The Concussion Conference 2.0May 2014

• Gaylord Hospital is a Long-Term Acute Care Hospital (LTACH) specializing in medically complex care and acute rehabilitation

Not-for-profit Independent Free-standing, 137-bed hospital, Wallingford 24/7 MD, RN, RT staff

• Gaylord Outpatient Services provides two locations staffed with certified, specialty trained therapists in each area

Gaylord Specialty Healthcare

Sarah E. Bullard, Ph.D., ABPPGaylord Center for Concussion Care

CONCUSSIONThe Impact on Schools:

Strategies and Adjustments in the First Weeks

• Majority (80-90%) resolve in short (7-10 day) period

• Traumatic Brain Injury

• Traumatic Brain

Traumatic Brain Injury

• Majority (80-90%) resolve in short (7-10 day) period

ModMild Severe

Severe GCS ≤ 8Moderate GCS 9 - 12Mild GCS 13 - 15

Teasdale et al Lancet 1974; ii: 81-4

Concussion

?

“Minimal”

Glasgow Coma Scale

• Majority (80-90%) resolve in short (7-10 day) period

• May take longer in children and adolescents

• Females have a higher concussion incidence and they experience more severe and persistent symptoms

• Pre-existing ADHD, LD and psychological distress may complicate recovery

• Dizziness was the sole ON FIELD factor predictive of protracted (> 21 days) time to recovery (Lau 2011)

Recovery From Concussion

• Majority (80-90%) resolve in short (7-10 day)

Factors to consider

Symptoms NumberDuration (>10 days)Severity

Signs Prolonged LOC (>1min)Amnesia

Sequelae Concussive convulsions

Temporal Frequency –repeated concussion over timeTiming – injuries close together“Recency” – recent concussion or TBI

Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

Age Child and adolescent (< 18 years old)

Co and Pre-morbidities Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders, first two weeks of menstrual cycle

Medication Psychoactive drugs; Anticoagulants

Behavior Dangerous style of play

Sport High risk activity; Contact and collision sport; High sporting level

• Expect gradual resolution within 7-10 days• Gradual return to school and social activities

that does not result in significant exacerbation of symptoms–Proceed through step-wise return to learn

Management

• Concussion may impact on the child’s cognitive ability to learn at school

• This must be considered and medical clearance is required before the child may return to school.

• It is reasonable for a student to miss a day or two of school after concussion, but extended absence in uncommon.

Return to Learn

• In some students, a graduated return to school program will need to be developed for the student.• If any particular activity worsens symptoms, the student will abstain from that activity until it no longer causes symptom worsening.• Use of computers and internet should follow a similar graduated program, provided that it does not worsen symptoms.• This program should include communication between the parents, teachers, and health professionals and will vary from student to student.

Return to Learn

• Saturday: Concussion• Sunday: Rest• Monday: No school• Tuesday: No school• Wednesday: Half Day*• Thursday: Half Day or Full Day• Friday: Half Day or Full Day9:00-1:00/ 10:00-2:00

Example of a Graduated RTL Schedule

• Monday: School• Tuesday: Concussion• Wednesday: No School• Thursday: No School• Friday: No School or Half Day

Alternate Example of a Graduated RTL

• To assess if being in the school environment produces any type of exacerbation of symptoms.–Fatigue–Nausea–Dizziness–Headache–Irritability–Confusion/distractibility–Light/noise sensitivity

What is the goal of the half day?

• If any of the symptoms worsen, call the parent or treating doctor. May need to back off and take another day off, or may need to extend the half days.

• Pay attention if the student is:–Asking to go to the nurse’s office often–Out sick–Complains of frequent headaches–Is falling asleep in class–Seems to be in a fog–Has a drop in grades

Goal of the half day continued

Concussion

Clinical Presentations in Concussion

Vestibular

Ocular

Cognitive/ Fatigue

Post Traumatic Migraine

Anxiety/Mood

Cervical

Based on model developed by UPMC Sports Concussion Program Presented on June 9, 2013 by Michael W. Collins, PhD

Clinical and Executive Director UPMC Sports Medicine Concussion Program

• Adjustments: temporary and occur between injury and a formal 504

• Accommodations: after a 504, but still temporary

• Modifications: a permanent change (IEP)

Return to Learn Strategies

• The return to school program should consider:–Later start times, half days, only certain classes–Auditing of classes (half day)–Reduce the workload!!–Shorter assignments (what is truly essential?)–Postpone or exempt larger tests/projects

• Adjust the due dates

–Do not penalize for class work/assignments not completed during recovery (be specific!)

Return to Learn Strategies

–Extra time to complete assignments/tests (be specific!)–Quiet room to complete assignments/tests–Alternate test formats: multiple choice & true/false–No more than one exam or quiz/day

• Point person to coordinate this among the teachers and the student (nurse, guidance counselor, etc.)

–Use of peer helper/tutor (notes) or notes and handouts from teachers–Allow for technology (symptom dependent)

Additional Strategies

–Allow the student to wear sunglasses or a hat–Avoidance of noisy areas such as cafeterias, assembly halls, sporting events, music class, shop class, etc.

• Have students change classes five minutes early• Arrange to have the student eat lunch with one or two friends in a

classroom or office• Need to consider planned assemblies and field trips (depends on

where student is in their recovery)

–Frequent breaks during class, homework, tests–Allow the student to go to the nurse’s office

Additional Strategies

–AP classes• Cannot modify the tests and often cannot allow extra

time• Make adjustments around the test—allow the student

to leave after completing the test, allow for the test to be taken in a separate room, adjust the workload temporarily in other classes during AP exam week

–Reassurance from teachers that student will be supported through recovery through accommodations, workload reduction, alternate forms of testing (i.e., multiple choice)

Additional Strategies

– Consider additional adjustments– Reach out to the parents and treating doctor– Refer for a neuropsychological assessment

What if Symptoms Persist?

• Important component in overall assessment and RTP.

• Aids in clinical decision making as well as school planning.

• Included as part of clinical neurological assessment by treating physician often with computerized NP screening tools.

• Formal NP testing not required for all but, if so, interpretation should be performed by trained neuropsychologist.

• Baseline testing not mandatory. May be helpful in test interpretation and for education opportunity

Neuropsychological Assessment

Care beyond the ordinary. 21

• Clinical interview (often pt + collateral)

• Review of medical records, imaging, labs, etc

• Assessment of several domains– Effort– Pre-morbid & current intelligence– Attention/Processing Speed/Executive Functioning– Visual spatial functioning– Verbal & non-verbal memory– Language– Motor– Emotional/Mood/Personality functioning

Elements of a NP Assessment

Care beyond the ordinary. 22

• NP unique because:– Use of formal measures of effort/engagement– Integration of data related to effects of mood on

cognition– Ability to combine cognitive data with other

sources of data to aid in diagnosis– Comprehensive reports– Feedback sessions - both to providers, schools

and patients and their families

Don’t Other Specialists Examine Cognition

Care beyond the ordinary. 23

“Jane”

Case Study

• Middle of three children; good health; A/B student

• 1st concussion in October of 2012

– Recovered within a week• 2nd concussion in September of 2013

– No memory for getting hit, brief LOC, immediately nauseous and tired

– Persisting headaches, ringing in her ears, sensitivity to light

– Remained out of school for a few days• Attended a volley ball practice and was

struck on the head

– Symptoms exacerbated

Jane: 14-yr-old female volleyball player

– Evaluated 6 weeks post concussion, complained of:

• Sensitive to light and sound• Occasional dizziness• Daily headaches that abated only somewhat

on weekends• Fatigue• Poor concentration• Difficulty recalling what she has read• Grades beginning to slip

– Was full time at school, no adjustments– Had pulled out of all extra-curricular activities

Jane: Initial visit

Jane: Initial Test Results

Impaired Borderline Low Avrg. Average High Avrg. Superior Very Sup.

Memory

Attention

Processingspeed

Executive Fx:hits a wall/lose track/

distracted Visual spatial

Language

• Oculomotor signs:

– smooth pursuit with symptoms, hypometric corrections during seccades

– Convergence 45cm (normal approx. 6cm)

– Dynamic visual acuity 7 line difference

– King Devick Score more than twice normal time

• Balance Assessment

– Deteriorated balance with movement and with eyes closed-Dynamic Gait Index 17/24-

– Activities Balance confidence scale- 64.4/100

– Poor ability to engage in simple cognitive tasks during physical exertion.

Jane: Initial PT Findings

• Half Days• Essential work• Extra time for tests/assignments• One test/day• Quiet room for tests• Note taker/iPad• No return to play• Nutritional recommendations• Follow up one month

Jane: Recommended Adjustments

• Improvement in headaches and fatigue– But headaches are still daily

• Improvement in light/sound sensitivity

• Still difficult to concentrate in a noisy environment

• Overall described as “brighter” by mom

• Described school as very supportive, which helped relieve stress

Jane: One Month Follow-Up

Jane: One Month Follow-up

Impaired Borderline Low Avrg. Average High Avrg. Superior Very Sup.

Memory

Attention

Processingspeed

Executive Fx:hits a wall/lose track/

distractedVisual spatial

Language

• Oculomotor signs:

– smooth pursuit without symptoms, seccades normal

– Convergence 10 cm (normal approx. 6cm)

– Dynamic visual acuity 3 line difference

– King Devick Score significantly reduced

• Balance Assessment

– Deteriorated balance with movement and with eyes closed-Dynamic Gait Index 22/24-

– Activities Balance confidence scale- 85/100

– Able to walk at 3.5 miles per hour while moving gaze to varied targets and engage in mild cognitive task.

Jane: One-Month Follow-Up PT

• Full days

• Essential work

• Extra time for tests/assignments

• One test/day

• Quiet room for tests

• Use of iPAD to take notes

• No return to play

• Worried about rebound headaches: contact pediatrician

• Follow up one month: at which time most adjustments are anticipated to be lifted

Jane: Updated Adjustments for School

Jane: Two-Month Follow-Up

*Effort intact; Mood intact

Average High Average Superior Very SuperiorLow AverageBorderlineImpaired

Attention

Processingspeed

Executive fx(hits a wall)

Memory

Language

Visual spatial(Spatial judgment)

• Cleared from PT to return to play/sport

• No ongoing adjustments needed at school

• Discussion with Jane and her father about the risks/benefits of contact sports and future concussions.

Jane: Final Result

“Kathy”Protracted Recovery

Case Study

• 16-year-old female• Whiplash injury in a motor vehicle

accident 2 months previous• Remembers immediate neck pain and

headache• Did not strike head • History of migraines• Participated in varsity track as well as

field hockey• A student, Honors & AP classes• Missing school

Kathy: Initial Appointment

• Light sensitivity- did not like wearing sunglasses because the pressure on her nose gave her a headache.

• Noise sensitivity• Fatigue/Poor sleep• Extremely Anxious and mildly depressed• Grades slipping • Hard to concentrate• Difficulty completing homework• Had been seen by chiropractor and but did

not get much relief from neck pain nor headaches

Kathy: Initial complaints

• Had been adjusted by chiropractor by her visit to PT

• Oculomotor signs: smooth pursuit with symptoms Convergence Within normal limits but symptomatic with testing Dynamic visual acuity 3 line difference

• Balance Assessment Deteriorated balance with eyes closed in sharpened Romberg and

standing on foam. Dynamic Gait Index 17/24- Activities Balance confidence not administered SLS R= 3 seconds L= 4 seconds

• Other PT findings Rapid alternating movements UE delayed. Finger to Nose dysmetria Mild cervical ROM limitation into extension with some posterior cervical

pain Muscle guarding in (B) SCM, Upper and middle traps, scalenes, lev

scapulae, spenius capiti. Unable to complete 10 minute exertion test due to headache, dizziness,

mild nausea- test stopped after 3 min 25 sec. Headaches daily

Kathy: Initial PT results (6 weeks)

Kathy: Initial NP Results (2 months s/p Injury)

*Effort intact

Average High Average Superior Very SuperiorLow AverageBorderlineImpaired

Attention

Processingspeed

*strategizing &thinking quickly on your feet

Flexibility/Multi-tasking

Verbal Memory

Mood: Depressed &

Anxious

• Half Days for two weeks• Extra time for assignments/tests• Note taking• Test format: multiple choice• Referred for psychotherapy• Refrain from driving until anxiety

improved• No sports• Nutritional recommendations

Kathy: Recommendations

• Complains of:– Fatigue (nap every afternoon)– Decreased attention/concentration– Forgetful– Daily headaches– Depression and anxiety

• School– Struggling to complete homework– Hard to start projects/hard to motivate– Not caught up in all classes

Kathy: 5 months later

• Oculomotor signs: – smooth pursuit without symptoms– Convergence without symptoms– Dynamic visual acuity same line reading

• Balance Assessment– Balance with eyes closed in sharpened Romberg and standing on

foam Within normal parameters.– Dynamic Gait Index 23/24- – Single limb stance R= 12 seconds L= 15 seconds

• Other PT findings– Other findings- Rapid alternating movements UE normal. Finger to

Nose testing normal– Cervical symptoms absent– Days without headaches. – Able to tolerate up to 20 minutes of minimal to moderate exercise

walking in treadmill or stationary bike.– Core stabilization continued to be weak for dynamic activities

Kathy: Follow-up PT Findings

Kathy: 5 months post Injury

*Effort intact

Average High Average Superior Very SuperiorLow AverageBorderlineImpaired

Attention

Processingspeed

*Organization/Planning

when unstructured

Flexibility/Multi-tasking

Verbal Memory

With structure

Mood: Depressed &

Anxious

• Test format: multiple choice• Extra time for assignments and tests

(headaches, fatigue, anxiety)• Separate room for tests• One test per day• Point person• No sports• Continued psychotherapy• Speech therapy

Kathy: Recommendations

• No more headaches• Breakthrough in psychotherapy:

mood dramatically improved• Fatigued somewhat more easily than

in the past, but able to manage without naps

• Felt like herself

Kathy: 8 months later

• Pt was referred to return to play protocol– Field Hockey

• Oculomotor signs: – smooth pursuit without symptoms– Convergence without symptoms– Dynamic visual acuity same line reading

• Balance Assessment– Balance with eyes closed in sharpened Romberg and standing on

foam Within normal parameters.– Dynamic Gait Index 24/24- – Single limb stance R= 30 seconds L= 30 seconds

• Other PT findings– Other findings- Rapid alternating movements UE normal. Finger to

Nose testing normal– Cervical symptoms absent– Headaches gone with physical activity. Pt did have headache

after riding in car to Boston for 2 ½ hours which recovered quickly.

Kathy: Final PT visit

Kathy: Final Eval 8 months post injury

*Effort intact; Mood intact

Average High Average Superior Very SuperiorLow AverageBorderlineImpaired

Attention

Processingspeed

Organization/Planning

when unstructured

Flexibility/Multi-tasking

Memory

Problem Solvingwith structure

• Full time school schedule• No adjustments• Cleared to return to play

– Thank you.Sarah E. Bullard, Ph.D., ABPP

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Kathy: Recommendations