TRAUMATIC BRAIN INJURY A BRIEF OVERVIEW

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Cathy OConnor AT, MD, FACS Goodall
Hospital Maine Concussion Management Initiative
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• Educate about Mild Traumatic Brain Injury
• How to identify a student with potential injury
• How brain injury affects academic performance
• Understand the need for academic accommodations
  during MTBI recovery.
• Review more commonly used academic
  accommodations.

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• No spare brains available
• Long lasting consequences if not managed properly
  in kids
• Education and patience is the key

No spare brains available Long lasting
consequences if not managed properly in
kids Education and patience is the key
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• Mild Traumatic Brain Injury (MTBI)
• Same injury and mechanism as what we see in
  military veterans who are victims of IEDs
• Throw out all previous assumptions about
  concussion- new game

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Brain Metabolism is Related to Recovery

• Over 200 High School Athletes Studied using fMRI
• Hyperactivation predicts CLINICAL recovery time
• Resolution of hyperactivation correlates with
  recovery

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Collins, et al. Neurosurgery 58275-286, 2006
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• Higher number of concussions/MTBI
• MTBIs occurring too close in time
• Re-injury prior to full recovery
• Pre-existing learning disability or migraine
  issues
• Physical exertion OR cognitive stress can cause
  symptom flare-ups prolong recovery.

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• May not be the athlete- could have happened
  outside of school, in gym class, slip and fall,
  etc
• Symptoms may be delayed or not manifest until
  brain is cognitively stressed
• Student not able to focus, pay attention, fails
  quiz or test, odd answer to verbal question,
  appears to have problem with lights

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• Physical
• Headaches
• Fatigue/tiredness
• Dizziness with movement or mental exertion
• Nausea
• Light/noise sensitivity
• Ringing in the ears

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• Cognitive
• Inability to focus
• Limited concentration
• Inefficient short-term memory
• Slowed thinking
• Feeling mentally foggy
• Poor reading comprehension

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• Sleep difficulties
• Trouble falling asleep
• Overnight awakening
• Oversleeping/undersleeping
• Feeling tired in the morning despite long hours
  in bed

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• Mood disruption
• Irritability
• Sadness
• Nervousness
• Anxiety
• Depression

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• COGNITIVE
• Fogginess
• Concentration
• Memory deficits
• Cognitive fatigue

SLEEP DYSREGULATION Falling asleep Fragmented
sleep Too much/too little sleep
SOMATIC Headaches Dizziness Light/noise
sensitivity Tinnitus
MOOD DISRUPTION Irritability Sadness Anxiety
Adapted from Camiolo Reddy, Collins Gioia, 2008
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• Wake up fatigued
• Develop headaches sitting in class
• Cant fully grasp class material
• Feel worse as the day wears on
• Bothered by light/sound at school
• Feel more exhausted after school
• More symptomatic trying to do homework
• Upset and worried they are falling behind
• Go to bed feeling worse

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• Controls for individual factors such as LD, ADHD,
  medications, etc.
• Can be done in large groups with educational
  seminars
• Orients athletes to concussion issues at start of
  season
• Annually for injured athletes every 2 years for
  those with no concussion history
• Baseline and post injury testing

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CASE 1 KICK-OFF RETURNER
DAY 3 6 10
13 14
Exertion
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• Improve with rest
• Physical/sports exertion
• Mental exertion
• Sustained attention in class and during school
  day
• Reading
• Homework
• Tests/quizzes

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• Temporary?
• Short-lasting?
• Improves more quickly with proper management
• Complete recovery typically expected

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• Athletic Trainer
• Monitoring of symptoms
• Periodic neurocognitive testing
• School Nurse
• Daily clinical evaluations
• Rest recovery area
• Medication
• Guidance counselor
• Coordinates academic accommodations

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• Teachers
• Adjust work according to changing status
• Reassurance
• Psychologists
• Specific input for LD-ADHD students
• Social Workers
• Adjustment support - especially in longer
  recoveries

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• Consistent Message to the Student
• The injury is real
• Waiting for a full recovery is critical.
• Prolonged recovery or even catastrophic injury by
  returning to activity too soon
• Academic accommodations can be provided during
  recovery

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• Individualization
• Accommodations
• Key staff
• Innovation
• Integration/Team work
• RN ATC
• Guidance Teachers
• Psychologists Social Workers
• Parents
• Fluid situation that will change over time

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• Excused absence from classes
• Time out of school/complete rest to start?
• Partial attendance as able
• Morning fatigue/poor sleep gt arrive late
• Afternoon fatigue in school gt leave early
• Selective attendance?
• Core classes vs. electives?
• Avoid classes that are too challenging?

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• Rest periods during the school day
• School nurses office
• Go to rest before symptoms become too intense
• Take Tylenol/Advil, etc. as recommended by
  doctor
• Return to classes if feeling better
• Early dismissal if rest does not help

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• Extension of assignment deadlines!
• Homework, papers, projects
• According to students capacity
• Removes major source of pressure
• Allows student to prioritize sleep
• rest!

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• Excuse from some assignments ?
• More common in lower grades
• Less catch-up to do during/after recovery
• Consolidate work into more manageable units

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• Postponement of quizzes tests
• Until student is able to prepare and symptoms are
  under better control
• Avoid high stakes testing (e.g. AP exams, SAT)
  while symptomatic
• Extended time (x1.5 or x2) until recovered
• Spring injuries - wait until summer to complete
  course work and exams?
• Evaluate true necessity of exam/quiz for student
  assessment- ? Alternative format

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• Accommodation for light/noise sensitivity
• Excuse from assemblies
• Able to eat lunch away from cafeteria
• Cap and/or sunglasses for light sensitivity
• Avoid fluorescent lights, windows
• Limit iPod, TV, computer exposure based on
  symptoms
• Limit texting
• Adapt music to what is comfortable

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• NO sports, gym, music/theater/dance
• Use time for rest homework
• Short practice visits to stay connected to team
• DO NOT ride bus to away games with team
• DO NOT sit on bench during games
• In stands with family if symptoms allow
• Prom

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• Limit other forms of physical exertion
• Heavy backpacks
• Climbing stairs
• Walking home from school/bus stop
• Caring for large animals, or walking the dog
• Operating heavy equipment
• DRIVING
• Be aware of impaired judgement/ability to react
  to dangerous situations

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• Outermost layer
• Learn new info
• Form thought
• Make decisions
• Memory function

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• Recent memory
• Emotions
• Concentration
• Ability to learn new info and retain it
• Storage of motor patterns and voluntary activity

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• Processing of sensory input
• Sensory discrimination
• Body orientation

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• Processing of all visual input

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• Expressed behavior childish, irritable, agitated
• Information retrieval
• Receptive speech/auditory input processing

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• www.cdc.gov/concussion
• www.impacttestonline.com
• www.sportsconcussion.net
• www.sportslegacy.org

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