Concussion Update 2016 Managing Return to Activities

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1 Concussion Update 2016 Managing Return to Activities New Horizons in Pediatrics April 16-17, 2016 David L, Marshall, MD Medical Director, Sports Medicine Overview of Concussion Acute (immediate) recognition and management Sub acute management Return to Learn Return to Play (school nurses, PAs, NPs, MDs)

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4 Acute (Immediate) Management What signs/symptoms warrant referral to ED? Worsening HA MS changes Difficult to arouse, lethargy Seizures Persistent vomiting (more than once) Weakness in arms or legs Slurred speech Neck pain Clear fluid from nose or ears Non frontal hematoma or enlarging hematoma

5 Sub-acute Management 3 steps First 1 7 days When is going back to school (RTL) appropriate? When is getting back to sports (RTP) appropriate? Return to Learn (RTL) Million dollar question: When should they return to school? RTL and RTP may be parallel processes, with RTL taking precedence To date, no agreed upon formula for RTL RTL is an extremely individualized process Cannot be one size fits all 14 First 1-7 Days Rest (brief) is key Neurometabolic crisis, ionic gradient shifts, depletion of ATP and reversible alteration in cerebral blood flow This functional injury is what accounts for the symptoms How much rest is needed? Is too much rest bad?

6 Recent Studies 335 pts age 8 23 divided in to 4 quartiles base on cognitive activity following concussion. The group with the highest cognitive activity had the longest post concussion symptom duration. There were no differences in the post concussion symptom duration in the other 3 groups Brown, et al Pediatrics 133 (2) (2014) ED pts age randomized in to 2 groups: 5 days strict rest 1 2 days cognitive rest followed by stepwise increase in activity No difference in neurocognitive or balance outcomes b/w groups 5 day strict rest group reported more daily symptoms and a slower resolution than the 1 2 day group Thomas, et al Pediatrics 135 (2) 2015 What does this mean? Prolonged cognitive inactivity is not only impractical but may not be the best initial treatment Depressed mood, anxiety, social isolation, loss of academic standing, worried about catching up 1 3 days at most seems appropriate followed by the return to school with academic adjustments The goal of rest is to modify those activities that trigger or worsen symptoms, not the cessation of all activities. Not too much, not too little Gioia, J Child Neulology (2014) The School s Role Diagnosis of concussion is a medical decision RTP is a medical decision In school adjustments (temporary accommodations) is best handled by the school personnel (teachers, administrators, school nurses) Adjustments may occur hour to hour or period to period

7 Ongoing Monitoring It is the responsibility of the school team to assess, to add and to remove academic adjustments as needed for the concussed student. A medical prescription is not necessary for academic changes. 19 Not one size fits all Which adjustments are needed? Based on the symptoms Poor concentration Fatigue, dizziness, balance problems Noise sensitivity Light sensitivity Visual disturbance Poor Concentration Core classes only. Even/odd classes. Rest b/w Shorten assignments and reading passages Closely monitor class work to verify comprehension Seat near the front of the room Provide pre printed class notes buddy notes Don t penalize for work missed Limit HW Limit technology Audio books, being read to

8 Fatigue, Dizziness, Balance problems Frequent rest breaks, ½ classes only Elevator pass Leave class early to avoid noisy halls at class change Limit weight of book bag Allow teacher and student to have signal Help school personnel understand that mental fatigue can manifest in emotional meltdowns Noise Sensitivity Avoid class change Lunch in library or school nurses office with friend No band, orchestra, chorus, assemblies Ear plugs Light Sensitivity Allow sunglasses Dim classroom lights Limit computer screen time

9 Visual Symptoms Limit reading or allow breaks while reading Limit computer time Buddy notes Provide reading assistant When do the adjustments start? No evidence based recommendations (yet) When tolerating 30 minutes of academic activity at home May be ready to attend school, but not ready to learn Less cognitive activity, more adjustments More cognitive activity, less adjustments Mostly cognitive activity, few adjustments Normal school day, no adjustments RTL One Plan K. McAvoy, PsyD, Director of Center for Concussion, Rocky Mountain Hospital for Children If symptoms occur with up to 10 minutes of mental activity, rest is required Complete cognitive rest (absence of all cognitive activity) is impractical and isolates the student. not too little, not too much If symptoms occur with up to 20 minutes, stay home from school, but try light reading, TV, texting, etc, as long as symptoms don t worsen When student tolerates 30 min of mental activity, return to school with academic adjustments may not be ready to learn 27

10 stage Description Activity level Crit for next stage 0 No return, stay home Low level cog and phys activity Cognitive challenge, read, math min No symptom exacerbation after 30 min challenge 1 Return to school, partial days (1-3 hours) Attend 1-3 classes with rest breaks Minimal productivity No test, quiz, or HW Able to tolerate 4-5 hrs activity with 2-3 rest breaks 2 Full day with maximal supports Attend most classes with 2-3 rest breaks Minimal HW (<60 min) Minimal -moderate expectations for productivity Symptoms improving Need only 1-2 rest breaks 3 Full school day Moderate supports as needed 4 Full school day Minimal supports Attend all classes, 1-2 rest breaks (20-30 min) Begin quizzes Moderate HW (60-90 min) Moderate expectations for productivity Design make-up schedule Attend all classes with 0-1 rest break (2 30 min) Begin modified tests(extra time) HW 90+ min Moderate-max expectations for productivity Cont symptom improvement Needs no more than one rest break per day no symptoms with cognitive of physical exertion during school day 5 Full return, no supports needed Full class schedule No rest breaks Maximum expectations for productivity Address make-up work -Gioia 2014 N/A Key Terms Academic adjustments Transient and more flexible Academic accommodations Rigid and long term (implies 504 plan) If still symptomatic after 4 weeks, the adjustments may need to be made into accommodations 504 plan legally binding document to protect the rights of people with physical or mental impairments the limit major life activities Summary 1 3 days rest (no school) is usually sufficient Diagnosis and clearance is a medical decision, RTL is best facilitated by the school personnel with hour tohour adjustments Must ID the case manager Can begin RTP before completely asymptomatic 504 form not necessary for most concussions

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