POSTCONCUSSION SYNDROME and RETURN TO SCHOOL CSMS Conference

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 1

Overview Post-concussion Syndrome – signs, symptoms, physical findings and management Recovery process (as affects school) and different adjustments Female concussions ADD Disclaimers: I have had one concussion I have no financial disclosures I will not discuss unapproved or off label products or their uses 2

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Concussions: They are a part of playing sports at all levels and also occur in nonsports activities and MVAs. One of the most discussed problems in US sports media coverage today Very difficult to manage especially when the symptoms are prolonged. 4

A Decade of Change… “Congress draws needed attention to concussions” Hearings put pressure on NFL to act Former NFL Players Call for Concussion Education: Congressional Hearing Reveals Education Needed at all Levels 5

FEMALE CONCUSSIONS

Girls have a higher rate of concussion than boys, particularly in similar sports Lincoln, et. al. , Am J Sports Med 2011; Giza, Kutcher, et al. , Neurol 2013

FEMALE CONCUSSIONS Tend to be worse and last longer Likely related to weaker neck muscles Related to more migraine headaches

Females have, compared to males: 25% less head neck segment mass 5% less head-neck segment length 12% less neck girth 50% less isometric neck flexor strength 53% less isometric neck extensor strength 44% greater head acceleration after contact

CHEERLEADING Often is not considered a sport, YET 50% of deaths in college woman’s sports Seem to have more PCS and are more difficult to manage in my experience

THE HIDDEN EPIDEMIC In Pediatrics Average High School in CT may have 50 -70/year

ISSUES IN CONCUSSION CARE n n Focus has been on return to play (sports) Schools don’t understand the need for assistance to students after a concussion It is not a visual diagnosis Lack of understanding by health care professionals on what are the best ways to assist a student following a concussion

The Good News… 80% of concussions resolve in 1 -2 weeks 13

How long does it take to recover from a concussion? Less than a week? AAP CT 2 -3 days? Sports authorities say less than a week

Individual Recovery From Football-Related m. TBI: How Long Does it Take? WEEK 1 WEEK 2 40% RECOVERED WEEK 3 80% RECOVERED 60% RECOVERED WEEK 4 WEEK 5 3 Year Prospective Study of 17 High School Football Teams N=2, 141 Collins et al. , 2006, Neurosurgery N=134 Concussed High School Football Players

Recovery: f. MRI Subsample (UPMC Program) Lovell et al; Mean Age: 16. 2 yrs Gender: 78% male Days to Recover Range: 4 – 211 days Mean = 26. 2 days Cumulative Percent Recovery 15 days – 25% 26 days – 50% 45 days – 75% N = 208 92 Days – 90% 16

Will now focus on the 20% who do not recover rapidly and review how their concussion impacts their school performance. Students who cover quickly usually do not require the many adjustments PCS students need

Definition of Post-Concussion Syndrome Concussion symptoms lasting more than 3 weeks This is the time when treatment is usually started

Symptoms of PCS n Headache Foggy and slowed down Dizziness (spinning) Ocular problems Balance Problems Concentration Memory Sleep Psych symptoms n Neck symptoms n n n n 19

Headache n n n Most common sx of concussion & PCS Initially constant, steady “pressure feeling” Then headache comes and goes, is dull/achy at rest and becomes throbbing with activity Doing cognitive/physical activity for more than 10 -20 minutes increases headache. Need to take breaks every 10 -20 minutes History of migraines increases risk of prolonged recovery 20

Feeling Foggy and Slowed Down n n Hard to define Brain feels like computer with a virus like your head is under water like a regular TV and not HD TV like your head is in a cloud When this resolves patient often wakes up one morning and says “Wow, I am better” Headache usually resolves within 1 -2 days after this symptom resolves 21

Dizziness n Spinning when stand up (room around patient or patient around room) This is different than just lightheadedness Difficulty with heights, moving crowds, stores, spiral staircases & busy patterns n Heights cause dizziness n Incr. awareness of normal motion n Bothered by busy patterns Suggestive of vestibular problems n 22

Ocular Problems Blurry, foggy vision n Light sensitivity (fluorescent light bother them) this sometimes is last sx to resolve. n Difficulty reading, depth perception off n Seeing double (suggestive of an eye convergence problem) n 24

Balance Problems Difficulty with balance in a dark room n Hard to maintain balance on stairs n Bang into walls n

Concentration and Memory Difficulty focusing and can only read or be on the computer 10 -15 minutes before symptoms increase n Can’t remember what they hear or read and have difficulty learning school work. n Repeat themselves, lose their train of thought, forget what they say in conversation. n

Sleep Symptoms n n n Altered sleep will delay recovery. Have trouble falling asleep or staying asleep Do not allow to sleep all the time after the first one to two days No naps after the first two days Maintain sleep pattern present prior to the concussion (same wake-up and bedtime schedule). Blue Light Blocking Glasses (orange-tinted glasses) No LED screens (TV, smart phone computer monitor, tablets) 27

Psychiatric Symptoms Irritability is usually present early on n If psychiatric symptoms were present preconcussion, they often become worse. n Depression due to pre-existing condition or not being able to attend school or sports. n Anxiety is common. (Will I ever recover? ) (especially with vestibular issues) n

Neck Pain and Spasm Need to examine the neck in any patient with a concussion. n Prolonged concussion headaches may be related to neck pathology. n Tingling or numbness in extremities may be an indication of neck pathology START NECK PT ASAP n 29

Physical Findings of PCS Lightheadedness with rapid lateral and horizontal eye movements Diagnostic of concussion Disappears around the time when the feeling foggy and slowed down resolves

Physical Findings of PCS Vestibular findings

Vestibular System Overview • Peripheral Vestibular System • Semicircular Canals • Otoliths: Utricle and Saccule • Vestibular Ganglia • Vestibular Nerve • Central Vestibular Projections • Vestibular Nuclei • Cerebellum • Autonomic Nervous System • Thalamus • Cerebral Cortex

Function of Vestibular System STABILIZE 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 n Near point of conversion should be less than 6 cm (normal is 0 -6 cm. ) n Usually resolves on its own n 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 n Difficult to assess without a baseline n Most helpful to use at time of the injury for making the diagnosis of a concussion n Appears to resolve more quickly than other symptoms following a concussion. (Catena 2011, Guskiewicz 2003)

TOOLS USED TO ASSESS PCS Neurocognitive testing (Im. PACT) MRI of head sometimes needed Full neuro-cognitive testing by a neuropsychologist (expensive, often not covered by insurance)

Neurocognitive/psych testing n 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” 37

VALUE OF Im. PACT CLINICALLY Finds 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 38

Predicting Who Will Develop PCS n n n n 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 On-Field Marker N Chi 2 P Odds Ratio 95% Confidence Interval Posttraumatic Amnesia 92 1. 29 0. 257 1. 721 0. 67 -4. 42 Retrograde Amnesia 97 . 120 0. 729 1. 179 0. 46 -3. 00 Confusion 98 . 114 0. 736 1. 164 0. 48 -2. 82 LOC 95 2. 73 0. 100 0. 284 0. 06 -1. 37 On-Field Symptom N P Odds Ratio 95% Confidence Interval Chi 2 Dizziness** 98 6. 97 0. 008 6. 422 1. 39 -29. 7 Headache 98 0. 64 0. 43 2. 422 0. 26 -22. 4 Sensitivity LT/Noise 98 1. 19 0. 28 1. 580 0. 70 -3. 63 Visual Problems 97 0. 62 0. 43 1. 400 0. 61 -3. 22 Fatigue 97 0. 04 0. 85 1. 080 0. 48 -2. 47 Balance Problems 98 0. 28 0. 59 0. 800 0. 35 -1. 83 Personality Change 8 0. 86 0. 35 0. 630 . 023 -1. 69 Vomiting 97 0. 68 0. 41 0. 600 0. 18 -2. 04 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 Lau, Kontos, Collins, AJSM 2011

SECOND BLOWS TO THE HEAD n 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%) n 12 Females and 8 developed PCS (67%) n Lee and Fine. CT Medicine 2010 41

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 SCHOOL FAMILY OCULAR NEUROPSYCH Vestibular PT neck

Post-concussion Syndrome (Patterns possibly requiring medication) Emotional Issues Physical Issues Headaches Dizziness Balance difficulties Light and noise Sensitivity Visual problems Nausea Depression Irritability More emotional Nervousness Thinking issues Attention problems Difficulty with memory “Fogginess” Cognitive Slowing Fatigue Sleep Issues Difficulty falling asleep Sleeping less than usual 44

Post-concussion Syndrome Emotional Issues Physical Issues Amitryptaline (Elavil) Nortryptaline Topamax/Depakote Vestibular therapy? Gabapentin Propanalol (? NCAA) SSRI: Lexapro Zoloft/Prozac Xanax Klonopin Therapy Thinking Issues Neurostimulants Amantadine Amphetamines Mehytlphenidate Strattera Sleep Issues Melatonin Trazedone 45

Headache Management Keep the dull and achy headache from becoming pounding and throbbing. Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache. Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms Tylenol as needed (Ibuprofen after a few days) 46

Pulled muscle analogy

Headache Management Keep the dull and achy headache from becoming pounding and throbbing. Activities can be done as long as the symptoms do not become worse. Discontinue any activity that increases the headache. Once there is significant improvement in the headache and symptoms at rest, may take short walks and do light activities that don’t increase symptoms Tylenol as needed (Ibuprofen after a few days) 48

EXERCISE n n n May start to exercise lightly after 2 -3 weeks even with mild headaches. No impact activities, limit head movement (elliptical or exercise bike initially) Start off very slowly (few minutes) and gradually increase. Can do multiple times a day. Leddy et al, Exercise treatment for PCS J Head Trauma Rehabil. 2013 Jul-Aug; 28(4):

SCHOOL Students recover quickly during Christmas, Spring and Summer vacations Need to remember (remind parents) the first priority is to get kids back to school ASAP. Sports is a secondary priority!

Different than other medical conditions causing school absence Can’t see the problem Only condition where you are unable to perform cognitive functioning needed to do school work

The return to school is a very critical time. If cognitive work is overdone, or increases inappropriately, the concussion symptoms will return, sometimes almost as much as right after the injury. Sady, Phys Med Rehab Clin N Am 2011: Howell, MSSE, 2013

SCHOOL ADJUSTMENTS (when they return to school) X + X = 2 X Excuse all non-essential school work No double workload – make-up work and new work.

SCHOOL ADJUSTMENTS Goal: Get the most out of the school day without worsening the symptoms. Optimize learning without creating quick fatigue.

SCHOOL (initial return) Sleep in, Leave early Alternate AM and PM classes to cover all (? Initially avoid Math, Chemistry, Foreign Language) Need to be driven to school initially (should not ride the school bus) Elevator passes if stairs (unless this makes them “dizzy”) Rest periods after 30 -45 minutes Don’t let student go to all “hard” classes! Some classes easier than others – ask! No gym class or exercising initially (are not to be allowed in P. E. class) 55

Trial and error needed (balancing act) 1 period, ½ day, full day Go to nurse’s office when HA increases Frequent breaks with rest periods Alternate class with rest period Gradually increase hours No extra-curricular activities or job 56

SCHOOL (initial return) No note taking (may need scribes) Pre-printed class notes helpful (should be sent home while not in school) Listen to lectures only Audio books helpful Limit computer time Avoid videos in class Tutoring may be needed to help catch up 57

SCHOOL (initial return) Workload may need to be reduced 50 -75% Progress to homework when no symptoms Homework less than 1 -2 hours a night Frequent breaks while doing homework Term papers postponed or forgiven

It is imperative that the student advocate for his/her needs. If an increasing headache develops they should not stay in class but should go to the nurse’s office. They can rest there (skip a period and try another class if the headache resolves). If it returns they need to go home.

HEADACHE n n Most common symptom of concussion Can distract student from concentration Can vary throughout the day and may be triggered by various exposures, such as fluorescent lighting, loud noises, reading, focusing or tasks Math, Chemistry Foreign Language seem to cause headaches to occur more than other subjects

HEADACHE ADJUSTMENTS Identify triggers and reduce their exposure n Frequent breaks n Rests, planned or as needed in nurse’s office or other quiet area n Give student class notes n Allow student to put head down in class n

NOISE SENSITIVITY AT SCHOOL: Hallways Lunch room Music classes (band/choir) P. E. classes Shop classes, Organized sports practices Should not listen to loud music (especially in cars or on Ipods) Should avoid attending dances, parties, music concerts and sports events until symptoms are gone 62

NOISE ADJUSTMENTS Allow use of ear plugs as needed n Leave class 5 minutes early to avoid hall noise n Quiet area to do work n Lunch in a quiet area with a classmate n Avoid/limit music, shop and P. E class n Avoid noisy gym and team/sports practice n

VISUAL PROBLEMS LIGHT SENSITIVITY, BLURRY/DOUBLE VISION 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) 64

VISUAL ADJUSTMENTS Allow sunglasses to be worn in school n Reduce exposure to computers, smart boards and videos n Reduce brightness on screens n Turn off fluorescent lights as needed n Consider use of audiotapes of books n

CONCENTRATION and MEMORY ISSUES Difficulty learning new tasks and comprehending new material n Difficulty with recalling and applying previous learned material n Difficulty with focusing and attention n Problems with test taking, especially longer more standardized tests n

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. 67

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 n n 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 Issues Isolation - 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?

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 72

ADHD AND CONCUSSIONS

ADHD Prevalence is Up Among Older Children Among youth aged 12 -17 years ADHD increased by 4% annually from 1997 -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 75

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 Stephanie Greene, M. D, Journal Neurosurgery: Pediatrics 6/25/13 Although not statistically significant, youth athletes with ADHD took on average 3 days longer to return to baseline neurocognitive testing compared with a control group without ADHD. Mautner, et al. , Cliniclal Journal Sports Medicine Nov. 2014

DILEMMA Should an athlete who never had ADD symptoms prior to a concussion be allowed to continue to play contact sports if ADD symptoms develop and persist after the concussion?

Are undiagnosed concussions one cause of ADHD in children

Issue for schools and sports How many concussions are too many? NO EASY ANSWER

Each athlete needs to be evaluated individually. n There is no magic number as to how many concussions are too many. n Return to play should probably be guided by symptoms and neuro-psych testing regardless of the number of concussions. n If it takes exceedingly longer to recover from each concussion or PCS occurs, perhaps it may be time to do a non-contact sport. n Do you allow fewer concussions in youngsters ( What if 3 or 4 concussions before age 12? ) n

CONTACT INFORMATION Michael A. Lee, M. D Connecticut Children’s Medical Center 95 Reef Road Fairfield, CT 06824 Office (203) 452 -8322 Fax (203) 254 -0358 www. concussionmd. com