Mild TBI: Out of Sight, but not Out of Mind

1. Mild TBI:Out of Sight, but not Out of Mind Ronald C. Savage, Ed.D.

6. The CDC’s definition of MTBI “An MTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a jolt to the head or body that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e. CT Scan, MRI). MTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or longer in some cases.” (Aubry et al., 2002; McCrory et al., 2005).

8. Defining mTBI mTBI is more “neuro-chemical” than it is “physio-mechanical”

9. 500 Calcium 400 K+ 300 Glucose % of normal 200 Glutamate 100 50 2 6 12 20 30 6 24 3 6 10 0 Cerebral Blood Flow hours days minutes Neurometabolic Cascade Following Cerebral Concussion/MTBI (Giza & Hovda, 2001) UCLA Brain Injury Research Center

11. mTBI/Concussion Facts • Most mTBI/concussions do NOT involve loss of consciousness • A direct blow to the head, face, and neck can cause a mTBI/concussion • An indirect blow elsewhere on the body can transmit an “impulsive” force to the head, causing a mTBI/concussion

12. How many Sports and Recreation concussions occur each year?An estimated 1.6 to 3.8 million sports- and recreation-related concussions occur in the U.S. each year, including those for which no medical care is sought. This range includes both concussions with and without loss of consciousness (LOC) and is based on studies that suggest that injuries involving LOC may account only for between 8% and 19.2% of sports concussions. This estimate supersedes that from an earlier CDC study that reported 300,000 sports- and recreation-related concussions per year which was based only on those injuries with LOC.

19. Individual Recovery From Sports MTBI: How Long Does it Take? WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 80% RECOVERED 60% RECOVERED N=134 High School Male Football Athletes 40% RECOVERED Collins et al., 2006, Neurosurgery

20. Examining Relevance of “Bell Ringers” in High School Athletes Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004

23. CNN Video National Youth Sports Concussion Tour (43 states in 6 months)

24. National Pediatric Trauma Registry Mechanism of Injury for mTBI (B-19 years) N = 8016

29. Measure…Monitor…Manage

30. Follow-up for aSprained Ankle • Ice to reduce swelling • No or limited weight bearing • Elevate and rest • Use of crutches, bracing, wrapping • Lessen activities / modify environment • Slow return to activity • Rebuild strength

32. Follow-up for Sprained Brain • Allow time for “chemistry” /swelling to subside • No or limited cognitive activities • Rest and more rest • Use of modifications, compensatory strategies • Lessen activities / modify environment • Slow return to activity • Rebuild strength

33. Adoption of Computerized Neurocognitive Testing for mTBI/Concussion ImPACT CogState Headminders ANAM

34. Other Factors to consider • Age of the child…younger is not always better • Symptoms that persist for longer than 6-8 weeks • Cumulative effects of multiple mTBI/concussions

35. When Can an Athlete Return to Play? • When medically cleared • No cognitive or physical activity of any kind while still symptomatic, including headaches • If symptom free with light “activity”, progress to increased activity • ALWAYS respect the brain and the time it needs to heal

36. When Can Student Return to School?Accommodations? Supports?

38. Confused, “foggy” Mixed up about time and place Can’t attend or concentrate Forgetful, trouble remembering things Difficulty organizing words or thoughts Misunderstands things Slow processing Takes longer to do homework Learning/Thinking Changes

40. Restless, irritable or fussy Acts without thinking Becomes easily upset, angry or loses temper Sad, depressed or withdrawn Anxious or nervous Gets into arguments with friends / peers Cries easily or for no reason Behavioral/Emotional Changes

42. Has headache, is dizzy or lightheaded Vomits or feels sick Parts of body tingle or feel numb Loses balance, trips or stumbles a lot Feels worn out or exhausted Tires easily Drowsy or sleepy Needs extra sleep Hard to fall and stay asleep Sensitive to light and noise Blurry vision Ringing in ears Physical Changes

43. Monitor w/ checklist Reduce assignments Build in rest periods Give more time to complete work Outline and order steps for big tasks Give written directions or template Use notebook check off “to do” list Write down schedules w/places, times, etc Meet with Teacher to review home work at end of day Inform school nurse, counselor, sp edu Tips for helping the Student

44. mTBI/Concussion Communication P&P • Coach / AT alerts school official • Nurse / Counselor alerts teachers • Nurse / Counselor meets with student • Nurse / Counselor tracks student with “Teacher Progress Reports” • Significant changes or ongoing symptoms reported to Coach/AT, Family, Physician… • Possible referral to other specialists • Learning supports and modifications

45. No head injury is too severe to despair of, nor too trivial to ignore Hippocrates, 4th Century, B.C.