Concussion in the Pediatric Population

Dr. Michael Vassilyadi Children’s Hospital of Eastern Ontario (CHEO)

ThinkFirst Canada

Pensez d’Abord Canada

April 2012thinkfirst.ca

Head Injury and Concussion Education Webinar Series

Before we begin…The information contained in this presentation is intended for

educational purposes only and is not meant to be a substitute for appropriate medical advice or care.

If you believe that you or someone under your care has sustained a concussion we strongly recommend that you contact a qualified health professional for appropriate diagnosis and treatment.

The collaborators have made responsible efforts to include accurate and timely information. However the individuals and organizations listed on this website make no representations or warranties regarding the accuracy of the information contained and specifically disclaim any liability in connection with the content of this presentation.

thinkfirst.ca

Questions to Answer Today:

What is the management and return to play recommendations for children with concussions?

What are the concerns with concussions? How can I help my child cope and manage

with return to life, school and sport? What are the potential chronic symptoms?

thinkfirst.ca

What is the leading cause of death for Canadians

under 45 years of age ?

INJURY!

Unintentional Injuries and Children

Very serious public health issue Imposes a heavy burden on the healthcare

system Leading cause of death among children 1-14

years of age Injury accounts for 14% of hospitalizations

Second-ranked cause of hospitalizations

Most common examples of unintentional injuries are falls, motor vehicle collisions, fires, and poisonings

Falls Largest cause of traumatic head injuries

among children and youth Occur primarily through sports and

recreational activities300,000 sport-related concussions each year

Unintentional Injuries and Children

Children and their Brain

The brain is surrounded by cerebrospinal fluid, which helps buffer the brain during movements

The brain is surrounded by a membrane and encased by a skull with the thickness of 1-2 pennies in children and up to three pennies in adults

thinkfirst.ca

What’s so special about the BRAIN?

The brain is made up of billions of neurons

The communications between neurons are how we think, move and feel

Neurons don’t grow back

This is why PREVENTION is the only cure for Brain and Spinal Cord Injuries

thinkfirst.ca

Traumatic Brain Injury (TBI)

Affects up to 2% of the population/year Major cause of death and severe disability Two causes

Impact damage (primary injury) Secondary injury

Develops after the impact Progression of hemorrhage, cerebral swelling,

decreased brain perfusion because of shock

thinkfirst.ca

thinkfirst.ca

Top Causes of Concussions

Females

Soccer Horseback Riding Cycling Ice Hockey Snowboarding

Males

Ice hockey Cycling Football Soccer Snowboarding

thinkfirst.ca

Sports Related Concussions

thinkfirst.ca

Concussion and the Brain:What goes on?

A concussion affects the brain at the cellular level

A blow to the head starts a neuro-metabolic cascade in the brain

thinkfirst.ca

Concussion and the Brain:What goes on?

thinkfirst.ca

Concussion and the Brain:What goes on?

thinkfirst.ca

Summary of Changes at the Cellular Level

Injury causes increased energy demand Restricted blood flow and oxygen debt

causes an ENERGY CRISIS Exhausted neurons leads to mental

confusion and failed memory Brain may take DAYS to WEEKS to restore

the chemical balance that constitutes recovery

Medical Attention

Required when: Loss of consciousness Seizure activity Severe headaches Confusion Nausea/ vomiting Diplopia Neurological deficit

thinkfirst.ca

Physician Advice with Mild Head Injuries

Do not return to play: If there are any persisting symptoms If there are any neurological deficits If there are any diagnostic imaging abnormalities

Once symptoms have resolved then may proceed with “step-wise return to play” protocol.

Stepwise Return-to-Play Protocol

Step 1 Complete rest, no activity

Step 2 Light exercise, such as free play, walking or

stationary cycling, for 10-15 min Step 3

Sport-specific activity for 20-30 min. (eg., skating in hockey, running in soccer)

Stepwise Return-to-Play Protocol

Step 4 “On field” practice with no contact

Step 5 “On field” practice with body contact, once cleared

by a physician Step 6

Game play

Concerns with Concussion

1. Second Impact Syndrome

2. Post Concussion Syndrome

thinkfirst.ca

Second Impact Syndrome

Symptoms may be worse Headaches, dizziness, visual

impairment, nausea, vomiting, balance problems, etc.

There is a period of time that the brain is more susceptible to a second injury

thinkfirst.ca

Young athletes with SIS are more likely to experience: post traumatic amnesia a disturbance in mental

status after each new injury

score lower on memory tests

The young brain loses its ability to autoregulate its blood supply which leads to vascular engorgement, marked increase in intra-cranial pressure, brain herniation and ultimately coma and death.

thinkfirst.ca

Post Concussion Syndrome

Collection of symptoms as a sequel to a head injury

Contribution of psychological factors Conversion reaction Secondary gain

Attention, financial reward, drug seeking,…

thinkfirst.ca

thinkfirst.ca

Symptoms of Post Concussion Syndrome

Decreased processing speed Short-term memory impairment Concentration deficit Irritability/ depression Fatigue/ sleep disturbance General feeling of “fogginess” Academic difficulties

thinkfirst.ca

Concussion in Children vs. Teen Athletes

Concussions represent an estimated 8.9% of all high school athletic injuries

Data is significantly lacking about concussions in grade school and middle school, athletes

Girls are reported to have a higher rate of concussions than boys in similar sports

Elementary School Aged Children

Continuing development of bodies and brain

At this age, connections between the 2 hemispheres of the brain are talking to one another

Brain injury during this period may interrupt development of critical cognitive and communication skills

thinkfirst.ca

If symptoms persist and are left untreated…

Teachers and family may notice increased irritability

School work may begin to suffer Behaviour may be attributed to

factors other than the head injury If the child continues to experience

problems, it could lead to depression or “acting out”

At risk for academic and social difficulties

At risk for further brain injury

thinkfirst.ca

Stages of Concussive Injury

Acute Concussion:Physical symptoms

(headache ,nausea)Cognitive deficits

(memory problems, concentration)Emotional disturbances

(irritable, mood swings)

Prolonged Post Concussion Syndrome:

Symptoms lasting >6 mosLower concussion threshold

Diminished athletic performanceDiminished school or work performance

Post Concussion Syndrome:Persistent concussion symptoms

Lasting 1-6 weeks after mTBISelf-limiting

CTE:Latency period (usually 6-10 yrs)

Personality disturbancesEmotional lability

Personal relationship failuresDepression

Alcohol/substance abuseSuicide attempt/completion

thinkfirst.ca

Importance of REST

Brain’s response to concussion is to want to rest

Rest allows the brain to use available energy to recover

Rest allows for symptoms to lessen Use of energy for other activities will increase

symptoms and delay recovery

thinkfirst.ca

Return to School Recommendations

Little to no headache Start with half days No immediate testing Limit homework to small blocks of time as

tolerated Allow to go to health room to rest if headaches

returns Allow to go home if headaches persist Allow for an appropriate time to make up work

Possible School Accommodations

Decreased homework load Allow for untimed testing as needed Tutoring may be needed with prolong PCS or

home schooling Use elevator in school if available Allow to use teacher’s notes or photocopy

classmates notes

Possible School Accommodations

If photophobic, use of sunglasses or hat as needed

May provide with pass to leave early from class to avoid crowded or noisy hallways

NO Physical Education class Eat somewhere other than cafeteria

Prevention

Regardless of the steps taken to prevent injury, some athletes will continue to be injured

The severity of the injury can be mitigated by the following:

1. EDUCATION for officials, referees, coaches, trainers, parents and athletes to :

a. Recognize the symptoms of concussion

b. Remove the athlete from play

c. Refer the athlete to a physician

thinkfirst.ca

2. Wearing the protective equipment appropriate for the sport engaged in:

a. Equipment should fit properly

b. Equipment should be well maintained

c. Equipment should be worn consistently and correctly

3. Athletes should follow their coaches’ rules for safety and the rules of the sport

Prevention

thinkfirst.ca

4. Teach your child/teen that it is not smart to play if they had an injury

It is not a badge of honour to play injured Discourage others from pressuring injured athletes to play Don’t let your child/teen convince you that he/she is “just

fine”

5. Tell all of your child/ teen’s coaches about any concussions they may have suffered in the past

6. Provide reassurance, support and request academic accommodations as needed

Prevention

thinkfirst.ca

Concussion Research Project

There is a need to both track and manage children with post concussion symptoms

One year pilot project Approved by the Research Ethics Board Use of ImPACT program, as well as

Neuropsychology assessments when necessary

http://www.impacttestonline.com/impactdemo/

thinkfirst.ca

CHEO CRP- Referral Criteria

Physician referral is required The patient is between the age of 10-17 Injury is sport-related The patient has post-concussion symptoms

3 months post-injury The concussion occurred within the last year

thinkfirst.ca

ImPACT Test

Tool to assess Functional Damage caused by concussion Measures multiple aspects of cognitive functioning in athletes,

including: Attention span Working memory Sustained and selective attention time Response variability Non-verbal problem solving Reaction time

Used by professional sports organizations, Universities, colleges in the US (over 900 schools)

Helps coaches, trainers, doctors, parents and athletes determine when to return to play and with school accommodations

Concussion Research Project - Questions

1. What is the severity, frequency and duration of symptoms in children who have sustained a traumatic brain injury while playing a sport and who remain symptomatic greater than three months following their injury?

2. What is the relationship between symptom experience, socioemotional functioning and health-related quality of life in this population?

3. What prognostic indicators can be identified for children at high risk for prolonged symptomatology?

Pilot Study Findings - May 2011 to Present

15 children who sustained sport-related head injuries and remained symptomatic at three months following their injuries, agreed to participate in a Concussion Research Project

Approximately twenty other children were assessed but did not meet all of the inclusion criteria for inclusion in the pilot study

CRP- Pilot Data n=15

Children ranged in age from 12 to 17 Ten males and five females participated Total number of concussions per patient ranged from

1 to 4, with a median of 2 11 of the 15 patients had at least a second

concussion 5 of the initial concussions resulted from hockey (in

all but one of these cases a helmet was worn) Others were from gymnastics, martial arts, rugby, BB

running, snowboarding (a helmet was worn), soccer

CRP- Pilot Data

The number of symptoms following the first concussion ranged from 0 to 20, with a median of 10.5, whereas for the second concussion the range was 6 to 23, with a median of 13.5

The number of moderate to severe symptoms following the first concussion ranged from 0 to 19, with a median of 5, whereas for the second concussion the range was 3 to 21, with a median of 11.5.

Symptom # Pts with Symptoms

Mild (%)Moderate To Severe

(%)

headache 10 13 53

poor concentration 9 20 40

memory problems 8 13 40

sensitivity to light 8 27 27

irritability 7 7 40

trouble falling

asleep

7 13 33

poor balance 7 27 20

drowsiness 7 13 13

feeling in a fog 6 13 27

sensitivity to noise 6 13 27

vacant stare/glassy

eyes

6 13 27

feel slowed down 6 20 20

thinkfirst.ca

Thank You!

Acknowledgements

Funding Public Health Agency of Canada Grant

Content CHEO ThinkFirst Foundation of Canada – Concussion

Education and Awareness Committee ThinkFirst Foundation of Canada Staff Elaine Keunen – ThinkFirst Hamilton

thinkfirst.ca