Pediatric Concussion Clinic

Concussions in Pediatrics Katie Weems, PT Carrie Tingley Hospital Disclosures Katie Weems, PT None Objectives Understand NM law regarding sport concussion Understand how to diagnose a concussion Understand treatment done by PT Understand return to learn model

Understand return to play model MTBI Definition (ace, G. Gioia & M. Collins, 2006 v2) A concussion (or mild traumatic brain injury (MTBI)) is a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural injury, and is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI).

Concussion may or may not involve a loss of consciousness (LOC). Concussion results in a constellation of physical, cognitive, emotional and sleep-related symptoms. Symptoms may last from several minutes to days, weeks, months or even longer in some cases. Pediatric Concussion Facts Between 1.7 and 3 million sports- and recreation-related concussions happen each year. Around 300,000 are footballrelated.

5 of 10 concussions go unreported or undetected. Girls' soccer sees the second-most concussions of all high school Stats from UPMC Concussion clinic sports. Girls basketball sees the third most.

Falls (50%) is the highest cause of brain injury, followed by assault (25%) in children aged 0-14 years (CDC) TBI is the leading cause of death and disability in children 0-4 years and adolescents (15-19 years) (CDC, 2015) and 80% of TBI are mTBI (CDC, 2003) 2 in 10 high-school athletes who play contact sports including soccer and lacrosse will suffer a concussion this year. NMAA Athletic Program Requirements Senate Bill 38; Concussion Law Grades 6 12

22-13-31.1 NMSA 1978; Section G: brain injury" means a body-altering physical trauma to the brain, skull or neck caused by, but not limited to, blunt or penetrating force, concussion, diffuse axonal injury, hypoxia anoxia or electrical charge RETURN TO PLAY GUIDELINES UNDER NEW MEXICO SENATE BILL 38 (2017) Remove athlete immediately from activity when signs/symptoms of a concussion are present. Athletes must not return to full activity prior to a minimum of 240 hours

(10 days). Athletes must be released to participation by an appropriate medical professional before returning. - MD, DO, PA, CNP, PT, Licensed Psychologist, Licensed Athletic Trainer (as per Senate Bill 38) School districts are required to develop head injury protocols (guidelines). NM Helmet Law

An Ounce of Prevention Beats a Pound of Cure All children up to the age of 18 years must wear a helmet while riding a: Scooter, Bicycle, Tricycle, and Skateboard and using roller skates University of NEW MEXICO RESEARCH Bottom Line: More concussions in PE than sports, so be alert to a

wide range of youth athletic activities! Undiagnosed Concussion Patients may present to us as medical professionals without a clear diagnosis of concussion: Child- playground injury - falls Assault Patient with multiple trauma from MVC Those that are unreported Child adolescent sports injury Be cognizant of concussion profile, probe history thoroughlymake referrals!

Symptomatic Recovery Period No exercise (24-48 hours only!) Decreased Avoid Role No school activity/hours (based on symptoms) decompensation

of added stressors 2 concussions are the same PATIENT EDUCATION!!! Silverberg and Iverson; J head Trauma Rehabil 2012 When to Refer OUT to Rehab

*Vidal PG,Goodman AM,Colin A, Leddy JL, Grady MF.Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent Concussion. Pediatrics. 2012:41:9 (1-6) PT Evaluation Subjective/ History/ Observation Oculomotor Musculoskeletal Vestibular (Day 4/5) Balance/ Gait (Day 4/5) Cardiovascular- Leddy Protocol (Day 5/6) Functional Testing / Cognitive Tasking/ Multi tasking

Post-Concussion Examination Subjective/ History/Observation SYMPTOMS Somatic headaches, nausea, vomiting, balance and or visual problems, dizzy spells, and issues with light sensitivity and noise Emotional sadness to the point of depression (even suicide), nervousness, and irritability Sleep disturbance Sleeping more or less than usual and trouble falling asleep

Cognitive Difficulty concentrating, troubles with memory, feeling mental slow or feeling in a FOG SYMPTOM CHECKLIST Find one that works for you! SUBTYPES

Adopted from UPMC CERVICAL PROFILE NECK pain, stiffness, soreness Headache, radiating from upper cervical spine forward

Precipitated/ aggravated by specific neck movements or sustained postures High Velocity trauma (eg: MVA) Unprepared for Hit Strong Rotational component to injury Balance Cervical Measures Neck Disability Index (NDI) Functional Cervical Motion Functional Strength Testing

Craniocervical Flexion Test Craniocervical flexion Maneuver Joint Position Error Test Cervical extension Deep neck Flexor Test

Postural Alignment Headache Disabiltiy Index (25 items) OCULAR/ VISUAL PROFILE Frontal headaches w/ visual work Difficulties with visually based classes and activity Pressure behind the eyes Visual focus issues Blurry vision Double vision Balance

Ocular/ Visual Measures VOMS Smooth pursuits Horizontal and Vertical Saccades Convergence Horizontal VOR Vertical VOR Visual Motion Sensitivity Test Mucha et al, 2014 COVER TEST / UNCOVER TEST

Testing for misalignment during binocular function VOMS VESTIBULAR PROFILE Dizziness Nausea/ Motion sickness one step behind Symptomatic in busy environments Off balance

Vestibular NOT AS COMMON IN THE PEDIATRIC POPULATION VESTIBULAR Measurement/ BALANCE Balance BESS Dix- Hallpike Test Clinical Test of sensory interaction BPPV

and balance (CTSIB) Nystagmus SOT/ HSSOT VOR IMPAIRMENT DGI Head impulse Test Functional Gait Assessment Clinical dynamic Acuity Activities Specific Balance Test Confidence Scale (ABC) PT CERVICAL TREATMENT ROM

Joint Mobilization STM Postural education Functional strengthening PT Ocular TREATMENT Convergence Exercises Advance program from Brock Sprint 3-D dot card

Static, to Dynamic then Eye Movement Control multi tasking Eye Focusing and coordination when Eye Teaming and improving binocular Function appropriate Accommodation

Pencil Push ups Summar y Concussions are VERY Common across all ages of kids Most concussions resolve within 10 days when treated properly Seek more care if symptoms persist past 10 days 504 plans are needed for R2P and R2L Encourage safe play and safe places CDC has training resources for health care professionals,

families, and coaches Contact us for a consultation as needed Flow Chart for Concussion Team Clinic meeting Evaluations MD Hx & P

PT Imagingtesting R2P Vestibular - balance Ocularmotor Muscularskeletal

PSY Mood Psychosoci al Cognitive R2L Referra ls

Vision Neurology Psychiatry Alternative 504 plan M D PT Ps

y Neuropsyc h Recommendations R2P, R2L, 504plan, treatment TEAM WORK Physician Neurologist Primary care Sports Medicine Pediatrician Physical Medicine and

Rehabilitation Emergency Medicine Rehabilitation Athletic Trainers Speech Therapist Occupational Therapist Neuropsychologist Rehab Psychologist Psychiatrist Vision Specialist Schoo l RN Therapies

School Teache rs Family Concussion Medicatio n Friend s

Rest Diet Exercis e Treatment planning Othe r ONLINE RESOURCES

e c r u o s e R s

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