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
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