1. PRITHA DALAL, M.D. REHABILITATION MEDICINE CONCUSSION PROGRAM DIRECTOR RADY CHILDREN’S HOSPITAL-SAN DIEGO STAFF PHYSICIAN, DEPT. OF PEDIATRICS, UC SAN DIEGO Concussion SBRCSNO SPRING 2016 CONFERENCE

2. Objectives Initial Management of Head injury Normal concussion symptoms Concerning symptoms Concussion management Return to learn and play Accommodations for school Prolonged recovery

3. Concussion Brain injury that is defined as a complex pathophysiological process affecting the brain and induced by biomechanical forces. It can be caused by direct or indirect force to the head, neck or face.

4. Concussion There is usually a rapid onset of short lived impairment of neurologic function that resolves spontaneously. In some cases signs and symptoms may evolve over minutes to hours. Although this creates a complex neuro-metabolic cascade at the cellular level within the brain, there is no structural damage or bleed.

5. Sideline assessment Emergency management – CAB’s Rule out cervical spine injury Address first aid issues first Monitor player for deterioration over first 24 hours. Do not need to wake up in the middle of night!

6. Pediatric GCS Traumatic Brain Injury SeverityGCS Mild traumatic brain injury13-15 Moderate TBI9-12 Severe TBI3-6

7. Imaging Head CT – image gently  Focal neurologic findings  Symptoms of increased intracranial pressure  Seizure activity  GCS less than 15 Concerning findings for spinal cord injury Other injuries

8. Concussion Symptom List Headache Pressure in head Neck painNauseaVomiting DizzinessBlurred vision Balance problems Sensitivity to light Sensitivity to noise Feeling slowed down Feeling “in a fog” “Don’t feel right” Difficulty concentration Difficulty remembering Fatigue/low energy ConfusionDrowsiness Trouble falling asleep More emotional IrritabilitySadness NervousnessAnxious Trouble staying asleep

9. Red flags that Need ED Evaluation Progressively worsening headache Worsening confusion or irritability Focal weakness or numbness Increased lethargy Continued vomiting Seizure Difficulty walking Speech changes Unequal pupils Concern for skull fracture Blood in ear drum/canal Disorientation

10. Patient that Needs ED evaluation Please provide as much information as possible as to what happened and your assessment Most patients will appropriately not need a Head CT. Concussion is a clinical diagnosis.

11. Initial instructions for Concussion Recommend REST  For at least first 24-48 hours recommend physical and cognitive rest Should be evaluated by Primary care provider with in next 2-3 days Tylenol is ok to take for headache Monitor for neurologic changes for next 4-6 hours. SHOULD NOT WAKE UP child at night or keep awake.

12. Initial instructions Patient should consider taking at least one day off of school depending on symptoms Should not return to school until symptoms are improved unless it has been over 2 weeks.

13. Concussion Assessment Tools ImPact testing – Computer based SCAT 3 – Symptom score, cognitive testing and balance testing ACE- Symptom list, history and information

14. Physician Visit History Physical examination – full neurologic examination Check balance Cognitive testing

15. Cognitive examination

16. Cognitive Assessment

17. BESS

20. Physician Visit Should give recommendations for Return to Learn Should also give recommendations for Return to Play Should give medication recommendations to take for symptom management

21. Risk Factors Risk factors – for prolonged recovery  History of previous concussion lasting longer than 1 week  Previous history of headaches or migraines  History learning disability, ADHD, Speech therapy  History of anxiety or depression

22. Treatment/Instructions Cognitive and physical rest Physical rest  Can walk  Stay around house  Progress activity if asymptomatic Cognitive Rest  Avoid screens  Limiting thinking activities  Avoid loud areas

23. Cognitive rest Initially this means being in a quiet/dark if needed room and limiting thinking activities Once feeling better can start playing simple games/board games, crafts If starting new activity only do it for 10-15 minutes and monitor for increasing symptoms Limit screens – videogames, iPads seem to be worse TV and Movies- rest breaks

24. Treatment Reminders for cognitive activities  Every day activities can cause symptoms  Grocery stores – loud, bright lights  Sitting in car- can trigger symptoms  Church – singing, loud noises can be trigger  Watching sports also not recommended

25. Symptom Treatment Headaches  Acetaminophen – first 24 hrs  NSAIDs after risk for bleed decreased  Rest

26. Sleep Reinforce normal sleep hygiene Can try Melatonin for sleep- helps more with difficulty falling asleep Trazodone – staying asleep in more severe cases

27. Return to Learn Even if student is feeling better symptoms may worsen with starting school Patient should be able to walk around for 20 minutes at home with out significant increase in symptoms. If still having symptoms but improving start back at ½ days of school Accommodations should be put in place based on symptoms

28. Return to Learn CIF

30. CIF School Accommodations

33. Are we overwhelmed yet? Communication Student advocate Help with transition Ask questions Look for red flags

34. Cases/Questions

35. Return to Play Patients should be tolerating full days of school prior to starting return to sport process Ideally would like to be completely asymptomatic or at baseline before returning to activity to prevent second injury  Return to play should ALWAYS be a graduated return to activities

36. CIF rules California Law states that full competition for athletes cannot be sooner than 7 days and that progression must be supervised by a DO or MD.

37. Graduated Return to Sports- CIF

40. Sport Specific

42. Return to Play Questions?

43. Prolonged Recovery Considerations Once patient has had symptoms for over 2 weeks complete rest no longer appropriate Start physical activity- gentle and gradual – still NO contact Aggressively treat symptoms

44. Prolonged Recovery Treatments Physical symptoms  Headaches  Long term headache medications  Rebound headache concerns  Neck pain  Physical therapy  Dizziness  Vestibular therapy  Blurry vision  Nausea  Fatigue  Increase activity  Monitor sleep

45. Prolonged Recovery Treatments Balance difficulties  Physical therapy Sleep  Medications  Good Sleep Hygeine Cognitive difficulties  Strongly consider 504 plan  Consider setting up meeting

46. Prolonged Recovery considerations Emotional/mood symptoms  Concussion symptoms similar to anxiety/depression symptoms  Recommend talking to school counsellor or psychologist  Normalize symptoms  Help with plan for stressors

47. Prolonged Symptom Recovery Activity  Progress to non-contact activity that does not increase symptoms (subthreshold)  Recommend physical activity daily  Encourage athletes to find new activities until symptoms improve

48. Prevention Helmets/headbands  Prevent against skull fracture and worse head injury but do not prevent concussion Should they stay out of sport?  Risks vs Benefit of sports

49. Concussion Clinic Information Dr. Pritha Dalal – pdalal@rchsd.orgpdalal@rchsd.org Rehabilitation Medicine  858-966-1700 ext 2661  Fax – 858-966- 6721  Administrative Assistant- Gina Luna

50. References McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. Halstead ME, Walter KE. Report—Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126:596-615. SCAT3 Sports concussion Assessment Test. Br J Sports Med 2013 47: 259 Child SCAT 3. Br J Sports Med 2013, 47: 263 Heads Up: Concussion http://www.cdc.gov/HeadsUp/index.html Page last updated February 16, 2015. Accessed April 4 th, 2016.http://www.cdc.gov/HeadsUp/index.html Giza CC and Hovda DA. The Neurometabolic Cascade of Concussion. Journal of Athletic Training. 2001;36(3):228-235. Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric Sports-related Concussion Produces Cerebral Blood Flow Alterations. Pediatrics. 2012 January; 129(1) 28-37. Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025 BESS http://knowconcussion.org/wp-content/uploads/2011/06/BESS.pdfhttp://knowconcussion.org/wp-content/uploads/2011/06/BESS.pdf Accessed – April 4 th, 2016 May KH, Marshal DL, Burns TG, Popoli DM, Polikandroitis JA. Pediatric Sport Specific Return to Play Guidelines Following Concussion. Int J Sports Phys Ther. 2014 Apr; 9(2): 242–255 California Interscholastic Federation Concussion. http://cifstate.org/sports- medicine/concussions/index Accessed April 4th, 2016.http://cifstate.org/sports- medicine/concussions/index