Chapters Transcript Video Pediatric Traumatic Brain Injuries Welcome, everyone. We're happy to talk to you today about pediatric traumatic brain injuries. We're really trying to give you some useful tools and tips about helping manage your patients with these, uh, injuries, really concussion type injuries. Um, we're gonna save questions for that and, but to get started, I just want you to be aware of um your follow-up and referral options here at UCSF for And pediatric PVI concussion related care. We have um multi multiple disciplines that manage concussions here first is in the sports concussion program, which is out of the Pete's ortho group that that's where myself and one other primary care sports medicine. Specialists will treat sports-related concussion. Um, usually we see people within 6 weeks of the injury. Um, if they have any abnormal scan or are younger than 8 years old, we will not, uh, see them. They should be referred to Pete's neurology instead. And the focus of this clinic is really on sports related injuries or injuries and competitive athletes or people are trying to get back to. For after um one of these uh TBIs. Um, the second group, um, where you can refer people are is the PETS neurology. They typically manage a sequela or symptoms lasting longer than 6 weeks, and they have, they people both in the general neurology clinic and then also in the PET neuro recovery clinic, which is, um, really dedicated to uh the cognitive recovery needs and, and support. OK, so to get us started, we'll start with a pole, um, You can either put your answer in the chat, I believe, um, cause I don't think you're able to speak, but the, we want you to put some thought into this. This is a seven year old who's been playing soccer and then he tripped and fell over another player and he hit his head on the grass. He did not lose consciousness. Um, he seems fine. He doesn't really have any symptoms, but you're asked by his coach about the next steps. Um, what would be some of your next steps and, and would you let him back on the field? Yes or no? So we can possily to think about that for a bit. It looks pretty split between yes and no. OK. Um, so, you know, that's reasonable. I think when we think about next steps, it's important to understand like how would we screen, like what would we use to evaluate, um, if we should let this kid go back to play or not. Um, when we think about concussion screenings, there are Some standardized tools that have been developed, um, both for the adults and pediatric population. I've listed them here. The concussion recognition tool is really for lay people, so we won't go into that too much, but the uh sport concussion assessment tool, the SCAT, um, most recent edition is the SCAT 6. Really the tool that is available for providers, uh, for sideline concussion assessment. And so when faced with a question like that, it's reasonable to think through the SAT or or perform a SAT, uh, in your assessment, which would help you make an informed decision about really back to play or not. And just a note that there is a child scat version which would be applicable to the kids 8 to 12 years of age. And then the last two are really highlighting some assessment tools that you might use in clinic. We know now that the SAT tends to be most effective up to 72 hours after the injury, so like in the 1st 3 days or so. And then after that, um, The most recent concussion consensus statement has recommended uh transitioning to the sport concussion office assessment tool, which is the SO fix um next slide. OK. So like I said, for medical providers, you wanna go to, you go to the next slide, uh, for We wanna use the scat. So what, what really is the scat? Um, the first step in it really is identification of red flags. So they're sort of highlighted in this table here. Um, the, the main Be aware of the red flags. I won't go through all of them, but seizures, loss of vision, double vision, any weakness, loss of consciousness, if they have any neck pain, vomiting, for instance, um, severe increasing headache. Those are red flags and they should be removed from play. If they don't have any of the mediate red flags, and there are other things you want. To consider. So do they have any observable signs of a concussion or a TBI? If the answer is yes, you still, you also want to remove them from play. Um, if not, we go on to sort of the next sections of the scan, which includes the Glasglaucoma scale performance, uh, and a neck assessment for tenderness or loss of range of motion, and, and, uh, ocular or coordination assessment as well. Um, if they have any one of these, um, being abnormal in your assessment, you do wanna hold them out and remove them, uh, promptly. So let's look a little closer at some of the observable signs. Oh So, um, the observable signs are, are listed here. They lying motionless on the, the field, um. Do they have any balance or gait difficulties? I think sometimes, a lot of times on in on-field concussions, it's not always noticed, right? And so you might catch it late or you miss the enticing event, the hit, um, I want to be clear that the, the hip does not have to be only to the head, it could be anywhere in the body that transmits a force abnormally to the brain. Uh, one of the things are quite sensitive if you're on the sideline and you're observing is, is balance, changing balance. If they're stumbling, they can't get a, and this is a positive observable sign and they should be held out. Um, and then, uh, of the other things listed here like blank or vacant look, I don't know if you've seen someone at the sideline with a concussion. It's pretty obvious and um really glaring how, how different they sort of look. Um. Of course, if they have any like facial injury, head trauma concern or uh or if they're disoriented or confused, all these are signs that we consider concerning for a concussion and you hold them out. And then you would, like I said, go through the sort of the other steps in the sca, the, the Glasglaucoma scale, a C spine assessment. You can check balance and coordination and then also we'll do uh a visual screen. And so I think for primary care providers, sometimes the visual screen assessment is a little unclear or not often talked a lot about, so we want to touch on that a little. So the, one of the main screens or visual vestibular oculomotor screen. That we do in concussion, uh, screening is called Avans testing, and there are a couple of different tenants of the smooth pursuits, the horizontal and verticals calls, which a lot of time we're doing in like a neuro assessment, um, and then there's the vest ocular testing, visual motion sensity testing, and then conversion. So this is a long test. It takes about 10 to 15 minutes. And a lot of times you don't have a lot of time to do it on the sideline. But I'll go through sort of with the steps and the, the parts of each of it. Uh, you know, I, when I see people for concussions, I do do this in the office, and it, it helps, um, Tailor their recovery like recommendations for therapy, um, recommendations for return to learn, return to sport based on any abnormal findings here. Um, most people that don't have a concussion will not have abnormal findings on this, but most of them that have one will, and almost all of them will have it immediately. And then for most of those that are concussed that have abnormal um screening. They, it will resolve, right? So in the 1st 4 weeks, but then there are people that have persistent abnormal bombs past 4 weeks, and these are the ones that we want to help get to rehab, etc. um, so we can help them um improve faster and not set them up for prolonged recovery from the concussion. OK, so for smooth pursuits, you're asking them to track side to side. I'd go back to the, the, the, um, like before. And so the thing with the bomb testing, you're, you're looking for symptoms. So are they having symptoms, dizziness, headaches, that, that's worsening. I feel nauseous, um, my eyes start to hurt a lot of. And we'll just like a pressure behind the eyes, things like that. So the pursuits are just following side to side, up, down, and then, uh, towards the nose. Um, so you're looking for any increased symptoms and also if they have, um, the sabus more than like 2 ft. And then you can do horizontal scas so you have two fingers like the side of a 3 ft away from them and like. Half of that separating and you want them to look side to side for horizontal and then up down for vertical. Uh, same with each tenant of the on testing, you're asking if you're having any increased symptoms or you're noting any problems with tracking. Sometimes they can't even smoothly track here, which is, it could be quite alarming. Um, and then the vestibular ocular testing, I usually use like a, a tongue depressor with like an X at the top, and I have them focus on that X so. You hold it about 3 ft from them. And then, um, first you start with the eyes on the X and, and head side to side. And so for formalO testing, you're supposed to use a metronome to get that done. So time and equipment really makes the fullOMS testing kind of impractical. But, um, if you have time. And those equipments in your office, you can use it for accuracy. Um, and so you do the vestibular oculum uh testing both vertically and horizontally. And then, uh, for visual motion sensitivity testing, you have them stick their thumb out. And look at the tip and they move side to side, about 80 degrees each way and while they're focusing on that, so I tell them to move side to side like you're spraying and then um again, symptoms or um a difficulty doing that would be positive. And then the last part of it is the convergences testing. So I use that same kind of repressor with the X. I bring it closer to their face, um, and you're trying to find out. All right, you're trying to test their ability to focus on a target uh close by without uh too much symptoms basically. And so without double vision, essentially, so you're asking, tell me when it becomes double vision. Um, uh, a near point conversion of at least 6 centimeters, um, or more than 6 centimeters from the tip of your nose is considered abnormal. Should be less than 66 or 6 and less. So you could move to the next side. So that's why you have sort of the general knowledge of the bones, but in practice, we now, we know that we can do a modified bos that is shorter and might be more effective for sideline testing in particular. And so, You don't have to necessarily record the baseline symptoms, but you wanna ask, did it make your headache that you already had worse, for example, that counts too. Um, and so for smooth pursuits, you would just do two horizontal and 2 verticals, uh, so much shorter, and then for the saccades, they just mentioned doing horizontal, um, and then same for the vesti ocular reflex, you wanna do um 10 repetitions. And the visual motor speed testing, um, instead of the last part, do that 5 times. And so this is as effective as doing the fullbos and, and way more, um, time effective. Um, but I encourage you to try and get into the habit of doing it because it can red flag or give you a sign for those that should be flagged for closer follow-up, those that might need vestibular ocular rehab to help with their, um, recovery. OK, next. OK, so this is another question for you guys. So, would you get a scan on this patient? I talked about the seven year old that he hit his head on the grass. Seems like some sometimes added. Yeah Do you have any thoughts in yet? We can't see the results, Maria. So I don't know if you can tell us what you're seeing on the polling. I know. Yeah, OK, so I think um So, I'm Aaron Jensen. I'm a trauma surgeon here at Oakland Children's. I'm the trauma medical director. And I think my role, I, I see a lot of kids with concussions. I don't do a lot of concussion treatment other than saying we have awesome teams with Doctor Watkins and Doctor Johnson Kerner and, and experts in concussion. But I often get involved for mild to moderate head trauma to answer that question, do we need to get a scan? Um, and really it's, it's useful in differentiating. Um, intracranial hemorrhage versus what we call, you know, just a concussion. It's never just a concussion, right? Um, and I think it matters because a lot of the symptoms are related to headaches and things that kids are gonna want to go home and use NSAIDs for. And if you give NSAIDs to somebody who have, you know, intracranial hemorrhage blood in their head and it expands, it's probably not gonna be a good day. So we have to ask ourselves, what are the risks of, of having uh clinically significant intraabdominal or intracranial hemorrhage and, you know, how can we make these decisions a little bit easier. I put this up. I do a lot of work with the federally funded EMSC Emergency Medical Services for Children's program. Um, and we actually have algorithms for all of the body regions that you might encounter that you may want to image after trauma, and you're not gonna order imaging from an outpatient clinic, but I would look at this as, you know, if this patient screens positive, um, by these clinical decision rules that can be applied in a clinic, probably needs to be referred to the ER for a urgent CT scan of the brain. Um, so I'm gonna go through the, the PCar and head rules, which is part of this and that QR code, um, Maria will share the slides later. If he's at that QR code, all of these are free online. You can download them and print them out or put them on an app or, you know, whatever you want, but um all of these are free, so um this is the one for the head. So what I'm showing on the screen now is the one for under 2 or for nonverbal kids. Um, on the next slide, I'll show you the one for older kids, um, which actually is a little graphically nicer, but understand, you know, the symptoms are a little bit different for kids who can talk versus those who can't talk, but the algorithms work the same. And these risks stratify. Um, your, your probability of having a clinically significant traumatic brain injury or intracranial hemorrhage into high intermediate, and low risk. The high risk kids all need a scan. They have a 4% chance of having an intracranial hemorrhage. And those are patients who have an abnormal glass cal coma scale. So they come into your office and they don't open their eyes spontaneously. You gotta like poke them to wake them up. Um, they talk, but they don't talk normally, or maybe they don't follow commands. You gotta like apply painful stimulus. It's pretty obvious, right? So, uh, diminished GCS everybody needs to be referred to the ER for a CT scan. Um, if you see signs on your physical exam of a basal or skull fracture, so bruising behind the mastoids or raccoon eyes or CSF draining from the ear or the nose, those patients need to go to the ER for a CT scan. Um, and patients that are just agitated or overly somulent, um, or they keep asking you questions over and over, those could Most likely, those are gonna be post-concussive symptoms, but those all suggest that the degree of brain injury is a little more significant cause we know that patients who have intracranial hemorrhage exhibit many of the same symptoms as severe concussion patients. So anybody who has one of those three factors definitely needs a CT scan every time. And then we get into the middle, which are intermediate risk factors. So these are important because these, these put you in a category where you need to think about a scan. But if you don't have any of the high risk factors and you don't have any of the intermediate risk factors, you don't need a CT scan and you can be discharged from clinic with just interval follow-up and return precautions. So the things we think about in little kids is a non-frontal hematoma. So if you got a big shiner on your forehead, we got sinuses in the front, and those sinuses serve as crumple zones, just like a car when you're in a crash, and they take all the blow. So, a frontal hematoma, we don't really worry about so much, but something around the parietal skull or occipital skull or something up top, there's not a lot of crumple zone there. There's no sinus there. We do worry about direct injury to the brain and skull fracture and underlying hemorrhage. Um, most concussions, um, that don't have intracranial hemorrhage will have a brief loss of consciousness, but if you have a prolonged loss of consciousness longer than 5 seconds, and sometimes it can be really hard to tell what happened cause what maybe 2 seconds seems like forever to that parent. But the history you get, they say, you know, they were knocked out for 30 seconds. That's a, that's an intermediate risk factor, OK? Mom says, you know, they look fine, but they're just not acting like themselves. Like, my baby is not normal and I know they don't talk and I know the baby looks normal to you, but I take care of this kid every day and my baby is not normal. OK? If mom is saying that, you gotta think twice. And then finally, how severe was that mechanism of injury? Is there enough force and enough energy in that mechanism to warrant getting a scan? OK. So those are the four things, and those mechanisms are are falls greater than 3 height. Uh, NBC hit by a car, fell off your bike, um, or struck by a high impact object. So if you have any of those factors, you should enter into a discussion with the parents. Do you want a CT scan so you can know right now? Or shall we observe you for 4 hours and see if you have progression of symptoms? So if a child had prolonged loss of consciousness, but they don't have any other symptoms, they're not vomiting, they're not acting abnormal, um, potentially, you could observe them for 4 hours cause we know that these kids who have clinically significant brain injuries are going to have additional symptoms within those 4 hours. So it is a completely acceptable approach to observe those kids. Most of us who see these patients in the ED um treat these four factors as additive. So if you come in and you only have one of those 4 risk factors, So maybe you don't have a hematoma, you had no loss of consciousness, you're acting completely normal, but you were in a really high energy car crash, right? So high risk mechanism but no other factors, or maybe it was low mechanism, but you have a non-frontal hematoma, right? If you just have one, most of us will recommend that for hour period of observation. If you have all four risk factors, your risk of clinically significant injury is actually between 2 and 3%, which is getting closer to the high risk category. So these should be treated as additives. So if you have more than one of these intermediate risk factors, you really need to more strongly consider just going to CT scan because your pre-test probability is higher. But the bottom line is, if you don't have any of these factors, you do not need a CT scan. OK, so our soccer player who was 7. Who fell from standing very low risk, who did not have loss of consciousness, who is acting normal and is asymptomatic, even though he hit his head and maybe it was a pretty violent fall, he does not need a CT scan and his risk of a clinically significant traumatic brain injury is less than 0.02%. That's 2 in 10,000 kits, OK? So, 2 in 10,000 is not zero. But the risk of a CT scan also is not zero, right? And we're going to do that math, right? So, 2 in 10,000 versus risk of CT scan inducing a malignancy and I have that in a few slides. So, um, I'll point out on this slide and we're on the next slide that we go to is going to show you the older one. This one has the scalp hematoma. This is not a factor in older kids. Um, and then this sort of not acting normal is not, is not a thing in older kids too. So, um, Doctor Johnson Kirner, if you want to go to the next slide. This is the older kid one. This is, this is not the one from the QR code. This is California ASAP. Theirs is much prettier. It's the same content. Uh, this you can get from Google. Um, there's this one for older kids and then the one for nonverbal kids is kind of a maroon color. Same thing, right? So high risk factors, and it's this intermediate risk category is different. OK? So that non-frontal hematoma is not here, but these kids tend to have vomiting more often and they complain of severe headaches. The way I look at this is if your headache's not better with Tylenol and you're getting ready to add that NSAID on top, and they, they have a headache that's requiring two drugs. And they had significant injury, you probably wanna scan them before prescribing NSAIDs with that risk of bleeding, OK? So these rules are very easy to use. These are ubiquitous. Uh, they're used in every ED that I've ever been a part of. They've been validated in tens of thousands of patients, probably 100,000 patients now. These have been around for well over a decade. I think they were first written about in 2009. These are tried and true and they work. So if you have a kid who doesn't have any high risk or intermediate risk factors, you don't need to send them to the ED for a scan. They have high risk factors. You need to send them right now to the ED. If they're intermediate risk, you could talk to that parent, particularly if they live close to the hospital and you can say, well, right now you're intermediate risk, but if you go home and your kid starts vomiting more, and your headache gets worse, you need to go to the ER and get a CAT scan, right? So provide a little bit more guidance for those kids who are in the intermediate risk category. OK, next slide. This is why it matters. So, um, With all of these large um health services databases, particularly in countries where they have single payer systems in Europe and in Asia, where they know exactly who got a CT scan, and because there's only one insurance company, the government, uh, that then has to take care of them later in life, they're able to track what happens to these kids. Um, so this was done in Europe, 2 million kids. With minor head trauma over a period of 8 years. Um, and they know which of those kids that, uh, presented got a CT scan and those that did not get a CT scan. In this cohort, they found 908 cancers, um, intracranial malignancies and leukemias. And we know that's the thing that CT scans cause the most is leukemias. It's actually not these weird soft tissue tumors, it's leukemias. Um, they compared patients who had received a CT for minor head trauma versus those that had not. And they found 1.7 excess, so above the population baseline, 1.7 excess neoplasms for 100,000 patient years. What's that mean? Well, if you do math and you assume a 60 year lifespan after that head strike. That's about 1 induced malignancy per 1000 CTs ordered, OK? And this is this actually um is true for abdominal CT and it's shown true for neck CTs. This 1 in 1000 seems to show up in all of the studies that are done. So it's not trivial to get a CT scan, but it's also, you know, it's not high, right? So, that's why the Pecorn rules are great. A lot of people are like, well, I don't know that 0.02% is still not zero. I want to get a scan, right? That child is more likely to get cancer from that scan than they are to have a clinically significant traumatic brain injury. OK? And if they have a clinically significant traumatic brain injury, they are going to progress and they are going to have more symptoms in the next 4 hours and they will come back to the ED. So I, I do think this counterbalancing measure of induced malignancy is real. But it's low enough to where like, if you really think a kid might have a problem, you, you probably should get the scan, right? So 1 in every 1000 scans of inducing a uh uh malignancy, particularly leukemias. It's low but not 0. Uh, so I'm gonna wrap it up there and I'm gonna hand the baton off to Doctor Johnson Kerner and we'll answer some questions later. Fantastic. Thanks. I'm Bethany Johnson Kerner, pediatric neurology, and it's nice to see a lot of familiar faces from or rather names from referring pediatricians in our audience today. I'm gonna talk to you a little bit more about imaging as well as management of symptoms after TBI. So this case I wanted to talk about, uh, is a 17-year-old patient. He went off of a really high ski jump, nothing that I would ever go off of, 30 to 50 ft high. He laid on the tips of his skis, fell onto his head. He had loss of consciousness for 1 minute, so higher risk injury, and experienced seizure-like activity for 4 minutes after the accident. It was described as tonic clonic by bystanders. Uh, medical personnel stated the patient was ANO 3. He had a GCS of 15 on arrival. He doesn't remember the event, but he's otherwise neurologically intact. His only pain, he has some right thumb, facial pain, and he has a swollen lip. Um, he had a following the pecor criteria that Doctor Jensen presented, he appropriately had a head CT given the high-risk nature of the accident, the fact that he had prolonged loss of consciousness, he had seizure-like activity, all very concerning features. Um, he completed a week of Keppra, and he, at 5-week follow-up in the neurology clinic, he's experiencing fatigue and headaches, um, and he has ongoing fatigue and difficulties with focus at 5 months after his injury. So now we're getting into that much more prolonged period. And so a question I have sort of building on the head CT conversation cause we haven't yet talked about MRI scans is would you get an MRI for this patient? Sort of thinking about what is the added value of additional imaging. There's obviously some malignancy risk with head CT. MRI is an option in some cases, not in all cases, but is an option. And thinking about what it adds to a case like this. So I'll just give people a minute to think and then if Maria or Christina, if you see anything in the poll, let us know. Sorry, the polls are a little bit funky today. It's looking like most people are saying no. Got it. OK, interesting. Great. So this was his head CT on day of injury, and this is his follow-up MRI 6 weeks later, and he does have some tiny small punctate which would push us over into thinking about this more in our sort of the current working framework we have for traumatic brain injury as a moderate TBI as opposed to a mild TBI. The, just a cautionary point here, the mild, moderate severe classification of TBI will probably change in the next 5 years or so. It's being reworked for adult medicine and will probably after that, be reworked in pediatrics. But often we think of mild traumatic brain injury as um no imaging findings and those with moderate as some Imaging findings. And while these are not impressive findings, he has some scattered punctate areas that are not blood vessels on an iron sensitive sequence. So a GRE or an SWI sequence, that would actually tip this more into the category of, um, diffuse axonal injury, which is important for this kid, and you'll see some practical implications for why that is. So, In about 10% of cases, the head CT can underestimate the impact of the brain injury, and so it's important to consider those. Kids who are more likely to have injury missed on a head CT are patients who like fall into this category. So particularly patients with loss of consciousness or persistent symptoms. Um, also those with a linear skull fracture, um, and multiple associated injuries. As I mentioned, the MRI is more sensitive for detecting diffuse axonal injury. Well, why does that matter? And I put here sort of potential benefits in quotes, which would be upstaging, and you might think, well, that's not good to go from thinking about mild to moderate. But in my experience, families are actually quite relieved and happy to have the most information that's possible. And unfortunately, in our really complicated system, it can Allow more access for some supports. It can also be very validating in the school setting, to say like, well, there actually are changes on the scan. We know that clinical MRI's are probably underestimating what is seen when you take football players and you put them in research grade MRI scanners, you can actually see white matter connectivity changes. We don't see those, so that's why the utility of MRI for An athlete with a concussion is almost zero and it's been looked at. We usually just pick up incidental findings. But for some of these cases, it can actually be really helpful to better understand, OK, what is, what is the dysfunction? Do we see any sign of um more significant injury that's present? And for whatever reason, because of limited access to neuropsychological testing in the pediatric neurology world, often we have to restrict our access to our neuropsychologists to patients who have some findings on their scan, which is super. and we can argue the pros and cons of that, um, but that's a little bit of the reality, whereas for concussion, um, it's harder for us to get access. I know that's not always the case in the orthopedic clinic, um, but that is, uh, historically been the case for us in the neurology setting. Um, as far as the drawbacks of getting an MRI, there's not a standard guideline as to when they're done. As I mentioned, about 15% will have incidental findings, which I always counsel, especially anxious families on who are interested in getting an MRI scan because it sometimes leads to a finding like an arachnoid cyst that then leads to a consultation with a neurologist or, or rather a neurosurgeon, or potentially follow-up imaging that's required, which doesn't necessarily add to the overall health of the patient, but is something that then needs to be follow up, followed up. I wanted to briefly touch on impact seizures or concussion cause it actually comes up a fair amount. Um, and neurologists think about them a little bit differently. Impact seizures occur in about 1% of concussions. You'll see practices all over the place. It's thought phenomenologically to be just quite different from epilepsy in general. I almost think of them like an autonomic response, a little bit like a breath holding spell you might see in a younger patient. Um, so as a result, often these kids get started on Keppra. Usually that duration is one week, very arbitrary, but it's not thought to be associated with any risk of seizures later down the line. For kids who have focal injury on an MRI or a head CT, there is a risk of Post-traumatic epilepsy, it's about 15% of those kids we know will go on to develop epilepsy later in life. But the gap between the TBI and the presentation of epilepsy can be decades. And so that's the reason why we don't actually end up starting a seizure medication for most kids. I wanted to turn things back over to Doctor Watkins to talk about cocooning. All right, so I'm sure we've all heard about uh the cocoon treatment for TBIs or concussions. Um, but we're here to tell you this is really a thing of the past. Um, let's look at this case. So this is a 14 year old with a mild TBI one month prior, he was struck with a basketball. He had no loss of consciousness. GCS was 15. He was counseled to stay home from school and avoid screens, avoid physical activity until symptoms resolved. He has headaches, dizziness, and fatigue. Looks like. OK, so what do you advise him? Should he continue to rest until symptoms resolve? Um, can he do some light aerobic exercise or should he have no activity restrictions, um, Since he's already 4 weeks out injury. Most, it looks like the majority is saying have them do light aerobic exercise with the next coming in, it continue to rest until rest until symptoms resolve. Awesome. So I, I probably gave you a hint there, but it is a thing of the past of cocooning. So, uh uh I mentioned this, um, consensus statement. The most recent one was in 2022 in Amsterdam, and that's where we, we have most of our up to-date literature and recommendations for sport concussion management, and we know now that we should be shifting away from cocooning. We know that early exercise um is helpful for recovery and it's been associated with um faster recovery. It encourages blood flow to the brain, which helps with recovery. Um, so we want you to recommend some early exercise and it can be in the 1st 24 hours if they're feeling OK. Um, but certainly after a period of uh modified activity, and we want to encourage activity. And then how do we get them out of that, uh, first couple of days period. Um, a mainstay of concussion management is having, um, people go through a progressive return to activity, when we want to Um, see if any symptoms return with activity. A lot of times people become symptom-free, but they haven't tested it, so they don't know if they go around or go back to their sport if symptoms will reoccur. So we have, uh, return to play progression, so we usually recommend, I want you to think about it as a stepwise progression to full activity. And the mainstay of it is Encouraging some activity that does not push them too far over their symptom threshold, um, while avoiding contact activity. You have to be cleared first before you go to contact activity. So in the first couple of days, you you have them do daily activity that won't provoke symptoms. So really, The 1st 24 to 48 hours. And then you want them to encourage them to do light aerobic activity. So it's gonna be like stationary bike, walking the dog, etc. These are the things that I recommend on that stage. And then, um, if they're having ongoing symptoms, that's a flag for you to refer for, um, either. PT, you know, for more extensive evaluation so we can help them with their recovery and tailor what they might need, uh, to help them with their recovery. A lot of them may have headaches or they might just have activity intolerance. Causing headaches and um a good test here is a buffalo concussion treadmill test. We do that in our physical therapy department here and it, it helps give people a guide for sort of their symptom threshold. So within what heart rate can I be active without having more symptoms. Um, and then after they've been able to progress through some sports specific stuff, they can do non-contact training and then full contact practice and gameplay, and we clear them before um full contact practice next time. And so the handout that I'm usually giving people is this handout from the CIF um just so that you are aware if you're practicing in California, which we all are, you, you have to hold these athletes out for at least 7 days. They can't go back uh sooner than 7 days after they had the concussion diagnosis. That's the law here and the this return to play from CIF, which is the Interscholastic, um, Federation for the high school athletes, um. Details the specific steps in the return to play. It's similar to the stepwise process that I just spoke about on the previous slide, but it gives you a little more detail because it has some exercise examples and it explains the objective. So kids can start going through this, um, on their own, and ideally they should go through it with under the supervision of like an athletic trainer or a coach, but that's not always available. Um, so sometimes we'll have them go through it and check in with us, for example. If they're having any symptoms. Each stage should be at least a day, um, so they shouldn't be going through stage 1 and 2 on the same day. And so as such, it takes about 7 days to complete the full process, which is why the 7 day rule for clearance uh exist. And so they should get clearance before, you know, some contact practice again and, and then they could progress to place, so they should do a contact practice before they do any full play. Excellent. OK, so another poll for you. What is the risk of concussion in children with previous history of concussion? Do they have no increased risk, 2 times higher, 3 times higher, or 5 times higher? Majority saying 2 times higher with a close second coming in at 3 times higher. All right. Oh, that's great. So, um, we have some literature that that gives us, you know, data on this. Uh, this is, uh, meta-analysis and systematic review that looked at 7 studies, so over 23,000 kids aged 5 to 18 was majority male, um, but it did show that Your risk of concussion was more than 3 times greater in children with a history of concussion compared to those without. And so, the mainstay of treatment is really trying to avoid a second hit before you are uh completely recovered because you know. That that prolongs recovery, but there is also a risk with going back even when you're fully recovered, you know, that you're gonna be at greater risk for a concussion. And it's important to discuss that with families so they can put it into perspective as they move forward with their options. OK, so a lot of people are are curious about this. There are a couple of things we know about sports and um binary gender in, in concussions. So this, this, um, figure here describes um different, a couple of different sports compared the concussion rate per 1000 athlete exposure between um Girls and boys. So the top part is for the boys, and you can see the highest rate, as you might expect, is with football, um, but also pretty high with wrestling and, um, judo. So martial arts, I think we underestimate that sometimes. Um, if you look at the overall risk, you can see, it looks like girls tend to be at higher risk. Girls. That do judo in particular, based on this study, and we know that girls are at higher risk for concussions than boys. Um, and then typically the contact sports, football, wrestling, martial arts tend to be higher risk for girls, soccer, uh, is pretty high up there as well. Um, and then lacrosse isn't on here, but we see a lot in lacrosse as well. And with all the talk of concussion, I think it's important to state that in general, we're pro sport, as obviously we know that sports have so many benefits for kids, but I wanted to address a little bit of chronic traumatic encephalopathy because this is a question that I get all. The time from families and a particularly anxious teenagers who worry a lot about the cumulative impact of concussions. So this was a Nature paper that came out in 2023 that was widely covered in the New York Times, really interesting study basically measuring the G force that people are experiencing. And I find a helpful data point to share, particularly with anxious families when they're on the fence about sports or how much physical activity they can do. It's just to compare the force that you or I experience from a concussion, whether it's sports or motor vehicle related or around the house, and then what our pro football players are experiencing. And in round numbers, when you or I experience a concussion at home, we're experiencing around 50 to 100 G. What a professional football player is experiencing, as you can see in this column here on the right, is on the order of 15,000 G forces. So it's a completely different order of magnitude. So we don't have high-quality studies that are looking at, OK, of like, let's say 30, the 30% of high school students that have one or multiple concussions. What's happening with them down the line, it's just a completely different um sort of level of risk that people are entering into. So I think It's just good to keep that in perspective because a lot of our student athletes are worried appropriately about chronic and traumatic encephalopathy and early onset dementia and things like that, but it has to be balanced with the reality of it's just a different magnitude of impact um that they're experiencing than professional football players. Which brings me a little bit to talking about one of the most challenging things we face in the neurology clinic, and I'm sure in your primary care clinics is persistent post-concussion symptoms. Um, so this was a case I had of a 17 year old with a mild TBI from a concussion 9 months prior. She has ongoing dizziness, both episodic vertigo, spinning, so and disequilibrium in the sense that everything is unsteady around her. She'd like to know if she can return to swimming, a non-contact sport, um, but, uh, swimming was how she actually sustained her concussion initially. Uh, she has a normal neuro exam and a normal MRI brain scan. I wanted to touch a little bit on post-traumatic dizziness, um, As the neurologist's approach to dizziness in general tends to be, what is the duration of your dizziness and that puts you down into different categories. I would say most of the patients we're seeing are experiencing dizziness that's episodic, usually hours or days. The kids who have seconds to minutes, that tends to be orthostasis, so dizziness with standing. Sometimes it can be inner ear changes, although we don't see a lot of that and then more rare genetic conditions like Meer's disease where you have dizziness and hearing loss. The hours kids are much more common. Those tend to be kids who have migraine or POTS, postural orthostatic tachycardic syndrome, and we can talk a little bit about that if there are questions, but quite common to have autonomic dysregulation after a concussion in some patients, and that can cause episodes of dizziness, particularly with standing. Um, and then for those that are lasting days, of course, if they have any abnormal features, that would be concerning for mass or demyelinating lesions such as multiple sclerosis. Um, but some of the most common things we see after a concussion would be like Doctor Watkins alluded to prior, so ocular motor changes, so convergence insufficiency where Because the eyes essentially sit on a very delicate pulley system, when you're concussed, they're very vulnerable to dysregulation there. And so kids can experience a lot of dizziness from eye dysfunction. So I usually try to get them in to see an optometrist with some um concussion experience. And then we see a lot of kids develop, about 150% will fall into the category of functional neurologic symptoms, FND. And in particular, there's a subtype of FND called triple PD which I found to be in general very helpful, um, new category of FND for families to, again, to have a name for it. Triple PD is persistent postural perceptual dizziness, which is essentially in the pre, despite the presence of a normal neurologic exam, people have the sense of disequilibrium that's ongoing for, for days longer. And of course, your red flag features thinking about more detailed imaging, there's something structural going on would be those abnormal eye movements, nice diagnos with mild gaze deviation. So just as I remember, a reminder, when, when you're looking for assessing for a nice stagnosis, you want to be at about a 45 degree angle on either side. Anybody, especially young teenagers. If you have them look to 180 degrees with keeping their heads still with extreme end gaze will often have persistent or sustained nystagmus. So you want to have them go to 45 degrees maximal and um often healthy teenagers will have one or two beats um looking to either side, but it should be self-limited and symmetric. I think it's interesting to look at the data on what happens to kids, um, after a concussion. And while we generally think of sort of most recovery in the first couple of weeks, which is the case, um, 20 to 30% of patients will have symptoms that last for longer than 4 weeks. And I often find that a helpful data point to share with families who often feel really frustrated, um. And discouraged by concussion recovery. We have patients, lots of patients who I'm sure you guys see too who have concussion symptoms that last for many months. We're still learning what makes those people more vulnerable and what's actually happening with them. Um, but as you know, PPCS is no longer a syndrome, it's symptoms. Um, there are known risk factors, and they tend to be associated with family history of headaches, history of mental health conditions, and then, uh, learning differences whether personal or in the family. So those are all, um, important variables, and if there's uh acute stress reaction, so, uh, maladaptive changes in the child or the family dynamic after the concussion, and I'll show a little bit of data before that. New comorbidities that I'm on the lookout for after a mild TBI because there isn't a magic pill or a treatment. Everything about concussion is symptom, you know, symptomatic treatment. Um, but I do look out for these medical comorbidities cause they commonly arise. So 25%. We have, um, new onset sleep apnea or whether it's new or detected after the concussion. 7% can have POTS and autonomic dysfunction. There's a high overlap between concussion and PTSD symptoms, and often we're recommending people get connected to coaching and therapy. Uh, endocrine disorders can, can occur in some kids. I wouldn't say I see that as much as 20%. I'd say, I'd see that much more common with, um, uh, severe TBI if it occurs at all. Um, insomnia is one of the most common things, um, with melatonin being a common treatment for that or cognitive behavioral therapy for insomnia, and then we've talked a little bit about ocular motor dysfunction. I wanted to touch on headaches cause they're one of the most common concussion symptoms and ourselves in neuro and ortho work with these kids a lot. Uh, this was a 10 year old who was struck on the left temple with a baseball bat. He's presenting with ongoing headaches. He wants to go lay down with his headaches in a quiet dark room. Prior to his injury, he had some rare headaches, and mom had some headaches. He had, has a lot of migraine markers. Um, so usually we think of these markers when they're present, just people being more vulnerable to migraines. So growing pains, frequent abdominal pains, car sickness, brain freeze. So he has some of those. He does not have any pediatric migraine equivalent, so torticollis versus vertigo, cyclic vomiting. Um, I think what's, if I, if there's a message I could also share with you today, there's no specific treatment for post-traumatic headache, but have a low threshold to start a preventative just because these, especially the nutraceutical options which are shown here are almost zero risk. It's just sort of, you know, frustrating. You have to go to the pharmacy and buy them and take them every day. Um, but this can be really beneficial to prevent headaches, and they don't work right away, unfortunately. All of our nutraceutical and Even prescription, uh, preventative headache options take 6 to 8 weeks of consistent use to see the benefit. It used to be the case that we would say if you need to have more than half of your days to start a migraine preventative, that's definitely not the case anymore. Um, so any of my patients in general practices, if you're having disruption in your activities, certainly if you're missing any school, very low risk to start a migraine preventative, um, and headache preventative in general. Um, So the options that are easy to reach for are shown here. So, and these are for uh dosing options for kids over 35 kg. We usually cut the dose in half for kids less than 35 kg. Melatonin, riboflavin, which is vitamin B2, magnesium, and then CoQ10 is another option as well. Um, so usually we're reaching for these and families are usually um happy to have an option to improve quality of life for, with the headaches. And we've alluded to some of these, but just to kind of tie it together, um, physical therapy can be really helpful for some people to guide some symptom aerobic activity for concussion recovery. One of the most important treatments we have for concussion is to actually get exercise, get moving. As I understand it, um, we don't have PT embedded in neurology. We work, we refer out for physical therapy, whether through our department of rehab or through physical therapists in the community. Most of the patients I see want to have physical therapy locally, so often we'll communicate with them. And then through the Department of Orthopedics, there's physical therapists, um, but I believe you guys will only do in-person, right? So nothing over Zoom. So families have to be like in-person for physical therapy appointments. Otherwise, we'll try to set them up with something closer to home. Vestibular therapy for dizziness and imbalance is really hard to find for kids, um, but it can be worth working with a physical therapist, um, and then often we'll do sort of bidirectional education or what to do. Headache treatments, we addressed school letters for 504 plans and IP testing. I didn't go into this too much depth today, but A lot of kids have pre-morbid learning differences and attention differences, and things sort of fall apart after the concussion. And it can be really destabilizing for kids to go back to school and then the teachers just say, like, get over it. My cousin had a concussion. They were better in a week. Like, why do you still have symptoms? That can be really distressing for a lot of families, um, and kids. So trying to give them some support there while also, you know, not enabling uh school avoidance or anything else that we may be seeing. Um, and then I just wanted to give a really quick plug for the cognitive piece, um, and we have a study. So if you have any patients that could potentially be interested, this is free and open to the community, and, uh, people would, uh, get paid for their participation. As I've alluded to, lots of kids are having executive uh dysfunction in the first year of injury. This is really disruptive for their memory, for their attention to their ability to focus in school, and most kids don't have access to a neuropsychologist. We know this to be the case. So we've partnered with a lab at UCSF called Neuroscape. They've developed video game platforms, they have platforms to help assess and intervene on ADHD. Their software platform is something called Engage, and it's essentially training attention skills. And this is interesting cause there's parallels to this the adult TBI recovery world as well, but of course the kid version would involve a video, a video game, but it's just improving attention skills through mindful attention. We don't know if this is something that will help kids after a concussion, and we don't know if it'll be acceptable to families, but we've designed a study to basically intake families, um, and I think I have the criteria here. So anyone with mild to severe TBI who's 8 to 16 at the time of injury, who's in the more chronic phases, so not that first month, but in 1 to 12 months post-injury, they have to be able to use their hands. Look at a screen like almost all of our kids can, um, and they do receive payment, so up to around $190 in Amazon gift cards for participating in the study, which involves um some intake questionnaires participating in the intervention, actually playing the video game for 30 minutes a day for 6 weeks, um, and then doing a midpoint and a post, uh, uh, intervention assessment. So this would help give us a lot of information because over time we really do want to be able to develop tools that are accessible to all. This is done fully remotely, doesn't require waitlists to be, you know, to get in with the neuropsychologist. People get feedback on their participation. It's actually something we can measure over time. So there's a QR code there and I put my email address here too if you have any families who might be interested. And so, I wanted to close there and I'll leave up our, now that you've heard from myself and Doctor Watkins and orthopedics, I just wanted to leave up the Cross Bay options for follow-up. We want to support you, uh, helping to manage concussion families, and I'll stop there. Great. Thank you. If you can, um, there are some questions in the Q&A. If you can stop sharing, I'm gonna put the QR code for the survey, and then we will share these slides, everyone will have all the references too. Let me pull up the slides with the QR code and then Doctor, doctor Kerner, did you wanna um Start off with the with the Q&A. Yeah, it looks like the first time we've had is, um, if a child had worrisome signs of a concussion at a sports event like vomiting, confusion, could they be transported to the ED by their parents and not by ambulance? It's a good question. I don't know, Doctor Watkins if you have a. Yeah, I'd say, so it depends. So like if there is EMS available quickly like it and they have red, red flag signs, they should be going by ambulance. So you want to get them there the fastest you can, right? But a lot of times at these games, like I Cover high school football games. They don't have EMS on site, and it's faster to go with, with their, their parents. Um, so I, I think it depends on, on the availability, but I'd say that you want to get them fast as fast as you can if they have true red flag symptoms, which usually is by EMS. And there was a question here about second impact syndrome. I'm glad you asked this question. Um, when I've sort of dove into the literature, there's not a lot out there. The original literature was from Football players who had pretty significant injuries, and I don't know Doctor Jensen, if you have more to add about this, but the skull fracture, subdurals were present, returning to sport in a really tight interval, usually within a week or two post-injury, then sustaining a second hit. Like these are kids with a skull fracture and a subdural who have returned to sport within 2 weeks, obtaining a second hit and developing cerebral brain edema and death. I think things have changed so much since those initial studies were reported. It's not something we think about as much. I think it's still persisting in like some of the concussion literature, especially that like handouts, things that families get and things like that. But I think from my perspective, and I'm curious what Doctor Jensen and Doctor Watkins think as well, it's really more about prolonging recovery. I don't worry as much about a catastrophic event, um, like second impact syndrome. I mean, we've seen rebleeds, you know, you have a subdural and. We tell you don't play football and you play football. And you come back with the, you know, your sub girls a lot bigger after taking a blood to your head. So, um, I, I do think it's important. I mean, if you, if you have. traumatic brain injury, you probably should sit out for a bit while, you know. But now with the new protocol like Dr. Watkins shared, you're gonna be sitting out for a week and then doing gradual return over a week. So I just think because there's been so many new regulatory changes around sports concussion, yeah, I just think it's less of a Yeah, I just think if you have blood in your head, it's different. Like, you, you probably shouldn't be playing helmet to helmet football for a while. Like, I want you back and like, you can. Practice and throw the ball and run and do aerobic activity. But actually, like smashing helmets with other people with blood in your head, you, you probably should let that blood resorb first, um. Yeah. Yeah, definitely. If they have abnormal scans and they're not, we're not encouraging early exercise. And a couple of people would uh comment that the CME, I guess it's the wrong QR code. Oh. Just so you know, Ria and Christina. Sorry about that guys. Um, oh, OK, then I'm gonna stop sharing and then I'll make sure the email that everybody gets is the correct QR code, um, and then just fill that out by Monday, so I apologize for that. Uh, there's a good question here. I know previous recommendations said that after 3 concussions, students should not participate in sports until cleared by neuropsych. Is that still the case? If that's not the case, how should we proceed with these kids after their 3rd concussion? And I'm curious from a neuro perspective because we generally don't have access to neuropsych and neurology unless somebody is in the moderate to severe category, we don't worry as much about this. And for like my patients who are months out after a concussion, um, If their exams are normal, I usually just try to engage with them to do graduated return to activity and sport just because kids who have been having post-concussion symptoms for 2 or more years, it's hard to imagine mechanistically that they're gonna, you know, have issues, um. As far as, you know, their concussion goes, so, you know, obviously we go through the risk-benefit discussion about return to sport, but at a certain point, it just becomes about managing sort of chronic dizziness and migraine and less, you know, thinking about like, oh this is post-concussion, if that makes sense. But I'm curious if, yeah, I'm not sure where that recommendation came from or if Doctor Watkins, you have anything to add about sort of sports for clearance after 3 concussions. Yeah, that is not current recommendation. Um, there is no number, like specific number where you absolutely have to sit out if you've had mild TBI, so no, um. Traumatic brain injury with abnormal imaging findings. We're talking about just concussions here um with normal imaging. Um, but after 4, you know, we do have a conversation about risk benefit profile. I think we know that there are so many benefits to sport participation. And sometimes they outweigh the risk of going back and taking another, having another concussion, right? And so, um, there is no, we also don't have great neuropsych access and everybody's not getting routine neuropsych assessment. It's not needed. It's not part of the recommendation for sports-related concussion, um, management, but after I'd say at least 4 or more, you do want to pause. Um, and the things you're looking for that can be worrisome outside of just the number is, is the, the time between the concussions decreasing and then your symptom burden is that getting Bigger. So now, you know, it's something that uh a simple hit on the head, the cabinet or something is making me feel like I have concussion symptoms and plus I had one, you know, 2 weeks ago or let's say 2 months ago, um, I was fully recovered and that's just considered a new one. They're getting uh longer to recover and shorter time in between each one. That's also concerning and should pause for discussion. I was uh listening to an interesting neurology podcast this morning. I was talking about the overlap between central sensitization and autonomic dysfunction, and like the insular cortex is doing that. So, it's also the case, I think about a lot of these patients is really falling into that central sensitization. I have lots of patients who, yeah, like suddenly an elbow to the head is now like causing a flare and especially for kids who are 2 or more years out from their original concussion. I wonder how many of those are just More just falling into the sensitization category and not necessarily re-injury, but this is the era of concussion and it'll be really interesting to see what we learn as far as white matter connectivity and long-term consequences from these, but I think it's reasonable to take reasonable, you know, activity risks as far as we, we can't cocoon, we don't want a cocoon, and we don't want our kids like not being able to do things like PE and other, you know, social forms of physical exercise and activity. Um, and I realized we're over time, um, so people have to go, feel free. Um, but we had a clinical case here in the chat, uh, nystagmus and isotropy in a 5 year old after a fall from a bunk bed in April, still with persistent symptoms, and now we're, I guess, a little bit over 3 months out. What would you do? I saw a neurologist yesterday, not recommended to do an MRI saw an ophthalmologist who recommended to do an MRI. Um, so this is interesting. I think for me, my biggest question is, what is the nature of the nystagmus, um, and then overall, what is the trajectory of the patient. Um, it's hard to imagine that, you know, more than 3 months out, we're missing something large cause it probably would have progressed at this point. Another challenging factor in this age group is 5. So, generally, Under age 8, it's pretty hard to get a non-sedated MRI scan. You might be able to, in the East Bay side, we have the ability to do, um, like headphones, so kids can listen to stories and things like that. But under age 8, it's, it's, it's worth trying, but a rapid MRI scan, which takes about 5 to 10 minutes of laying still, um, you're definitely could be potentially missing some small areas of injury. Um, And, but it's not really clear that a full MRI would necessarily be that helpful just because like we've talked about, um, you know, they often don't show a lot. So I think it would really come down to the trajectory that the patient is experiencing. Um, and sort of risk benefit discussion about to sedate or not to sedate, you know, for a more complete MRI. Sometimes it can be helpful to start with, um, vision therapy, um, especially around if there's like new esotropia and some nice stagus. So literally, these kids will be recommended to do what's called pencil push-ups. So a lot like the popsicle stick that Doctor Watkins recommended with the Exon top, you have them look back and forth. So like essentially practicing their scads and their targets and that can help re-engage and strengthen the ocular motor system and You know, could try that as an exercise and then think about other testing. Perfect. Looks like all the questions. Thank you all so much for presenting today and taking time out of your very busy schedules. We really appreciate it. We apologize to everybody for the technical difficulties. We'll make sure you have the correct survey link um in the email that will go out this afternoon, and thank you all so much for attending. Looks like there might have been. Oh, I was just typing a question. There was one. Is amitriptyline used for treatment of post-concussion headaches? So, uh, things have moved away from specific treatments for post-concussion headaches. Um, so, um, usually we just start with the nutraceuticals and then after that, any medication that you're comfortable with is, is fine to start. So amitriptyline or nortriptyline, either is fine, um, propranolol is often used as well, so. Sorry, Maria, thank you. No, no, you're OK. We wanna make sure you read all the questions. Again, thank you all for attending. We hope to see you next week, uh, for our CME presentation with urology, and we hope you all have a great rest of your week. Bye, everybody. Created by
