2/4/19 CONCUSSION UPDATE 2019: 3RD ANNUAL SCHOOL CONCUSSION CONFERENCE I have no financial relationships to disclose or Conflicts of Interest (COIs) to resolve. Wednesday January 29,2019 Matthew Grady, MD, FAAP CAQSM Assistant Professor of Clinical Pediatrics Perelman School of Medicine University of Pennsylvania Objectives Definition At the conclusion of this activity, Definitions participants should be able to: Concussion is traumatic brain injury induced by 1. Be Familiar with most recent biomechanical forces. concussion research (Berlin Concussion 2. Develop a contextual framework to evaluate concussion Guidelines 2017) 3. Understand basis for school recommendations 4. Develop return to school strategies for simple concussion Concussion: Real-Life Definition • Concussion is a brain injury. Brain function is Medical Definition impaired = The brain does not work right . • No abnormality on standard imaging • Imaging is recommended only to • This includes dysregulation of normal functions: evaluate possibility of other injuries as clinically indicated cerebral blood flow, balance and eye tracking, • May or may not involve LOC (only about 10% with LOC) memory, processing, concentration, higher level • Most recover spontaneous (10-14 days thinking, impulse control, and emotional in adolescents, shorter in college students) response • Smaller percentage (10-20%) may have prolonged sx • Symptoms will be related to real life demands 1
2/4/19 UPDATE 2019: Risk Factors Concussion Diagnosis Risk Factors Highlights Quest for the Holy Grail- Risk Factors for getting a Concussion Objective Data to make the Diagnosis ADD/ADHD • Iaccarino MA. Neurol Clin Pract. 2018 Oct – • MRI- less than 1% of MRI detected any Poor dynamic balance performance • abnormalities after concussion Klein AP. J – Johnston W. Am J Sports Med. 2018 Dec Neurotrauma. 2019 Jan Risk factors for prolonged recovery Experimental Adolescent females • • DTI- Diffusion tensor imaging (DTI) has been – Ledoux AA. JAMA Pediatrics 2018 Nov able to show fluid abnormalities in white matter Migraine Headaches • – Terry DP. J Neurotrauma. 2018 Aug of brain Churchill NW. Hum Brain Mapp. 2018 Dec 26 Exercise Intolerance on testing • • EEG- portable evoked potential framework to – Orr R. Clin J Sport Med. 2018 Nov extract 'brain vital signs' using Poor Sleep • – Howell DR. J Child Neurol. 2019 Jan electroencephalography Fickling SD. Brain. 2019 Jan Concussion Diagnosis Concussion Diagnosis Blood Work: Quest for serum biomarkers Blood Work: Quest for serum biomarkers • Bad news : High intensity interval training (bike) • Serum biomarkers: β-amyloid peptide 42 [Aβ 42 ], increases biomarkers in blood (the following all increased: total tau, ubiquitin carboxy-terminal hydrolyzing s100 calcium-binding protein beta (S100B) , neuron- enzyme L1, S100 calcium binding protein B specific enolase (NSE), brain-derived neurotrophic factor (BDNF), [S100B], glial fibrillary acidic protein [GFAP], neurogranin (NRGN), peroxiredoxin (PRDX)-6, creatine kinase-BB isoenzyme (CKBB), von Willebrand factor (vWF), monocyte microtubule associated protein 2 [MAP2], and 2',3'- chemoattractant protein (MCP)-1, matrix metalloproteinase cyclic-nucleotide 3'-phosphodiesterase [CNPase] (MMP)-9, and total tau (T-tau) • GFAP, MAP2, and CNPase below limits of – Di Battista AP. Front Physiol. 2018 Sep quantification. • Protein S100B increases after treadmill running, lifting weights • Conclusion: S100B levels detected if testing and playing football done within 4 hours of concussion – Rogatzki MJ. Scand J Med Sci Sports. 2018 Dec • Conclusion: Blood Markers not reliable • Asken BM. Neurology. 2018 Dec currently Concussion Diagnosis Diagnosis: Objective Data Objective Eye Tracking CHOP Updates: Quest for Objective Data • Reliability of Objective Eye-Tracking Are Eyes a Window to Diagnosing Measures Among Healthy Adolescent Athletes. Howell DR Clin J Acute Concussion in Youth? Sport Med . 2018 Jun • Published on Oct 09, 2018 in CHOP News • 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 2
2/4/19 Concussion Signs and Symptoms Autonomic Nervous System Signs and Symptoms Concussion Symptoms: My new view Autonomic Nervous System Dysfunction Headaches Light sensitivity Visual/Vestibular Autonomic Nervous Regulate vision Fatigue Noise sensitive systems System Regulate Lightheaded Exercise hearing Dizzy intolerance Regulate blood Nausea Orthostatic pressure hypotension Cognitive Brain fog Emotional Sleep Regulate sleep Poor school disturbance performance Grady MF and Master CL. Pediatr Ann. 2017 Mar 1; 46(3):e93-e98. Vestibular signs and symptoms Cognitive Signs and Symptoms Cognitive Dysfunction Visual/Vestibular Dysfunction Attention Headaches Not Keeping up Difficulty Convergence span Difficulty with pace of reading Divergence Headaches class remembering Memory Difficulty taking Smooth Pursuits Nausea Not following Difficulty class notes Processing Saccades directions concentrating Fatigue Motion Sickness Speed Gaze Stability Not completing Mentally foggy Dizziness Difficulty Abstract assignments Balance (mostly Poor school Poor school walking in reasoning accurately not needed for crowds, performance performance school) hallways Mood dysfunction signs and symptoms Youth Football concussion rates Mood Dysfunction Youth (5-14) football concussion rates 863 youth football players followed (996 player-seasons) Youth with history of concussion had a 2-fold increased Irritable risk for sustaining an incident concussion Headaches Youth with depression had a 5-fold increased risk of Overwhelmed concussion Anxiety Fatigue Nervous CONCLUSIONS: Depression Nausea 51/996 (5.1%) sustained a concussion during the More Emotional season Poor school “Not trying” 50% of athletes returned to school by 3 days performance 50% returned to sport by 13 days 50%youth were still symptomatic 3 weeks after injury. Chrisman SPD . J Pediatr. 2018 Dec 3
2/4/19 Concussion epidemiology Concussion Recovery New updates 2018: concussion recovery 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 Ledoux AA et al Natural Progression of Adolescent females had Symptom Change and Recovery From Natural Progression of Symptom Change and Recovery From Concussion in a Concussion in a Pediatric Population.JAMA slowest recovery Pediatrics Nov 2018 Pediatric Population.JAMA Pediatrics Nov 2018 The Effect of Cognitive Activity Level on Duration of Post- Exercise after concussion Concussion Symptoms Early exercise concerns: Physical Exercise 0 Complete No reading, homework, text messaging, video game playing, online “Cognitive Activity Days” and Concussion: Animal Models cognitive rest activity, crossword puzzles or similar activities. The most stimulating activities at this level would be watching television, watching movies or Cognitive activity level x days between each visit Early forced aerobic activity immediately following listening to music acute concussion is associated with worse cognitive function 1 Minimal No reading, homework, crossword puzzles or similar activities. Less than 5 cognitive text messages per day, less than 20 minutes per day combined of online However, exercise after a rest period is associated activity activity and video games with improved outcomes compared to prolonged rest alone . 2 Moderate Reading less than 10 pages per day, less than 20 text messages per day, Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise cognitive and doing less than 1 hour combined of homework, online activity and following traumatic brain injury: brain-derived neurotrophic factor upregulation and activity video games per day recovery of function. Neuroscience. 2004;125:129-139. Griesbach GS , Tio DL, Nair S Hovda DA Recovery of stress response coincides with 3 Significant Reading less, doing less homework, working less online, text messaging responsiveness to voluntary exercise after traumatic brain injury. J Neurotrauma. cognitive less and doing crossword or other activities than you would normally do, 2014 Apr 1;31(7):674-82 activity but more than listed in level 2 4 Full cognitive You have not limited cognitive activity at all activity Brown 2013 AMSSM annual meeting Activity after Concussion The Effect of Cognitive Activity Level on Mental Activity after Concussion Duration of Post-Concussion Symptoms • 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. 4
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