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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
500
400
300
200
0
50
100
% o
f no
rmal 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.
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
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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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.