1 POST-CONCUSSION SYNDROME and RETURN TO SCHOOL CSMS Conference April 28, 2015 Michael A. Lee, MD Staff Physician; Connecticut Children’s Medical Center Attending Physician Pediatrics; Yale University CCMC – Fairfield Satellite Office Member, Connecticut Concussion Task Force Charter Member, AMSSM Member, AAP-COSMF, Former Chairman, CSMS Committee on Medical Aspects of Sports Former Editor, SPORTSMed Newsletter
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1 POST-CONCUSSION SYNDROME and RETURN TO SCHOOL CSMS Conference April 28, 2015 Michael A. Lee, MD Staff Physician; Connecticut Children’s Medical Center.
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POST-CONCUSSION SYNDROMEand RETURN TO SCHOOL
CSMS Conference April 28, 2015
Michael A. Lee, MDStaff Physician; Connecticut Children’s Medical CenterAttending Physician Pediatrics; Yale University
CCMC – Fairfield Satellite Office Member, Connecticut Concussion Task ForceCharter Member, AMSSMMember, AAP-COSMF, Former Chairman, CSMS Committee on Medical Aspects of Sports Former Editor, SPORTSMed Newsletter
• Central Vestibular Projections • Vestibular Nuclei
• Cerebellum • Autonomic Nervous System
• Thalamus • Cerebral Cortex
Function of Vestibular SystemSTABILIZE VISION WHILE HEAD MOVES
Normal VOR:Able to maintain focus on stationary object
while moving head without loss of visual focus or dizziness
Physical Findings of PCS
Eye convergence difficulty Near point of conversion should be less
than 6 cm (normal is 0-6 cm.) Usually resolves on its own Sometimes may need exercises or prism
glasses if persists greater than 3-4 weeks (can be cause of persistent headaches
when reading).
Physical Findings of PCS
Abnormal balance findings Difficult to assess without a baseline Most helpful to use at time of the injury for
making the diagnosis of a concussion Appears to resolve more quickly than other symptoms following a concussion. (Catena 2011, Guskiewicz 2003)
TOOLS USED TO ASSESS PCS
Neurocognitive testing (ImPACT)
MRI of head sometimes needed
Full neuro-cognitive testing by a neuropsychologist (expensive, often not covered by insurance)
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Neurocognitive/psych testing Zurich conference emphasized role of testing
“In the absence of NP and other (e.g. formal balance assessment) testing, a more conservative return to play approach may be appropriate.”
“Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance”
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VALUE OF ImPACT CLINICALLYFinds patients with extremely low scores (low single digits on all parameters) who
are more likely to develop Post-Concussion Syndrome
Shows when patients are not following activity restrictions because the scores
decrease on serial testing
Tells how long it takes to have cognitive fatigue and later finds patients with memory loss or overdoing activity
Predicting Who Will Develop PCS Patients with Vestibular findings Multiple blows at time of or around injury Extremely low scores on neuro-cog testing Previous Post-concussion Syndrome History of migraine headaches Motor Vehicle Accidents (especially females) History of ADD Compulsive, type A excellent student
Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players
The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from 92-98. The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive.
**p<.01
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SECOND BLOWS TO THE HEAD
37 athletes had a second blow to the head within 2 weeks of the first blow. No case of Second Impact Syndrome occurred.
25 Males and 13 developed PCS (52%) 12 Females and 8 developed PCS (67%)
Lee and Fine. CT Medicine 2010
Since most concussion symptoms usually will resolve
by 3 weeks, no treatment is usually necessary prior to that
time (except for neck PT)
Every patient’s treatment needs to be individualized
IT TAKES A VILLAGE TO HELP SOME PATIENTS RECOVER FROM THEIR CONCUSSION
PT neckVestibularSCHOOL FAMILY OCULAR PSYCHNEURO-PSYCH
AT SCHOOL: Artificial lighting Smart boards, slide presentations Computers, Handheld computer tablets Movies
Sunglasses may be necessary if photophobia is present (outdoors and sometimes indoors)
Avoidance of bright sunlight and exposure to flashing lights (strobe/computer games)
No movie theaters (loud noise and bright flashing lights)
VISUAL ADJUSTMENTS
Allow sunglasses to be worn in school Reduce exposure to computers, smart
boards and videos Reduce brightness on screens Turn off fluorescent lights as needed Consider use of audiotapes of books
CONCENTRATION and MEMORY ISSUES
Difficulty learning new tasks and comprehending new material
Difficulty with recalling and applying previous learned material
Difficulty with focusing and attention Problems with test taking, especially
longer more standardized tests
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SCHOOL TESTS IS TESTING IN A BRAIN INJURED STUDENT VALID?
Quizzes, tests, PSAT/SAT, ACT tests, mid-terms, final exams may need to be delayed/postponed.
TESTS ONLY AFTER STUDENTS CATCH UP ON SCHOOL WORK!!Tutoring in school may be needed to help catch up
Extra time (un-timed tests) may be necessary when test taking is resumed. May need to take breaks. Tests
may need to be taken over multiple sessions.
No more than one test a day when test taking resumed.
Initially, if test results are poor, they should be voided or retaken.
SCHOOL TESTS (cont.)
If significant concentration and memory problems are present:
May need reader for exams
Oral exams may be necessary (or if students develop headaches taking written tests).
Consider having students do take home tests so they can catch up quicker.
Open book tests may be needed for some students (especially if memory issues are present)
PROLONGED SCHOOL ABSENCE
After 2-3 weeks of missing school it is important to let students go to school for a brief period in order to see their friends, even if they are unable to do any school work.
(Should do no cognitive work)
Very Prolonged PCS School Issues
What if student can’t attend school and has to stay home and both parents work, who takes care of the student?
If home tutoring is needed will the school allow it to be done in blocks of time followed by a break?
Some schools may require tutoring to be done in school only.
If go to school for one period do you lose home tutoring?
Very Prolonged PCS School IssuesIsolation - Students need to see friends (Will the school allow brief visits to school-one period a day?) How to manage school with multiple rehab/physician visits.
Taking students out of honors/AP classes
Who pays for needed neuro-cognitive testing?
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No spinning carnival rides and no boating in rough seas until concussion is completely
resolved.
Recommendation: No carnival rides for 3 months (perhaps never if vestibular findings)
No chiropractic adjustments
ADHD AND CONCUSSIONS
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ADHD Prevalence is Up Among Older Children
Among youth aged 12-17 years ADHD increased by 4% annually from1997-2006.
No increase in those aged 6-11 years.
Thought to be due to a greater awareness of clinicians in diagnosing this condition
Audrey Kubetin, Pediatric News, August 2008, Vol. 42 Issue 8
ADHD Related to Longer Lasting Head Injury?
ADHD patients compared with non-ADHD patients after a concussion.
25% had moderate disability and 56% recovered after 6 months
vs
2% in normal group had moderate disability and 84% recovered after 7 weeks