seattle pacific university educational series february 3, 2015 chris ladish, phd pediatric...

Seattle Pacific University

Educational Series

February 3, 2015

Chris Ladish, PhDPediatric NeuropsychologyMary Bridge Pediatric Psychology & Psychiatry Service1220 Division AvenueTacoma, WA 98403(253) 403-4437, #2http://www.multicare.org/marybridge/pediatric-

psychology-psychiatry-3

Returning Children to Play & School Following Concussion:

What you need to Know

1. Discuss the physical, cognitive and emotional

symptoms of concussion2. Discuss the educational implications of

concussion symptoms3. Understand risk factors in prolonged

concussion recovery4. Assist in the development of appropriate

physical, educational and cognitive recommendations in the return to learn and return to play decision-making process

Ding Got his/her bell rung Saw Stars Just a Concussion

3.9 million activity/sports related concussions per year (CDC)

Falls, accidents and assault Media attention- professional sports, legislation

Nearly all states now have legislation regarding sports concussions

Washington was the first state to have such a lawNo athlete may return to sports if concussion

suspectedFurther evaluation by licensed professional

Complex pathophysiological process effecting the brain induced by traumatic biomechanical forces.

May be caused by direct blow to head, face or neck, or elsewhere on body with “impulsive forces” transmitted to head.

Typically involves rapid onset of short-lived impairment of neurological function that resolves spontaneously.

Clinical symptoms largely reflect functional disturbance rather than structural injury.

Results in graded set of clinical symptoms that may or may not involve LOC.

No abnormality evident on standard neuroimaging.

PECARN

CT scan rate 35.3%Traumatic Brain Injury 5.2%ciTBI 0.9%Neurosurgical intervention 0.1%

8

Removal from field if concussion sustained SCAT3 work group developed to improve

SCAT2 Validating SCAT for pediatric pts < 8 yo Evolving condition, reassessments needed “Bell ringers” = transient dysfunction of

neurological function (mgmt ???) Injury2 days rest (> 10 days possibly

harmful)graded exercise even if sxs persist

Physical Cognitive Emotional Sleep

headache nausea/vomiting imbalance (ataxia), motor problems excessive drowsiness, fatigue photosensitivity auditory sensitivity numbness, tingling blurry or double vision (diploplia)

Intelligence General language functioning Knowledge base (long term memory)

Awareness/Orientation Attention Mental Flexibility Working Memory Executive Functioning Processing Speed Reaction Time

Core deficits seen in concussion have functional effect on other skills

Trends may be subtle but significant

Day to day work, play, relationships and life impacted by key challenge areas.

Disinhibition Emotional Lability Irritability/Reactivity Anxiety Depression Frustration Hopelessness Downplaying impact

Confusion, disorientation Retro/anterograde amnesia Headache Nausea, vomiting Motor weakness, incoordination Dizziness, imbalance Sensory sensitivity (light, sound) Fatigue, increased need for sleep

Decreased processing speed Short-term memory impairment Difficulty retaining new information Irritability, depression, anxiety Fatigue, sleep disturbance “Foggy” feeling Frustration

High risk age groups:

Children aged 0 to 4 years

Adolescents 15 to 19 years

TBI rates higher for females > males in similar sports› Girls 1.7/10,000 AE > Boys 1.0/10,000

Boys 0 to 4 years = highest rates of TBI-related ED visits, hospitalizations, and deaths

Football: 47.1% Girls’ soccer: 8.2% Boys’ wrestling: 5.8% Girls’ basketball: 5.5%

Marar M, McIlVain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. American Journal of Sports Medicine; 2012, Jan 27 (Epub ahead of print).

Player to player contact: 70.3% of incidents

Player to playing surface: 17.2%


22% of all hockey injuries are concussion


Struck By/Against Events

Includes colliding with a moving or stationary object, as in sports

Cause of 25% of TBI’s in children 0-14 years

Broglio, Univ. of Michigan, 2010

study cohort linear acceleration

Pellman(2003)

Professional(75% injury risk)

98g

Guskiewicz(2007)

Collegiate(mean of 13 concussions)

102.8g

Broglio(2010)

High school(CART of 13 concussions)

96.1g

Metabolic Cascade(hours to days)

Developing brain(neuroplasticity vs. increased

vulnerability)

Overuse(implications to exertion)

Neuroanatomical involvement

Neuroplasticity: younger brains are still developing and thus are more resilient to trauma due to brain’s ability to form alternate neural connections for function.

Vulnerability: higher mortality rate seen with TBI in younger children likely due to higher rate of cerebral edema.

Animal models support both factors.

Unilateral cortical lesions.

Recovery of function associated with increased dendritic growth within uninjured cortex dependent upon use of the intact forelimb.

Restraint of uninjured forelimb with overuse of the injured limb results in failed dentritic enhancement, increased lesion size in injured cortex, and longer behavioral deficits.

Some mitigation with delayed use: no lesion increase but functional recovery still delayed.

Considerations Regarding Resumption of ‘Activity’

(Silverberg, N. and Iverson, G., 2012. Jnl Head Trauma RehabThomas, D., Apps, J., Hoffmann, R., McCrea, M., Hammeke, T. 2015. Pediatrics)

Complete rest beyond 3 days probably not helpful in most cases (not all)

Gradual resumption of preinjury, non impact activities should begin as soon as tolerated

Supervised exercise of benefit to patients with persistent symptoms both physically and emotionally

Caution re early restrictions establishing a “mindset” for recovery expectations

Physical symptoms and altered mental status usually first noted

Physical symptoms often improve before cognitive.

Cognitive symptoms may worsen during first 48-72 hours due to cellular and metabolic changes.

Majority of pediatric cases with mild injury are back to baseline at ???

Physical Cognitive Emotional Sleep

Acute Phase (Injury – 3 days)

Post Acute (3 days-3 months)

Prolonged (PPCS) (> 3 months)

Activity restriction determined by extent of current injury, history of previous injuries, functional presentation of patient

Ongoing evaluation to inform treatment needs and monitor recovery trends

Rest Reduction of Stimulation Reduction of Exertion

› Physical, emotional & cognitive Modified Expectations

› Assessment of rehab needs› Education re care provider roles› Brief directed cognitive assessment

(EF, working memory, stim tolerance, endurance)

› Set and monitor activity restrictions› Support adjustment to activity limitations› Facilitate return to activity (and

stimulation)› Reintegration to school

What is Head Injury

Recovery Course and What to Expect

Symptoms & Management

Resources

Cognitive Rest Limit stimulation Time off from

school Reduction in work Educational

Accommodations (504,IEP)

Don’t panic 10-20% of pediatric concussions can

take 3 weeks or more HS athletes take twice as long as

college/professional athletes to recover (10-14 days vs. 3-7 days)

Younger kids take longer They will get better, even if it takes a

while

Psychosocial stress Bright kids Anxiety Depression Chronic medical

illness Difficulties at home

Learning disabilities ADHD Dyslexia

Previous history Concussions Headaches Family hx of HA

Sleep problems

Prior high standard of academic performance “Overnight” changes to functioning More time needed for homework/studying Frustration with current deficits Increased cognitive exertion exacerbates

symptoms Teachers/peers not aware b/c student at

grade level Student feels unsupported/deficits minimized At risk for depression/anxiety/pessimism re:

future

Headache- most common Makes concentration difficult Avoid triggers (e.g. lights, noises, subjects

(math, high level science, foreign language) Is this present at baseline Limit NSAIDs Focus on sleep Riboflavin, magnesium, fish oil Occasionally consider amitriptyline or neuro

referral

Dizziness/lightheadedness Vestibular system/sensory organization problem

Usually worsened by quick movements, video or hallwaysVestibular therapy

Lightheaded- sense that they may pass out with position changeMore problematic because of limited cerebral perfusion Light aerobic activity or exercise in lying positionCareful position changes

NauseaZofran

Neck strain- often present with head injurySometime can drive symptoms, even

cause dizzinessTreat with heat, PT, massage, even muscle

relaxers at times

Sleep disturbance – makes most symptoms worseCan’t fall asleep, wake up at night,

excessive nappingAffects ability to attend and focus, new

learning is difficult If you don’t sleep you can’t do anything

well, even without a head injuryTreat aggressively- sleep hygiene,

melatonin, sometimes other meds

Mental health Head injuries have a way of unmasking underlying

problems Depression, anxiety, conversion disorder Concussed kids lose coping strategies (high

performance in sports or school, exercise for stress relief, social interaction, video games)

Address and normalize what they are going through

Psychology referral when necessary

Difficulty with concentration and short term memoryOften most persistent symptomsSchool accommodationsPatience (often take months, reassuring

when there is a trend toward improvement)Often pre-existing learning issuesStimulants on occasionCognitive rehabilitationNeuropsychology referral

Need for education re management Presence of preinjury risk factors:

learning, attention, psychosocial Cognitive challenges School issues Change in behavior, mood, personality Undue parental, coach pressure re RTP Need for cognitive clearance for RTP

Collaborative effort between student, parents, educators, coaches, and health care professionals

Careful plan to facilitate transition/reduce risk of failure

Focus on individual student needs (current functional deficits, pre-existing risk factors, academic status)

Set clear goals with student

Close monitoring and feedback to student/parents

Adjust plan with recovery

Modifying the school schedule (reduced endurance, fatigue, processing)

› Reduced school day/late arrival

› More frequent breaks in school day

› Additional study period/study skills class

› Drop classes with significant new learning: foreign language, higher-level math and science classes (e.g., calculus, physics, chemistry)

Safety precautions(increased vulnerability,Increased distractibility)

› No PE

› No activities in gym or on playground

› No woodshop, auto mechanics, any class with risk of injury

› Early dismissal from class to avoid crowded hallways

Environmental accommodations (inattention, sensory sensitivity)

› Preferential seating

› Reduction of distractions

› Testing in a quiet environment

› Avoid noisy environments (e.g., cafeteria, assemblies)

› Rest periods in nurse’s office if headaches/fatigue

Adjusting requirements/grading (reduced cognitive resource, fatigue,

slowed processing)

› Forgive missed work

› Grades based on completed/representative work

› “Freeze” grades

› Assign incompletes

› Use pass/fail option

Modifying assignments (processing, attention, memory, learning)

› Decrease work load (e.g., length of spelling/ vocabulary word list, even or odd math problems)

› Use aides: calculators, computers, “cheat sheets”

› Assign peer note-taker

Modifying tests (processing speed, retrieval)

› Untimed testing option

› Open book, “cheat sheets,” note cards

› Recognition tests (multiple-choice, T/F)

› Assistance with first few steps/problems

Support for new learning

› Review of previously learned academics› New material/concepts presented in context of

familiar or already-acquired knowledge› New material/concepts broken down into small

chunks› Multimodal instruction› Repeated exposure to novel information› Frequent review of new material

Implement schedules, calendars, to do lists Maintain pictures/lists of assignments Break down large tasks Frequent reinforcement Provide concrete time limits and

communicate them directly (verbal, written, timer, task-based)

Frequent feedback, and redirection if needed

› Approximately 24 hours (or longer) in between each step› If symptoms, stop activity, rest until symptom-free 24 hours, return to previous

step› If symptoms increase, seek medical attention

1. Light General Conditioning Exercises (Goal: Increase HR)

2. Moderate General Conditioning and Sport Specific Skill Work Individually (Goal: Add Movement, individual skill work)

3. Heavy General conditioning, skill work individually and with teammate. NO CONTACT (Goal: Add Movement, teammate skill work)

4. Heavy General conditioning, skill work, and team drills. No live scrimmages. VERY LIGHT CONTACT. (Goal: Team skill work, light static contact)

5. Full Team Practice with Body Contact

Quick to administer Administration “standardized” Randomized forms Serial tracking of recovery with less

chance for practice effect Available to non-NP providers and can be

given in schools and office. Some higher measurement sensitivity.

What are we truly measuring?

Does less data lead to less ability to generalize findings?

Response type constrained by computer

Requires careful oversight of administration.

Athletes “dumbing down” baseline screens.

Increased risk for another TBI with more severe symptom presentation

Cumulative effects of repeated injuries

Potential catastrophic or fatal outcomes of repeated injuries within short time period

Increased risk of sustaining concussion

Longer recovery period from concussion

Rapid early recovery from moderate/severe TBI but…

Increased risk for

Alzheimer’s disease

Parkinson’s disease

Other brain disorders associated w/ aging

http://www.cdc.gov/concussion

Concussion is a multifaceted and complex functional injury.

Neurocognitive symptoms may be present which are not immediately evident during the first few days of evaluation.

Recovery course from concussion is variable with outcomes determined by previous risk factors, injury severity, past concussions and management.

Caution is warranted with all concussions and return to activity remains a medical decision which should be informed by ongoing attention to physical, cognitive, and emotional factors.

seattle pacific university educational series february 3, 2015 chris ladish, phd pediatric...

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