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New Approaches to Youth Concussion
Tracy Fabri
May 5th, 2018
Outline
1. About Holland Bloorview
2. What is a concussion?
3. Concussion research in youth: current update
4. Concussion management & active rehab (family, HCPs, school &
sport)
5. Return to learn and sport after concussion
6. Resources for you
About Holland Bloorview
• Holland Bloorview is Canada’s largest kids rehabilitation hospital
• Specialize in youth concussion
• Clinicians specifically trained in pediatric brain injury and leading researchers in the field of youth concussion
• Focus on getting kids back to what they need, want and love to do
About Holland Bloorview
Research
Clinical
Education
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About Holland Bloorview
What is a concussion
Concussion statistics
• 43% of Canadian youth and adolescents participate in organized sports at least once per week (Clark, 2008)
• Six times more likely to experience a concussion in organized sport than other leisure activities (Browne & Lam, 2006)
• Concussions account for 441-754 per 100,000 pediatric emergency room visits (Macpherson, 2014)
• Hockey/skating most common specific cause of youth sports-related concussions in Canada (Macpherson, 2014)
What is a concussion?
• An injury to the brain
• Caused by blow to head or another part of the body
• Blow causes the brain to move rapidly inside the skull
• Movement causes stretching of brain cells
• Stretching causes chemical changes in the brain
(McCrory et al., 2013; CDC, 2016)
The invisible injury
“People don’t understand because they don’t see my
concussion as an actual injury, if they don’t see it – you’re not actually hurt in their eyes”
17 year old client with persistent concussion symptoms
#DearEverybody Campaign
#DearEverybody Campaign
Signs and symptoms of concussion
• Every injury is different (experience, recovery time)
• Symptoms may take up to 24-48 hours to appear
• Only need 1 symptom to treat as a suspected concussion
• Concussions cannot be seen on a CT scan or MRI, therefore must rely on how we act and feel
Signs and symptoms of concussion
3 ways to identify signs and symptoms of a suspected
concussion:
• Self-reported signs & symptoms
• Observed signs & symptoms
• Peer-reported signs & symptoms from child/youth, teachers,
coaches and/or parents
Early recovery vs persistent symptoms
~70% of children/youth will recovery (symptom free and return to regular activities) within 4 weeks
~30% of youth have symptoms and lack of full return to regular activities for longer than 4 weeks
What promotes early recovery: May take longer to recover or have persistent symptoms if:
Proper medical assessment Education (child, parents, teachers,
school, coaches) Gradual engagement in symptom
limited activity Appropriate school and sport
accommodations to support recovery
Have a concussion history Have co-morbidities: depression, ADHD,
anxiety, sleep disorders, migraine history, learning disability
Female Age 13-17 Symptom presentation in first 24-48
hours Return to activities too soon or delay
return to activities for too long (Zemek, 2016)
Screening for high risk for persistent symptoms
Females and concussion
• Some large scale studies indicate that girls and women are at greater risk for having symptoms that persist for more than a month
• The extent to which recovery is slower for females is still unclear
Mental health and concussion
• Persistent concussion symptoms can have an impact on mental health that is often under-recognized
• Mental health issues may take longer to appear, and may sometimes result from physical symptoms (Yeates et al. 2012;Carroll &
Rosner, 2011)
• Mental health issues experienced are compounded by lack of participation in meaningful activities (Schneider et al 2013)
• If sport is a large part of identity, may be more susceptible to changes in mental health (Podlog & Eklund, 2005)
Bill 193 (Rowan’s Law)
Davis et al. 2016
McCrory et al. 2016
New Conclusions
Rowan’s Law (Bill 193)
Rowan’s Law (Bill 193)
1. Reviewed the concussion awareness resources approved by the Minister of Tourism, Culture and Sport. For individuals under 18 years of age or such other prescribed age, the parent or guardian of the individual must also confirm that they have reviewed the resources.
2. A sport organization must establish a concussion code of conduct.
3. A sport organization must establish a removal-from-sport protocol for athletes who are suspected of having sustained a concussion. The protocol must, among other things, establish a specific process to implement the immediate removal of an athlete and must designate persons who are responsible for ensuring the removal of the athlete and ensuring that they do not return to training, practice or competition, except in accordance with the sport organization’s return-to-sport protocol.
4. A sport organization is required to establish a return-to-sport protocol that applies with respect to athletes who have sustained a concussion or are suspected of having sustained a concussion. The protocol must, among other things, establish a specific process to implement the return of an athlete to training, practice or competition and must designate persons who are responsible for ensuring that an athlete does not return until permitted to do so in accordance with the protocol.
New conclusions in the research this year
• A brief period of cognitive and physical rest (2-5 days) should be followed
with gradual symptom-limited physical and cognitive activity
• All schools are encouraged to have a concussion policy and should offer appropriate academic accommodations to support students recovering from concussion
• Children and adolescents should not return to full contact sport play until they have successfully returned to school schedule and workload. However early introduction of symptom-limited physical activity is appropriate.
Davis et al. 2016
New conclusions in the research this year
• Recurring predictor variables of persistent symptoms were acute
headache, migraine and dizziness (all when higher than preinjury levels), as well as female sex and history of receiving multiple concussions.
• Adolescents (12-18) may require more academic support during concussion recovery.
• Prolonged absence from school and school environment should not be encouraged in concussion recovery
Davis et al. 2016
Remove from sport/activity protocol
General concussion symptoms vs ‘red flag’ symptoms
Sideline ax
Medical assessment/diagnosis
• Recommended that ANY child with a suspected concussion see’s a Medical Doctor or Nurse Practitioner as soon as possible (ER, walk-in clinic, family doctor)
• Why is it important to receive medical assessment?
– Want to rule out more severe injury
– Obtain proper diagnosis
– Receive a medical note of for concussion diagnosis to support return to school and sport accommodations
• When to go to ER vs immediate appointment with MD/NP?
– 911 or ER immediately if red flag symptoms are present
Medical assessment/diagnosis
GTHL Canada & Holland Bloorview Concussion Policy
Medical assessment/diagnosis
WHEN A HEALTHCARE PROFESSIONAL IS PRESENT
Sideline Medical Assessment: When an child/youth is suspected of sustaining a concussion and there is no concern for a more serious head or spine injury, the participant must be removed immediately from the activity.
Important notes of assessment tools (i.e. SCAT5 or Child SCAT5):
• Should only be used by a licensed medical professional who has experience is using these tools
• Results can be normal in the setting of acute concussion
• Can be used to document initial neurological status, but should NOT be used to make return-to-activity or diagnostic decisions for suspected concussions
• Every participant who has a suspected concussion must be referred for medical assessment by a medical doctor or nurse practitioner regardless of sideline assessment results.
Medical assessment/diagnosis
WHEN HEALTHCARE PROFESSIONAL IS NOT PRESENT
Sideline Medical Assessment: Sideline assessment using clinical assessment tool is not appropriate. If any reported or observed signs and symptoms of a concussion after an impact the head or body, participant is considered to have a suspected concussion. If there is any doubt whether a concussion has occurred, it is to be assumed that it as. When in doubt, sit them out.
• Once removed participants are to be referred immediately for Medical Assessment by a medical doctor or nurse practitioner, and the athlete must not return to play until receiving medical clearance.
• Highly recommend organizations have injury report forms to record and track incidents of suspected concussion.
Initial Recovery
• Everything we do in our day uses “energy”
• When you have a concussion, need to conserve this energy to:
• Allow for proper healing
• Avoid exacerbation of symptoms
Initial recovery – finding balance
• Exercise is medicine
• When you have a concussion you need to gradually build activity level:
• Allow for proper healing
• Avoid activity intolerance or deconditioning
Paniccia & Reed, 2017
Initial recovery– Finding Balance
8-10 hours Routine No caffeine No technology
Balanced diet Eat often Water! (2-3L) Carbohydrates
Explore/Try Practice! Record stress Recognize stress
Prioritize Plan Pace Position
Initial recovery– Lifestyle modifications
Initial recovery - Active rehabilitation
Neurology Centre of Toronto, Dr. Evan Lewis
Initial recovery - Active rehabilitation
Neurology Centre of Toronto, Dr. Evan Lewis
Initial recovery - Return to school and sport
A new focus in initial recovery… • Suggested activities children/youth can do vs what they
can’t do • Building cognitive and physical tolerance • Light aerobic activity earlier in recovery
• Symptom threshold or symptom limited vs symptom free
McCrory et al. 2016
Gradual return to school and sport
McCrory et al. 2016
Active Rehabilitation – Sport and physical activity
McCrory et al. 2016
Active Rehabilitation – School
Return to life after concussion
Stage 0: Initial and brief rest period (24-48 HRS)
Stage 1: Daily activities at home that do not give child symptoms
Stage 2: Daily activities (in or outside school). Start light physical activity.
Stage 3: Part time school. Increase aerobic activity & sport drills
Stage 4: Full time school and sport specific skill work and non-contact practices
Stage 5: Return to contact sport and/or competition
GOAL: Initial period of 24–48 hours of both relative physical rest and cognitive rest
STAGE 0: Initial and brief rest period
• Restful activities in home environment
• No school or sport
• Monitor for increasing and/or changing symptoms presentation
• Seek medical diagnosis from MD or NP
GOAL: Gradual return to typical activities
STAGE 1: Daily activities at home that do not give
child symptoms
Diagnosis is sent to the Wernham Ham Centre for Learning
Cognitive and physical activities:
Participating in physically and cognitive resting activities that does not worsen symptoms.
For more recovery strategies download the concussion handbook hollandbloorview.ca/concussionhandbook
STAGE 2: Daily activities (in or outside school). Start
light physical activity.
GOAL: Gradual return to typical activities
Cognitive activities:
Participating in physically and cognitive activities that to do not worsen symptoms at home and school.
Cognitive activities and school work done at home as tolerated (reading, writing, cooking, etc.).
Attempts sitting through a class by attending and listening with limited active participation. No assignments or test taking.
Physical activates:
Light aerobic activity (i.e. walking, running, stationary bike, and swimming) with duration and exertions levels as tolerated at home.
STAGE 3: Part time school and Increase aerobic
activity & sport drills
GOAL: Increase academic activities and school attendance COGNITIVE ACTIVITY
Classroom tasks: Reading, computer/screen time, writing as tolerated in classroom
Test taking: Initially no test taking, but can gradually build to test taking for cognitive tolerance if appropriate (i.e. formative assessments).
Homework/assignments: As tolerated in evenings. Start with 30-60 minutes and build if it does not provoke symptoms. Focus on core classes.
PHYSICAL ACTIVITY
Symptom limited light aerobic activity (i.e. walking, running, stationary bike, swimming) and non-contact sport specific skill work done at home in controlled environment. * Can begin resistance training as tolerated.
COGNITIVE ACTIVITY
Testing taking: No more than one quiz/test per day on initial return. Student prioritizes core classes, and school official monitors frequency of tests.
Homework/assignments: Focus on core classes on initial return. Consider option of a temporary free period for homework to minimize workload on nights and evenings while getting caught up.
GOAL: Full return to academic activities & catch up on missed knowledge
STAGE 4: Full time school and start gradual
RTP
PHYSICAL ACTIVITY
Reintegration into school sport specific exercises through return to play protocol (Stages 3 and 4 of Return to Sport).
Non-contact sport specific skill work and non-contact full team practice.
No full return to contact sport practice or full competition until return to full school schedule and workload participation.
GOAL: Full return to academic activities & catch up on missed knowledge
STAGE 4: Full time school and start gradual
RTP
Progressing in return to school
Diagnosis is sent to the Wernham Ham Centre for Learning
How do we know when we’re ready to progress to next stage?
• A student is able to progress through stages when able to tolerate activity with either no symptoms OR minimal symptoms that are not significantly aggravated by school attendance and activities prior to progressing to next stage.
• Amount of time in each stage is dependent on the student and determine in combination with school official and medical recommendations
Return to life after concussion
Stage 0: Initial and brief rest period (24-48 HRS)
Stage 1: Daily activities at home that do not give child symptoms
Stage 2: Daily activities (in or outside school). Start light physical activity.
Stage 3: Part time school. Increase aerobic activity & sport drills
Stage 4: Full time school and sport specific skill work and non-contact practices
Stage 5: Return to contact sport and/or competition
STAGE 5: Return to contact sport and/or competition
Attendance:
Student is participating in full school schedule and workload with no symptoms
COGNITIVE ACTIVITY LEVEL:
Test taking, homework, assignments: Student is participating in homework, tests and assignments with no ongoing symptoms
GOAL: Full return sport activities
STAGE 5: Return to contact sport and/or competition
PHYSICAL ACTIVITY LEVEL:
Student has competed full return to play protocol and been cleared by an MD or NP
Return to Phys. Ed class
Full return to contact practice/gameplay or full competition
GOAL: Full return sport activities
McCrory et al. 2016
Return to sport protocol (general)
Progression in return to sport
Diagnosis is sent to the Wernham Ham Centre for Learning
• An initial period of 24–48 hours of both relative physical rest and cognitive rest is recommended before beginning the return to sport progression.
• There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the child/youth should go back to the previous step.
• Resistance training should be added only in the later stages (stage 3 or 4 at the earliest).
• Best practice has shown to wait minimum 10 days for an children/youth to return to contact activity after concussion for reducing repeat in-season concussions.
• All students must be full participating in school schedule and workload prior to return to full sport play and/or competition
Medical clearance to in return to full sport
Diagnosis is sent to the Wernham Ham Centre for Learning
• The final decision to medically clear a child/youth to return to full game activity should be based on the clinical judgment of the medical doctor or nurse practitioner taking into account the client’s past medical history, clinical history, physical examination findings and the results of other tests and clinical consultations where indicated.
• Prior to returning to full contact activity or competition/game play, children and youth must provide Medical Clearance Letter that specifies that a medical doctor or nurse practitioner has personally evaluated the client and has cleared the athlete to return full participation for contact activity, or activities that have the potential for contact.
Return to sport protocol (examples)
DOES OCA HAVE A POLICY??? What is it?
Return to school and activity
In summary… 1) Mandate medical assessment and clearance: All children/youth must be
seen by a medical doctor or nurse practitioner for 1) Diagnosis and 2) Medical Clearance
2) Prolonged rest is not recommended: After initial rest period children/youth can be encouraged to become gradually and progressively more active (without worsening their symptoms).
3) Symptom limited activity helps recovery: Closely monitored active rehabilitation programs involving controlled sub-symptom-threshold, have been shown to be safe and may be of benefit in facilitating recovery.
4) Full return to school before sport competitive play: All children/youth should receive medical clearance by a physician and be able to return to full school workload and schedule prior to competitive contact play.
McCrory et al. 2016
Resources for you
Handbook for parents & kids
Our clinical services
