Concussions in the Pediatric Population: An Overview Cranford 4/27/11

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Concussions in the Pediatric Population An
OverviewCranford 4/27/11

• Dr. Joseph Rempson
• Co-Medical Director of the Atlantic
  HealthConcussion Center at Overlook Hospital
• Director of he Department of Rehabilitation at
  Overlook Hospital
• Atlantic Neurosurgical 310 Madison Avenue
  Morristown, New Jersey 07960
• Appointment 908 522-6395
• Office Tel [phone]
• Cell 973 908-1091
• E-mail rempson_at_msn.com

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Epidemiology

• 1.6 to 3.8 million sports and recreational
  mild traumatic brain injuries/year
• Closed head injury (Acceleration/Deceleration
  Injury)

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CONSEQUENCES AND AFFECT(Potentially Short and
Long Term)

• Academics
• Social Relationships
• Behavior
• Emotions

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• High school sports participation has grown from
  an estimated 4 million participants during the
  1971--72 school year to an estimated 7.2 million
  in 200506.
• 1.1 million played high school football in 2008
  and 2009 and 43,000 to 67,000 were diagnosed with
  concussion

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TABLE 1 Concussion Rates in High
School Sports Sport Injury Rate, per 1000 Athlete
Exposures Football 0.471.03a,b Girls soccer
0.36a Boys lacrosse 0.280.34c,d Boys soccer
0.22a Girls basketball 0.21a Wrestling
0.18a Girls lacrosse 0.100.21c,d Softball
0.07a Boys basketball 0.07a Boys and girls
volleyball 0.05a Baseball 0.05a
a Data from Gessel LM, Fields SK, Collins CL,
Dick RW, Comstock RD. Concussions among United
States high school and collegiate athletes. J
Athl Train. 200742(4)495503. b Data from
Guskiewicz KM, Weaver NL, Padua DA, Garrett WE.
Epidemiology of concussion in collegiate and
high school football players. Am J Sports Med.
200028(5)643 650. c Data from Lincoln AE,
Hinton RY, Almqueist JL. Head, face, and eye
injuries in scholastic and collegiate lacrosse
a 4-year prospective study. Am J Sports Med.
200735(2) 207215. d Data from Hinton RY,
Lincoln AE, Almquist JL. Epidemiology of lacrosse
injuries in high school-aged girls and boys a
3-year prospective study. Am J Sports Med.
200533(9) 13051314.
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All of the recent consensus statements on
sport-related concussions recommend a more
conservative approach to concussion management
for athletes under the age 18 than for older
athletes

• Third International Conference on Concussion in
  Sport, Zurich 2008
• The American College of Sports Medicine's 2006
  Consensus Statement on Concussion (Mild Traumatic
  Brain Injury) and the Team Physician
• National Athletic Trainers' Association 2004
  Position Statement Management of Sport-Related
  Concussion

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Why are kids different (theories) ?

• Brain tolerance to biomechanical forces differ
  between adults and children (2-3 fold force is
  needed to create similar symptoms in children)
• Immature brain may be 60 times more sensitive to
  glutamate-mediated N-methyl-D-aspartate
• (NMDA) one example an increase in
  intracellular calcium
• Significant neural development of the brain
  through the age of 15
• Second Impact Syndrome (felt to only occur in
  adolescence)

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Are Girls Different Than boys ? Some say Yes.
Still debated.

• Why are girls at increased risk?
• Neck musculature?
• Muscle mass in boys
• likely diminishes force
• transmission
• Susceptibility?
• Boys and girls brains are
• not the same
• More likely to report?
• Boys may be more likely
• to hide symptoms
• Also take longer to recover.

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On Field Evaluation
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On Field Evaluation

• SCAT 2
• SAC
• Maddocks Questionnaire
• Balance Error Scoring System (BESS)

• ABCs and cervical spine (most important)
• Basic neurologic exam is often normal
• Asking month, year, and day not sensitive.
• Symptoms can take up to 48 to 72 hours to fully
  manifest themselves.

• On field/sideline evaluation

• Dont forget

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Concussion Signs /Symptoms (may occur up to 3
days after a concussion)

• Headaches (pressure) 70
• Feeling slowed down (58)
• Poor concentration (57)
• Dizziness (55)
• Feeling Foggy (53)
• Fatigue (50)
• Visual blurring or double vision (49)
• Irritablity

• Light sensitivity (47)
• Memory Dysfunction (43)
• Balance problems (43)
• Increased sensitivity to loud noises
• Anxiety and/or depression
• Sleep disturbances
• Nausea
• Vomiting
• Feeling sluggish
• Seizure (on field)

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When Should I get a CAT Scan?
Neuro-imaging (CT) should be considered whenever
suspicion of an intracranial structural injury
exists. Signs and symptoms that increase the
index of suspicion for more serious injury
include severe headache seizures focal
neurologic findings on examination repeated
emesis significant drowsiness or difficulty
awakening slurred speech poor orientation to
person, place, or time neck pain and
significant Irritability. Any patient with
worsening symptoms should also undergo
neuroimaging. Patients with LOC for more than 30
seconds may have a higher risk of intracranial
injury, so neuroimaging should be considered for
them.
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• Grading Scales are not used !!!!!!!!!!
  Individualized care of each patient is now the
  standard of care !!!!!!

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Acute Concussion Management
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Management of Acute Concussion

• Baseline Neuropsychological testing
• Balance Error Scoring System (BESS)
• Cognitive Rest/Physical Rest !!!!!!!!!!!!!!!!!!!
• Symptom Free Repeat Neuropsychological Test when
  available
• Exertion Protocol (if no test available one
  suggestion is 1 week symptom free then start
  exertion NJSIAA 2010)

• Minimize medications (no evidence medications
  facilitate healing)
• Special groups for consideration Migraines,
  ADHD, learning disabilities, depression, and
  other underlying disorders
• Remember in children symptoms can resolve before
  neuropsychological testing returns to baseline
  (different than adults)

• Basic Management

• Consideration

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Treatment(Cognitive Rest)

• School
• Television
• Video Games
• Noise (ear plugs)
• Lights (glasses)
• Hanging out with friends
• Riding in a car
• Computers
• Going to games

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_____No gym class.   _____Restricted gym class
activity as specified below    _____Full
academic accommodations as specified
below _____untimed tests _____preprinted class
notes _____tutoring _____reduced workload when
possible _____frequent breaks from class when
experiencing symptoms _____modified
homework assignments _____extended time on
homework, projects _____Other   _____Additional
recommendations below    
Academic Modifications (Not a 504) for
cognitive rest in school.
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Exertion Protocol

• When returning athletes to play, they should
  follow a stepwise symptom-limited program, with
  stages of progression.
• Step 1 rest until asymptomatic (physical and
  mental rest)
• Step 2 light aerobic exercise (e.g. stationary
  cycle)
• Step 3 sport specific training
• Step 4 non-contact training drills (start
  light resistance training)
• Step 5 full contact training after medical
  clearance
• Step 6 return to competition (game play)
• There should be approximately 24 hours (or
  longer) for each stage and the athlete should
  return to the prior stage if symptoms recur.
  Resistance training should only be added in the
  later stages.

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Considerations for Kids

• Children shouldnt return to play until
  completely symptom free which may require a
  longer time frame than for adults.
• Cognitive rest was highlighted with special
  reference to a childs need to limit exertion.
• It is appropriate to extend the amount of
  asymptomatic rest and/or length of the graded
  exertion in children and adolescence.
• Children arent professional athletes?

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Post-concussion Syndrome
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Post-concussion syndrome (A clear definition for
postconcussionsyndrome does not exist)

• A recently proposed definition of post-concussive
  syndrome is the presence of cognitive, physical,
  or emotional symptoms of a concussion lasting
  longer than expected, with a threshold of 1 to 6
  weeks of persistent symptoms after a concussion
  to make
• the diagnosis.

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Symptom Scale (Pardini et al. 2004)N327, High
School and University Athletes Within 7 Days of
Concussion Cognitive Factor Analysis,
Post-Concussion
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A Few Treatment Options for Persistent Symptoms
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Low level exertion caN BE HELPFUL FOR ALL OF THE
ABOVE

• Gradual exercise may help restore brain
  auto-regulation
• Helps restore sense of self
• Not exercising changes the physiology of the body
• We start this about 4 to 6 weeks into the injury.
  We find this to be invaluable.

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Some Post Concussion Sequela

• Compared with similar students without a history
  of concussion, athletes with 2 or more
  concussions also demonstrate statistically
  significant lower grade-point averages.
• Three months after a concussion, children 8 to 16
  years of age have been found to have persistent
  deficits in processing complex visual stimuli.
• Headaches (which can be migraine like) can be
  debilitating and difficult to treat.

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504 Plan Academic Modifications

• Section 504 is a civil rights law that
  prohibits discrimination against individuals with
  disabilities. Section 504 ensures that the child
  with a disability has equal access to an
  education. The child may receive accommodations
  and modifications.

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Chronic Sequel a of Brain Injury Why does this
area cause such heated debate ?
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Chronic Traumatic Brain Injury

• CTE
• Depression
• Alzheimer's

• Zurich 2008 (3rd international conference)
• Epidemiologic studies have suggested an
  association between repeated sports concussions
  during a career and late-life cognitive
  impairment. A panel discussion was held and no
  consensus was reached on the significance of such
  observations at this stage.

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Un-named Athlete (18 years old)
18 yo HS athlete - 2 documented
concussions in football - Multi-sport
athlete - Early CTE changes on
autopsy
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Owen Thomas (21 years old)
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Journal of Neurotrauma 2010 - Functionally-Detecte
d Cognitive Impairment in High School Football
Players Without Clinically Diagnosed
Concussion. Under Peer Review

• With the use of the HIT system, Impact testing,
  and fMRI they tested 11 high school football
  players ages 15-19. They found 3 categories of
  players
• 1) No diagnosis of concussion and no change in
  clinical behavior. (4 patients)
• 2) Diagnosis of concussion and a change in
  clinical behavior. (3 patients)
• 3) No diagnosis of concussion, but a change in
  visual working memory and fMRI (altered
  activation in the dorsolateral prefrontal
  cortex). Greater number of hits to the top of
  the head in this category. (4 patients)
• Small sample size so must be careful how to
  interpret !!! However, raises questions.

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References

• Halsted M, Walter K. Clinical Report Sports
  Related Concussions
• in Children and Adolescents. Pediatrics 2010
  3 597-615
• McCrory P, Meeuwisse W, Johnston K, Dvorak J,
  Aubry M, Molloy M, Cantu R. Concensus statement
  on concussion in sport The 3rd International
  Conference of Concussion in sport, held in Zurich
  November 2008
• McDonald JW, Johnston MV. Physiological
  pathophysiological roles of excitatory amino
  acids during central nervous system development.
  Brain Res Rev 1990 1541-70
• Omaya AK, Goldstein W, Thibault L. Biomechanics
  and neuropathology of adult and pediatric head
  injury. Br J Neurosurg 2002, 16 (3) 220-242
• Talvage T, Nauman E, Breedlove E, Yoruk
  Functionally-Detected Cognitive Impairment in
  High School Football Players Without Clinically
  Diagnosed Concussion. Journal of Neurotrauma.
  Submitted by Author 9/27/2010. For Peer Review
• Leddy J, Kozlowski K, Fung M. Regulatory and
  autoregulatory physiological dysfunction as a
  primary characteristic of post-concussion
  syndrome Implications for treatment. NeuroRehab
  2007, 22 199-205