

Brain Stem

Breathing

Heart Rate

Blood Pressure

Movement & sensation

for head, neck, eyes,

hearing

Relays

messages for

other movements

and sensations

Regions of the

Brain

Modern view: Neural networks

248 E.A. Wilde et al. / Pediatric traumatic brain injury: Neuroimaging and neurorehabilitation outcome

Fig. 3. Neuroimaging methods now permit the identification of networks, including important “hubs” that represent important points where

network information passes through and/or is relayed to other brain regions. This illustration demonstrates the high-resolution connectome (C)

derived from DTI showing with red circles where hubs were located, where the size of the colored circle represents the size of the hub. Color also

represents the number of connections. Part (D) shows the same connectome, but only the most important connections. Note this connectome does

not include subcortical connections, rather just connections of the cortical mantle. Used with permission from Elsevier, from van den Heuvel and

Sporns [48]. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/NRE-2012-0794)

ness of the situation in which each developing brain is

interacting with its environment precludes the possibil-

ity of any two brain injuries ever producing identical

effects. For the rehabilitation clinician, this means that

each injury needs to be first understood in terms of how

the trauma came about, how the brain was initially de-

formed, what gross pathologies can be identified (i.e.,

regions of focal injury, contusion, brain edema, etc.)

and how brain morphology is altered by the injury. It

may also be the case that outcome depends much more

on how the network is disrupted than where a lesion

may reside [8].

4. Neuroplasticity in recovery of function

A major problem in the developing brain, first for-

merly articulated by Kennard (see Dennis 2010 for

historical commentary) are the ways in which the

experience-dependent developing brain adapts to in-

jury and the role of neuroplasticity in recovery of func-

tion [16]. In theory, if a developing network is not

fully formed, another network that had equipotentiality

with the original network would be able to assume its

function. Brain networks have always been assumed

to be complex, but until the development of advanced

magnetic resonance (MR) imaging techniques includ-

ing DTI and resting state (rs) functional MR imaging

(fMRI), there has not been a practical way to study

or even display such networks. Fortunately, rudimen-

tary networks now can be displayed, with even basic

networks exemplifying their complexity as shown in

Fig. 3. Given the network depicted in Fig. 3, start-

ing anywhere within the network will ultimately lead

to a pathway connecting to any other region. In the

experience-dependent developing brain, priorities are

established for given pathways to dominate in driving

or regulating a particular function. However, if the pri-

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

15

‘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)

US-Concussion Statistics

Children and Adolescents

16 ‘The Burden of Concussion in British

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)

17 Sports and Recreation Related Concussion

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

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)

26

C.Giza, BIS

2015

33

• Synapses (connections between

neurons)in the gray matter (outer layer of

the brain) are overproduced during early

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 Brain Development Milestones:

The most rapid postnatal brain growth occurs in the

first three years of life

By  a

g

e  3,

  a  ch ild’s  brain  has  fo rmed  1,000  trillion  

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.

Gray matter maturation

Gogtay, Giedd et al PNAS 2004. N = 13 (7 male, 6 female) typical subjects

Maturation process

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

In majority of kids and adolescents:

85%

Symptom free by 4 weeks

No risk factors for slow recovery

Progressive improvement

No mental health or LD

No drug or alcohol use history

COMPLEX

13-15 % will have persistent sx by 3 months and

2% by one year . (Barlow,K. 2010)

Anticipate prolonged recovery if risk factors present

‘concussion was actually a more severe injury

Concussion and mental health

Concussion and chronic headaches

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

Social consequences

•Isolation from friends

•Loss of social engagement with team mates

•Loss of self esteem

Physical consequences

Deconditioning

Weight gain

Tachycardia and orthostatic hypotension

Insomnia due to inactivity and worry

Poor concentration – exercise improves attention

Emotional consequences

•Loneliness

•Isolation

•Anxiety about school and friends

•Worry about brain injury

Active Rehab versus Rest

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.’

50

(McAvoy, K., 2009)

51 Why Is The Student So Tired?

Energy Crisis in the Brain Neurometabolic Cascade following TBI (Giza & Hovda, 2001)

Period between concussion and recovery: “window of vulnerability” (return to play during this time could cause more severe or even catastrophic brain injury.)

Unsafe to

return to

sport until

brain

activity has

returned to

normal

53

Symptom Wheel (Colorado Dept. of Education Concussion Management Guidelines)

Colorado Dept. of Education: Concussion Management Guidelines, 2012

Authors: Karen McAvoy, PsyD and Kristina Werther, LCSW

Emotional Changes

Irritability/easily angered

Frustration/impatience

Anxiety

Depression (can impact cognition)

May be related to poor sleep and/or pain

May be difficult for parents and teachers to differentiate

between adolescent behavior and concussion behavior

(is the behavior different from prior to the concussion?)

54

Cognitive (Thinking) Changes (Returning to School After A Concussion: A Fact Sheet for School

Professionals, Centers for Disease Control and Prevention)

Attention/Concentration

Memory

Slower thought processing

speed

Reaction times (slower, more sluggish)

May be affected by Sleep, Mood and/or Pain

55

Physical Symptoms

(immediate or delayed)

Headaches (most frequently reported)

Fatigue

Sleep disturbance

Dizziness/nausea

Sensitivity to noise or light

Visual changes

56

RESOURCES

Tiers of Service

Tier 4 subspecialty provincial service

Tier 3 local regional service Tier 2

Pediatrician, local community

providers, BIS, OT, PT,

Tier 1 family doctor, ER,

nurse practioners

Berlin: 5th International conference on concussion in sport: October 27-28, 2016

GF Strong AC3 referrals for complex concussions: 604-734-1313