>> Hi I'm Dr. Christina Master. I'm one of the sports medicine physicians and one of
the co-directors of the Minds Matter Concussion Program here at The Children's Hospital of
Philadelphia. We see a lot of concussions in children here at The Children's Hospital
and we're sure that you do as well. We'd like to share with you a lot of the new information
that we're learning and update you on how to best diagnosis and identify concussions
in children in your practice.
I'd like to introduce you to Ava. She's one of our patients who's had a couple of concussions
from sports. She plays ice hockey. She's completely recovered now, but she's agreed to help us
demonstrate the physical exam and the history that we would be taking to help you identify
concussions in your practice.
All right Ava, so tell me about your last concussion.
>> It happened about a month ago.
>> OK, tell me a little bit about how it happened.
>> I was going into a corner with a kid who was bigger than me and he hit me from behind.
>> OK, and did you have symptoms right away?
>> No.
>> OK, when did you start to have symptoms and start to wonder that maybe you had a concussion?
>> The next day.
>> OK, and what were those symptoms?
>> I was feeling nauseous. I had a headache and sensitivity to light.
>> OK, and you were able to finish the game without any problems?
>> Yes.
>> OK, did you go to school the next day?
>> Yes.
>> Okay what happened at school?
>> I couldn't focus, my head hurt.
>> When did you start to think that you had a concussion?
>> That night.
>> OK, and at that point did you seek care with anybody else?
>> My mom.
>> OK, all right. And that's when you decided to call and get an appointment to come in.
All right, and were you continuing to do homework?
>> Yes.
>> And how about spending time on your cell phone or a desktop computer?
>> Yes.
>> And how did those make you feel?
>> They made my head hurt.
>> OK, have you done any exercise since you had your injury?
>> No.
>> OK, and then after resting for a bit at home, did that help you symptoms a little?
>> Yes.
>> OK, in addition to the history of the current concussion, we'd also like to get
some past information on her. We usually like to find out how she's done in school prior
to this. What were her grades before her injury? We also like to find out in her history, or
in her family, does anybody have ADHD, dyslexia, or a learning disability. Because these are
some factors that can sometimes complicate the recover.
In addition, we like to ask if there's any history of migraines, anxiety or depression.
In particular, we're also realizing now that it's important to find out if there's any
visual disturbance in the family. Whether or not she wears glasses, and is nearsighted
or farsighted. Or if there's any history in the family, or in Ava, of strabismus, amblyopia,
eye surgery, or eye patching for any kind of lazy eye kind of phenomenon.
We also like to know if there's any history of motion sickness because the vestibular system
can often being effected after concussion. And a sign of motion sickness in the car may
indicate they may have more of those symptoms after a concussion.
All right, so Ava I want you to take a look at my finger. Follow my finger with your eyes.
Don't move your head. We'll start slowly and go faster. Let me know if it gives you any
symptoms, otherwise if it doesn't give you any symptoms, we'll keep going, OK? All right.
As you can see Ava is doing a great job following my finger. And as we go faster, she's able
to keep up. She doesn't have any problems with any symptoms. She's not blinking or having
her eyes water excessively, or complaining of headache or dizziness.
Just to note, when you track sometimes you can have a few beat of a nystagmus at the
end, gaze, like she has here, that's normal. But when you come to the middle, she locks
in nice and solid and there's no nystagmus in the central gaze. This is the smooth pursuit
portion of the exam.
Now Ava, I want you to hold your head still. I want you to look at my fingers left right,
left right as fast as you can until it gives you symptoms or I tell you to stop, OK? Go ahead.
Now as you can see Ava's preforming the horizontal saccades. She's going nice
and smoothly. It's not fatiguing, it's not tired. She's not blinking or stopping because
she's having headache or dizziness.
Often times when kids are acutely symptomatic, they will have trouble with this movement.
What happens is they'll often have their eyes start to water, or they'll blink, or they'll
stop and they say that they either have headache or dizziness provoked by this maneuver.
Let's do it up and down now, Ava. Up and down, keep your head still, look at both of my fingers
as fast as you can. So again, as you can see, Ava is not having any symptoms. She's not
having any watering of her eyes. Her eyes are not fatiguing. She's not blinking or stopping
because she has dizziness or headache. But often what we'll do is also ask the kids.
Did that cause any dizziness or headache, Ava?
>> No.
>> Great, wonderful, all right. Take a look at my thumb. I want you to focus on my thumb.
And then I want you to bounce, and keep bouncing and let me know when that starts to give you
any headache or dizziness, or bother you at all. Otherwise, we'll keep going and I'll tell
you when to stop. This is the vertical vestibulo-ocular reflex, or gaze stability testing. All right
you can stop, Ava. That looks great. When kids have symptoms with this, they'll often stop
or they won't be able to do it quite as rapidly. Often, they can have their eyes start to water,
or they'll complain of worsening headache or dizziness.
Now we'll do the horizontal vestibulo-ocular reflex. Focus on my finger. Shake your head
side to side, and keep going until I tell you to stop or if it gives you symptoms.
Great, did that give you any symptoms at all, headache or dizziness?
>> Nope.
>> Great, wonderful. So now we're gonna measure some binocular vision function. In particular,
we're interest in convergence. And this ruler is called a convergence rule. You can purchase
this, it's a specialty piece of equipment used by developmental optometrist. If you
don't have access to a convergence rule, you can also us a pen, and have the patient bring
it close to their face, and their nose, to estimate what they're convergence is in the
same manner.
We're going to have her take a look at the letters on this card. We're going to ask her
when they become blurry and when the line becomes double. And that will give us a sense
of where her convergence point is. Ava take a look at the letters on the card, are they
clear?
>> Yep.
>> Great, tell me when they get blurry.
>> Blurry.
>> Tell me when they become double.
>> Double.
>> Tell me when it's single again.
>> Single.
>> Tell me when it's clear again.
>> Clear.
>> Great, and then now we're gonna measure her accommodation. Cover your left eye, this
is single eye accommodation. Are those letters clear?
>> Yep.
>> Tell me when they get blurry.
>> Blurry.
>> And then cover your right eye. Are those letter clear?
>> Yes.
>> Tell me when they're blurry.
>> They're blurry.
>> Great, so we would record all of those numbers for convergence and accommodation
and track that over time as she recovers. In general kids should be able to converge
less than 6 cm, and we would expect that to be normal.
Lastly, we'll take a look at your balance. We're going to step out into the hallway.
I'd like you to walk heel toe, heel toe like you're on a tight rope. And we'll do it forwards
and backwards with your eyes open and closed. OK? All right great.
So now we're gonna test her balance. We like to challenge their balance by having them
do a tandem gait forwards and backwards with their eyes open and their eyes closed. Each
step of the way gets a little bit more challenging, and is able to provoke more problems with
kids who have concussion. And you'll be able to identify them if they have balance difficulty.
Please note that kids with concussion, may have very poor balance. And so be aware that
you're near them, or nearby so that if they lose their balance, you can help steady them
so that they stay safe.
All right, Ava, we're going to walk in a tandem gait, heel toe, heel toe, eyes open going
forward. And then I'll tell you when to close your eyes. Go ahead. Great, so you can see
she's doing a great job. Now close your eyes. She has no sway. She's keeping her hands by
her side. Open your eyes and stop. Now we're going to go backwards, eyes open. And this
is a little bit more difficult than going forwards. And then closing your eyes is the
most difficult part of all. Great, you can stop.
So a lot of our kids, when they have an acute concussion will have trouble with any of these
maneuvers. Sometimes they'll sway back and forth, sometimes they'll have their arms go
up from their sides to help them maintain their balance. And sometimes they'll step
off the tandem gait line because they're not able to maintain their balance.
So that concludes the pediatric history and physical for the concussion. Thanks for joining
us, and thanks to Ava for contributing and participating with us on this.