Concussion in the
Pediatric Population
Dr. Michael Vassilyadi
Children’s Hospital of Eastern Ontario (CHEO)
Head Injury and Concussion
Education Webinar Series
ThinkFirst Canada
Pensez d’Abord Canada
April 2012
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Before we begin…
 The
information contained in this presentation is intended for
educational purposes only and is not meant to be a substitute
for appropriate medical advice or care.
 If you believe that you or someone under your care has
sustained a concussion we strongly recommend that you
contact a qualified health professional for appropriate diagnosis
and treatment.
 The collaborators have made responsible efforts to include
accurate and timely information. However the individuals and
organizations listed on this website make no representations or
warranties regarding the accuracy of the information contained
and specifically disclaim any liability in connection with the
content of this presentation.
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Questions to Answer Today:
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What is the management and return to play
recommendations for children with
concussions?
What are the concerns with concussions?
How can I help my child cope and manage
with return to life, school and sport?
What are the potential chronic symptoms?
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What is the leading cause of death
for Canadians
under 45 years of age ?
INJURY!
Unintentional Injuries and
Children
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Very serious public health issue
Imposes a heavy burden on the healthcare
system
Leading cause of death among children 1-14
years of age
Injury accounts for 14% of hospitalizations
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Second-ranked cause of hospitalizations
Unintentional Injuries and
Children
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Most common examples of unintentional
injuries are falls, motor vehicle collisions,
fires, and poisonings
Falls
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Largest cause of traumatic head injuries
among children and youth
Occur primarily through sports and recreational
activities
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300,000 sport-related concussions each year
Children and their Brain
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The brain is surrounded by
cerebrospinal fluid, which helps
buffer the brain during movements

The brain is surrounded by a
membrane and encased by a skull
with the thickness of 1-2 pennies in
children and up to three pennies in
adults
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What’s so special about
the BRAIN?
 The
brain is made up of billions of
neurons
 The communications between neurons
are how we think, move and feel
 Neurons don’t grow back
This is why PREVENTION is the only cure
for Brain and Spinal Cord Injuries
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Traumatic Brain Injury (TBI)
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Affects up to 2% of the population/year
Major cause of death and severe disability
Two causes
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Impact damage (primary injury)
Secondary injury
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Develops after the impact
Progression of hemorrhage, cerebral swelling,
decreased brain perfusion because of shock
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Top Causes of Concussions
Females
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Soccer
Horseback Riding
Cycling
Ice Hockey
Snowboarding
Males
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Ice hockey
Cycling
Football
Soccer
Snowboarding
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Sports Related Concussions
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Concussion and the Brain:
What goes on?

A concussion affects the brain at the cellular
level
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A blow to the head starts a neuro-metabolic
cascade in the brain
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Concussion and the Brain:
What goes on?
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Concussion and the Brain:
What goes on?
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Summary of Changes at the
Cellular Level
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Injury causes increased energy demand
Restricted blood flow and oxygen debt
causes an ENERGY CRISIS
Exhausted neurons leads to mental confusion
and failed memory
Brain may take DAYS to WEEKS to restore
the chemical balance that constitutes
recovery
Medical Attention
Required when:
 Loss of consciousness
 Seizure activity
 Severe headaches
 Confusion
 Nausea/ vomiting
 Diplopia
 Neurological deficit
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Physician Advice with
Mild Head Injuries
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Do not return to play:
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If there are any persisting symptoms
If there are any neurological deficits
If there are any diagnostic imaging abnormalities
Once symptoms have resolved then may
proceed with “step-wise return to play”
protocol.
Stepwise Return-to-Play Protocol
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Step 1
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Step 2
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Complete rest, no activity
Light exercise, such as free play, walking or
stationary cycling, for 10-15 min
Step 3
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Sport-specific activity for 20-30 min. (eg., skating
in hockey, running in soccer)
Stepwise Return-to-Play Protocol
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Step 4
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Step 5
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“On field” practice with no contact
“On field” practice with body contact, once cleared
by a physician
Step 6
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Game play
Concerns with Concussion
1.
Second Impact Syndrome
2.
Post Concussion Syndrome
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Second Impact Syndrome
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Symptoms may be worse
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Headaches, dizziness, visual
impairment, nausea, vomiting,
balance problems, etc.
There is a period of time that
the brain is more susceptible
to a second injury
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Young athletes with SIS
are more likely to
experience:
 post traumatic amnesia
 a disturbance in mental
status after each new
injury
 score lower on memory
tests

The young brain loses its
ability to autoregulate its
blood supply which leads to
vascular engorgement,
marked increase in intracranial pressure, brain
herniation and ultimately
coma and death.
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Post Concussion Syndrome
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Collection of symptoms as a sequel to a
head injury
Contribution of psychological factors
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Conversion reaction
Secondary gain
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Attention, financial reward, drug seeking,…
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Symptoms of
Post Concussion Syndrome
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Decreased processing speed
Short-term memory impairment
Concentration deficit
Irritability/ depression
Fatigue/ sleep disturbance
General feeling of “fogginess”
Academic difficulties
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Concussion in
Children vs. Teen Athletes
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Concussions represent an estimated 8.9% of
all high school athletic injuries
Data is significantly lacking about
concussions in grade school and middle
school, athletes
Girls are reported to have a higher rate of
concussions than boys in similar sports
Elementary School
Aged Children

Continuing development of
bodies and brain

At this age, connections
between the 2 hemispheres of
the brain are talking to one
another
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Brain injury during this period
may interrupt development of
critical cognitive and
communication skills
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If symptoms persist and are left
untreated…
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Teachers and family may notice
increased irritability
School work may begin to suffer
Behaviour may be attributed to
factors other than the head injury
If the child continues to experience
problems, it could lead to
depression or “acting out”
At risk for academic and social
difficulties
At risk for further brain injury
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Stages of Concussive Injury
Prolonged Post Concussion
Syndrome:
Acute Concussion:
Physical symptoms
(headache ,nausea)
Cognitive deficits
(memory problems, concentration)
Emotional disturbances
(irritable, mood swings)
Symptoms lasting >6 mos
Lower concussion threshold
Diminished athletic performance
Diminished school or work performance
CTE:
Post Concussion Syndrome:
Persistent concussion symptoms
Lasting 1-6 weeks after mTBI
Self-limiting
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Latency period (usually 6-10 yrs)
Personality disturbances
Emotional lability
Personal relationship failures
Depression
Alcohol/substance abuse
Suicide attempt/completion
Importance of REST
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Brain’s response to concussion is to want to
rest
Rest allows the brain to use available energy
to recover
Rest allows for symptoms to lessen
Use of energy for other activities will increase
symptoms and delay recovery
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Return to School
Recommendations
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Little to no headache
Start with half days
No immediate testing
Limit homework to small blocks of time as
tolerated
Allow to go to health room to rest if headaches
returns
Allow to go home if headaches persist
Allow for an appropriate time to make up work
Possible School
Accommodations
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Decreased homework load
Allow for untimed testing as needed
Tutoring may be needed with prolong PCS or
home schooling
Use elevator in school if available
Allow to use teacher’s notes or photocopy
classmates notes
Possible School
Accommodations
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If photophobic, use of sunglasses or hat as
needed
May provide with pass to leave early from
class to avoid crowded or noisy hallways
NO Physical Education class
Eat somewhere other than cafeteria
Prevention
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Regardless of the steps taken to prevent injury, some
athletes will continue to be injured
The severity of the injury can be mitigated by the
following:
1. EDUCATION for officials, referees, coaches, trainers,
parents and athletes to :
a. Recognize the symptoms of concussion
b. Remove the athlete from play
c. Refer the athlete to a physician
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Prevention
2. Wearing the protective equipment appropriate for the
sport engaged in:
a. Equipment should fit properly
b. Equipment should be well maintained
c. Equipment should be worn consistently and
correctly
3. Athletes should follow their coaches’ rules for safety
and the rules of the sport
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Prevention
4. Teach your child/teen that it is not smart to play if they had an
injury
 It is not a badge of honour to play injured
 Discourage others from pressuring injured athletes to play
 Don’t let your child/teen convince you that he/she is “just
fine”
5. Tell all of your child/ teen’s coaches about any concussions they
may have suffered in the past
6. Provide reassurance, support and request academic
accommodations as needed
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Concussion Research Project
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There is a need to both track and manage
children with post concussion symptoms
One year pilot project
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Approved by the Research Ethics Board
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Use of ImPACT program, as well as
Neuropsychology assessments when necessary
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http://www.impacttestonline.com/impactdemo/
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CHEO CRP- Referral Criteria
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Physician referral is required
The patient is between the age of 10-17
Injury is sport-related
The patient has post-concussion symptoms
3 months post-injury
The concussion occurred within the last year
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ImPACT Test
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Tool to assess Functional Damage caused by concussion
Measures multiple aspects of cognitive functioning in athletes,
including:
 Attention span
 Working memory
 Sustained and selective attention time
 Response variability
 Non-verbal problem solving
 Reaction time
Used by professional sports organizations, Universities, colleges
in the US (over 900 schools)
Helps coaches, trainers, doctors, parents and athletes determine
when to return to play and with school accommodations
Concussion Research
Project - Questions
1.
2.
3.
What is the severity, frequency and duration of
symptoms in children who have sustained a
traumatic brain injury while playing a sport and who
remain symptomatic greater than three months
following their injury?
What is the relationship between symptom
experience, socioemotional functioning and healthrelated quality of life in this population?
What prognostic indicators can be identified for
children at high risk for prolonged symptomatology?
Pilot Study Findings May 2011 to Present
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15 children who sustained sport-related head
injuries and remained symptomatic at three
months following their injuries, agreed to
participate in a Concussion Research Project
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Approximately twenty other children were
assessed but did not meet all of the inclusion
criteria for inclusion in the pilot study
CRP- Pilot Data n=15
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Children ranged in age from 12 to 17
Ten males and five females participated
Total number of concussions per patient ranged from
1 to 4, with a median of 2
11 of the 15 patients had at least a second
concussion
5 of the initial concussions resulted from hockey (in
all but one of these cases a helmet was worn)
Others were from gymnastics, martial arts, rugby, BB
running, snowboarding (a helmet was worn), soccer
CRP- Pilot Data
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The number of symptoms following the first
concussion ranged from 0 to 20, with a median of
10.5, whereas for the second concussion the range
was 6 to 23, with a median of 13.5
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The number of moderate to severe symptoms
following the first concussion ranged from 0 to 19,
with a median of 5, whereas for the second
concussion the range was 3 to 21, with a median of
11.5.
# Pts with
Symptoms
Mild (%)
Moderate
To Severe
(%)
headache
10
13
53
poor concentration
9
20
40
memory problems
8
13
40
sensitivity to light
8
27
27
irritability
7
7
40
trouble falling
7
13
33
poor balance
7
27
20
drowsiness
7
13
13
feeling in a fog
6
13
27
sensitivity to noise
6
13
27
vacant stare/glassy
6
13
27
6
20
20
Symptom
asleep
eyes
feel slowed down
Thank You!
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Acknowledgements
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Funding
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Public Health Agency of Canada Grant
Content
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CHEO
ThinkFirst Foundation of Canada – Concussion
Education and Awareness Committee
ThinkFirst Foundation of Canada Staff
Elaine Keunen – ThinkFirst Hamilton
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