Post-Concussion Cognitive Care:
Focus on Return to Learn
25th Annual NJAAP School Health
Conference : School Health 2016
October 18, 2016
Matthew Grady , MD, CAQSM
Sports Medicine &Performance Center
The Children’s Hospital of Philadelphia
Objectives
At the conclusion of this activity, participants
should be able to:
• 1. Learn to Perform Concussion Focused
exam to identify eye tracking problems that
would interfere with school learning
• 2. Develop return to school protocol that
addresses short time cognitive deficits
• 3. Understand the principles of concussion
rehabilitation.
Disclosures
• No disclosures
Why is Concussion a
Pediatric/Adolescent problem
• The “job” of this age group is
school work, not sports- so
how does concussion affect
reading, learning,
socialization?
• 40,000,000 pediatric athletes
vs 3,000 professional athleteswho does concussion effect?
Concussion:
Medical Definition
• Concussion is a brain injury
and is defined as a complex
pathophysiological process
affecting the brain, induced
by biomechanical forces.
(Zurich Concussion
Guidelines 2012)
Medical Definition
– No abnormality on standard imaging
• Imaging is recommended only to
evaluate possibility of other injuries as
clinically indicated
– May or may not involve LOC (only about
10% with LOC)
– Most recover spontaneous
– Small percentage may have prolonged sx
Pathophysiology ?
2. Potassium
efflux
K+
K+
K+
K+
K+
5. Na/K ATP-requiring
transporters work
overtime to restore
balance
K+
Na/K
ATPase
Glut
Glut
Ca2+
Glut
Na+
Glut
K+
Depolarization
Ca2+
Glut
Glut
Glut
SYNAPSE
1. Widespread
depolarization and
neurotransmitter
release
3. Calcium in the
cell impairs ATP
production in
mitochondria,
worsening energy
crisis
Ca2+
Ca2+
4. Calcium influx also
causes axonal swelling
Slide courtesy Nicole Ryan
Healing: Glucose via Cerebral Blood
Flow Drives ATP transport proteins
• Mild and moderately injured cells can upregulate glucose fueled Na/K ATPasedependent ion membrane transport proteins
and restore the intracellular balance.
During Healing:
“The Vulnerability Window”
• Both basic science and animal models have
demonstrated a repeat injury, prior to the first
injury recovery, leads to either prolonged recovery
or axonal degeneration
• Hence- no sports activities while symptomatic early
in the concussion.
•
•
•
Prins ML, Alexander D, Giza CC, Hovda DA.Repeated Mild Traumatic Brain Injury: Mechanisms of Cerebral
Vulnerability, J Neurotrauma. 2013 Jan 1;30(1):30-8
Prins ML, Hales A, Reger M, Giza CC, Hovda DA. Repeat traumatic brain injury in the juvenile rat is associated
with increased axonal injury and cognitive impairments Dev Neurosci. 2010;32(5-6):510-8
Yuen TJ, Browne KD, Iwata A, Smith DH. Sodium channelopathy induced by mild axonal trauma worsens
outcome after a repeat injuryJ Neurosci Res. 2009 Dec;87(16):3620-5
Concussion Deficits
• 1. Autonomic Nervous System Deficits:
Photophobia, postural hypotension, fatiguemental stamina
• 2. Vestibulo-ocular deficts: Eye tracking,
balance
• 3. Cognitive: Concentration, memory deficits
• 4. Emotional: mood deficits- anxiety,
depression, irritable
The Effect of Cognitive Activity
Level on Duration of PostConcussion Symptoms
Naomi Brown, MD
Boston Children’s Hospital
April 20, 2013
AMSSM Annual Meeting
Cognitive activity definitions
0
Complete
cognitive rest
No reading, homework, text messaging, video game playing, online
“Cognitive Activity Days”
activity, crossword puzzles or similar activities. The most stimulating
activities at this level would be watching television, watching movies or
Cognitive
activity level x days between each visit
listening to music
1
Minimal
cognitive
activity
No reading, homework, crossword puzzles or similar activities. Less than 5
text messages per day, less than 20 minutes per day combined of online
activity and video games
2
Moderate
cognitive
activity
Reading less than 10 pages per day, less than 20 text messages per day,
and doing less than 1 hour combined of homework, online activity and
video games per day
3
Significant
cognitive
activity
Reading less, doing less homework, working less online, text messaging
less and doing crossword or other activities than you would normally do,
but more than listed in level 2
4
Full cognitive
activity
You have not limited cognitive activity at all
Kaplan-Meier Curve of Symptom
Duration after Concussion
Cox Proportional Hazard Ratio
T
Hazard ratio
P
95% CI
Sex
1.1759
0.249
0.8930 – 1.5484
Age
1.0503
0.086
0.9930 – 1.1109
LOC
1.1504
0.392
0.8347 – 1.5854
Number prior
concussions
0.9799
0.722
0.8763 – 1.0958
Total initial PCSS
0.9835
0.001
0.9781 – 0.9890
Amnesia
1.297
0.067
0.9820 – 1.714
Cognitive activity
days
0.9951
0.001
0.9936 – 0.9966
But…Too
much rest
may be
bad
Activity After Concussion
• Old view
– Rest until symptoms resolve
• New view
– Relative rest, more on the first day then the following days
– Gradual re-introduction of activity staying below thresholds
of cognitive and physical levels that make symptoms
markedly worse
– One caveat- early aerobic activity does not mean restarting
sports training while symptomatic
Acute Treatment
• In adolescent population, about 80-90%
spontaneously recover in 4 weeks
– Treatment is scale back school and ramp up
slowly
– Academic accommodations based on deficits,
mostly eye tracking and cognitive stamina
– When in full school with no symptoms start
Return to Play (sports) Protocol
• In those who do not recover in 4 weeks- active
rehabilitation is needed.
Physical Examination- School Return
• PE is important so we can understand where
student may have problems when they return
to school
• Eye tracking, concentration, energy level, mood
issues all affect learning
Physical Examination- School Return
• PE has to focus on Function
– Eye tracking, saccades, gaze stabilization, convergence,
accommodation, King-Devick testing
– Balance testing- heel toe backwards eyes close, Bess
Testing
– Cognitive Function- computerized neuropsych test/SCAT
2/formal neuropsych
CHOP Experience: Vision Deficits
Study Design
100 unique patients ages 11-17 years
Treated for concussion in children’s hospital
affiliated concussion program
7/1/2013—2/14/2014
Vision examination including assessment:
Visual acuity
Binocular vision (eye teaming)
Accommodation (focusing)
Eye movements (saccadic function)
Convergence Insufficiency Symptom
Scale with additional mTBI questions
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
<1 month
1-2 months
2-3 months
>3 months
Results
• Vestibular and Vision Deficits
– Vision Problems 69%
– Vestibular Problems 55%
– Both Vision and Vestibular Deficits 49%
– Only Vision Deficits 16%
– Only Vestibular Deficits 20%
Prevalence of Vision Problems After Concussion in
Children 11-17 years old
Christina L. Master, MD, CAQSM1, Mitchell Scheiman, OD2, Michael Gallaway OD2, Arlene Goodman, MD, CAQSM1,
Roni Robinson RN, MSN, CRNP1, Stephen R. Master, MD, PhD3, Matthew F. Grady, MD, CAQSM1
Eye Movements
• Eye Movements
– saccades,
– gaze stabilization
– Tracking fast moving
object
– Convergence/
accommodation
Neuropsych Testing
• Testing is a snap shot in time (which is not
what it was developed for)
• Test scores = performance
• When the performance is not good what does
that mean
– Tired, hungry, emotionally upset, not motivated,
performance anxiety
• Still just a
PIECE of the PUZZLE
Return to Learn Pathway
•
•
•
•
•
•
Cognitive rest
Self-pace at home
Working up to mimic school day
Return to school partial, half or full day
Return to cumulative courses 1st (math)
Attend same classes every day
Cognitive Rest: What
Does it look like? • Subsymptom threshold cognitive
activity:
o Keep cognitive activity below
the level that triggers
symptoms
o Self-paced activities
• Removal from school until
symptoms are improved &
tolerating some school work at
home
• Do NOT have to be “symptom
free” to return to school
• Socialization is important
Peds Annals, 2012
School Re-Entry
• 1st week most crucial time to rest and shut down
• Student with IEP may be sent back sooner
accommodations are already in place for them
• Younger students can sometimes be back quicker
less academically demanding
• Emotional component return sooner
• High achievers won’t pace themselves– return
later & have them pace at home
• Homebound last resort after all else has failed
Symptoms in the Classroom
• Headaches:
o Can distract the student
from concentration
o Can vary throughout the
day and may be triggered
by various exposures,
such as fluorescent
lighting, loud noises, and
focusing on tasks
Symptoms in the Classroom
• Dizziness/lightheadedness:
o May make standing quickly or walking in crowded
environment challenging
o Often provoked by visual stimulus (rapid movements,
videos, etc)
• Visual symptoms: light sensitivity, double vision, blurry
vision
o Slide presentations, Smart boards, Computer & Handheld
computers (tablets)
o Artificial lighting
o Difficulty reading and copying
o Difficulty paying attention to visual tasks
Symptoms in the Classroom
• Noise sensitivity
o Lunchroom, Shop classes, Music classes (band/choir), Physical
education classes
o Hallways, stairs
• Difficulty concentrating or remembering
o Challenges learning new tasks and comprehending new
materials
o Difficulty with recalling and applying previously learned material
o Lack of focus in the classroom
o Troubles with test taking
o Troubles with standardized testing
o Reduced ability to take drivers education classes safely
Accommodations in the Classroom
Accommodations in the Classroom
• Dizziness/lightheadedness/fatigue:
o Short rest breaks then returning to class
• Visual symptoms:
o Reduce visual clutter
o Single sided vs. double sided copies
o Audio books when appropriate
o Copies of notes & power point presentations
o Guided reading tools to reduce visual fatigue
o Large Font (18)
o Reading Glasses
Accommodations in the Classroom
• Extended time to complete assignments
– Processing is slowed BUT task can be completed when
student is allowed to take breaks
– Memory of information may need to be supported by
academic adjustments/accommodations
• Cued recall (multiple choice, word banks, matching)
• Open note quizzes and tests
• Evaluating student’s knowledge of subject/content
through alternative assessments/assignments
– Attention deficits: Competitive Academic Environment
• Keep student actively involved with multi-modality
learning
* Reduce cognitive load – core content aligned , sometimes this
means less number of classes with standards
Accommodations in the Classroom
• Noise sensitivity
o Lunchroom-eating lunch
in a quieter
environment, shorter
lunch then rest in nurse’s
office
o Exchange a shop class,
music class (band/choir),
physical education class
with a study
hall/resource
room/break
Accommodations in the Classroom
• Difficulty concentrating or
remembering
– Review-preview-teach-review-preview
in order to ensure that new learning is
happening and being retained (student
and/or teacher directed)
– Student needs to identify, with the
teacher, learning gaps and where
difficulty with content occurs, in order
to get the specific help they need
Accommodations in the Classroom
• Emotional
o Socialization very important-students go from their
“normal” life to feeling very isolated and alone
o “old self” vs. “new self”
o Social status/cliques
o Identification of self (e.g., AP student, athlete, band
member, theater)
o Mental health history
o Student, Family, School, Medical need to
communicate the signs and concerns with emotional
changes
Management beyond the Acute Phase:
• Long term cognitive function not injured by
additional brain stimulation
• Work to the threshold of provoking
symptoms- then REST, RECOVER, RETURN to
activity
– My personal rule- headache on 10 point scale can
get 2 points worse before decreasing activity
(physical or mental)
Long Term Treatment
• Cognitive Rehab- school work for most
• Aerobic Therapy – daily aerobic activity
• Vestibular- Ocular Therapy- Balance, saccades,
gaze stabilization, convergence retraining
• Mental Health- counseling, bio-feedback,
psychologist, psychiatrist (meds needed)
Cognitive Therapy/Rehab
• School work in small incrementswith breaks as needed
• Work until symptoms, rest,
recover and restart work
• Watering down classes does not
achieve full rehab- better to do
harder classes but less classes
• Persistent issues with cognitive
deficits:
– Speech-Language therapy
– Neuropsychology evaluation
Aerobic Rehab
• Daily Aerobic Exercise helps recovery
– Exercise to threshold of symptoms- should
provoke mild symptoms
• Powerful benefits of Physical activity
–Improved mood
–Better sleep
–Increased energy
Vestibular/Oculomotor Therapy
• Weekly formal therapy with specialist
• Daily home exercise program essential!
Consequences of Prolonged Recovery
• Alterations in mood
– Counseling
– Support Groups
– Psychiatry for mood stabilizers
• Amplified Pain Syndrome
– CHOP Rheumatology Program
• Postural Orthostatic Tachycardia
Syndrome :Dysautonomia
– Cardiology