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Concussion and TBI in Children - What Pediatric Dentists should know

Gerard A. Gioia, PhDChief, Division of Pediatric Neuropsychology

Children’s National Health SystemProfessor, Depts. of Pediatrics and Psychiatry & Behavioral Sciences

George Washington University School of Medicine

Disclosure Statement

Psychological Assessment Resources, Inc.

– Test Author (royalties)

• Behavior Rating Inventory of Executive Function (BRIEF)

• Tasks of Executive Control (TEC)

Many other tests & measures (no royalties)

1.Define concussion, signs & symptoms, underlying neuropathophysiology

2.Describe screening, assessment methods for diagnosis

3.Articulate specific issues of concern for pediatric dentist

Objectives

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Mild TBI 15-20 Years Ago

• Little understanding of mTBI

• Few treating healthcare providers

• Few medical tests or tools

• Minimal research/funding

• Little public awareness of risks

• No rules to protect athletes

CONCUSSION 101

WHAT DO WE KNOW?

Evolution of Concussion Knowledge

20012004200820122016

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What is a concussion?

• A bump, blow, or jolt to the head or body that causes the brain to move rapidly back and forth

• Causes stretching of brain, causing chemical changes, and cell damage

• Causes change in how brain works (signs and symptoms)

• Once these changes occur, brain is more vulnerable to further injury and sensitive to increased stress

Brain Motion...

Joel Stitzel, jstitzel@wakehealth.edu

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Neurometabolic Cascade Following Traumatic Brain Injury

2 6 12 20 30 6 24 3 6 10

minutes hours days

500

400

300

200

0

50

100

% o

f n

orm

al

K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

Effects of Concussive Forces on the Brain

• Typically, the “software” of the brain is affected – Neurometabolic/ neurochemical processes

– Physiological

• Not the “hardware”– Structure

Anatomical Timeline of a ConcussionDefining the Key Factors

LOC<10%

Antero-grade

Amnesia25-40%

Pre-InjuryRisks

Retro-grade

Amnesia20-35%

Cognition, balancePost-Concuss Sx’s

Sec-Hrs Hours - Days - Weeks+Sec-MinSec-Hrs

A. Injury Characteristics B. Symptom AssessmentC. Risk Factors

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Signs of a Concussion(What you observe)

Cognitive• Appears dazed/stunned• Confused about events

(assignment or position)• Answers questions more

slowly• Repeats

questions/forgets instruction or play

• Can’t recall events prior to or after the hit/fall

Physical• Vomiting• Loses consciousness• Balance problems• Moves clumsily • Drowsy

Behavior/Emotion• Behavior or personality

changes

Symptoms of a Concussion(What they feel and report)

Physical• Headache

• Fatigue

• Visual problems(blurry/double)

• Nausea/vomiting

• Balance problems/ dizziness

• Sensitivity to light/noise

• Numbness/tingling

Sleep • Sleeping more/less

• Trouble falling asleep

• Drowsiness

Cognitive • Mental fogginess • Difficulty concentrating • Difficulty remembering• Feeling slowed down

Emotional• More emotional• Irritable• Sad• Nervous

Concussion Effects

Injury

Effects

Vestibular

P.T. MigraineCognitive

Emotional

Ocular Motor

Fatigue

Sleep

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Concussion History

CDC Toolkits: 1990s+

5 international CIS meetings 2001-2016

Vienna, Prague, Zurich x 2, Berlin

AAP Clinical Report 2010

IOM Report (2013)

AAN evidence-based review/rec’s 2013

TEAM 2015

CDC evidence-based review/rec’s 2016

NIH pediatric concussion workshop 2016

Concussion’s Medical NeighborhoodConnected Care

Injury

Point of Entry

Emerg Dept

Urgent Care

Primary Care

Primary Care

Continued Care “Typical”

Continued Care“Atypical”

Specialty Care

Rehabilitation Services

1. Safety2. Managed Return to Activity

SchoolPhysical/Recreation/Sports

Social

Athletic Trainers

Parents/Coaches/ Group Leaders/

Peers (R&R)

Pediatric Dentist

Berlin 2016

Duration/ Prognosis

Assessment Tools

Treatment

School Management

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Research literature is still limited with respect to understanding concussion recovery outcomes across full age range, and for boys and girls (IOM, 2013).

Be careful about expecting “7-10 days” for recovery.

Largest pediatric study (Zemek et al., 2016; n>3,000; age 5-18) indicates 70 +/-% symptom recovery within 4 weeks.

Epidemiology of RecoveryOur Best Guess

Sports Participation: The Numbers

Youth/ High School

ProAdult

Collegiate/ Intramural/ Military

Early Identification: A Shared Goal

Recognize (Non-Medical)

Home

Recreation setting

Sports setting

School

Youth Group

Screen- Diagnose (Medical)

Emergency Dept.

Urgent Care

Primary Care

Specialty Care

Other Care

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CDC-inspired/funded Tool Development (2003-2017)

1. Acute Concussion Evaluation (ACE) – office, ED

2. ACE Care Plan; Home/School Instructions

3. Post-Concussion Symptom Inventory (PCSI)

5-7, 8-12, 13-18; Parent

4. Behavior Rating Inventory of Executive Function (BRIEF) –Concussion Monitoring – Parent, Self-Report

5. Children’s Exertional Effects Rating Scale (ChEERS)

6. Concussion Learning Assessment & School Survey (CLASS) –Parent, Self-Report

7. Progressive Activities of Controlled Exertion (PACE)-Self Efficacy (Child, Parent)

8. Multimodal Assessment of Cognition & Symptoms (MACS)

9. Tasks of Executive Control (TEC)

10. Concussion Recognition & Response (CRR) –Parent/Coach app

11. Concussion Assessment & Response (CARE)- Medical app

Public Health Toolkits

Public Health model : Recognize & Respond

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+Blow / Force to Head / Body

Change in Function /   Behavior / Performance

Post-Concussion Signs & SymptomsPhysical Cognitive Emotional SleepHeadache Concentrate Irritability MoreFatigue Memory Emotional LessBalance/ Speed of control CannotDizziness Thinking Sadness

1 2“I SUSPECT!”

How to Recognize a Possible Concussion:Look for 1 + 2 using your tools

How To Respond to a Suspected Concussion

“When in Doubt, Sit Them Out”

Removal from sport

Protect from further injury

Notify Parent

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Medical Evaluation

Support Recovery

= “I Suspect”1 + 2

Clinical Tools

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CDC/ Berlin CLINICAL RECOMMENDATIONS FOR HEALTHCARE PROVIDERS

[CDC] 8. Healthcare providers should use an age-appropriate, validated symptom rating scale as a component of the diagnostic evaluation in children presenting with acute mTBI. (Level B)

[Berlin] 1. An age-appropriate, validated symptom rating scale should be used as a component of the diagnostic evaluation in children presenting with suspected SRC.

2. An age-appropriate, validated symptom rating scale should be used to assess recovery in children with SRC.

3. Further research is needed to determine whether certain symptoms or signs have greater diagnostic or prognostic accuracy than others, and whether their accuracy varies as a function of children’s age.

Clinical RecommendationsCDC Assessment Tools and Prognosis

18. Healthcare providers should use a combination of tools to assess recovery in children with mTBI. (Level B)

20. Healthcare providers may use validated cognitive testing (including measures of reaction time) to assess recovery in children with mTBI. (Level C)

Acute ID & Management

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Screen, Inform, Prevent

Goal: A collaborative effort launched in Dec. 2014 to bring sports and military best practices for concussion screening and early management to civilian emergency care centers 

Collaborators: One Mind, CDC, DVBIC, GE, NFL, NIH; scientific experts incl. G Manley, D Wright, J Bazarian, G Gioia, M McCrea, J Waeckerle

Progress: EPIC has incorporated the screening tool into EHR; Cerner possibly. 

Plans: Current piloting (Emory, D Wright); dissemination and implementation of screening tool, CDC patient discharge instructions, RTS/RTW letters in peds/ adult EDs across USA

Providing a Pathway

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Discharge Education as (Re)habilitation

1.Concussion Education (definition, risks)

2. Reasons to return to ED (red flags)

3. Safety Restrictions: sports, risk activities

4. Activity restriction & management

5. School/work return

6. Follow Up: PCP

Discharge Education:Key Components

Discharge Education

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Emergency Dept. study (CNMC, CHP), age 5‐21

Standard care vs. ACE Intervention group

Intervention: Standard use of ACE‐ED and Discharge Instructions

Follow‐up care was improved at 1, 2 and 4 weeks

(32% vs. 61% at Week 4, p<0.001). 

Parental recall of discharge instructions was significantly increased

Student received greater academic assistance (RTS letter)

Patient’s mean total post‐concussion symptom score was significantly higher

Report of return to normal activity was significantly longer.

Patient/ Family Education/ Managementin the Emergency Dept.

CDC Award U49CE001385NIH # M01RR020359, P30/HDO40677-07

Office Evaluation & Management

Gioia, GA (2012) Pediatric Assessment and Management of Concussions. Pediatric Annuals, 41(5), 198-203.

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Acute Concussion Evaluation (ACE) 2007/ 2008

ACE is a clinical protocol to assist diagnosis of mTBI/ concussion in medical settings

Ages 4-adult Elements of clinical assessment protocol are

evidence-based Link to follow-up care via ACE Care Plan

Acute Concussion Evaluation (ACE)

A. Define Injury Characteristics

B. Assess for Symptoms (22) (Lovell & Collins, 1998)

C. Identify Risk Factors for Prolonged Recovery

D. Red Flags for Neurological Deterioration

E. Establish the Diagnosis

F. Plan Follow-Up Action / Referral

Acute Concussion Evaluation (ACE) Key Elements

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Acute Concussion Evaluation (ACE)A. Injury Characteristics

Injury Description

Cause

Amnesias (retrograde, anterograde)

Loss of Consciousness (LOC), Seizures

Early Signs

basketball

Sept. 7, 2008Fell to ground, hit head on ground, kneed in right temporal region; dazed initially but

continued to play with bad headache. Felt sluggish and confused.

Acute Concussion Evaluation (ACE)B. Symptom Checklist

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4

1

2

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Acute Concussion Evaluation (ACE)C. Risk Factors for Protracted Recovery

Research findings have linked these risk factors to longer periods of recovery

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Acute Concussion Evaluation (ACE)D. Red Flags for Neurological Deterioration

Physicians and parents/ patients need to be aware of signs that signal the need for

emergency care.

Concussion Treatment / Management

Concussion/ mTBI is Treatable

Symptom-based treatments are available Post-traumatic headache

Vestibular dysfunction

Oculomotor dysfunction

Sleep disruption

Cognitive dysfunction

Anxiety/ depression

Three studies demonstrating efficacy of discharge instructions (educ, sx counseling)

RestManaged Activity

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Management and Treatment of mTBI in ChildrenPatient/Family Education and Reassurance

24. In providing education and reassurance to the family, the healthcare provider should include the following information: Warning signs of more serious injury

Description of injury and expected course of symptoms and recovery

Instructions on how to monitor post-concussive symptoms

Prevention of further injury

Management of cognitive and physical activity/rest

Instructions regarding return to play/recreation and school

Clear clinician follow-up instructions (Level B)

CDC Recommendations

Management and Treatment of mTBI in ChildrenCognitive/Physical Rest and Aerobic Treatment

25. Healthcare providers should counsel patients to observe more restrictive physical and cognitive activity during the first several days following mTBI in children. (Level B)

26. Following these first several days, healthcare providers should counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of symptom expression (number, severity). (Level B)

CDC Recommendations

“Active” Aerobic Rehabilitation

• Aerobic Activation (Gagnon et al., 2009; Leddy et al, 2010)

• Structured and monitored subsymptom threshold exercise to facilitate healing.

• Progressive “controlled” exercise below level that produces symptom occurrence or worsening.

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30. To assist children returning to school following mTBI, medical and school-based teams should counsel the student and family regarding the process of gradually increasing the duration and intensity of academic activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms. (Level B)

31. Return to school protocols should be customized based on the severity of postconcussion symptoms in children with mTBI as determined jointly by medical and school-based teams. (Level B)

Management and Treatment of mTBI in ChildrenReturn to School

CDC Recommendations

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Resources for School Management

State Legislative Action for the Youth Athlete:

3 Core Principles of the Concussion Laws

1) Concussion Education: Coach, Parent, Athlete

2) Identification-Removal / Protection

3) Medical Evaluation & Written Clearance

All 50 states & DC have youth concussion laws

When Return to Play/ Clearance?/ Criteria for RTP

• No longer have any symptoms (Use standardized symptom scale – PCSI or ACE or SCAT3)– No longer need medicine to control symptoms.

• Cognitive function & balance back to “normal.”– After rest and gradual activity (exertion)

• Cleared by medical professional to begin gradual Return to Play (RTP) program – RTP ideally conducted by ATC

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Put Me in Doc! I’m Ready to Play!

Gradual Return-To-Play Protocol

British Journal of Sports Medicine 2013 47,

250-258.

Issues/ Questions for the Pediatric Dentist

For patients who have recently had concussion or mild TBI:

Any precautions to take with patients?

What to look for?

Length of time we should wait between concussion/ TBI and dental work

Any contraindications for sedation/ nitrous oxide administration/ length of treatment?

Issues/ Questions for the Pediatric Dentist

There are no medical/neurological issues with dental work

BUT

Is anesthesia is good after concussion?

Is a painful facial/cranial procedure good after concussion?

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Piling on…

Normal symptoms induced by anesthetic/ dental work could contribute to, exacerbate, intermingle with or otherwise complicate the symptom reporting after concussion

Anesthesia can cause headaches, nausea, vomiting, incoordination, etc, so try to avoid it during acute concussion recovery

Try to avoid painful cranial procedures during the acute phase of concussion recovery

With your (new) knowledge of concussions…

Should the patient with oral-facial trauma (or otherwise) report:

(1) blow to head or body jerking the head, and

(2) Change in the function (cognitive, physical, energy, emotional, sleep)

SCREEN/ ASSESS IT with your Tools!

Where Are We Today?

• Increased public awareness

• Significant increase in recognition of sport-relatedmTBI/ concussion

• Expanding research knowledge/ understanding

• Training more healthcare providers, clinics

• Developing more clinical tests and tools

• Implementing laws/ rules to protect athletes

• Developing & implementing policies, protocol

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Materials

• Acute evaluation & management paper– SIP toolset

– ACE

– Discharge education

• CTE handout