Mild TBI and RTL

Pediatric TBI and RTL

Karen Laugel, MD, FAAP

Chair, CT AAP TBI-RTL Initiative

Medical Director, Head Zone

Founder, Pediatric Care Assoc. of CT

Assistant Clinical Professor,

Quinnipiac School of Medicine

Who is here?

A non-profit organization that provides educational services...

Incidence

A Pediatric Problem:

• ~500,000 ED visits/y

AZ EDs 2012: TBI Rates

634 concussions (out of 84,706 incidents) reported in 2011; Ontario School Board Insurance Exchange (78 School Boards) ; OSBIE 2011

Not just ‘sports’... Reported by Schools

17, 321 children who presented to ED with TBI

Meehan W; J of Peds, Dec 2010; Vol 157 (6)

REPORTED BY ED’S: •Children in 600 ED’s in US •0-19 yo; 2002-2006 •144,000 concussions/y •30% sports related •70% NOT sports related

• 40-70% pediatric TBI is not sports related

• Need a system of care that works outside of the “athletic department”

• Collaboration of Docs & Schools

.

www.CHIRPreports.org

What makes a successful ‘Return to Learn?’

A system of care that:

• includes all children (not just HS athletes)

• encourages collaboration between Docs and schools

• provides individualized accommodations

• monitors & adjusts academics during recovery

>= 2 Concussions... Two or more concussions

223 HS Athletes, 0, 1, 2 concn >6mo; conc < 1wk Baseline NCT testing 1999-2000 Moser RS: Neurosurgery, Vol. 57(2), August 2005

Those with history of two concussions (asymptomatic, >6 mo) scored just as poorly as those with recent concussion (< 1 week)

Decreased attention, concentration, and GPA

Marchi N, Bazarian JJ, www.Plosone.org; March 2013 | Volume 8 | Issue 3 | e56805

Repeated sub-concussive blows

Increased serum astrocytic protein correlates with # head hits; also predicts MRI-DTI abnormalities and cognitive changes 6 mo. later

Metabolic Mismatch

Functional Injury

No Need to Wake Patient

Guskiewicz; J Athl Train. 2004;39(3):280–297.

Trigger Avoidance & Sub-Symptom Pacing

Pediatric Annals Sept. 2012

Home Prescription

• Cognitive rest

• Trigger avoidance

• Sub-symptom pacing

• Medication over-use

syndrome

• Nutrition

• Sleep hygiene

Metabolic Mismatch

I. Neurovestibular History

II. Neuro- vestibular Exam

III. Neurocognitive Testing

3 Part Exam by Day 3

Age appropriate

symptom scales

• Trigger avoidance

• Homework at home before school

• Sub- symptom pacing several times/day; increase the next day

• Ready for school when 30 min sustained reading, 2h paced HW

Readiness for School

The Problem

55 children, age 10-18y

• 90% RTS after four days

• 74% headaches • 65% cognitive

deficits • 75% math most

difficult class

Gioia; Children’s National Medical Center, May 2010

Timing Return to School Back to School Early

3,740 Pediatric Concussion

Patients

• Median 37 missed school days

• Median 66 days until symptom-free

• 13% missed >6mo

• 66% required accommodations

• 61% drop in grades

• 28% comorbid condition (ADD, depression, anxiety)

Corwin, CHOP, AMS Sports Med Conference, April 2013

Not Symptom-Free

Cognitive Exertion

Majerske, CW. JAT, 43(3)

Cognitive Pacing is

Key

ariel.laugel-schloss@hotmail.com

Increased cognitive activity is associated

with longer recovery from

concussion.

Mean age 15yo; Mean duration of symptoms 43 days

Brown; PEDIATRICS February 2014; 133 (2); 335 pts, prospective study 10/09-7/11,

Boston Children’s Hospital

ariel.laugel-schloss@hotmail.com

Mean age 15yo; Mean duration of symptoms 43 days Brown; PEDIATRICS 133 (2), February 2014;

335 pts, prospective study 10/09-7/11, Boston Children’s Hospital

“Moderate levels of cognitive activity had better outcomes than those engaging in highest and lowest levels of activity.”

Sub symptom pacing is key

Put child in ‘driver’s seat’

Mild TBI

Vestibular

Oculomotor

Cognitive

Migraine

Cervical

Anxiety

> 1 week post injury, can identify type of injury to guide treatment , school accommodations, & exercise

Collins M; Sports Medicine DOI 10.1007/s00176-013-2791-6; Nov 2013

Six Trajectories

“EYES” BALANCE

VOR VSR

Balance assessment

• Stance : adjacent, tandem; floor/pad

• Gait: 10’ tandem,

forward/backward

with head movement

Head and Neck Exam

• Signs of trauma

(hematoma)

• Cervical ROM

• Spurling’s test

(cervical radiculopathy)

Musculoskeletal

therapy of

cervicogenic pain:

manipulative & exercise therapy reduced headache frequency and intensity

Early PT Referral

Jull G.; Spine 2002 Sep 1; 27 (17); 200 patients, through 12 mo. f/u

Oculomotor Pathways

Primary oculomotor

deficits in mTBI: difficulty reading

(oculomotor specific), vergence,

accommodation, and saccadic gain

abnormalities. Eye tracking assessment : examination of saccades,

fixation, and smooth pursuit eye movements

• Dysmetria

• Nystagmus

• Smooth pursuits

• Saccades

• Gaze stability

• Convergence insufficiency

• Confrontational

visual fields

Ped. Annals 41 (9) Sept. 2012

Oculomotor Exam

Cifu DX, J of Head Trauma Rehab, April 2014

Subjects with mTBI had

measurable & SS abnormalities in

saccades and smooth pursuits

Video-based binocular eye tracker; Sixty military service members with PCS and 26 asymptomatic controls

Abnormal Visual Tracking

Rapid number naming Three cards Two minutes

Measures saccadic eye movements & cognition

$45.00 for book

www.KingDevickTest.com

King-Devick >=6yo

“KD testing accurately identifies real-time concussion in adolescents...Athletes should undergo pre- and post-season KD testing.”

Presentation Amer Acad Neurology, 2014

141 HS Hockey Players •20 reported head injury •All had KD > 5sec longer than baseline •Also detected asymptomatic concussion in 11players

Correctly identified concussions:

• 52% by SAC alone

• 79% by K-D alone

• 89% by K-D and SAC

• 100% by K-D, SAC, and BESS

217 Collegiate male and female football, LAX, soccer athletes; Marinedes Z, Neurol Clin Practice, July 2014

Tracks Recovery

“KD test appears effective in objectively monitoring concussion

recovery and symptom resolve

over several months.”

Tjarks BJ; Journal of the Neurological Sciences 334 (2013) 148–153; August 2013

Mucha A., AJSM 42 (10); Aug. 2014 (demo on You Tube)

“VOMS”

Provoked Symptoms

• Symptoms

• Oculomotor exam

• Vestibular provocation

• Balance

• Cognition

Physician’s Exam

Memory, speed,

processing

http://impacttest.com/

Tjarks BJ; Journal of the Neurological Sciences 34 (2013) 148–153; August 2013

Correlation between KD total

time and all composite ImPACT scores.

Mild TBI

Vestibular

Oculomotor

Cognitive

Migraine

Cervical

Anxiety

>1 week post injury, can identify type of injury to guide treatment , school accommodations, & exercise

Collins M; Sports Medicine DOI 10.1007/s00176-013-2791-6; Nov 2013

Six Trajectories

Refer for RX

• PT/Vestibular therapy

• Vision therapy

• Dynamic Exercise

• Speech therapy

(memory, cognition)

• OT /AT (handwriting,

assistive technology)

• Cognitive behavioral RX

• Neuropsychology

• Pharmacotherapy

Post-Trauma Vision Syndrome

Vision Therapy: www.eyecanlearn.com

Ciuffreda. Optometry. 2008. 79 (1)

Identify Triggers & Readiness

•Avoid bus ride •Partial day school •Lunch in quiet place •No band/chorus/noisy gym •Pass early in hall •Ear plugs •Limit screens (computers, Smart Boards) •Dim screen •Sunglasses •Note-taker, pre-printed notes •Sit in back of class •Reduced work load •Scheduled breaks •No testing; no timed testing •Alternative testing •No gym •Protected gym for aerobics

140 School Nurses

Washington D.C.

•

True Stories

TRUE STORIES:

• RTS “left in mailbox”

• RTS “stuck in email”

• “I don’t oversee the teachers”

• “the teachers don’t believe injury”

• “I don’t speak to the gym

teacher unless he passes my door”

• did not inform the recess monitor

• did not inform the substitute

• did not inform the coaches

• informed the DED, but DED doesn’t

follow medical advice for CMTs,

CAPTs, SBACs, etc

Need organization... Need to work together

BRAIN 101

School

Concussion

Management

Policy and

Teams

Oregon Concussion Management Program www.brain101.orcasinc.com

School Policy

determines

chain of

communication

Staples HS, Westport, CT

Physician to School

Physician should: •Determine readiness •Ask parent to meet with nurse upon re-entry •Fax accommodations attention: nurse •Follow-up call to student after first day

SM + AM

to coordinate:

• Students

• Parents

• Physicians

• Teachers

• Coaches, ATCs

Need School Team

Westport Schools: SNAP Note

Academic Adjustments:

The above student will benefit from the following checked short term academic supports for proper concussion management in school

□ No school for ______ days

□ No school until re-evaluated on _________________

□ No recess

□ No Music/Band class

□ No Computer

□ Shortened day or modified schedule, as indicated

□ Homebound tutoring as tolerated

□ Extra time to complete coursework, assignments, tests, No more than one test per day every other day

□ No significant classroom testing or standardized testing

□ Pre-printed material/notes, if available

□ Schedule periodic rest breaks as needed in health office during day

□ Allow student to go to health office if symptoms worsen during the day

□ Allow school concussion team to gradually modify accommodations if student remains symptom free

□ Other recommendations: ______________________________________________________________________

Physical Exertion Accommodations

The above student should adhere to the following recommendations regarding physical education (PE) and athletic participation (checked items apply):

□ May not return to PE or sports/athletics until further notice

□ Aerobic, non-contact PE as tolerated (walk, run, jog)

□ Is medically cleared to participate in full PE

□ May gradually return to school sports/athletics (for student athletes)under the supervision of an appropriate person (e.g. athletic trainer, coach). Return to play as per return-to-play guidelines

These recommendations will be reviewed and updated on ___________________________________.

Westport Public Schools: Sample E-mail Template

Symptom Monitor

• Symptom Monitor=Nurse

• Meet with parent and child upon re-entry

• Establish contact with doctor

• Notify teachers & coaches

• Evaluate child regularly

• Weekly follow-up with teachers, coaches, ATCs, Dr.

Symptom Monitor

Extracted from PA “BrainSTEPS”

Rapid number naming Three cards Two minutes

Measures saccadic eye movements & cognition

$45.00 for book

www.KingDevickTest.com

King-Devick >=6yo

• Guidance, Teacher, Psychologist, SW

• Feedback from teachers

• Meets w/Nurse

• Educate school staff

Academic Monitor

Extracted from PA “BrainSTEPS”

• Evaluates child regularly

• Follow-ups with Dr, teachers, coaches, ATCs

• Develops a Concussion Management Plan

• RTL before RTP

• Concur with RTP or initiate “504 Plan” process if recovery is prolonged

The School CMT

www.brain101.orcasinc.com

As appropriate, the school nurse will obtain data from the academic team and report follow-up data including school attendance, academic performance and symptom assessment to the physician prior to the medical evaluation.

• It is essential that the Medical Provider hear from the school as to present level of functioning and present adjustments in place.

• Give feedback to physician regarding progress of recovery in school

Communication with Medical Provider

Recovery time unique

Estimated 20% > 4 weeks 20% take > 4 weeks

• Student continues to be symptomatic with headache, fatigue, irritability and difficulty sleeping

• Attendance has been impacted and she is beginning to fall behind in academics

• Although sub clinical pacing has been instituted she has not made progress in recovery from concussion

Westport Public Schools: Week Three

When the student is requiring educational adjustments beyond three weeks as determined by recommendations from the student’s physician after a follow –up appointment and receipt of recommendations, a team meeting with the academic team will be convened to develop a Concussion Management Plan to address appropriate health services/educational supports and accommodations and to review the ‘return to learn’ process.

• A meeting is scheduled with parent, student, administrator, guidance counselor and school nurse

• Plan developed and sent to all teachers

• Review again in 1 month

• Consider eligibility for 504 plan

WPS: Concussion Management Plan

WPS: Individual Concussion Management Plan

WPS: Concussion Management Plan

WPS: Concussion Management Plan

WPS: Concussion Management Plan

WPS: Concussion Management Plan

•An individual with a disability means any person who has a mental or physical impairment that substantially limits one or more major life activity

504 Plans

•Section 504 is a part of the Rehabilitation Act of 1973 that prohibits discrimination based upon disability... in public schools, colleges and universities

504 Eligibility ADA Amendments Act of 2008:

• "major life activities” include: seeing, reading, bending, concentrating, thinking, learning, sleeping

• “major bodily functions” include neurological & brain

• “six month rule no longer applies”: impairment that is episodic or in remission is a disability

Assistive Technology

For “Low Vision” Students:

IPAD Use

VoiceOver Audio Textbooks Speech to Text Text to Speech

Video Magnifiers Readers & Scanners

Info Scan Pens Electronic Notetakers

Screen filters

American Foundation for the Blind www.afb.org

Audio Books

bookshare.org learningally.org

iBooks App

Dictate, Upload,

Transcribe document in

minutes

Breathe 2 Relax

Clear Record

Study Tools and Organizers

Audible Books

www.brainline.org

Learning Strategies Online

Study aids and guidelines (also for 504 Plans & IEPs)

projectlearnet.org

cokidswithbraininjury.com

What do we do with...

Symptoms Lasting: •1-4 weeks •4-8 weeks •and beyond

http://cokidswithbraininjury.com

Help with the chronic injury

http://cokidswithbraininjury.comf/

At 3-4 weeks: Some students may have permission for non-contact aerobics before academic test-taking

“Conditioning is not RTP”

Leddy. Clin J Sport Med 2010;20:21–27; treadmill, 5-6 d/wk, 80% symptom threshold HR

“Treatment with controlled exercise is a safe program that appears to improve PCS symptoms.” (decline in PCS symptoms correlated with peak exercise heart rate, 12 adults)

ariel.laugel-schloss@hotmail.com

Combination of school and PE

“Athletes participating in school activity and light activity at home (e.g., slow jogging, mowing the lawn) performed better on ImPACT” (than athletes with higher or lower levels of exertion).

Majerske CW. J of Athletic Training 2008; 43 (3)

Conditioning during recovery

UPMC Restore: The Science of Concussion. Advancement in Assessment, Management, and Rehabilitation; UPMCPhysicianResources.com/Ortho; March 2013

Striking a balance:

• Recovery is not linear

• Cognitive fatigue

• Trigger avoidance

• Sub-symptom threshold pacing

Management of RTL

• “Homework at home before schoolwork at school”

• RTS: 30 min reading

• Partial Day: 2 h paced homework

• Full Day: 3-4 h paced homework

• Testing: if full academic load (extra time, untimed, >= qd-qod testing)

RTL Progression

ACE:

graduated

progression of

cognitive load

Coordinate with Physician

Available on

website

ORCAS: Brain 101

ConcusssionCORPS.org

Return to full

academics

(including test-

taking)

before initiating

“Return to Play”

protocol

Academic Monitor

School Readiness

School Accommodations

School Progression

RTL before RTP

ATC to Doc...

& Vice Versa

• Walk

• Jog

• Run

• Sports Drills

• (Contact

Practice)

RTP initiated by Doctor

Supervised by Coaches, ATCs, or PTs

Metabolic Mismatch

I. Neurovestibular History

II. Neuro- vestibular Exam

III. Neurocognitive Testing

Post-RTP Medical Exam

McGrath, N. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Injury, 2013. 27(1), 103-113

A total of 27.7% of concussed

student-athletes who were symptom-free and returned to baseline on ImPACT at rest (i.e. no longer demonstrated

performance deficits on neurocognitive tests) exhibited cognitive decline following moderate physical exertion

27.7% of concussed student-athletes who were symptom-free and returned to baseline on ImPACT at rest exhibited cognitive decline in memory scores following moderate physical exertion (54 student-athletes; 15-25 min 60-80% HR aerobics)

Nine Days More

Medical Clearance to Play

Your Call to

Action

“Best Practices”

Ped Annals Sept. 2012 Pediatrics Oct 2013

www.ConcussionCORPS.org: Awareness: Scholarly Articles

Do Online Training

www.CDC.gov

Online training

programs

Clinical Shadowing

www.ConcussionCORPS.org

•ConcussionCORPS.org •Awareness We Raise •Partnering With Schools

Organize your

school :

policies

and teams

Post on website (names, phone, fax)

Post School Policy

Form Your CMT

Link to Education

Ask

Questions