thinkfirst canada pensez d’abord canada april 2012
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Concussion in the Pediatric Population Dr. Michael Vassilyadi Children’s Hospital of Eastern Ontario (CHEO). Head Injury and Concussion Education Webinar Series. ThinkFirst Canada Pensez d’Abord Canada April 2012. Before we begin…. - PowerPoint PPT PresentationTRANSCRIPT
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.
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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?
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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
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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
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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
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Top Causes of Concussions
Females
Soccer Horseback Riding Cycling Ice Hockey Snowboarding
Males
Ice hockey Cycling Football Soccer Snowboarding
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Sports Related Concussions
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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
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Concussion and the Brain:What goes on?
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Concussion and the Brain:What goes on?
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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
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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
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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
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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.
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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,…
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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
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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
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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
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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
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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
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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
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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
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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
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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/
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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
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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
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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
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