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Navigating Pediatric Concussions with Dr. Mayur Patel · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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We have an episode on atypical pneumonia, in case you're interested.
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Check this Pediatrics Now news feed. Brought to you by the Department of Pediatrics
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at UT Health San Antonio and University Health's new Women's and Children's Hospital.
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Today, I'm bringing you Grand Rounds. Here's a talk by Dr.
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Mayur Patel, Professor, Department of Neurology at UT Health San Antonio. know.
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Dr. Patel's talk is on the approach to pediatric concussion in the outpatient
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setting. Let's listen in.
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All right. So hi, everyone. My name is Mayor Patel. I'm a adult neurologist
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here at UT with a board certification in brain injury medicine.
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And I'm going to talk about my experience with treating pediatric concussion
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because I think that's a population that oftentimes, you know,
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there isn't much information about and so even though I'm an adult neurologist,
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I've had some experience treating pediatric concussion as well.
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So just wanted to kind of add my expertise and, you know, provides introspection
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into how I treat them and to see if that can help as well. All right.
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So today we're going to talk about mild TBI and concussion and so we have three
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separate types of traumatic brain injury. We have mild, moderate, and severe.
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From a nomenclature perspective, a mild TBI is considered the same thing as a concussion.
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However, they're trying to move away from the term concussion and now use mild
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TBI more so as a descriptor of the clinical injury.
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But for the course of this presentation, I'm going to say mild TBI and concussion
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are the same thing, just to make it simpler.
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As we know, you know, a lot of people with concussion or mild TBI tend to recover fairly quickly.
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And what I mean by fairly quickly is within a month. However,
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there are people that can't have persistent symptoms for months to years,
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and that can be very disabling for people.
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The one thing I will say, though, is that kids, for whatever reason,
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tend to get better quicker than adults do.
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And that's something that I've noticed in my practice as well.
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And I think one of the main reasons for that is that patients with pre-existing
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conditions like headaches, sleep abnormalities, mental health disorders tend
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to have a more prolonged course of recovery.
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And you can imagine why, because a lot of those symptoms are going to occur
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after you have a concussion, right?
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And so if you have a pre-existing history of something like this,
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that kind of makes you more prone to having an exacerbation of those symptoms.
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And so, So, you know, your adult patients, for those of you that,
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you know, do med-peds or see adults, are more likely to have some of these issues
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just by virtue of being older and having lived longer lives, right?
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They're more likely to have been diagnosed with like a headache syndrome, for instance.
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Symptoms can include a wide variety of issues, including somatic,
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cognitive, psychological, and sleep disturbances. And I'm going to go a little
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bit into each of those and kind of my approach to treatment.
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And hopefully provide some insight into there. Within the pediatric population,
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a sports-related concussion is one of the biggest considerations that people
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need to take into account because that's fairly common, right?
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Kids of all ages are playing sports and, you know, whether it's football or,
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you know, even soccer or basketball, I've had figure skaters that have come in with concussions.
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You know, you can certainly have any kind of concussion or you can certainly
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play any kind of sport and have a concussion.
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Just one little tidbit to throw in there from research.
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So concussion is primarily a clinical diagnosis, but where our research is really
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looking at is are there biomarkers that can be shown not only to diagnose concussion,
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but also predict future recovery.
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And so UCHL1 and GFAP are two of them that have been studied so far.
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The reason that they haven't really taken off yet is because a lot of our biomarkers
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that we're looking at are CSF or cerebrospinal fluid biomarkers,
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which makes it hard, right?
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Because, you know, the way to get CSF is to do a lumbar puncture on someone,
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which is obviously very invasive, whether you're dealing with a child or an adult.
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But now we're looking at blood biomarkers and there's some really big promise
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as to potentially using these in the future in then like an ER setting,
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but also in an outpatient setting as well to show, you know,
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how well someone has recovered.
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So a really exciting area of research that we're looking into.
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So as I mentioned earlier, there's three types of traumatic brain injury.
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We have mild, moderate, and severe.
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And that's, you know, this chart does a good job of separating out the three.
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You are going to have some overlap between the three of them,
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right? You know, you may have someone who had GCS of 12, for instance,
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that had a loss of consciousness for less than 30 minutes and a non-focal neurologic exam otherwise.
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So there can be some overlap, but they typically tend to fall more or less within these guidelines.
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What I typically see as a neurologist is more so the mild TBI because a mild TBI is,
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A, going to oftentimes have fewer rehab needs, and B, they oftentimes deal with
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a lot of neurologic issues that can be more disabling.
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And the vast majority of patients with TBI are also mild as well.
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With moderate or severe, you run into more of these issues where spasticity
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and rehab is a big need because these patients have severe, severe deficits.
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And rehab doctors do a great job with those patients as well.
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So I'll typically defer those patients to rehab doctors. But from my perspective,
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where I can really add some insight is with mild TBI or concussion,
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and that's kind of what I'll talk about today.
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So for a long time, and not even for a long time, for now actually,
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diagnosing mild TBI and concussion is primarily a clinical diagnosis.
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But the American Congress of Rehab Medicine recently, within the last few years,
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released this paper that helps you diagnose mild TBI through an algorithmic pathway.
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And so I'll go a little bit into that. A lot of this is self-explanatory,
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and the paper is fantastic if you do want to look it up to help your practice in the future.
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But the specific criteria, so the first criteria is there has to be a mechanism
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of injury that's plausible, right?
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And so, okay, someone got hit in the head, you know, someone was throwing a
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baseball and it happened to hit them in a, that's plausible, right?
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The other, what's not plausible, someone falls down on their knees,
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trips and falls, but they land on their knees, there's no whiplash,
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there's no head in, there's no head impact, nothing like that.
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That's not really a plausible mechanism for a concussion right then you have
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to kind of think of other causes and then if you have that plausibility most
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likely you can move down to the next criteria so criteria two is clinical signs
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and that's a lot of in the moment stuff right and so.
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That's where your history taking from loved ones that were there or EMS if they're
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coming in via the emergency route is very important because,
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you know, a patient may not know that they lost consciousness immediately following the injury.
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They might not know if they were confused immediately following the injury.
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They may not know if they had motor incoordination upon standing or seizure
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or other neurologic signs immediately following the injury.
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The complete or partial amnesia is something that they will know or that they
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can know, but the other signs, more or less, I typically rely on either family
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members or EMS or some form of witnesses to help with that.
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For criterion three which is acute symptoms
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that's stuff that the patient will report to you right so
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an alteration in mental status so
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some kind of cognitive difficulty that they're having or i guess that would
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be some kind of mental status difficulty they're having in the morning or in
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the moment but then cognitive symptoms can also be there physical symptoms headache
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nausea dizziness a lot of these are self-explanatory and symptoms that we do see with concussion.
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Criterion four is more so your objective findings, right?
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So you find cognitive impairment on exam when you do it.
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You find a balance impairment on exam when you test them. You also can see oculomotor impairment.
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You can also, and then the last part, the elevated blood biomarkers is something,
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as I mentioned, that they are looking into, but that could be something that
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they will also include as well.
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The one caveat with this algorithm and one thing that they specifically mentioned
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is you have to use caution when employing this criteria, especially for young children,
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but also in individuals who have a pre-injury cognitive and or communication impairment.
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And so that's one thing to be careful about whenever employing this criteria.
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I as an adult neurologist
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don't usually see children that young and it's a little bit outside my
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training so I haven't run into that issue as much
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but for the kids that I see that are usually above like you know 10 to 12 and
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older typically mostly teenagers it's much easier for me to employ this criterion
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but just kind of be cautious about
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this in your practice as per the recommendations of the study for very,
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very young children when applying this criteria.
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But overall, this is a criteria that I myself, seeing mostly brain injury, do find very useful.
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As I mentioned, concussion and mild TBI has been primarily a clinical diagnosis for a long time.
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And so having something that we can work through from an algorithmic perspective
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has been very, very useful.
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So the meat of my presentation is going to be talking about these specific symptoms
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of concussion that I deal with and how my approach to them is.
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But just as a case example, and this is a common finding that we see,
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so a 15-year-old suffered a concussion during a game, didn't lose consciousness,
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but hit and fell on his helmet.
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And again, as we were going back to that last site, criteria one,
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plausible mechanism of concussion, right? He was pulled from the game and taken
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to the ER where they did a CAT scan, which was normal.
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And then over the next week, he continued to have the symptoms, right?
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And so he had headache, dizziness, vertigo, brain fog, irritability, insomnia.
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And so we're gonna go into each of these symptoms as far as from an umbrella
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perspective and go into how the treatment algorithms and diagnosis can help
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these patients get better.
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So as I mentioned, specific post-concussive symptoms, these are the five that
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I see most often, and they're pretty much copied over from the last side,
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but as I mentioned, headaches, so post-traumatic headaches, sleep difficulties,
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mood abnormalities, vertigo, and dizziness is included in that,
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and then any kind of cognitive difficulties.
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And so we'll go into each five of these and kind of show my approach to them.
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So we'll start with headaches. Headaches are, out of all my traumatic brain
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injury patients that I see, headaches are probably the most common.
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Now, you know, I probably have a little bit of a bias for this as I'm a neurologist
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and most of the time patients are being sent to me for headaches regardless,
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but I do end up teasing out quite a bit of post-traumatic headaches when talking
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to patients and getting their history.
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It's one of the most commonly reported symptoms acutely following a mild TBI or concussion?
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The diagnosis is important. So it's the onset of a new headache or worsening
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of a previous headache within seven days of trauma to the head.
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Personally speaking, I think that seven days is kind of a long time to be diagnosing
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this. And I've discussed this with other brain injury doctors as well.
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If someone hits their head, you know, or suffers a concussion,
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they're probably going to have a post-traumatic headache within the first couple of days, right?
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From a definition perspective, the seven days is there, but in my experience,
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I typically see patients having these issues within two to three days after a trauma to the head.
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And then it's persistent if the symptoms remain for greater than
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three months again most patients get better within that time but
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there are a few subset that do last longer so
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talking about new headache or worsening
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of a previous headache again in a younger child it's probably
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going to be the onset of a new headache however in in
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teenagers especially especially young young
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women they may have already
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started developing headache syndromes such as
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migraines and so that's something to keep in mind is
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if there's a young girl that has a migraine or better sorry
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that has a pre-existing history of migraine and then the headaches get worse
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then that still counts because that's worsening of a pre-existing headache so
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something to keep in mind in your older children headaches can be of any headache
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phenotype so again we have lots of different types of headaches migraines and
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tension headaches do tend to be the most common.
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And then one thing that I've noticed
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that often happens is people have a cervicogenic headache at times.
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And those will be people that have a lot of whiplash as a result of their accident.
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So think people that were involved in car accidents.
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So even within your kits, it's always a good idea to check the cervical spine.
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And that doesn't necessarily mean image of the cervical spine,
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but feel for points of tenderness along the back of their neck and along the musculature.
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So often, and this may be more so in your older kids or your teenagers,
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you know, they're on their phones all the time, that their muscles start to
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tighten up in their neck because they're looking downwards, right?
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And so the way I explain it to parents and adults as well is that your head's
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obviously attached to your neck, which is attached to your shoulders.
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And so any kind of tightness in that region can pull on the muscles of the head
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and lead to referred pain. And so we call that a cervicogenic headache.
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And so if you've suffered whiplash before, if your patient has suffered whiplash,
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that's something to look into.
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Physical therapy works really well. Gentle stretching works well as well for
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this. You can alternate ice and heat.
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But that's something that I find that is ignored quite a lot in this patient
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population is looking at the neck and shoulder. So always look into that.
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And then as an adult, young girls tend to be affected more than young boys for
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whatever reason with regards to post-traumatic headache. But that does not mean
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that young boys can't develop post-traumatic headaches, so it's obviously something
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to try to keep in mind and look into.
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So headache management, there unfortunately aren't very many studies into this.
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Non-pharmacologic, especially as I mentioned on that last slide,
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for that cervicogenic headache with neck tightness is very helpful.
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You know, a short course of physical therapy.
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If they're dizzy and that's driving their headaches, vestibular therapy can help.
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And I'm going to talk about vestibular therapy when we talk about vertigo later,
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but just adding it as a placeholder for here.
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I'm going to skip down to acute therapy because, again, in kids,
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they tend to recover better than adults or quicker than adults.
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You don't really, if rarely, ever get to the point where they need preventative therapy.
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But acute therapy is really nice because there is good evidence for alternating Tylenol and Motrin.
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So what we found is that in school-age children, alternating acetaminophen and
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ibuprofen can help limit headache days.
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And then improve to school, return to school rate, which is important in this population.
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The one thing to be careful about is that the more that you take up these medications,
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the more it can lead to rebound headaches.
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And we see that more so in our adult population in which someone is taking acetaminophen
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or ibuprofen around the clock.
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But if you've got a child on it for, you know, weeks to months at a time,
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that is a consideration to keep in mind.
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So I typically say do it for about two weeks. most
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should be better in two weeks but if they're not better in two weeks doing
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that then obviously we need to look into something else if
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there is a concern for migraine and again that would be within
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pediatrics that would be your older older girls or teenagers then you can try
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low dose tryptans i'm not a big fan of prescriptions in this age population
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so i try to avoid that if i can i typically start with the alternating of the
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acetaminophen and the ibuprofen but you can try that if needed.
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Preventative, again, this is going to be more so of a thing that you're going
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to do rarely, but my mantra as a physician, as a neurologist,
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is if you can treat multiple things with one medication, that's the route I try to go with.
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So as you can imagine within TBI, a lot of people have headaches,
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they have mood abnormalities, they have sleep abnormalities,
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and so I really like amitriptyline a lot.
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It actually has very good evidence in post-traumatic headaches and can be used
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in pediatrics, primarily within patients above the age of 12.
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And the reason that I like that is that if you've ever heard that mantra,
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kill two birds with one stone, amitriptyline actually kills three birds with
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one stone potentially, which would treat potentially insomnia,
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potentially head pain, and potentially mood disorder. It's an antidepressant.
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So it can provide some benefit in all three, and it's dosed once nightly QHS, which is nice as well.
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The primarily preventative treatments besides amitriptyline are typically medications
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that are used in migraines, and so propranolol, topiramate are used as well.
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Again, in this age population, I'm not a big fan of starting Topamax or propranolol
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unless someone badly needs it, so I try and avoid those if possible.
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Typically speaking, I'll try either melatonin, which has good evidence within
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pediatrics, or amitriptyline.
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They tend to be tolerated a little bit better and work
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a little bit better again that's just my anecdotal evidence but that's simply
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what i go to topiramate even in adults it tends to have
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allowed nasty side effects so we try and avoid it propranolol is
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usable but with beta blockers you have to monitor certain things so that's makes
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it kind of tricky as well but that's typically my pattern for how i treat post-traumatic
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headaches i typically will start with a non-pharmacologic and acute ibuprofen
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Tylenol alternating within kids and then kind of escalate from there.
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All right, so the next one is sleep. And so the time since injury plays a pretty large role.
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So within the first week or so after a concussion, kids will tend to have the
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biggest sleep issues and then it'll aggressively decrease up until about three months post-injury.
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There's a bi-directional relationship between sleep depression and deprivation
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and post-concussion symptoms.
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And that makes sense, right? And that if you're not sleeping well,
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your concussion symptoms are probably going to get worse and vice versa.
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What they found is that pre-injury sleep disturbances and older age ed injury
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have been shown to have an increased prevalence of sleep disturbance after pediatric MTBI.
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And so that was kind of what I mentioned earlier on,
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is that pre-existing issues that patients have
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before a concussion can exacerbate the
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symptoms of concussion especially if they're the same thing so something
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to keep in mind they have trouble falling
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asleep and sleeping either more or less than usual but
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drowsiness is actually the most commonly reported initial symptom
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so you'll have these kids that suffer head injury and all they want
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to do for the next 48 to 72 hours is sleep because their brain is just exhausted
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right i i give this example to my patients all the time and parents as well
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and that whenever you suffer a concussion it almost feels as if your brain is
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running a mile a minute and it's just wearing itself out and so rest is very
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important especially in the acute setting.
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It's important to recognize poor sleep, especially in this population,
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as it can cause difficulties with school and cognitive functioning,
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and then also emotional and psychological well-being.
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One of my fellowship directors, Carolyn Geis, is a physical medicine and rehab
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doctor at the University of Florida, and her mantra to treating concussion was
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actually treating sleep first and foremost, because she found that if patients sleep better,
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then they do a lot better as far as recovery.
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And so I found a lot of benefit in learning how to treat sleep from her.
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And that's been helpful in my practice as well, because, you know,
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if we can get people sleeping faster, again, with that bi-directional relationship,
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it's shown improvement in results.
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So treatments, sleep hygiene is the biggest thing, right?
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So especially in your older kids that have phones and screens,
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it's great to sleep, but make sure you do not take this into bed.
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Do not exercise prior to going to bed.
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If people have or kids you know
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adults whatever have sleep issues that last for
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a long time then cognitive behavioral therapy is very useful
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and then last case is pharmacologic management right and so we talked about
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amitriptyline or melatonin those are good the one thing i didn't mention in
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amitriptyline is that it has an anticholinergic property to it so it can have
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some cognitive slowing but it's usually pretty tolerable especially at a low
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dose and i don't find that to be too much of an issue.
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Trazodone is not really indicated in children. I just kept it in there in that,
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you know, if you can refer to a sleep doctor and they can try it,
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just be careful with your adult or with your males as pre-epism is a rare but serious side effect.
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Sleep doctors aren't the biggest fans in the world of trazodone,
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so as it can cause rebound insomnia, and it's not something you really want
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to use in a kid's population because it's not indicated under the age of 18
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but i have seen it used before benzodiazepines absolutely avoid in any population
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especially in children but also in elderly adults as well,
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And then last but not least, if it's not the insomnia issue,
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but it's the hypersomnia issue, then you can try setting a schedule,
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strategic naps, stimulants.
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I've actually seen quite a few teenagers that have had hypersomnia as an issue after a concussion.
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And one of the biggest things that I've found that actually works for them is
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setting a schedule, right?
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And so you're going to go and walk the dog at this time. You're going to go
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hang out with friends at this time. You're going to go to school from this time.
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You're going to go study at this time.
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And then you can finally go to bed. And I think parents buy into that a lot as well.
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And that's something that I've seen that works really well for this population.
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And then obviously you don't have to give them stimulants or anything like that.
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Cognition. And so cognition is the third symptom that we're going to talk about.
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And it can be very subtle, but within both pediatrics and adults,
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attention and executive function tend to be the most affected and can be seen
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as long as three months after injury.
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So within the sports population or with kids that are returning to play,
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we do the sports concussion assessment tool, SCAT-6, and that's like a full
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battery of tests that we do before prior to,
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or before we can clear a child to return to play.
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And so the cool thing about that is, is that it's an objective test,
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right? And they test their cognition, their balance, their symptom score.
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And then once they pass that, then they can go back to return to play.
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The whole return to play protocol. And we'll talk a little bit about that in
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the coming slides. And so this is actually a screen of the SCAT-5.
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They just updated it to the SCAT-6. So I need to go and get a screenshot and update my slides.
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But it's a multi-page test that you can do in office.
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And so cognitive treatment, and we're going to talk about return to school in
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the next slide, is you treat the underlying cause, right?
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And this is more so within adults, but you can also see it with kids as well.
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Mood disorders following a concussion can lead to your cognition being slowly
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or being slower than it was before, but also coexisting headaches and sleep abnormalities, right?
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If you're not sleeping well, then your brain's not going to be at the full functioning.
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And that's what I try to explain to parents.
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But also headaches, right? If a patient is in pain all the time and that pain
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has not been treated, then that can also lower your cognitive resurgence.
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And the important thing to tell parents is that this will get better once the
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underlying cause is retreating.
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For a long time, we used to tell people that when you have a concussion,
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you want to rest as much as possible and sit in a dark room.
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Well, what our science is actually finding now is that that is bad for you the longer you do it.
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So, you know, if there's one point you can take away from this thing,
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it's that in most cases, you should only cognitively rest for the first 24 to 48 hours.
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Prolonged rest has actually been associated with an increased recovery time.
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So after the first 24 to 48 hours, you want patients to typically start to return
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to their normal activities, right?
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And so whether that's going outside, hanging out with friends, within reason, right?
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And so if someone, let's take an example for studying, right?
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And so if you have a child that wants to study, it's okay to let them start
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studying again after the first 48 hours, but you do it.
25:15
Breaks in between. And so what I'll tell people is, okay, you can start doing
25:20
your activity, start for about 10 or 15 minutes, see how you feel.
25:23
If you feel like you're doing fine, then keep going.
25:26
But at the first moment that you start to feel symptoms, that's a sign that
25:30
you're overdoing it, right?
25:32
So say you get to 20 minutes and you start feeling symptoms,
25:34
that means that you need to take a break, go do something else,
25:37
let your mind recharge, and then you can get back at it when you feel like you're ready to.
25:41
And so slowly, you'll be able to progressively, patients will be slowly able
25:45
to progressively increase their tolerance as time goes on.
25:49
Return to school is a big thing, especially within this population.
25:52
And so it's common to have academic accommodations. And so I'll oftentimes write
25:56
letters saying so-and-so would benefit from half days for a couple of days with
26:01
increased return to work or return to school as tolerated, increased time on
26:05
tests, quizzes, homework.
26:07
So that's fairly common and schools will be willing to work with you on that.
26:10
It is important to have good communication between the medical team and the
26:14
school because the patient, you know, if there's not a letter,
26:16
if there's not some form of communication, then the patient will be lost in between.
26:19
And the schools may not be used to dealing with kids that have had concussions, right?
26:24
And so they'll be willing to work. They just kind of need some doctor guidance
26:28
and letters. And so that's where we come in as clinicians.
26:32
So this is from the American Academy of Neurology, and it's a graded return to school strategy.
26:38
And so the first goal is to do daily activities at home that do not give the child symptoms.
26:44
And so again, that's like reading, texting, screen time.
26:50
Again, you don't want to push for it, but as long as they're able to tolerate
26:53
that, then you can gradually start to build up. And then we go to school activities,
26:57
and that was what I was talking about, the studying, and how long they're able to study.
27:03
And then you can go to school part-time and full-time. And that typically works.
27:07
You know, your older children that may be working jobs, this can also be helpful
27:12
for them as well, and that you can write letters to employers kind of working with them as well.
27:16
But as far as the graded return to school strategy, this is kind of my strategy
27:20
that I follow. and I haven't had much pushback, if any, from schools at all on there.
27:26
All right, so we talked about headaches, sleep, and cognition.
27:31
Next, we're going to talk about mood, and then last, we'll talk about vertigo and dizziness.
27:35
So with mood, anxiety and depression are two of the most common mood disorders
27:39
that you see following a mild TBI.
27:43
And they've actually now found studies that have shown a link between sustaining
27:47
a concussion and having a risk of developing a new affective or behavioral disorder.
27:52
And these can actually last pretty long. They've shown that you can develop
27:56
the mood disorder up to four years after the injury, which to me seems very
28:00
long, but that's what different studies have shown.
28:03
What's important to recognize within children, they've done studies in children
28:08
aged 5 to 18 years that have shown children with a concussion have an increased
28:12
risk of mental health visits, psychiatric hospitalizations, and self-harm.
28:16
So that's something that's very, very important to recognize in your children
28:19
when you're seeing them in clinic, as that can be something that's untreated
28:24
and could potentially lead to issues down the line.
28:27
So mood treatments, again, I'm not a pediatric psychiatrist,
28:31
so not the biggest expert in the world in these.
28:34
But again, kill two birds with one stone is my biggest thing, right?
28:38
So amitriptyline works really well.
28:40
It's not the greatest antidepressant in the world, but for concussion patients,
28:45
it tends to do well because it treats other things, which helps them feel better.
28:48
And that's one of the things with mood disorders is that kids and adults,
28:54
you're going to generally be sad because you don't feel well, right?
28:57
And so if it helps treat the other symptoms that in and of itself may help treat the mood disorders.
29:05
SNRIs, venlafaxine is another one that I like, and you can use that in pediatrics
29:10
as well, 37.5 milligrams once a day.
29:13
That's nice because it has a little bit more of an activating effect,
29:17
whereas the TCAs have more of a sedating effect. So you can kind of decide which
29:21
one the patient needs more.
29:23
Venlafaxine also helps with post-traumatic headaches and migraines as well as a preventative.
29:28
SSRIs are there as well. Mirtazapine is a nice drug in adults,
29:31
but it's not as well studied in children.
29:33
Lastly, therapy as well, right? So if someone had a, you know,
29:38
cognitive behavioral therapy works well, this is, you know, beyond my scope
29:42
as a neurologist, but psychiatry would probably be able to comment a little bit more on that.
29:46
But also talking to a therapist, especially if there's like a PTSD involved from a head injury,
29:51
that was something that was something very mentally
29:54
traumatic for a patient that can obviously bump
29:57
as well and then the last symptom that
30:00
we're going to talk about is vertigo and so
30:02
this is tougher within children because i find they have a little bit of a harder
30:06
time explaining this but it's important to differentiate true vertigo which
30:11
is that classic spinning sensation versus light headedness they say often overlap
30:16
within patients right and so it's tricky within athletes and especially, you know,
30:21
school-age children that are sports-related concussion,
30:24
if they have dizziness or vertigo, they've actually found that it's independently
30:28
predictive of a prolonged recovery.
30:31
So that's something to keep in mind is that you want to treat the dizziness
30:35
and vertigo sooner rather than later, because the sooner that you treat it,
30:38
the quicker that they'll have
30:40
a chance as far as recovery and be able to return to their play faster.
30:45
Vestibular dysfunction is something that I find is typically not taught very
30:49
well within neurology residencies and with medical schools.
30:53
So, you know, that's something that I enjoy teaching residents about.
30:57
But the way I basically explain it is you have your peripheral vestibular system
31:01
and you have your central vestibular system.
31:03
Your central vestibular system, kind of like your brain is or kind of like your
31:07
central nervous system originates in the brain.
31:09
The peripheral vestibular system is the
31:12
system that's far far more often affected though
31:15
and you know your ENTs would probably be able to tell you a lot more about this
31:20
but basically you know your vestibular structures are inside on the inside of
31:23
your ears on both sides and they can commonly be affected following a head injury
31:28
and that's you know probably because they're so prone to damage as a result
31:32
of their location and so they're very easy to be damaged as a result of trauma.
31:36
And so vestibular dysfunction, such as BPPV, benign paroxysmal positional vertigo,
31:42
are the most common cause of post-traumatic vertigo.
31:45
And if you go back to your med school studies, BPPV is that classic case in
31:51
which someone wakes up in the morning, or the test question,
31:53
I guess, is when someone wakes up in the morning,
31:55
turns their head to the side, and then suddenly has spinning that lasts for
31:58
about 30 to 45 seconds because the crystals get displaced.
32:02
And so the Dix-Hallpike is the test to kind of test for that,
32:05
and then the Epley is to fix that.
32:08
One thing that I also think gets ignored or not looked into as much is ocular
32:12
issues following concussion, non-traumatic brain injury.
32:16
And so ocular issues can be very disabling for people, just as disabling as headaches.
32:22
And the biggest thing that I find is convergence insufficiency.
32:25
So if you test it on your cell, if you put your finger out in front of you, you should C1.
32:31
And then what I ask patients to do is slowly move it in towards their nose until
32:36
it doubles. For me, it's about right here,
32:39
And for most people that are normal, it should be under 10 centimeters.
32:43
For people with traumatic brain injury or concussion, especially in an acute
32:47
setting, it's typically much farther out.
32:50
You know, it can even be 20, 30 centimeters at times.
32:53
And the reason that that can be disabling is people don't realize how much your
32:58
eyes have to converge to function on a day-to-day basis, right?
33:01
Imagine you have a book or your phone in front of you. Your eyes have to converge
33:05
to see that. So if you're getting diplopia or double vision that far out,
33:09
you're going to get diplopia, you know, on something that's 5,
33:12
10 centimeters away from your face.
33:14
And so that can be very disabling and double vision can lead to worsening of headaches.
33:19
So that's something that I certainly look into. with regards to the slow pursuits,
33:23
saccades, and that stuff, that goes in with the vestibular dysfunction, right?
33:27
And so I'll put my finger out and just have them go side to side,
33:30
keep your head straight and move your eyes side to side.
33:34
And that oftentimes brings out dizziness in these patients and that's a sign
33:38
of vestibular dysfunction.
33:39
And so for the convergence insufficiency, I find neuro-ophthalmology is actually very, very helpful.
33:45
And you typically only find these at academic places
33:48
and we have a great neuro-ophthalmology team here at UT
33:51
and what they'll do is they can do tests
33:54
to help diagnose this convergence insufficiency but they can
33:57
also put like stick-on prisms into the glasses so that kid or adult with these
34:02
issues is able to converge a lot better and so they don't even need to have
34:08
a prescription for glasses you can get just like the normal glasses without
34:12
any refraction in them but they can put prisms in them to help adjust it which is nice.
34:17
So treatment, vestibular rehab is a big component.
34:21
We actually have a great vestibular rehab therapist here at the market.
34:25
His name is Barry Morgan.
34:26
Sent him a lot of patients and we've had great results.
34:30
So vestibular rehab is basically a subset of physical therapy.
34:34
And they work primarily on issues with the vestibular system.
34:40
And so physical therapy works fantastic for this. If there is any lesions such
34:45
as a dehiscence or a fistula, again, very rare, but can happen,
34:51
then ENT is a great referral source for that.
34:55
Vestibular migraine is a consideration, although more so in adults that already
34:59
have migraine compared to younger children.
35:02
And then medication. So maclosine is oftentimes prescribed by the ER in patients
35:07
that have dizziness, and it works great in the short-term setting.
35:10
I would recommend limiting it to
35:13
more than or to children over the
35:16
age of 12 not younger but the one thing I would
35:19
also recommend is avoid using this long-term consistent use of meclizine has
35:23
actually been shown to hinder central recovery so central vestibular recovery
35:28
right so patients will feel better in the moment which is fine if you're doing
35:31
it short-term but longer term it can actually slow down their central recovery
35:36
so something to keep in mind,
35:38
venlafaxine and gabapentin these are more just anecdotal evidence of medications
35:43
that I've tried that have had good recovery for your refractory vestibular syndrome
35:48
patients that have still continued to have symptoms even after doing vestibular therapy.
35:54
So this is the Dix Hall bike in Epley. That's a picture of the Epley for BPPV.
36:00
Rare, again, in children, but it is within the realm of possibility.
36:05
And a physical therapy visit, the physical therapist will actually be able to do the Dix Hall bike.
36:12
And then they'll do the Epley as well there, but they'll also teach the family
36:16
how to do the Epley so that the family can do it at home, which is nice if the symptoms reoccur.
36:23
Lastly i wanted to touch base on a special
36:26
consideration of athletes so a return to play protocol
36:29
is very very paramount and what return to play is basically
36:32
is it's a step-wide ladder that patients
36:35
have to climb in order to get back to full right and a physician has to be involved
36:40
either a neurologist like myself or a sports medicine doctor or sports neurologist
36:44
and basically what happens is if you remember we did we showed the scott six
36:49
earlier and so you'll see the patient in clinic.
36:53
And then once they pass and are back at baseline, pass their testing with the
36:57
SCAT, then the doctor will sign off and then it's in the hands of the school
37:01
district and the trainer.
37:02
And so the trainer will work them advancing every 24 hours from stage one all the way to stage six.
37:09
And these stages vary based off the school district.
37:12
This is just an example. and if the patient
37:16
is able to get through one stage without symptoms
37:19
and are able to do well the rest of the day 24
37:22
hours later they can try to do the next stage if they develop symptoms
37:25
at that next stage then they do not advance and they stay at that stage or go
37:29
back until they're able to tolerate the symptoms or tolerate the stage without
37:33
doing the symptoms the reason that this is important is second impact syndrome
37:39
is a real thing it's very very rare but that's rare as a result of.
37:44
Athletes returning in a better manner than before.
37:48
But basically, second impact syndrome is if a patient,
37:52
it can be a child or an adult, suffers a second concussion without having recovered
37:58
from the first one, then that can lead to the syndrome, which is fatal and leads
38:04
to cerebral swelling and can be very fatal.
38:06
So again, I've never personally seen this before.
38:09
It's extremely rare, but it is something to keep in mind.
38:11
The retirement talk is something that comes up very often, especially within younger populations.
38:17
It's very individualized. It's doctor and patient specific and very from athlete to athlete.
38:22
This is one that I find to be, you know, very ethically challenging, right?
38:26
Because if people were to ask, would you let your kids play football? My answer is no, right?
38:31
As a neurologist, I know too much. But, you know,
38:34
you think about this from like a socioeconomic perspective imagine
38:37
you have like this inner city child who's come
38:40
from a financially disadvantaged background and
38:43
this is the chance that they've got to make
38:47
it big for themselves and their family it's it's
38:50
a very very hard conversation to have because ethically speaking you
38:53
know you should do no harm right you should tell the patient i
38:56
i you should tell every patient i think you should retire but you know who am
39:00
i to say that you know this is your one chance to this is your biggest chance
39:04
to make it big who am I to say that no you shouldn't so you know ethically that's
39:08
something that I've found challenging and the way I you know the way I reason it to myself is I.
39:15
Just have to be the objective person and tell the risks and at the end of the
39:19
day you know it's going to be a family's family's decision one way or another right.
39:23
Well well if you're a kid from a inner city disadvantaged bat brown this is
39:29
your chance to make you big I heard it say so I was like.
39:36
For my kid no i would tell him don't you know don't claim
39:39
for okay so i
39:42
was just sharing these two i like i said these are
39:45
not financial disclosures i didn't get paid for any of this or
39:48
anything like that this is just something i did
39:52
on podcast i was invited to and something that you can share
39:54
with your patients they're both on youtube the bottom one is probably
39:57
more relevant to the pediatrics and it was kind of talking
40:00
about what i was talking about on the last slide as far as you know the ethical
40:05
quandaries of football and contact sports and so i don't see any slides your
40:11
powerpoint somehow sharing let's see is it gone now or is it gone for everybody
40:18
at least for me i don't see it.
40:21
Oh, yeah, this can see it. Okay. Oh, there's something must be must be my laptop. Yeah.
40:28
Yeah. No problem. Okay. So, yeah, like I said, this is I didn't get paid for this.
40:32
So not a financial disclosure or anything, but it's available on YouTube if you want to take a look.
40:36
The bottom one was the one that I think may be more relevant to children and pediatrics.
40:41
And then lastly, we have a multidisciplinary click.
40:45
I heard that there's actually one that's been created for pediatrics as well,
40:48
which is fantastic news. But we're starting a new adult clinic at the Brain Health Building at UT.
40:55
But I also see patients in the traditional outpatient setting at UT Health Days of Ottawa.
41:01
If there's a patient you'd like me to see, like I said, just by virtue of my
41:05
training, you know, under the age of 10 to 12, it's, you know,
41:08
probably not, I probably won't be able to help as much.
41:12
But especially if there's like someone a little bit older or teenager
41:15
or even you know potentially a little bit younger than that
41:18
that you would like me to see please feel free to reach out to me
41:21
directly that's my email i'm also
41:24
available through epic via both the uhs
41:27
and ut epic system so you can direct message me as well the middle initial is
41:32
h as in harry i don't know if there's another minor hotel at ut but if that
41:36
comes up but like i said i'm happy to talk through patients with you guys hopefully
41:41
this has been enlightening but happy to answer any questions that there may be.
41:45
Thank you, Dr. Padal. There are some questions in the chat box.
41:49
Do you differentiate pure post-traumatic headaches from my TBI?
41:55
Let me see. Sorry, let me read that
41:56
real quick. You differentiate pure post-traumatic headaches from my TBI.
42:00
I kind of put the two and two together. Just, you know, if there is,
42:06
I'm trying to figure out how to word this.
42:09
I mean, because a post-traumatic headache could also occur from a moderate or a severe TBI as well.
42:14
So I don't know if that's where the question's coming from.
42:17
I treat them the same way, though, whether it's due to a mild versus moderate or severe TBI.
42:23
Because again, the goal for the headaches, for the post-traumatic headaches,
42:27
is treating the underlying headache syndrome.
42:30
So regardless of if it comes from a mild, moderate, or severe TBI,
42:34
I end up treating them the same way.
42:37
This is another question in the chat box.
42:40
I have heard anecdotal evidence of baclofen helping short-term.
42:45
Do you think it is cervicogenic aspect of the headaches that is helping with?
42:51
Yeah. Oh, yeah. I like baclofen a lot.
42:54
Tizanidine is another one that I like, but that's probably more so in adults
42:58
because I think it can be quite sedating for children.
43:00
I like baclofen. I typically will go to the physical therapy first just because
43:07
it's a non-pharmacologic route, especially if they're able to get in quickly.
43:11
But a low-dose baclofen is certainly a reasonable option as well.
43:15
And again, you know, what we worry about is like the Tylenol ibuprofen causing rebound headaches.
43:21
Excuse me, with baclofen, it's not as much of an issue, which is nice.
43:25
And again, you target the cervicogenic headaches.
43:28
There is another question by Dr. Akbar. If the patient is already on LVL or
43:33
migraines prior to the concussion and after that has worsening of headaches
43:39
and insomnia, other than increasing the dose, do you add anything else?
43:44
Non-triptyline can help sleep more and also any role of amatidine.
43:49
So, good, great questions. Typically speaking, because I find that kids are
43:54
on such low doses of amitriptyline, I'll probably increase it just a little bit.
43:59
What you really worry about the anticholinergic effects of amitriptyline,
44:04
which is, you know, weight gain and cognitive slowing is more so around 50 milligrams.
44:09
Now in a child, you're probably not going to get to that high.
44:12
But with an adult, sometimes we get patients up to 50 milligrams and that can
44:15
be tough because then you start to notice some of the side effects.
44:20
Nortriptyline is useful. I actually find in my, or I guess how we're taught
44:26
as adults, is nortriptyline actually doesn't help as much in sleep compared to amitriptyline.
44:32
Again, that just may be what we're taught, but nortriptyline,
44:35
if you're worried about the anticholinergic side effects, that's something that
44:39
you could certainly switch amitriptyline over to.
44:41
You may just not get as much of the, you know, the benefits of the sleep,
44:46
but you'll certainly get the headache benefits as well.
44:49
Or Phenadrine, I haven't seen that used this much. I'd actually have to do more
44:54
research into that because I haven't prescribed that as much.
44:58
Typically speaking, again, in this population, the Bacodin is the one I use the most.
45:01
The Tizanadine and cyclobenzaprene are available as well, but hate using those
45:05
in children just because of how sedating they are, and we typically keep those with the adults.
45:10
Thank you so much for listening to that fascinating talk.
45:14
Don't forget to click on the link for MOC credit.
45:18
Coming up next week, what's the frenzy about phrenectomy?
45:23
Why are so many parents wanting their baby to get it?
45:28
What to watch out for? What to say to patients when they're requesting this?
45:32
A Cautionary Tale by one of our pediatric ENT experts.
45:39
Our sister podcast is Pediatrics Now for Parents.
45:43
Pediatrics Now for Parents can be found wherever you get your podcasts,
45:47
or the web address is pediatricsnowforparents.com.
45:52
Do you have a question for Dr. Patel? Email that to me, and if you feel comfortable
45:58
sending me a voice email, we may run that on the air.
46:03
Music.