Brains, behavior, concussions, and common sense

GPA Annual Meeting
4/15/2016
Brains, behavior, concussions,
and common sense
SRC vs. LD,ADHD, other TBI, etc.
What makes pediatric SRC unique?
Purpose of assessment? (What’s a given score going to add or change?)
Timing: immediacy, frequency, timeliness
Marla Shapiro, Ph.D., N.C.S.P.
Sports Neuropsychologist
Developmental Neuropsychologist
Atlanta, GA
Sources of information – cannot test in a silo
GPA Annual Meeting
April 15, 2016
School accommodations models and laws – K-12, Post-secondary
Environmental and cultural considerations
Risk factors and modifiers
Unique sociopolitical and cultural factors
Pediatric SRC vs. adult SRC
What makes pediatric SRC unique?
Agenda
The concussion crisis & cultural context
Definitions
 Evaluation, management, recovery and
scope of practice

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Kids’ brains are different!
Can you be sure the same tests are measuring the same things?
Measuring moving targets
Unique sociopolitical and cultural factors, and mixed messages
Consider comprehension, expression, affect
Appreciating risk, impact on future
Greater reliance on others to help or hinder
P.S. No disclosures.
Absence of control
Concussion crisis in (youth) sports
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Marla Shapiro, Ph.D.
Concussion rates doubled
2005-2012 (Rosenthal et al., 2014)
Estimates in the millions and
climbing (CDC, etc.)
30% HS athletes fail to report?
(Meehan, 2013)
Football enrollment dropping
Testing agency trends
“astounding”
Lawsuits in NFL, NHL, MLS,
NCAA
Quote of the Day
“As we have stated close to
eleventybillion times now; the
actual injury of concussion is not
the issue of this crisis, rather it is
the mismanagement of the injury
that is the problem.”
--The Concussion Blog
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GPA Annual Meeting
4/15/2016
Suck-it-up-and-play culture
Addressing the
exponential
increase in
Tommy John
surgeries,
particularly in
youth athletes:
Calls for change
“…Coaches and parents may lack knowledge about normal
development and signs of readiness for certain tasks,
both physically and psychosocially.
∘ This can result in unrealistic expectations that cause
children and adolescents to feel as if they are not making
progress in their sport.”
Unrealistic expectations
Nearly 8 million HS athletes
460,000 compete at NCAA schools
 Fraction of that group make it to pro’s

Parenting trends

Tough love, helicopter, or bulldozer?

From a pop psychology parenting website, Storknet:

“In teaching your children to suck it up, you better
prepare them for the adult world.
They learn that responsibility is a
powerful and rewarding value.”
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Today’s teens

Today’s teens
CDC’s, High School Youth Risk Behavior
Survey
◦ Seriously considered suicide in last 12 mos:
17.0%
◦ Non-academic computer use or video games
more than 3 hours/day on schooldays: 41.3%
33.2 % of public high school graduates in
2013 took an AP Exam (vs. 18.9% in 2003)
 2006-13: exponential increase in gap year
programs (often due to burnout) (AGA)
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CDC’s, High School Youth Risk Behavior Survey
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Importance of sleep
◦ Less than 8 hours sleep on school night: 68.3%
◦
◦
◦
◦
◦
Learning, attention, executive functioning
Fluency and processing speed
Somatic complaints – headache, fatigue, sleepiness
Mood (anxiety, depression)
Impaired driving, baseline testing
See AAP, 2014; de Freitas Araujo & de Almondes, 2014; Lehto & UusitaloMalmivaara, 2013; Meldrum & Restivo, 2014; Mihalik et al., 2013; Shochat
et al., 2014
Who’s in charge?
Turf wars
Podiatrists and mammograms
PCP’s
Sports Medicine (MD,ATC)
 Neurology
 Neuropsychology
 PT
 OT
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Realities of competitive marketplace
EXAMPLE: “Concussion guidelines for return to school, book work and studies”
Stage of
healing
Home Activity
Stage 1 –
Your child
still has
many
symptoms
and
problems
School Activity
Physical
Activity
(and who do they work for?)
Realities of competitive marketplace
Quick appts and one-size-fits-all protocols
Emphasis on “rest” + confusion over
definition
 Unnecessary neuropsychological testing
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Stage 2 –
Your child
still has
some
symptoms
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Realities of competitive marketplace
Myth and folklore
Sports medicine = big business
(competition vs. interdisc. collaboration)
 Computerized testing marketed HARD
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◦ Analogous to car sales
Marketing, easy access to testing
(reification of computerized tests)
 Baseline testing another gateway drug?
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◦ Proliferation of bad baselines
◦ Baseline testing by anyone, anywhere
Part 1, Myths and Misunderstandings
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Fogginess is a normal part of football
You have to ____________ to have a
concussion
◦ Have a headache
◦ Pass out
◦ Have memory loss
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Stay home until you feel better
No homework or tests until you feel better
Stay out of sports 1 week after you feel better
If not better in __ it must be Post-Concussion
Syndrome
It was just a little dizziness, not a
concussion
 They passed the __________________
so they didn’t really have a concussion
◦ Concussion test
◦ Doctor’s test
◦ Sideline test

If symptoms go away they can return to
play
Samples of my days…
8 year old flipped off lawn mower.
 Parents go to ED
 Advised to keep him in dark room, 0
electronics, no school
 Was in dim basement for 4 days, at most
played Go Fish with mom
Samples of my days…
Samples of my days…
23 year old college student
 2 MVA’s in 4 months
 Saw neurosurgeon, chiropractor,
neuropsych, clinical psych, adult
neurologist.Told to suck it up.
 Sleep apnea?
 Migraine history
 History undiagnosed learning-related
difficulties
Prep school sophomore, 13 months post
concussion.
 Cleared by MD
 Symptom score < 10
 “Passed the ImPACT test”
 Ball in face, but RTP because still passing
 On anti-depressants, psychotherapy
 Selected All-American
 Near vomiting on vestibular testing
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Samples of my days…
Samples of my days…
High school student referred to
neuropsych
 ImPACT scores not budging
 Migraines
 History of anxiety
 Vestibular therapy making her worse
 Can’t read
 4-5 hours of testing by neuropsych
Pre-teen referred to Neuropsych-for therapy?
 History of OCD
 10-12 hours/week sports for stress
management
 Driven academically
 Migraines not well controlled
 No progress in vestibular therapy
 Hospital-homebound, not going well
 Memory concerns
My typical work day
Not a new fad
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UVA research since 1980’s
NFL baseline testing since 1994
◦ NHL in 1997
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2001: 1st Concussion in Sport meeting in
Prague
◦ Last 2012 Zurich
◦ Next 2016 Berlin
 1st
Comparison of Annual Incidence
Breast Cancer
HIV/AIDS
 Spinal cord injuries
 Multiple Sclerosis
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Traumatic Brain Injuries
 Concussions
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307.000
43,681
11,000
10,400
possibly 4 – 19 mil??
1.6-3.8 million often cited?
maybe as high as 4-5 million?
Ref: Brain Injury Association of America, Centers for Disease Control and Prevention, American
Cancer Society, National Multiple Sclerosis Society
Who’s most at risk? (NCAA ‘09-’14)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Marla Shapiro, Ph.D.
state laws 2009, with 43 more 2009-12
Wrestling (10.92)
Ice hockey (M=7.91,W=7.52)
Football (6.71…3417 annually)
Women’s soccer (6.31…1113 annually)
Women’s basketball (5.95…998 annually)
Women’s lacrosse (5.21)
Field hockey (4.02)
Men’s basketball (3.89…773 annually)
Women’s volleyball (3.57)
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GPA Annual Meeting
4/15/2016
Definitions & Diagnostic Criteria
Witnessed impact with a measurable effect on
neurological function
 Direct to head, or indirect
 Initial obvious physical signs consistent with
concussion (though onset may be delayed)
 Athlete reports any symptoms, whether or not
“passes” sideline test
 Abnormal neurocognitive and/or balance exam
 Grading passe’

Neurometabolic Cascade Following
Traumatic Brain Injury (Giza & Hovda, 2001)
500
Functional disturbance vs. structural injury
Complex process induced by traumatic
biomechanical forces
 Linear and rotational forces
 It results in regional and temporal cellular
alterations and may produce cell death
 It produces a state of energy crisis and
subsequent metabolic diaschisis
 It changes the priorities for fuel

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Another view of neurometabolic
cascade
Calcium
400
% of normal
Pathophysiology
K+
300
Glucose
200
Glutamate
100
50
2
0
6
12
20
30
6
24
hours
minutes
3
6
days
10
Cerebral Blood Flow
•
•
•
•
•
•
Physical
Emotional
•
•
•
•
Modifiers
Headache
Fatigue
Dizziness
Phono/photosensitive
Balance problems
Nausea, vomiting
Irritable
Sad
Nervous
More emotional
Marla Shapiro, Ph.D.
•
•
•
•
Remembering
Concentrating
Slowed down
Foggy
Cognitive
Sleep
•
•
•
•
Drowsiness
Sleeping less
Sleeping more
Trouble falling asleep
Symptoms
• Number
• Duration (>10 days)
• Severity
Signs
Prolonged LOC (>1 min), Amnesia
Sequelae
Concussive convulsions
Temporal
• Frequency-repeated concussions over time
• Timing (Recency)
Threshold
Repeated concussion occurring w/ progressively less
impact or slower recovery after each one
Age
Child and adolescent (<18)
Comorbidities,
premorbidities
Migraine, depression, anxiety, other mental health
ADHD, LD, sleep disorders
Medication
Psychoactive drug, anticoagulants
Behavior
Dangerous style of play
Sport
High-risk activities, contact and collision sport, high level
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GPA Annual Meeting
4/15/2016
Bottom Line
Guiding principles
How do we get them better?
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Interdisciplinary, multi-focal team
approach
We are evaluating a rapidly evolving injury in a
developing organism within a fluid context.
Brain injury is complex!
Brain injury rarely manifests in single domain of
functioning
Functional impact of brain injury does not
occur in vacuum
No single score, test, measure, person, discipline
can provide ALL measures, answers about even
mild brain injury
Interdisciplinary, multi-focal team
approach
Building policy
Calendar issues
Awareness
•
•
•
•
Education
Risk management
Sport and school culture
Role of baseline testing
Administrators
Legislators ATC’s
Leagues
Athletes
Coaches
Parents / Spouses
Teachers / Supervisors
Team Culture
Team Docs
Identification
LEA policy
Licensing laws
State DOE regs
ADAAA
Management
Management
Section 504
Guiding principles
The same words can mean different
things to different people…especially at
different ages.
 HOW you ask the question matters.
 Be careful of attributing to concussion
that which can be more easily explained
by common sense.
 Correlation does not imply causation.

Marla Shapiro, Ph.D.
GA Regents
Assessment strategy
Contributing Factors
History/Risk Factors
Academic Context
Family Issues
Extracurricular Demands
Social-Emotional Status
Vestibular/Ocular
Cervical
Neurocognitive
Sport Culture
Social Context
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GPA Annual Meeting
4/15/2016
Concussion assessment
Seasonal issues
Non “neuropsychological” just as important
Brief clinical history and interview
 Risk factors
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◦ Learning, attentional, affective; personality “type”
◦ Headache, migraine history
◦ Sleep, hydration
Contextual and cultural factors
Academic, social, extracurricular schedule
 Self-awareness, advocacy, management
 Family / parenting dynamics
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Home-related issues
SLEEP!!
Parental oversight & control
Other activities – video games, internet,
messaging, parties, driving, mall, ipods,
concerts, dog wrestling, etc.
 Jobs
 Parental support & pressures
 Social life
 Drinking
 Driving
 Outside medical advice
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Testing windows
 College admissions tests
 Homecoming, Prom
 Playoffs
 Tryouts
 AP’s
 Allergies
Concussion assessment
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Social-emotional screening
◦ Parent vs. self-report, scale length, when
indicated
◦ Babikian et al., 2013; McNally et al., 2013
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Symptom assessment – parent and selfreport, and include baseline
◦ Amaya-Hodges et al., 2013; Gioia et al., 2009; Kontos et
al., 2012; Randolph et al., 2009; Sady et al., 2014;Valovich
McLeod et al., 2013;
Concussion Assessment
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Neurocognitive testing
◦ Computer: Cogsport/Axon,
Headminders/CRI,ANAM, CNS Vital Signs,
ImPACT
◦ Paper/Pencil:Trails, Coding, DS, HVLT, BVRT
◦ Malingering measures
Neurobehavioral exam, symptom
provocation
 VOR, balance (e.g.,VOMS; Mucha, Collins, 2014-)
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Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
ImPACT

Computerized measure of skills most
vulnerable to concussion
◦ Verbal/visual memory, reaction time,
processing speed, efficiency
◦ Baseline, pre-, post-test symptom scales
◦ 5 alternate repeatable forms
What ImPACT IS
What ImPACT is NOT
A test of cognitive skills vulnerable to
concussion
 A tool to help communicate postconcussion status
 A tool that helps health care professionals
and educators make decisions about
academic needs following concussion
 A tool to help track recovery
 The most scientifically researched
concussion management tool
 ONE piece of the process
Meant to be used in isolation!
A "panacea" or cure-all for concussion, as
there is no such thing.
 A tool to diagnose concussion, which
should always be diagnosed by a qualified
health care provider.
 A substitute for medical evaluation and
treatment.
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Next-Greatest-test-du-Jour
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e.g., Dowel-Puck
Management: Starts with definition
Usually rapid onset of short-lived impairment
of neurological function (resolves
spontaneously), sometimes delayed onset
 Functional vs. structural
 Resolution typically sequential course, but in
some cases symptoms may be prolonged –
age & risk factors are modifiers

** Make sure children know & understand
this!
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Management
Antidote to fuel crisis: REST, REST, REST
Rest body, rest brain
 GOAL: avoid, discontinue, interrupt,
modify activities BEFORE symptoms
recur or worsen
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◦ Cognitive rest
◦ Physical rest

Not as simple as it sounds…
Challenges

Culture
◦ Sports: suck it up and play
◦ Academics: push, push, push harder (woundtoo-tighters)

Lack of awareness
More Challenges
Mental / cognitive exertion is essential to
new learning
 Invisible injury
 School can help or hinder recovery

◦ Opportunities exist for cognitive, physical,
social (over) exertion
◦ Ready mechanisms for treatment (504 plan,
IEP) not terribly helpful
◦ Hospital-homebound models
◦ Begets under-reporting & mistruths
Prevalence of misinformation
One-size-fits-all
 Traditional medical hierarchy + $$
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Everyday Functional Effects: School
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Concentration
Remembering directions
Disorganized
Completing assignments
Fatigue
Fall behind, fail tests,
reduced grades
Challenges to ID:
What kids aren’t squirrely?!
How do you spot an invisible injury?
Marla Shapiro, Ph.D.
Hot spots in the classroom
White boards
Computers, iPads
 Position in the classroom
 Testing
 Fluorescent lighting
 Working memory, attention
 Music / band / chorus
 Notetaking, math
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GPA Annual Meeting
Hot spots at school, outside of class
4/15/2016
So then how do we manage, treat?
Walking up stairs
 Noise in hallways, lunchroom
 Sunlight
 Standing up too fast
 Walking across campus
 Recess
 Bus
 Drills, assemblies

AKA Brain Death Therapy
Treatment assumptions
Symptom exacerbation after physical or
cognitive exertion suggests brain’s
dysfunctional (neuro)metabolism pushed
beyond current tolerable limits
 In guiding recovery, management of
neurometabolic demands is KEY
 Don’t exceed physiologic threshold

What students are most concerned
about (Saedy,Vaughn, Gioia CNMC)
Facilitating Recovery in the School
Contributing Factors
History/Risk Factors
Academic Context
Family Issues
Extracurricular Demands
Social-Emotional Status
Vestibular/Ocular
Cervical
Neurocognitive
Sport Culture
Social Context
Marla Shapiro, Ph.D.
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GPA Annual Meeting
School-Related factors
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Specific subjects vs all subject areas
Time of day, class length, difficulty level, time of year,
grade, stakes
Class work, homework
Speeded time frames
Exams – school,“high stakes”
Work ethic, reputation, credibility
Extra-curricular involvements
Physical demands–stairs, layout, hallways, lighting, etc.
School “went electronic”
4/15/2016
Hot spots in the school day
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White boards
Computers
Position in the classroom
Partner work
Hallways
Lunchroom
Recess
Music / band / chorus
Bus
Testing
Hot spots outside of school
Home-Related issues

Showering
 Rolling over in bed
 Riding in car
 Driving car
 Watching practices
 Watching sports on TV
 Mall, grocery store, movies
 Music, computer, phone
 Noise at home
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Management
Giza, SNS 2015

SLEEP!!
Parental oversight & control
Other activities – video games, internet, text
messaging, parties, driving, mall, ipods,
concerts, dog wrestling, etc.
 Jobs
 Parental support & pressures
 Social life
 Drinking
 Driving
 Outside medical advice
GOAL: avoid, discontinue, interrupt,
modify activities BEFORE symptoms
recur or worsen
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Gioia & Vaughn, SNS 2015
Attendance and Return to School
 When
to go back
 Modified Day: Classes w/ rest breaks,
partial day, alternate classes
 Prioritize!
 Shortened classes
 Use specials for rest & catching up
 Excused absences
Decrease Cognitive Processing Load
Fallacy of “just core classes”
 Partner work – or group of 3 vs. 2
 Bullets vs. sentences
 Assist with organization
 Note-taking support
 Abbreviated, substituted homework
 Alternate work with breaks
 Testing accommodations

Marla Shapiro, Ph.D.
Gioia & Vaughn
Modified Workload
Modify as much as possible – outlines vs. full
reports, every/other problem, etc.
 Drop all but essential work
 Shorten projects
 Allow extra time
 Gradually increase work periods, alternating
work/rest (think radiator)
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Testing Accommodations
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Is it really necessary
#1 push-back:“Just give it a try.”
Input/output accommodations
Goal: reduce processing load (amount of effort, focus,
working memory required)
Reduce load, e.g., mark on test booklet
Consider pace, timing, breaks
Consider impact of “no testing”
College Board,ACT
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GPA Annual Meeting
Managing Fatigue, Physical Symptoms
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4/15/2016
Facilitating recovery at Home
Collaborative management
 Cost / benefit approach - dangle carrots
 Buy-in of all family members – and WHY
 Monitor cognitive exertion
 Monitor sleep
 Make child/teen the decision maker &
determine priorities
 ACTIVE recovery
Rest breaks as needed, in or out of class, including head
on desk
Hat, sunglasses inside
Adjust brightness on monitor, use anti-glare screens
Unrestricted nurse’s pass – or closer place to rest?
Think creatively
Avoid hallways at transitions, lunchroom, maybe bus?
Leave class early / next class late = short breaks
Elevator vs. stairs
Head, eye movements? ..with note-taking, discussions

Consider the cultural context
Role of active rehabilitation

Think sales – who’s buying what?
◦ Athlete, family, school, workplace, coach, team

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How is “rest” defined? …implemented?
Anticipate push-back & problem-solve
Importance of physical activity, with
cautions
 Vestibular, occulomotor therapy

◦ Symptom specific exercises to decrease
dizziness and disequilibrium
◦ Exercises may reproduce dizziness
◦ Practice, rehabituation key


Biggest challenges I see
Medical management
Cervicogenic, ortho issues
How do we know when recovered?
Poor lifestyle adjustments (can’t say no)
Wound-too-tighters
 Insufficient sleep
 Persistent headache/migraine
 Vestibular deficits


** why test when there’s low-hanging fruit?
Marla Shapiro, Ph.D.
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GPA Annual Meeting
Recovery determination
Which test?
 Back to baseline levels of functioning at
typical academic load

◦ Symptoms – multiple reporters
◦ Neurocognitive functioning
◦ Don’t have to be fully caught up

Graduated, structured, RTP protocol
4/15/2016
Graded RTP Protocol
Rehabilitation stage
Functional exercise at each
Objective of each stage
stage of rehabilitation
1. No activity
Symptom limited physical and
cognitive rest
Recovery
2. Light aerobic exercise
Walking, swimming or
stationary cycling keeping
intensity <70% maximum
permitted heart rate
No resistance training
Increase HR
3. Sport-specific exercise
Skating drills in ice hockey,
running drills in soccer. No
head impact activities
Add movement
4. Non-contact training drills
Progression to more complex
training drills, eg, passing drills
in football and ice hockey
May start progressive
resistance training
Exercise, coordination and
cognitive load
5. Full-contact practice
Following medical clearance
participate in normal training
activities
Restore confidence and assess
functional skills by coaching
staff
6. Return to play
Normal game play
Stereotypical case example…
Typical these days
Paideia junior
1 AP class, 2 seminar classes
 Ultimate player, 5 practices/week
 Games on weekends
 Social life
 Bedtime?
 Wake up time??
 Calendar factors???


Managed by sports med for 1-2 months
◦ ImPACT weekly
◦ Restricted school days following cognitive
protocol

Referred to neuro – months to get in
 Referred to PT – 6 month therapy rec
 Referred to neuropsych – full day of
testing, results 1-2 weeks later, report
after that

Case example w/ neuropsych
College athlete referred to me for ADHD
testing per NCAA regs to take stimulants
 Returned winter break & reported
concussion

◦
◦
◦
◦
◦
ATC administered ImPACT – scores not good
Referred neuropsych – testing 1 or 2 sessions
Feedback week later, report several wks later
No collateral info
deficits
Marla Shapiro, Ph.D.
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GPA Annual Meeting
4/15/2016
Prevention, education
Professional preparation
Educate, educate, educate
Manage, monitor risk factors
 Change rules

Know limits, scope of practice
 Professional meetings, training, and not
just weekend workshops!
 Sports Neuropsychology Society


◦ “Heads-Up Football”
◦ Limiting contact practices
◦ Minimum age for headers

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◦ Annual meeting late April/early May
◦ Houston 2016
Safety monitors
Reduce risk – hydration, nutrition,
conditioning


Key Points
Refer, consult
Address misuse of psychological tests
Key Points

Doing nothing, mismanagement are the real crises

Science continuing to evolve

Focus on return to learn AND play – return to
life!

There are few absolutes (how many is too many?)

Injury = manifestation of brain-behavior
relationships

We can manage this injury and safeguard kids
WITHOUT pulling them from the sports they
love

Team approach key
◦ Must consider larger cultural and developmental
contexts
◦ Must consider non-injury factors!
mshapiro@ganeuropsych.com
www.ganeuropsych.com
@DrMShapiroGA
Marla Shapiro, Ph.D.
16