2/4/19 CONCUSSION UPDATE 2019: 3RD ANNUAL SCHOOL CONCUSSION - - PDF document

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CONCUSSION UPDATE 2019: 3RD ANNUAL SCHOOL CONCUSSION CONFERENCE

Matthew Grady, MD, FAAP CAQSM Assistant Professor of Clinical Pediatrics Perelman School of Medicine University of Pennsylvania

Wednesday January 29,2019

I have no financial relationships to disclose or Conflicts of Interest (COIs) to resolve.

At the conclusion of this activity, participants should be able to:

Objectives

• 1. Be Familiar with most recent

concussion research

• 2. Develop a contextual framework to

evaluate concussion

• 3. Understand basis for school

recommendations

• 4. Develop return to school strategies for

simple concussion

Definitions Concussion is traumatic brain injury induced by biomechanical forces. (Berlin Concussion Guidelines 2017)

Definition

Medical Definition

• No abnormality on standard imaging
• Imaging is recommended only to

evaluate possibility of other injuries as clinically indicated

• May or may not involve LOC (only

about 10% with LOC)

• Most recover spontaneous (10-14 days

in adolescents, shorter in college students)

• Smaller percentage (10-20%) may have

prolonged sx

• Concussion is a brain injury. Brain function is

impaired = The brain does not work right.

• This includes dysregulation of normal functions:

cerebral blood flow, balance and eye tracking, memory, processing, concentration, higher level thinking, impulse control, and emotional response

• Symptoms will be related to real life demands

Concussion: Real-Life Definition

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Risk Factors Highlights

Risk Factors for getting a Concussion

• ADD/ADHD

– Iaccarino MA. Neurol Clin Pract. 2018 Oct

• Poor dynamic balance performance

– Johnston W. Am J Sports Med. 2018 Dec

Risk factors for prolonged recovery

• Adolescent females

– Ledoux AA. JAMA Pediatrics 2018 Nov

• Migraine Headaches

– Terry DP. J Neurotrauma. 2018 Aug

• Exercise Intolerance on testing

– Orr R. Clin J Sport Med. 2018 Nov

• Poor Sleep

– Howell DR. J Child Neurol. 2019 Jan

UPDATE 2019: Risk Factors

Quest for the Holy Grail- Objective Data to make the Diagnosis

• MRI- less than 1% of MRI detected any

abnormalities after concussion Klein AP. J

• Neurotrauma. 2019 Jan

Experimental

• DTI- Diffusion tensor imaging (DTI) has been

able to show fluid abnormalities in white matter

• f brain Churchill NW. Hum Brain Mapp. 2018 Dec 26
• EEG- portable evoked potential framework to

extract 'brain vital signs' using electroencephalography Fickling SD. Brain. 2019 Jan

Concussion Diagnosis

Blood Work: Quest for serum biomarkers

• Serum biomarkers: β-amyloid peptide 42 [Aβ42],

total tau, ubiquitin carboxy-terminal hydrolyzing enzyme L1, S100 calcium binding protein B [S100B], glial fibrillary acidic protein [GFAP], microtubule associated protein 2 [MAP2], and 2',3'- cyclic-nucleotide 3'-phosphodiesterase [CNPase]

• GFAP, MAP2, and CNPase below limits of

quantification.

• Conclusion: S100B levels detected if testing

done within 4 hours of concussion

• Asken BM. Neurology. 2018 Dec

Concussion Diagnosis

Blood Work: Quest for serum biomarkers

• Bad news: High intensity interval training (bike)

increases biomarkers in blood (the following all increased: s100 calcium-binding protein beta (S100B), neuron-

specific enolase (NSE), brain-derived neurotrophic factor (BDNF), neurogranin (NRGN), peroxiredoxin (PRDX)-6, creatine kinase-BB isoenzyme (CKBB), von Willebrand factor (vWF), monocyte chemoattractant protein (MCP)-1, matrix metalloproteinase (MMP)-9, and total tau (T-tau) – Di Battista AP. Front Physiol. 2018 Sep

• Protein S100B increases after treadmill running, lifting weights

and playing football – Rogatzki MJ. Scand J Med Sci Sports. 2018 Dec

• Conclusion: Blood Markers not reliable

currently

Concussion Diagnosis

Objective Eye Tracking

• Reliability of Objective Eye-Tracking

Measures Among Healthy Adolescent Athletes. Howell DR Clin J Sport Med. 2018 Jun

• Eye Tracking as a Biomarker for

Concussion in Children. Bin Zahid A. Clin J Sport Med. 2018 Aug

• Oculomotor, Vestibular, and

Reaction Time Effects of Sports- Related Concussion: Video- Oculography in Assessing Sports- Related Concussion Kelly KM. J Head Trauma Rehabil. 2018 Sep

Concussion Diagnosis

CHOP Updates: Quest for Objective Data

Are Eyes a Window to Diagnosing Acute Concussion in Youth?

• Published on Oct 09, 2018 in CHOP News

Diagnosis: Objective Data

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Concussion Symptoms: My new view

Concussion Signs and Symptoms

Autonomic Nervous System Visual/Vestibular systems Cognitive Emotional

Grady MF and Master CL. Pediatr Ann. 2017 Mar 1; 46(3):e93-e98.

Autonomic Nervous System Dysfunction

Regulate vision Regulate hearing Regulate blood pressure Regulate sleep

Light sensitivity Noise sensitive Exercise intolerance Orthostatic hypotension Sleep disturbance Headaches Fatigue Lightheaded Dizzy Nausea Brain fog Poor school performance

Autonomic Nervous System Signs and Symptoms

Visual/Vestibular Dysfunction

Convergence Divergence Smooth Pursuits Saccades Gaze Stability Balance (mostly not needed for school) Difficulty reading Difficulty taking class notes Motion Sickness Difficulty walking in crowds, hallways Headaches Nausea Fatigue Dizziness Poor school performance

Vestibular signs and symptoms

Cognitive Dysfunction

Attention span Memory Processing Speed Abstract reasoning

Not Keeping up with pace of class Not following directions Not completing assignments accurately Headaches Difficulty remembering Difficulty concentrating Mentally foggy Poor school performance

Cognitive Signs and Symptoms

Mood Dysfunction

Anxiety Depression

Irritable Overwhelmed Nervous More Emotional “Not trying” Headaches Fatigue Nausea Poor school performance

Mood dysfunction signs and symptoms

Youth (5-14) football concussion rates

863 youth football players followed (996 player-seasons) Youth with history of concussion had a 2-fold increased risk for sustaining an incident concussion Youth with depression had a 5-fold increased risk of concussion CONCLUSIONS: 51/996 (5.1%) sustained a concussion during the season 50% of athletes returned to school by 3 days 50% returned to sport by 13 days 50%youth were still symptomatic 3 weeks after injury. Chrisman SPD. J Pediatr. 2018 Dec

Youth Football concussion rates

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New updates 2018: concussion recovery

Concussion epidemiology

2716 children in the study 5-7 yo olds- 75% recovered by 2 weeks 8-12 yo (82%) recovered by 4 weeks 13-18 yo (86%) recovered by 4 weeks Adolescent females had slowest recovery

Ledoux AA et al Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population.JAMA Pediatrics Nov 2018

Concussion Recovery

Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population.JAMA Pediatrics Nov 2018

Early exercise concerns: Physical Exercise and Concussion: Animal Models

Early forced aerobic activity immediately following acute concussion is associated with worse cognitive function However, exercise after a rest period is associated with improved outcomes compared to prolonged rest alone .

Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004;125:129-139. Griesbach GS , Tio DL, Nair S Hovda DA Recovery of stress response coincides with responsiveness to voluntary exercise after traumatic brain injury. J Neurotrauma. 2014 Apr 1;31(7):674-82

Exercise after concussion

The Effect of Cognitive Activity Level on Duration of Post- Concussion Symptoms “Cognitive Activity Days” Cognitive activity level x days between each visit

Complete cognitive rest No reading, homework, text messaging, video game playing, online activity, crossword puzzles or similar activities. The most stimulating activities at this level would be watching television, watching movies or listening to music 1 Minimal cognitive activity No reading, homework, crossword puzzles or similar activities. Less than 5 text messages per day, less than 20 minutes per day combined of online activity and video games 2 Moderate cognitive activity Reading less than 10 pages per day, less than 20 text messages per day, and doing less than 1 hour combined of homework, online activity and video games per day 3 Significant cognitive activity Reading less, doing less homework, working less online, text messaging less and doing crossword or other activities than you would normally do, but more than listed in level 2 4 Full cognitive activity You have not limited cognitive activity at all

The Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms

Brown 2013 AMSSM annual meeting

Mental Activity after Concussion

• Overdoing cognitive activity has worst outcome
• Moderate cognitive activity and minimal cognitive

activity had same outcome

Take home message

• Moderate Cognitive Activity

with symptoms is safe and does not delay recovery.

Activity after Concussion

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Early Exercise with hard stopping points is safe

Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Leddy JJ. Clin J Sport Med. 2018 Jan An Exploration of the Impact of Initial Timing of Physical Therapy on Safety and Outcomes After Concussion in Adolescents. Lennon A. J Neurol Phys Ther. 2018 Jul

Physical Activity: exercises with stopping points - good

Just like mental activity, too much physical activity early in concussion is BAD Playing with Symptoms = Delayed Recovery

• Removal From Play After Concussion and Recovery Time. Elbin RJ.
• Pediatrics. 2016 Sep.
• Immediate Removal From Activity After Sport-Related Concussion Is

Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes. Asken BM. Am J Sports

• Med. 2018 May.

Too much exercise early in concussion- bad

• Old view
• Rest until asymptomatic
• New view
• Relative rest, more on the first day then progressively

less on the following days

• Gradual re-introduction of activity staying below

thresholds of cognitive and physical levels that make symptoms markedly worse

• One caveat - early aerobic activity does not mean

restarting sports training while symptomatic

• Most concussions resolve in a few weeks (80% in 4 wks)

Activity After Concussion

Concussion Recovery 2019

• Medical Literature Supports Gradual

Return to Both Mental and Physical Activity

• This means students will restart work WITH

symptoms

• How does school balance less than normal

academic load with recovery ?

• Home may be the starting point for

recovery but School becomes a place where Recovery/Rehab continues

Concussion Recovery

So What’s the Treatment ?

Concussion: Signs and Symptoms

Autonomic Dysfunction

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Aerobic Activity as Rehab for Concussion

• Effectiveness of an Exercise-Based Active

Rehabilitation Intervention for Youth Who Are Slow to Recover After Concussion. Gauvin-Lepage J. Clin J Sport Med. 2018 Aug

• A Preliminary Study of the Effect of Early

Aerobic Exercise Treatment for Sport-Related Concussion in Males. Leddy JJ Clin J Sport

• Med. 2018 Sep
• Dynamic cerebral autoregulation is

attenuated in young fit women. Labrecque L. Physiol Rep. 2019 Jan

Aerobic Activity as Rehab

Autonomic System Rehab = Cardio

Autonomic Rehab

Autonomic

Concussion: Signs and Symptoms

Visual Vestibular

• Vision and Vestibular Deficits in Concussion
• Vision Problems 69%
• Vestibular Problems 55%
• Both Vision and Vestibular

Deficits 49%

• Only Vision Deficits 16%
• Only Vestibular Deficits 20%
• Master CL, Scheiman M, Gallaway M, Goodman A, Robinson RL, Master SR, Grady MF.

Vision Diagnoses Are Common After Concussion in Adolescents. Clin Pediatr. 2016 Mar

CHOP Study on Vision Deficits in Concussion

School Work with Eye tracking Deficits

• How do we re-integrate students back into the class if

they can not read or take notes?

• What mechanism can school have in place immediately

when students return to school?

• Do we need doctors notes to request special

accommodations or can we do something for everyone?

New Research

• Vision and Vestibular System Dysfunction Predicts Prolonged

Concussion Recovery in Children Master CL. Clin J Sport Med. 2018 Mar

• Vestibular Rehabilitation Is Associated With Visuovestibular

Improvement in Pediatric Concussion. Storey EP J Neurol Phys Ther. 2018 Jul

Vestibular and Ocular REhab

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Implications : Rehabilitation

• Vestibular Therapy
• Aerobic Rehabilitation
• Vision Therapy

Eye tracking deficits and Rehab

Implication: Vision Therapy

• Voluntary convergence

–Brock String sequence

• Fusional vergence
• Accommodative therapy
• Saccadic & Pursuit

therapy

Binocular Vision Retraining

Vision Rehab = Eye Exercises

Visual

Concussion Rehab

Vestibular Rehab = Eye and Balance Exercises

Vestibular

Concussion Rehab

Concussion: Signs and Symptoms

Cognitive Dysfunction

New Research on Cognitive Deficits

• Visual memory performance following mild

traumatic brain injury and its relationship with intellectual functioning. L'Ecuyer- Giguère F Appl Neuropsychol Adult. 2019 Jan

• Examining Motor Tasks of Differing

Complexity After Concussion in

• Adolescents. Howell DR Arch Phys Med
• Rehabil. 2018 Sep

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Cognitive Rehab = Mental Activity School Work

Cognitive

Cognitive Rehab

Concussion: Signs and Symptoms

Mood Dysfunction

• Alterations in mood:
• Barrier to recovery
• Stress, anxiety
• Emotional labiality
• Depression
• Poor coping mechanism
• Self injurious behavior-

cutting, Suicidal Ideation

Emotional Effects of Concussion

Stockimages/freedigitalphotos.net

Concussion and Mood Problems

• Association Between Traumatic Brain

Injury and Risk of Suicide. Madsen T

• JAMA. 2018 Aug
• Treatment :
• Address school work stress early- make

expectations for catch up clear to everyone.

• Counseling/Support Groups Psychiatry

for mood stabilizers

Stockimages/freedigitalphotos.net

Mood Rehab = Empathy and Appropriate Demands Counseling/Meds as second line

Mood

Concussion Symptoms: What are the causes

Initial/Immediate management

• Rest for 24-48 hours. (you can do more harm than good in

first 48 hrs)

• Slow ramp up of physical and cognitive activities- do not

guess on long term questions

• Follow up in a few days with PMD
• Goal is to be back in school around the one week mark- for

some it may take longer, for others in may be quicker.

• Avoid prolonged school absence, esp if history of anxiety

Management immediately after concussion

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• Counseling
• Meds

(second)

• Cognitive work
• Meds (second)
• Vestibular

therapy

• Vision

Therapy Cardio Meds (second)

Autonomic Visual Vestibular Mood Cognitive

• Concussion symptoms can be due to autonomic

dysfunction, visual/vestibular dysfunction, cognitive dysfunction or mood dysfunction

• Identification of all these barriers allows for thoughtful

rehabilitation plan

• School accommodations should be developed with

these systems in mind

• Short- and Long-term rehab starts while the school re-

entry process is ongoing

Conclusions

Our clinical Team

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Christina Master, MD Olivia Podolak, MD Matt Grady, MD Michael Nance, MD Brian Vernau, MD Danielle Magrini, MD Noami Brown, MD Lindsey Calandra, CRNP Roni Robinson, CRNP

Thank you!

Eileen Storey Research Asst. Kate Easby, ATC Andrea Mallon, RN Concussion Nurse Navigator Christopher Renjilian, MD

Thanks

School Accommodations: Autonomic Dysfunction

• Fatigue: Short frequent breaks if stamina is

a problem, esp in long classes, decrease the number of classes with breaks between classes, decrease overall work volume

• Light sensitivity: Sun glasses, Decrease

brightness on computer screen

• Noise: Ear plugs or testing in quiet

environment (not in class), eat in quiet area

School Accommodations: Autonomic

Image courtesy of stokeimages at FreeDigitalPhotos .net

School Accommodations: Eye Tracking Deficits

• Pre-printed teachers notes (eliminates looking up

and down)

• Large print (18 font)- easier to track side to side
• Can use over the counter reading glasses (1.5

readers) for convergence deficits

• Decrease reading requirements (books on tape)
• Extra time for tests- (it takes longer to read)
• “Chunk” work- do in smaller segments
• Reading strips

Eye movement deficits: School accommodations

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Accommodations for Cognitive Dysfunction

• Decrease cognitive load- decrease
• verall number of classes with breaks

between classes to recover (try not to water-down classes)

• Quiet testing environment
• Extra tutoring
• Self-pacing on assignments
• Extra time to take tests/complete

assignments

Cognitive Dysfunction

Image courtesy of stokeimages at FreeDigitalPhotos.net

Accommodations for Cognitive Dysfunction

• Alter testing format : Less rote memory
• r allow memory bank for test
• Prioritize work: Medically excuse some

work, spend all available time and energy on core work – esp. classes that require work done in a certain order such as math etc.

• Stimulants may have a role:

– Amantadine, Methylphenidate

Autonomic Dysfunction

Image courtesy of stokeimages at FreeDigitalPhotos.net

• School work in small increments -

with breaks as needed

• Work until symptoms, rest, recover

and restart work

• Testing is part of rehab
• Just need to ramp up slowly

Cognitive Therapy/Rehab

Resources: chop.edu/concussion

• Practical content

–Updated School letters *** –Updated Smart Sets***

Resources: chop.edu/concussion

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Highlights of changes:

• “Academic adjustments”
• It’s ok to be in school with symptoms
• Do not go home if symptoms occur, start at

school, take short frequent breaks

Resources: chop.edu/concussion

• Practical content

– Families – Schools – Coaches – Clinicians

• Downloads

– Infographics – Posters – Fact sheets – Video FAQ

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Minds Matter: Concussion Care for Kids Research Studies

• Please contact Sports Medicine to

refer:

– Acute injuries: within 1-7 days of injury – Ages: 12 and up

• Multiple Studies enrolling acute

injuries involving:

– Physiologic changes after concussion – Blood biomarkers – Saliva analysis – BCAA – Imaging – Exercise – Objective measures to aid concussion diagnosis

• Eye tracking, balance, pupillary dynamics,

brain oxygenation changes etc.

Contact: Andrea Mallon, RN Concussion Nurse Navigator 215-590-5262 *** CHOP Staff Only*** Do not give to families.