1 post-concussion syndrome and return to school csms conference april 28, 2015 michael a. lee, md...
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POST-CONCUSSION SYNDROMEand RETURN TO SCHOOL
CSMS Conference April 28, 2015
Michael A. Lee, MDStaff Physician; Connecticut Children’s Medical CenterAttending Physician Pediatrics; Yale University
CCMC – Fairfield Satellite Office Member, Connecticut Concussion Task ForceCharter Member, AMSSMMember, AAP-COSMF, Former Chairman, CSMS Committee on Medical Aspects of Sports Former Editor, SPORTSMed Newsletter
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OverviewPost-concussion Syndrome – signs, symptoms,
physical findings and managementRecovery process (as affects school) and different
adjustmentsFemale concussionsADD
Disclaimers: I have had one concussion I have no financial disclosures I will not discuss unapproved or off label products or their uses
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Concussions:
They are a part of playing sports at all levels and also occur in non-sports activities and MVAs.
One of the most discussed problems in US sports media coverage today
Very difficult to manage especially when the symptoms are prolonged.
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A Decade of Change…
“Congress draws needed attention to concussions” Hearings put pressure on NFL to act
Former NFL Players Call for Concussion Education: Congressional Hearing Reveals Education Needed at all Levels
Girls have a higher rate of concussion
than boys, particularly in similar sports
Lincoln, et.al., Am J Sports Med 2011; Giza, Kutcher, et al., Neurol 2013
FEMALE CONCUSSIONSTend to be worse and last longer
Likely related to weaker neck muscles
Related to more migraine headaches
Females have, compared to males:
25% less head neck segment mass
5% less head-neck segment length
12% less neck girth
50% less isometric neck flexor strength
53% less isometric neck extensor strength
44% greater head acceleration after contact
CHEERLEADINGOften is not considered a sport, YET
50% of deaths in college woman’s sports
Seem to have more PCS and are more difficult to manage in my experience
ISSUES IN CONCUSSION CARE
Focus has been on return to play (sports)
Schools don’t understand the need for assistance to students after a concussion
It is not a visual diagnosis Lack of understanding by health care
professionals on what are the best ways to assist a student following a concussion
How long does it take to recover from a
concussion?
Less than a week? AAP CT 2-3 days?Sports authorities say less than a week
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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
All Athletes No Previous Concussions 1 or More Previous Concussions
N=134 Concussed High School Football Players
WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5
40%RECOVERED
60%RECOVERED
80%RECOVERED
Collins et al., 2006, Neurosurgery
3 Year Prospective Study of 17 High School Football Teams N=2,141
Individual Recovery From Football-Related mTBI: How Long Does it Take?
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Recovery: fMRI Subsample (UPMC Program)Lovell et al;
Mean Age: 16.2 yrs
Gender: 78% male
Days to Recover
Range: 4 – 211 days
Mean = 26.2 days
Cumulative Percent Recovery
15 days – 25%
26 days – 50%
45 days – 75%
92 Days – 90%N = 208
Will now focus on the 20% who do not recover rapidly and review how their
concussion impacts their school performance.
Students who cover quickly usually do not require the many adjustments PCS
students need
Definition of Post-Concussion Syndrome
Concussion symptoms lasting more than 3 weeks
This is the time when treatment is usually started
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Symptoms of PCS Headache Foggy and slowed down Dizziness (spinning) Ocular problems Balance Problems Concentration Memory Sleep Psych symptoms Neck symptoms
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Headache Most common sx of concussion & PCS Initially constant, steady “pressure feeling” Then headache comes and goes, is dull/achy
at rest and becomes throbbing with activity Doing cognitive/physical activity for more than
10-20 minutes increases headache. Need to take breaks every 10-20 minutes History of migraines increases risk of
prolonged recovery
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Feeling Foggy and Slowed Down
Hard to define Brain feels like computer with a virus
like your head is under water like a regular TV and not HD TV like your head is in a cloud
When this resolves patient often wakes up one morning and says “Wow, I am better”
Headache usually resolves within 1-2 days after this symptom resolves
Dizziness Spinning when stand up (room
around patient or patient around room)This is different than just lightheadedness
Difficulty with heights, moving crowds, stores, spiral staircases & busy patterns
Heights cause dizziness Incr. awareness of normal motion Bothered by busy patterns
Suggestive of vestibular problems22
Ocular Problems
Blurry, foggy vision Light sensitivity (fluorescent light
bother them) this sometimes is last sx to resolve.
Difficulty reading, depth perception off
Seeing double (suggestive of an eye convergence problem)
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Balance Problems
Difficulty with balance
in a dark room Hard to maintain balance
on stairs Bang into walls
Concentration and Memory Difficulty focusing and can only read or be
on the computer 10-15 minutes before symptoms increase
Can’t remember what they hear or read and have difficulty learning school work.
Repeat themselves, lose their train of thought, forget what they say
in conversation.
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Sleep Symptoms Altered sleep will delay recovery. Have trouble falling
asleep or staying asleep Do not allow to sleep all the time after the first one to
two days No naps after the first two days Maintain sleep pattern present prior to the concussion
(same wake-up and bedtime schedule). Blue Light Blocking Glasses (orange-tinted glasses) No LED screens (TV, smart phone computer monitor, tablets)
Psychiatric Symptoms
Irritability is usually present early on If psychiatric symptoms were present pre-
concussion, they often become worse. Depression due to pre-existing condition or
not being able to attend school or sports. Anxiety is common. (Will I ever recover?) (especially with vestibular issues)
Neck Pain and Spasm Need to examine the neck in
any patient with a concussion.
Prolonged concussion headaches may be related to neck pathology.
Tingling or numbness in extremities may be an indication of neck pathology
START NECK PT ASAP29
Physical Findings of PCSLightheadedness with rapid lateral and
horizontal eye movements
Diagnostic of concussionDisappears around the time when the feeling
foggy and slowed down resolves
Vestibular System Overview
• Peripheral Vestibular System • Semicircular Canals
• Otoliths: Utricle and Saccule • Vestibular Ganglia • Vestibular Nerve
• Central Vestibular Projections • Vestibular Nuclei
• Cerebellum • Autonomic Nervous System
• Thalamus • Cerebral Cortex
Function of Vestibular SystemSTABILIZE VISION WHILE HEAD MOVES
Normal VOR:Able to maintain focus on stationary object
while moving head without loss of visual focus or dizziness
Physical Findings of PCS
Eye convergence difficulty Near point of conversion should be less
than 6 cm (normal is 0-6 cm.) Usually resolves on its own Sometimes may need exercises or prism
glasses if persists greater than 3-4 weeks (can be cause of persistent headaches
when reading).
Physical Findings of PCS
Abnormal balance findings Difficult to assess without a baseline Most helpful to use at time of the injury for
making the diagnosis of a concussion Appears to resolve more quickly than other symptoms following a concussion. (Catena 2011, Guskiewicz 2003)
TOOLS USED TO ASSESS PCS
Neurocognitive testing (ImPACT)
MRI of head sometimes needed
Full neuro-cognitive testing by a neuropsychologist (expensive, often not covered by insurance)
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Neurocognitive/psych testing Zurich conference emphasized role of testing
“In the absence of NP and other (e.g. formal balance assessment) testing, a more conservative return to play approach may be appropriate.”
“Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance”
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VALUE OF ImPACT CLINICALLYFinds patients with extremely low scores (low single digits on all parameters) who
are more likely to develop Post-Concussion Syndrome
Shows when patients are not following activity restrictions because the scores
decrease on serial testing
Tells how long it takes to have cognitive fatigue and later finds patients with memory loss or overdoing activity
Predicting Who Will Develop PCS Patients with Vestibular findings Multiple blows at time of or around injury Extremely low scores on neuro-cog testing Previous Post-concussion Syndrome History of migraine headaches Motor Vehicle Accidents (especially females) History of ADD Compulsive, type A excellent student
Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players
Lau, Kontos, Collins, AJSM 2011
On-Field Marker N Chi2 P Odds Ratio
95% Confidence Interval
Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42
Retrograde Amnesia 97 .120 0.729 1.179 0.46-3.00
Confusion 98 .114 0.736 1.164 0.48-2.82
LOC 95 2.73 0.100 0.284 0.06-1.37
On-Field Symptom N Chi2 P Odds Ratio
95% Confidence Interval
Dizziness** 98 6.97 0.008 6.422 1.39-29.7
Headache 98 0.64 0.43 2.422 0.26-22.4
Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63
Visual Problems 97 0.62 0.43 1.400 0.61-3.22
Fatigue 97
0.04 0.85 1.080 0.48-2.47
Balance Problems 98 0.28 0.59 0.800 0.35-1.83
Personality Change 8 0.86 0.35 0.630 .023-1.69
Vomiting 97 0.68 0.41 0.600 0.18-2.04
The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.
**p<.01
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SECOND BLOWS TO THE HEAD
37 athletes had a second blow to the head within 2 weeks of the first blow. No case of Second Impact Syndrome occurred.
25 Males and 13 developed PCS (52%) 12 Females and 8 developed PCS (67%)
Lee and Fine. CT Medicine 2010
Since most concussion symptoms usually will resolve
by 3 weeks, no treatment is usually necessary prior to that
time (except for neck PT)
Every patient’s treatment needs to be individualized
IT TAKES A VILLAGE TO HELP SOME PATIENTS RECOVER FROM THEIR CONCUSSION
PT neckVestibularSCHOOL FAMILY OCULAR PSYCHNEURO-PSYCH
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Post-concussion Syndrome(Patterns possibly requiring medication)
Emotional IssuesDepressionIrritability
More emotionalNervousness Thinking issues
Attention problemsDifficulty with memory
“Fogginess”Cognitive Slowing
Fatigue
Physical IssuesHeadachesDizziness
Balance difficultiesLight and noise Sensitivity
Visual problems Nausea Sleep Issues
Difficulty falling asleepSleeping less than usual
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Post-concussion Syndrome
Emotional IssuesSSRI: LexaproZoloft/Prozac
XanaxKlonopinTherapy
Thinking IssuesNeurostimulants
Amantadine Amphetamines
MehytlphenidateStrattera
Physical IssuesAmitryptaline (Elavil)
NortryptalineTopamax/DepakoteVestibular therapy?
GabapentinPropanalol (?NCAA)
Sleep IssuesMelatoninTrazedone
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Headache ManagementKeep the dull and achy headache from
becoming pounding and throbbing.
Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache.
Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms
Tylenol as needed (Ibuprofen after a few days)
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Headache ManagementKeep the dull and achy headache from
becoming pounding and throbbing.
Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache.
Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms
Tylenol as needed (Ibuprofen after a few days)
EXERCISE
May start to exercise lightly after 2-3 weeks even with mild headaches.
No impact activities, limit head movement (elliptical or exercise bike initially) Start off very slowly (few minutes) and gradually
increase. Can do multiple times a day. Leddy et al, Exercise treatment for PCS J Head Trauma Rehabil. 2013 Jul-Aug;28(4):
SCHOOL
Students recover quickly during Christmas, Spring and Summer vacations
Need to remember (remind parents) the first priority is to get kids back to school ASAP. Sports is a secondary priority!
Different than other medical conditions causing school absence
Can’t see the problem
Only condition where you are unable to perform cognitive functioning needed to do school work
The return to school is a very critical time. If cognitive work is overdone, or
increases inappropriately, the concussion symptoms will return,
sometimes almost as much as right after the injury.
Sady, Phys Med Rehab Clin N Am 2011: Howell, MSSE, 2013
SCHOOL ADJUSTMENTS(when they return to school)
X + X = 2XExcuse all non-essential school workNo double workload – make-up work and new work
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SCHOOL ADJUSTMENTS
Goal: Get the most out of the school day without worsening the symptoms.
Optimize learning without creating quick fatigue.
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SCHOOL (initial return)Sleep in, Leave early
Alternate AM and PM classes to cover all(? Initially avoid Math, Chemistry, Foreign Language)
Need to be driven to school initially(should not ride the school bus)
Elevator passes if stairs (unless this makes them “dizzy”)
Rest periods after 30-45 minutesDon’t let student go to all “hard” classes!
Some classes easier than others – ask!No gym class or exercising initially
(are not to be allowed in P.E. class)
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Trial and error needed (balancing act)
1 period, ½ day, full day
Go to nurse’s office when HA increases
Frequent breaks with rest periods
Alternate class with rest period
Gradually increase hours
No extra-curricular activities or job
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SCHOOL (initial return)No note taking (may need scribes)
Pre-printed class notes helpful
(should be sent home while not in school)
Listen to lectures only
Audio books helpful
Limit computer time
Avoid videos in class
Tutoring may be needed to help catch up
SCHOOL (initial return)
Workload may need to be reduced 50-75%
Progress to homework when no symptoms
Homework less than 1-2 hours a night
Frequent breaks while doing homework
Term papers postponed or forgiven
It is imperative that the student advocate for his/her needs. If an increasing headache develops
they should not stay in class but should go to the nurse’s office.
They can rest there (skip a period and try another class if the
headache resolves). If it returns they need to go home.
HEADACHE
Most common symptom of concussion Can distract student from concentration Can vary throughout the day and may be
triggered by various exposures, such as fluorescent lighting, loud noises, reading, focusing or tasks
Math, Chemistry Foreign Language seem to cause headaches to occur more than other subjects
HEADACHE ADJUSTMENTS
Identify triggers and reduce their exposure Frequent breaks Rests, planned or as needed in nurse’s
office or other quiet area Give student class notes Allow student to put head down in class
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NOISE SENSITIVITY AT SCHOOL: Hallways Lunch room Music classes (band/choir) P.E. classes Shop classes, Organized sports practices
Should not listen to loud music (especially in cars or on I-pods)
Should avoid attending dances, parties, music concerts and sports events until symptoms are gone
NOISE ADJUSTMENTS
Allow use of ear plugs as needed Leave class 5 minutes early to avoid hall
noise Quiet area to do work Lunch in a quiet area with a classmate Avoid/limit music, shop and P.E class Avoid noisy gym and team/sports practice
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VISUAL PROBLEMS LIGHT SENSITIVITY, BLURRY/DOUBLE VISION
AT SCHOOL: Artificial lighting Smart boards, slide presentations Computers, Handheld computer tablets Movies
Sunglasses may be necessary if photophobia is present (outdoors and sometimes indoors)
Avoidance of bright sunlight and exposure to flashing lights (strobe/computer games)
No movie theaters (loud noise and bright flashing lights)
VISUAL ADJUSTMENTS
Allow sunglasses to be worn in school Reduce exposure to computers, smart
boards and videos Reduce brightness on screens Turn off fluorescent lights as needed Consider use of audiotapes of books
CONCENTRATION and MEMORY ISSUES
Difficulty learning new tasks and comprehending new material
Difficulty with recalling and applying previous learned material
Difficulty with focusing and attention Problems with test taking, especially
longer more standardized tests
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SCHOOL TESTS IS TESTING IN A BRAIN INJURED STUDENT VALID?
Quizzes, tests, PSAT/SAT, ACT tests, mid-terms, final exams may need to be delayed/postponed.
TESTS ONLY AFTER STUDENTS CATCH UP ON SCHOOL WORK!!Tutoring in school may be needed to help catch up
Extra time (un-timed tests) may be necessary when test taking is resumed. May need to take breaks. Tests
may need to be taken over multiple sessions.
No more than one test a day when test taking resumed.
Initially, if test results are poor, they should be voided or retaken.
SCHOOL TESTS (cont.)
If significant concentration and memory problems are present:
May need reader for exams
Oral exams may be necessary (or if students develop headaches taking written tests).
Consider having students do take home tests so they can catch up quicker.
Open book tests may be needed for some students (especially if memory issues are present)
PROLONGED SCHOOL ABSENCE
After 2-3 weeks of missing school it is important to let students go to school for a brief period in order to see their friends, even if they are unable to do any school work.
(Should do no cognitive work)
Very Prolonged PCS School Issues
What if student can’t attend school and has to stay home and both parents work, who takes care of the student?
If home tutoring is needed will the school allow it to be done in blocks of time followed by a break?
Some schools may require tutoring to be done in school only.
If go to school for one period do you lose home tutoring?
Very Prolonged PCS School IssuesIsolation - Students need to see friends (Will the school allow brief visits to school-one period a day?) How to manage school with multiple rehab/physician visits.
Taking students out of honors/AP classes
Who pays for needed neuro-cognitive testing?
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No spinning carnival rides and no boating in rough seas until concussion is completely
resolved.
Recommendation: No carnival rides for 3 months (perhaps never if vestibular findings)
No chiropractic adjustments
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ADHD Prevalence is Up Among Older Children
Among youth aged 12-17 years ADHD increased by 4% annually from1997-2006.
No increase in those aged 6-11 years.
Thought to be due to a greater awareness of clinicians in diagnosing this condition
Audrey Kubetin, Pediatric News, August 2008, Vol. 42 Issue 8
ADHD Related to Longer Lasting Head Injury?
ADHD patients compared with non-ADHD patients after a concussion.
25% had moderate disability and 56% recovered after 6 months
vs
2% in normal group had moderate disability and 84% recovered after 7 weeks
Stephanie Greene, M.D, Journal Neurosurgery:Pediatrics 6/25/13
Although not statistically significant, youth athletes with ADHD took on average 3 days longer to return to baseline neurocognitive testing
compared with a control group without ADHD.Mautner,et al., Cliniclal Journal Sports Medicine Nov. 2014
DILEMMAShould an athlete who never had ADD
symptoms prior to a concussion be allowed to continue to play contact sports if ADD symptoms develop and persist after
the concussion?
Each athlete needs to be evaluated individually.
There is no magic number as to how many concussions are too many.
Return to play should probably be guided by symptoms and neuro-psych testing regardless of the number of concussions.
If it takes exceedingly longer to recover from each concussion or PCS occurs, perhaps it may be time to do a non-contact sport.
Do you allow fewer concussions in youngsters
( What if 3 or 4 concussions before age 12?)