Pediatric Issues in sports concussion assessment

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Pediatric Issues in (sports) concussion
assessment management

• Gerard A. Gioia, Ph.D.
• Pediatric Neuropsychologist
• Chief, Division of Pediatric Neuropsychology
• Director, Safe Concussion Outcome, Recovery
  Education (SCORE) Program
• Childrens National Medical Center
• Washington, DC

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In Honor of Mark Ylvisaker
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Kids are Different Duh!

• Different brains (moving target/ jello hardens)
• Different skills (attention, memory, speed,
  executive functions, social behavior)
• Different life (acquisition practice of
  knowledge and skill)
• Different system (adults are responsible for kids)

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Kids are Different Duh!Therefore,

• Management is different

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Pediatric (Sport) ConcussionComponents

• Neuroscience ? Developmental Neuroscience
• Public health ? Preparing the systems, knowledge
  and awareness
• Clinical science ? Applications to the real world
  of the child and family

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Concussion/ mTBIDefinition

• A concussion (or mild traumatic brain injury) is
  defined as a
• complex pathophysiologic process affecting the
  brain,
• induced by traumatic biomechanical forces
  secondary to direct or indirect forces to the
  head.

CDC Heads Up Brain Injury in Your Practice (2007)
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Concussion/ mTBIDefinition

• Disturbance of brain function is related to
• neurometabolic dysfunction, rather than
  structural injury
• typically associated with normal structural
  neuroimaging findings (i.e., CT scan, MRI).
• Concussion may or may not involve a loss of
  consciousness (LOC). (lt 10-20)

CDC Heads Up Brain Injury in Your Practice (2007)
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Concussion/ mTBIDefinition

• Concussion results in a constellation of
  symptoms
• physical, cognitive, emotional and sleep-related.
  
• Duration of symptoms are variable may last for as
  short as several minutes and last as long as
  several days, weeks, months or even longer in
  some cases.

CDC Heads Up Brain Injury in Your Practice (2007)
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Points to Consider

• Look to the Definition for what we do
• Less brain structure, more neurometabolic
  functioning
• Constellation of symptom, neurocognitive, daily
  functioning
• May or may not involve LOC (the obvious sign)
• Variable presentation and time to recovery

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Pediatric (Sport) Concussion

• Developmental Neurometabolic differences
• Brains response to force
• Response to recovery?
• Early identification/ assessment process
• Young self report less reliable requires
  knowledgeable adult
• Lack of professionals sideline
• Access to generic medical care (ED, Pediatrician)
• Fewer tools available

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Pediatric (Sport) Concussion

• Treatment
• Factors interfering with recovery
• Over-exertion Cognitive, Physical
• Unique opportunities learning
• cognitive exertion
• ? Neurometabolic rates of cognitive learning
  exertion vs physical exertion

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Pediatric (Sport) ConcussionNecessary Tools

• Educational programs medical, sports, school,
  family/ child
• Developmentally-sensitive Neurocognitive tests
  sensitive to injury and recovery
• Symptom assessments Child, Parent, Teacher
• Neurometabolic activity (MRS, fMRI), integrity of
  neurotransmission (DTI)
• Longitudinal - Tracking recovery
• Physical and cognitive activity/ Exertional
  Effects management

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Current State of Youth Concussion/ Mild TBI
Management
Lack of education and awareness
Under-identification under-recognition
Poor/ incomplete management
Increased risks
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Realities of Pediatric (Sport) ConcussionSystems
Need Work

• Reality The medical, athletic and school systems
  are currently ill-equipped to diagnose and manage
  these injuries.
• Emergency Dept.
• Primary Care Pediatricians
• Specialty care Neurology, Neurosurgery,
  Orthopaedics, (Sports Medicine)
• High School, Youth leagues

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Realities of Pediatric (Sport) ConcussionThe Kid

• Reality Kids MAJOR priority is development.
• The developing brain may pose greater
  vulnerabilities to injury than the mature brain.
• Schools play a major role.
• Schools are currently ill-equipped to manage this
  injury.

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Exertional EffectsOverworking the Brain

• Increase or re-emergence of post-concussion
  symptoms following significant exertional
  activity
• Physical activity
• Cognitive activity

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Realities of Pediatric (Sport) Concussion

• Few on-field athletic health professionals

Elite
For everyone 1 concussion in the NFL, there are
50,000 at the youth level.
Youth
30-45 million non-scholastic sports participants
(NAYS, NCYS)
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What to Do on the Sideline?

• Use of Responsible Adults
• Parents, Coaches
• CDC Educational Toolkits
• Clipboard Signs and Symptoms, Fact Sheets
• Pediatric-Specific Sideline Assessments
• Kiddie SCAT2

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What Can we do with the Kids?

• Developmental Neuroscience
• Neurometabolic functioning
• Clinical Science
• Assessment of concussion
• Treatment of concussion

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Neurometabolic Cascade FollowingTraumatic Brain
Injury
(Giza Hovda, 2001)
UCLA Brain Injury Research Center
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NAA and proton Magnetic Resonance Spectroscopy
(1H-MRS)
Single voxel placed in the white matter of the
frontal lobes
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fMRI and ImPACT TESTING14 Year-Old Motocross
Racer
5 DAYS POST INJURY
20 DAYS POST INJURY
Average score is 100 (SD15)
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Neuropsychological Effects of Concussion

• Attention, concentration
• Working memory (holding info in mind during
  activity)
• New learning memory storage/ retrieval
• Speed of processing information
• Reaction time

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4 Symptom Categories

• Physical
• Headache
• Fatigue
• Dizziness
• Sensitivity to light and/or noise
• Nausea
• Balance problems

• Emotional
• Irritability
• Sadness
• Feeling more emotional
• Nervousness

• Sleep
• Drowsiness
• Sleeping less than usual
• Sleeping more than usual
• Trouble falling asleep

• Cognitive
• Difficulty remembering
• Difficulty concentrating
• Feeling slowed down
• Feeling mentally foggy

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Over the past day Have you had headaches? Has
your head hurt?
YES
NO
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Over the past day Have you had headaches? Has
your head hurt?
How much?
A Little?
A Lot?
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Evaluating Pediatric (Sport) Concussion

• Reliable/ valid assessment of post-concussion
  symptoms is central component of diagnosis and
  management
• Unique considerations related to reliability and
  validity of self-reported symptoms in younger
  student-athletes
• Reliability of child report
• Childs concrete cognitive style, sense of time
  (now vs yesterday)
• Vocabulary level of symptoms (foggy, irritable)
• Scaling of symptoms 7 choice Likert scale
• Emotional maturity wanting to please
  shy/inhibited
• Proxy reporting/ parent observations are
  frequent in health-related assessments

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Post-concussion symptom inventory (PCSI)

• Parent/Teacher Symptom Report (26-item)
• Child (5-12) Symptom Report 3-point Likert scale

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Post-concussion symptom inventory (PCSI)

• PCSI data collected from typically developing and
  clinical (mTBI) samples of children and their
  parents aged 5-18 years
• (1) Normative samples Child and Parent (n gt 600)
• (2) mTBI samples Child and Parent (n gt
  700)
• (3) ADHD/ LD samples
  (n gt 75 )
• mTBI samples gathered retrospective, pre-injury
  and serial post-injury

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PCSI findings

• Parents
• Reliably report post-concussion symptoms in their
  children
• Add significant symptom information above and
  beyond childs own symptom reports
• Child
• Younger (5-7) have difficulty reporting on their
  symptoms, less reliable reporting overall with
  less predictive value in detecting presence or
  absence of mTBI.
• Older (8-12) generally reliable reporters
  self-reports have moderate predictive value.
• Adolescents (13) reliable reporters

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Updated Guidelines for Pediatric (Sport)
Concussion

• Zurich 2008

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Zurich 2008 CIS Consensusfor Kids

• Clinical evaluation include patient and parent,
  and school when appropriate
• Evaluation generally similar to adults timing of
  testing differs to assist treatment planning in
  school and home
• Age-appropriate baseline necessary
• More important to use neuropsychologists to
  interpret assessment data, particularly with LD
  and ADHD.
• Strongly endorsed view no return to practice or
  play until clinically completely symptom free

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Zurich 2008 CIS Consensusfor Kids

• Cognitive rest highlighted
• More conservative return to play approach
• - appropriate to extend amount of time of
  asymptomatic rest and/or length of graded
  exertion
• It is not appropriate to RTP on the same day of
  injury
• Concussion modifiers apply even more than adults
  and may mandate more cautious RTP advice.

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Anthony11 yo hockey goalie

• Evaluated in SCORE clinic 6 days post-injury
• Self-reporting no symptoms
• Father reporting no symptoms
• ImPACT testing revealed significant
  neurocognitive deficits
• Held from game play and practice no PE Rest
• School notified to monitor academic learning and
  performance

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Anthony11 yo hockey goalie

• Re-evaluated in SCORE clinic 1 week later
• Self-reporting no symptoms no school problems
• Mother reporting no symptoms
• ImPACT testing revealed significant improvement,
  normal neurocognitive functioning

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Asymptomatic 11 year old
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Asymptomatic 11 year old
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Hypothesis mTBI results in physiological
dysfunction (MRS, DTI) that a) correlates to
clinically measurable parameters (symptoms,
cognitive deficits) or b) predicts development of
long term symptoms.
Monitor Activity (cognitive physical) /
Environment
Monitor Activity (cognitive physical) /
Environment
Post-inj Time 3,4 Day 14, 30
Pre-injury factors/ baseline
Post-inj Time 1 Day 1
Post-inj Time 2 Day 7
Outcome
Injury
Sx list ImPACT MR Spec DTI Anat MRI
Sx list ImPACT MR Spec DTI Anat MRI
Sx list ImPACT MR Spec DTI Anat MRI
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New State of Youth Concussion Management
Lack of education and awareness
Education and awareness
Under-identification under-recognition
Identification Recognition
Poor/ incomplete management
Complete management
Increased risks
Decreased risks
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Contact Information

• Gerard A. Gioia, Ph.D.
• Director, Pediatric Neuropsychology Program
• Director, SCORE Program
• Childrens National Medical Center
• 14801 Physicians Lane, Ste. 173
• Rockville, MD 20850
• Phone [phone]
• Fax [phone]
• E-mail ggioia_at_cnmc.org
• Jennifer.Janusz_at_gmail.com