Pediatric Concussion update OCTOBER 14, 2016 NANAIMO BRAIN INJURY - - PowerPoint PPT Presentation
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,
OCTOBER 14, 2016 NANAIMO BRAIN INJURY SOCIETY
GF STRONG REHAB, CENTRE ADOLESCENT COMPLEX CONCUSSION CLINIC BCCH, SHHCC DIV. OF DEVELOPMENTAL PEDIATRICS
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
(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.
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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
and sensations
248 E.A. Wilde et al. / Pediatric traumatic brain injury: Neuroimaging and neurorehabilitation outcome “ ”
from Zasler et al, Brain Injury Medicine
Rat model
Slide adapted from Dr. Giza
‘Estimated annual incidence 1.6-3.8 million
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)
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)
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.
http://www.ncaa.org/health-and-safety/medical- conditions/ssi-task-force-explores-issues-challenges-around- concussions
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)
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C.Giza, BIS 2015
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neurons)in the gray matter (outer layer of the brain) are overproduced during early adolescence.
synapses.
strengthened (e.g. learning a new language, learning a new sport) while
becomes more efficient.
"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)
The most rapid postnatal brain growth occurs in the first three years of life By a g e 3 , a c h ild’s brain has f
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.
Gogtay, Giedd et al PNAS 2004. N = 13 (7 male, 6 female) typical subjects
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 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
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
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
Improves sleep Mood Sense of well-being Concentration Brain healing
Social consequences
with team mates
Physical consequences
Deconditioning Weight gain Tachycardia and orthostatic hypotension Insomnia due to inactivity and worry Poor concentration – exercise improves attention
Emotional consequences
friends
‘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.’
(McAvoy, K., 2009)
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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
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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
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?)
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(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
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Headaches (most frequently reported) Fatigue Sleep disturbance Dizziness/nausea Sensitivity to noise or light Visual changes
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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