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

Ronald C. Savage, Ed.D.

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).

Defining mTBImTBI is more “neuro-chemical” than it is

“physio-mechanical”

Neurometabolic Cascade Following Cerebral Concussion/MTBI

2 6 12 20 30 6 24 3 6 10

minutes hours days

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% o

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mal K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

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

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.

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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School Male Football Athletes

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

40%40%RECOVEREDRECOVERED

60%60%RECOVEREDRECOVERED

80%80%RECOVEREDRECOVERED

Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004

Examining Relevance of “Bell Ringers” in High School Athletes

CNN Video

National Youth Sports Concussion Tour (43 states in 6 months)

National Pediatric Trauma RegistryNational Pediatric Trauma Registry

Mechanism of Injury for mTBI (B-19 years)Mechanism of Injury for mTBI (B-19 years) N = 8016N = 8016

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Measure…Monitor…Manage

Follow-up for a Sprained 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

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

Adoption of Computerized Neurocognitive Testing for mTBI/Concussion

1. ImPACT 2. CogState3. Headminders4. ANAM

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

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

When Can Student Return to School?Accommodations? Supports?

Learning/Thinking Changes

• 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

Behavioral/Emotional Changes

• 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

Physical Changes

• 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

Tips for helping the Student

• 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

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

No head injury is too severe to despair of, nor too trivial to

ignore

Hippocrates, 4th Century, B.C.