Dr. Lisa Thornton discusses second impact syndrome, post-concussion syndrome and links between concussion and mental health issues.
DR. LISA THORNTON: I want to remind you that the definition of concussion is just a temporary disruption of brain function that results from a direct or indirect blow. So now we know that you don't have to actually get hit in the head to have a concussion. You can actually get hit in the body, and your brain can be jarred. And that can lead to concussion as well. So don't always have to have a hit. Usually no visible structural entry. But there's always a change of some kind in the sensorium. And I'll talk a little bit about that in a minute. Usually no loss of consciousness. Only about 10% have a loss of consciousness. So the reason that we've all started talking about this is because of-- still having technical difficulties on my end, sorry-- is because of the second impact syndrome. And Chuck referred to this. So the reason that we talk about this is that this young man named Zack-- I think we're in business now. OK. Zack Lystedt sustained a catastrophic brain injury. This was a 13-year-old kid who played football. He went on the football field. He sustained a concussion. He came out of the game for 15 minutes, and they put him back in the game. He got hit again. And he had a catastrophic brain injury with cerebral edema and coma and severe permanent disability. So if you google him, you'll see that he's alive, but he is severely brain injured. And his family was pissed off. So they decided that that should never happen to another kid. And they began lobbying their legislators in Seattle and eventually got this law passed, called the Zack Lystedt law, that requires school boards, in conjunction with state interscholastic activity associations, to develop educational materials and guidelines for athletes, coaches, and parents. That's why pediatricians are now being inundated with concussion stuff, because of this law. And it requires that parents and athletes sign an informed consent form that acknowledges that they recognize the dangers of concussion before they participate in sports. This is a law. So every school is supposed to be doing this who has organized sports. And an athlete is supposed to be removed from a game if a suspected concussion happens. And they can't return until they're evaluated and given clearance to play from a licensed health care professional. That is not defined in the law, what equals licensed health care professionals. So some places do use trainers as a licensed health care professional. But usually parents say, I need the pediatrician to clear my kid. All right, so the initial evaluation on the sidelines is often done by a few fairly simple tests. One is called the SCAT2. The best thing about the SCAT2 is it is free. The impact test, the third one down, and the King-Devick both cost money. And so the SCAT2 is probably the most commonly used on the sidelines. And embedded within it is something called the SAC, the sideline assessment of concussion, and somatic questions. So the SEC is simple. It says, what month is it? What's the date today? What's the day of the week? What year is it? And what time is it right now within an hour? So it's stuff the kid should know. They knew going into the game what that stuff was. And a Maddocks score says, where are we today, what venue? Which half is it now? Assuming there are halfs. Who scored the last point in the match? What team did you play last week? And did your team win the last game? So those are things that every athlete knows. I never know that when you ask about my kids' stuff. But my kids always know. So they ask those questions, and depending on what the answers to those questions are, it's concussion or no. If it's suspected concussion, even if they answer all those questions correctly, you're supposed to pull the kid out of the game and have them assessed before they go back in. Now, one big question is should the kid go to the emergency department? And in most cases, in many cases, the answer is no. They don't need to be assessed by an ER physician. But no coach is going to make that determination. So all these kids are probably going to an ER. And usually an imaging study is not necessary. But if you end up in an ER, it's highly likely that you will get one. And so really, the indications for doing an imaging study are if the mental status is not normal, if there's a focal neurological abnormality, or evidence of a skull fracture, or significant intracranial pathology, or abnormal signs on neurological testing. And obviously if a kid has a seizure, you'll probably end up getting a scan. And if a patient's worsening also, and if they're significantly drowsy. So neurological signs should lead you to get a scan. But many kids, by the time they reach an emergency department, their Glasgow coma score is 15. They're feeling good. They're awake and alert. And what they need is followup. They don't necessarily need scans. So the reason that we get concerned about concussion is not because it's a blow to the head in the immediate and it makes the kid a little dizzy in the immediate. But it's because the question is what happens later? Is there going to be any permanent damage? And everybody who has listened to any news story knows about the football concussion issues and the long-term sequelae that can happen from concussion and repeated concussions over time. But even one concussion can cause the postconcussive syndrome. And these are some of the symptoms of the postconcussive syndrome. And I will tell you that-- oh, you'll see it on the next-- if I do this, I think you'll see it. No, still don't see it. OK. So that says feeling especially-- feeling foggy. Fogginess is what that word is that's covered up. And drowsiness is the other word that's covered up. So slowed down, sadness, drowsiness, or feeling more emotional. It's a 22-point item scale that looks at symptoms and asks the person whether they have any of these symptoms. The goal of this scale was to objectively document what these kids are going through. And so the interesting thing about this scale is that athletes are asked to talk about what's happening right now. So they're not asked to recall, like in the last week, did you have any feelings foggy or drowsiness? They say right now in this moment, how are you feeling? And they ask these questions. And you can do this serially to see if the person is having any postconcussive symptoms. And some kids will have these for a long time. One of my good friend's sons was playing baseball, got hit in the head with a baseball. And this was four weeks ago. And he's still not quite back to where he was, which is really unusual. Usually these things do resolve. But some kids can have lingering symptoms. And we don't really understand why one brain is more susceptible than another brain, why some kids will get multiple concussions and seem to be fine and recover quickly and other kids get one or two and seem to have lingering problems. So in this study in applied neuropsychology, this scale was administered three times between 1 and 30 days postinjury. And athletes self-rated on the scale. And the things that they endorsed the most were this feeling slowed down, sadness, fogginess, drowsiness, or feeling more emotional. Those were the most frequently endorsed symptoms within the first 30 days after a concussion. And these were the least endorsed symptoms. There was no more vomiting. If you're vomiting long after a concussion, you really need to be evaluated. But feeling more emotional, numbness or tingling, nervousness or sadness, those things seem to go away. But these other things seem to persist. Interesting that they've listed sadness in both. But another study looking at postconcussive syndrome specifically in children looked at 235 patients ages 11 to 22 who presented to the ED with an acute concussion. And these were the most common symptoms at presentation-- headache, dizziness, fatigue, and taking longer to think. So a little slow processing. And they gave them a concussion questionnaire. And they then did serial questionnaires over time. So they'd send this questionnaire to the parents and ask them to fill out this questionnaire about concussive symptoms. And what they found was that there were persistent symptoms for a couple of weeks in these kids very commonly. So irritability, on average, lasted 16 days. Sleep disturbance, 16 days. A little bit more frustrated and poor concentration. These were the most common symptoms that persisted in these kids. And not in all the kids. But these are the ones that, if they persisted, this is what they saw. So by about one month after the concussion, still 20% were complaining of headache, fatigue, and taking a little longer to think. But by three months, most of the kids were fine. They were back to normal. So tincture of time is really the message there, that these things can persist for a while. And we've got to reassure parents. I'll give you some other strategies to use in a minute. But still, about 15% had symptoms at 90 days postconcussion. And these were the most common symptoms that they saw. So still persisting. Headache is so common after concussion. And in kids who are headachy before their concussion, they're more likely to be more headachy after the concussion. So what do you tell parents? Well, the first thing you tell them is the time course is highly variable and unpredictable. So we don't know who's going to end up with these persistent symptoms. But you can reassure them that most kids come through this without any problems. Rest is very important after concussion. And while there's not a lot of solid scientific data behind it, most of us believe that rest helps the brain to heal after concussion. Recovery can be uneven. So there can be good days and bad days. And a lot of times when kids have good days, they want to power through because they know they weren't feeling great yesterday. But it's best to try to remain consistent in how much activity they have. Because they power through, and then the next day, they may feel worse again. And then interventions can help, we think. And then create an environment for recovery. So quiet, low stimulation. You may need to get a 504 plan at school, because if a child gets injured at a Friday night football game and has a big test on Monday, he shouldn't take it. And so it's important for parents to know and be empowered to call the school and say, you know what? My doctor said that my kid can't take this test or he needs more time for the test, or whatever. But we think that we shouldn't do big cognitive challenges immediately after a concussion. For one thing, you might not be actually testing the child's knowledge base because they're a little foggy and not concentrating as well and taking longer to think. So there are four main postconcussive syndrome categories. Somatic symptoms, which are mostly headache but can include nausea and vomiting and dizziness, balance problems, sensitivity to light, and sensitivity to noise. So this increased sensitivity is another thing that kids will have. And sometimes they're not even sure why they're so irritated by the TV playing loud or by the dog and the TV and the sibling all being in the room at the same time. And it's annoying them. They're on heightened anxiety. So calming things down for these kids without them having to ask for it is a really good idea. Sleep disturbance is another one. This includes feeling tired and drowsy, trouble falling asleep, sleeping more, or sleeping less than usual. So sleep disturbances come in a lot of flavors. Cognitive problems, like feeling slowed down, mentally foggy, trouble concentrating, trouble remembering. And then emotional lability, including sadness and nervousness and more emotional than usual. So in order to address these, what we think you're supposed to do is, first of all, rest. So cognitive and physical rest. And a lot of people go so far as to say no cellphone, no TV, no talking on the phone, truly taking it down and out. Now, if you thought you had an agitated teen before that, take those things away. But that is the recommendation. And then, of course, you remove them from most activities. You limit how much demands are going to be placed on them. And cognitive rest is very hard to, again, validate scientifically. So I can't point to a lot of studies that have said if a child doesn't use their cell phone or watch TV or talk on the phone, they recover from their postconcussive syndrome faster than a kid who does those things. It's just this is what has developed as the approach to these children. Promote good sleep hygiene. So this is an example of bad sleep hygiene, where there is a TV playing and a computer and a video game and a phone on her chest. Well, that's actually an iPod, which tells how long ago this must've been taken. So we want kids to be nondistracted when they're trying to sleep, in a dark room with quiet, if possible. And avoid distractions. Have them avoid nicotine and caffeine and alcohol use and all those things. And then, we know that there's a link between concussion and mental health issues. And again, all over the news, the suicides and the famous Junior Seau case, where he killed his family and himself. And these things are blamed on postconcussive syndrome or repeated concussions over time. We do know that there is a risk of mental health issues after concussion and certainly a greater risk for depression. When they looked at kids who showed up with concussion in the ED, they found that new psychological disorders were present in about three-- they had about threefold increase in new psychological disorders being diagnosed in the year following a concussion. Now, a lot of kids who get brain injuries have some sort of mental health issue. So kids with ADHD, for example, get more brain injuries and concussions than kids without ADHD. So they already have a preexisting mental health issue. But we know that we also see new mental health issues emerging after brain injuries. And so the question becomes what do you do with that? So you know it can happen. Do you just alert parents that there might be a change in mood, and if there is to let you know? We certainly can't screen every postconcussive kid for depression. That would just be onerous and could not be done. But I think that we need to inform parents that if they see anything new that isn't like the child was before, they need to inform us so that we can then send them on to the appropriate practitioners, who will follow me in this discussion today, actually. And then cognitive deficits can persist. This is really rare. After a brain injury, it's very common. After severe brain injury, it's super common. But after a concussion, it's rare. But this memory concentration, slow processing speed, happens for a period of time. And so again, in kids who have big things coming up, it's best to tell them that so they can anticipate that they probably shouldn't take the MCAT a week after they got a concussion. And they might need to wait for big things like that, because there's a big possibility that they are still dealing with foggy brain syndrome. And then the return to learn-- when to send them back to school. So return to learn is not well defined in terms of when to send kids back. I think that the hard part about concussion is that we need to see these kids rather quickly after the concussion. So kid gets injured on a Friday night, they really need to be in a doctor's office Monday morning being evaluated to see where they are. So we get the baseline. So we can then guide what's happening next. And I think that's probably rare. I think probably what happens is most kids go home, they rest, they feel a little better, they go back to school. And these persistent symptoms are not paid attention to. And the symptoms eventually go away. So maybe they have a little dip in performance and then their performance level comes back up. And they just go, OK, I'm feeling better. If the performance dip persists, I hope that they're seeking the advice of their pediatrician. But there is a graduated return to play protocol that I wanted to be sure you all were familiar with. And this was developed at the Zurich conference, which has happened, I think, three times for concussion management. It's a consensus conference, and it's printed in multiple journals, the results of the Zurich conference. And what they said is that there should be this graduated return to play protocol. Now, this says that each of these steps-- there are six steps to return to full play-- in each step you're supposed to spend at least 24 hours on that step. If you move to a step and you have symptoms, you're supposed to back up to the preceding step where you had no symptoms. So step one is no activity until asymptomatic at rest. Step two is light aerobic, no resistance. Three is sports-specific exercises and a little increased aerobics. And this is one day after another. Step four would be noncontact training and add some progressive resistance. Step five is full contact practice. Step six is return to play. So in seven days, a kid can go from concussion to back into play. But no sooner than seven days, based on this protocol. Now, who's doing this? Nobody, right? Because they're not going to see the pediatrician every day. They're not going to tell their parents if they have a symptom, because they want to play. The coach is not going to implement this. So it's a little impractical. But I want you know it's out there, because this is the standard. This is what is supposed to happen. What I can tell you is that certainly not before seven days should a kid be back in full sport, because they couldn't have moved through this protocol. So that's one thing you can say to parents. And we really need something like this for academics. You really need to have the parents keep in touch with the teachers in that first week after concussion. And if the kid is seeming to be having trouble in school, then you probably want to have them talk to the school about backing off on some things, letting the kid stay home a couple days, maybe, with rest, just to be sure they're fine. The CDC has a nice, free program called HEADS UP. If you're not familiar with it, just google it. It has a lot of resources there, mostly for parents and coaches, some for practitioners. The AAP has a few nice articles on concussion and kids that you can look at. And then the Zurich conference is a good one to look up.
