EditorialPublication Exclusive

An office-based approach to pediatric and adolescent concussions

A health care issue that has received considerable or unprecedented attention and generated substantial public interest is concussion. Despite this increased attention, there is still confusion and controversy in many areas of concussion, including how to make the diagnosis, optimal management strategies and long-term outcomes.

With an estimated 1.6 million to 3.8 million sports- and recreation-related traumatic brain injuries occurring each year in the United States, concussions have become a national health care epidemic. The pediatric and adolescent concussion populations account for the majority of these injuries, most of which can be treated safely and effectively by primary care providers. Timely assessment, diagnosis and establishment of a treatment plan as soon as possible after the injury are vital in ensuring a typical concussion recovery pattern, over the course of a few weeks.

Roni Lynn Robinson

Clinical assessment and diagnosis

To date, there is no one diagnostic modality — whether biochemical, radiographic or neurocognitive — which can be solely relied upon to determine the diagnosis of concussion. Once there is concern for concussion, in-office assessment by a primary care physician is essential, as concussion is a clinical diagnosis and is made after a thorough evaluation is completed.

As with all clinical entities, taking a thorough history including injury date and mechanism are important. Establishing an accurate injury date helps the clinician start the recovery clock in determining clinical progress and symptoms to date, tailoring recovery management strategies based on how far out from the injury the patient is. Concussions lasting a few weeks require different management strategies than those lasting greater than 4 to 6 weeks. Concussion occurs when there is a blow or jolt to the head, where forces are transmitted to the head, causing the brain to shake; without a legitimate mechanism of injury, further investigation is warranted as to the etiology of symptoms.

Along with date and mechanism of injury, a comprehensive concussion assessment includes clinical symptoms experienced at the time of the injury, as well as ongoing symptoms. Common symptoms in concussion are generally divided into four categories: physical/somatic; cognitive/thinking/remembering; sleep; and emotional/mood disruption. Children aged younger than 12 years tend to have more changes in behavior (eg, clingy, irritable or more distractible) and may even experience regression of developmental milestones, such as potty training. Their recovery pattern is typically longer as well, with some residual symptoms lasting several months.

Establishing a past medical history that includes conditions known to be associated with prolonged recovery should be obtained. Specific attention should be given to information about a personal and family history of attention-deficit/hyperactivity disorder; dyslexia; learning disability; amblyopia/strabismus; reading or visual tracking disorders; mood disorders such as anxiety or depression, migraine or chronic headaches; and prior history of concussion.

Cognitive testing also should be a part of the initial concussion assessment. The Child-Scat3 (patients aged 5 to 12 years) or the Scat3 (patients aged 13 or older) can be done quickly and easily in the primary care setting. Computerized cognitive testing such as ImPACT or Axon Sport should only be administered by a clinician who is able to interpret the results about management.

The last part of the clinical assessment is the physical examination, which should include a targeted neurologic exam focusing on the components typically affected by traumatic brain injury. Cranial nerve exam should include comprehensive assessment of extra-ocular movements with special attention to features such as nystagmus, tracking evaluating both pursuits and saccades, convergence and accommodative insufficiency, and the vestibulo-ocular reflex. Cerebellar function including tests for dysmetria, ataxia and balance (tandem gait both forward and backward and with both eyes open and closed) should be assessed. Many of these physical examination findings can be easily overlooked and the neurological exam may appear “grossly normal” if the PCP does not actively look for these deficits.

Diagnosis of concussion is made after a clear mechanism of injury has been established and a constellation of positive physical exam findings. It is important to recognize that concussion symptoms may initially appear mild and may worsen over the subsequent 24 to 48 hours after the injury, especially if cognitive and physical rests are not instituted. Referral for brain imaging is generally not indicated unless there is particular concern for a high-impact mechanism of injury, skull fracture or acute intracranial hemorrhage in the hours immediately after the injury.

Management

Once a diagnosis of concussion is made, the initial management in the acute phase is cognitive and physical rest, which should be implemented immediately. The length of rest should be individualized for each child and literature suggests that the first few days after a concussion are the most crucial time to rest, avoiding activities that provoke or make symptoms worse. Generally, activities that require ample eye tracking seem to provoke symptoms and should be avoided; those would include (but are not limited to) video games, texting, busy environments and most school work.

Once the child shows some clinical improvement and starts to feel better, a trial of short periods of cognitive activity can be performed. Waiting for the child to be symptom-free is not necessary, as this may take several more days to occur. Short amounts of cognitive activity are recommended, resting when symptoms worsen, and then resuming when symptoms have lessened. It is important to keep in mind that after concussion, cognitive stamina is decreased, and the student may not tolerate a full day of school initially.

Once the child is able to tolerate more prolonged periods of cognitive activity at home, they are ready to return to school. The PCP can write for academic accommodations to support the student during concussion recovery. Occasionally, specific accommodations are needed and may include limited eye tracking (copy of class notes, limited reading and writing), additional time for testing and assignments, and breaks when needed. Most students will be able to return to school within 1 to 2 weeks, and then gradually advance back to a full academic work load by 2 to 3 weeks. In the adult population, neurocognitive testing has been used in decision-making for return to play; however, in the pediatric and adolescent population, where academics are the focus, it has been shown to be of great use in determining readiness of return to school.

It is no longer necessary for concussed patients to sit in a dark room and do nothing until symptoms remit. In fact, early on in the concussion, daily light activity, such as a brisk walk, is permitted as long as it does not provoke or worsen symptoms. Once the student is tolerating a full day of school without symptoms, a full academic workload, and is caught up in school, the student may start a step-wise return-to-play protocol. This should be guided by the PCP and can be carried out by a certified athletic trainer or athletic coach. The Zurich Consensus Statement from 2013 contains the definitive return-to-play protocol that is the model for return to play across the country and around the world.

Role of medications

Within the first 3 to 4 weeks after a concussion, medications to alleviate concussion-related symptoms are typically not recommended. Acetaminophen and ibuprofen have not been reported to be helpful in relieving concussion-related headaches and may mask symptoms, causing patients to overexert themselves. Prolonged daily use of these medications also may result in rebound medication-associated headaches. Melatonin (3 mg to 6 mg), taken 1 hour before bedtime, is safe in this population and is a useful adjunct to help initiate sleep.

It is important that PCPs have the knowledge and skill set to recognize and diagnose pediatric and adolescent concussion. Accurate and prompt diagnosis and initiation of appropriate management strategies can result in timely resolution of symptoms. Followed by a gradual increase of cognitive and physical activity, this care plan may prevent a protracted recovery from concussion, requiring further medical, educational and rehabilitative interventions.

Disclosure: Robinson reports no relevant financial disclosures.

A health care issue that has received considerable or unprecedented attention and generated substantial public interest is concussion. Despite this increased attention, there is still confusion and controversy in many areas of concussion, including how to make the diagnosis, optimal management strategies and long-term outcomes.

With an estimated 1.6 million to 3.8 million sports- and recreation-related traumatic brain injuries occurring each year in the United States, concussions have become a national health care epidemic. The pediatric and adolescent concussion populations account for the majority of these injuries, most of which can be treated safely and effectively by primary care providers. Timely assessment, diagnosis and establishment of a treatment plan as soon as possible after the injury are vital in ensuring a typical concussion recovery pattern, over the course of a few weeks.

Roni Lynn Robinson

Clinical assessment and diagnosis

To date, there is no one diagnostic modality — whether biochemical, radiographic or neurocognitive — which can be solely relied upon to determine the diagnosis of concussion. Once there is concern for concussion, in-office assessment by a primary care physician is essential, as concussion is a clinical diagnosis and is made after a thorough evaluation is completed.

As with all clinical entities, taking a thorough history including injury date and mechanism are important. Establishing an accurate injury date helps the clinician start the recovery clock in determining clinical progress and symptoms to date, tailoring recovery management strategies based on how far out from the injury the patient is. Concussions lasting a few weeks require different management strategies than those lasting greater than 4 to 6 weeks. Concussion occurs when there is a blow or jolt to the head, where forces are transmitted to the head, causing the brain to shake; without a legitimate mechanism of injury, further investigation is warranted as to the etiology of symptoms.

Along with date and mechanism of injury, a comprehensive concussion assessment includes clinical symptoms experienced at the time of the injury, as well as ongoing symptoms. Common symptoms in concussion are generally divided into four categories: physical/somatic; cognitive/thinking/remembering; sleep; and emotional/mood disruption. Children aged younger than 12 years tend to have more changes in behavior (eg, clingy, irritable or more distractible) and may even experience regression of developmental milestones, such as potty training. Their recovery pattern is typically longer as well, with some residual symptoms lasting several months.

Establishing a past medical history that includes conditions known to be associated with prolonged recovery should be obtained. Specific attention should be given to information about a personal and family history of attention-deficit/hyperactivity disorder; dyslexia; learning disability; amblyopia/strabismus; reading or visual tracking disorders; mood disorders such as anxiety or depression, migraine or chronic headaches; and prior history of concussion.

Cognitive testing also should be a part of the initial concussion assessment. The Child-Scat3 (patients aged 5 to 12 years) or the Scat3 (patients aged 13 or older) can be done quickly and easily in the primary care setting. Computerized cognitive testing such as ImPACT or Axon Sport should only be administered by a clinician who is able to interpret the results about management.

The last part of the clinical assessment is the physical examination, which should include a targeted neurologic exam focusing on the components typically affected by traumatic brain injury. Cranial nerve exam should include comprehensive assessment of extra-ocular movements with special attention to features such as nystagmus, tracking evaluating both pursuits and saccades, convergence and accommodative insufficiency, and the vestibulo-ocular reflex. Cerebellar function including tests for dysmetria, ataxia and balance (tandem gait both forward and backward and with both eyes open and closed) should be assessed. Many of these physical examination findings can be easily overlooked and the neurological exam may appear “grossly normal” if the PCP does not actively look for these deficits.

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Diagnosis of concussion is made after a clear mechanism of injury has been established and a constellation of positive physical exam findings. It is important to recognize that concussion symptoms may initially appear mild and may worsen over the subsequent 24 to 48 hours after the injury, especially if cognitive and physical rests are not instituted. Referral for brain imaging is generally not indicated unless there is particular concern for a high-impact mechanism of injury, skull fracture or acute intracranial hemorrhage in the hours immediately after the injury.

Management

Once a diagnosis of concussion is made, the initial management in the acute phase is cognitive and physical rest, which should be implemented immediately. The length of rest should be individualized for each child and literature suggests that the first few days after a concussion are the most crucial time to rest, avoiding activities that provoke or make symptoms worse. Generally, activities that require ample eye tracking seem to provoke symptoms and should be avoided; those would include (but are not limited to) video games, texting, busy environments and most school work.

Once the child shows some clinical improvement and starts to feel better, a trial of short periods of cognitive activity can be performed. Waiting for the child to be symptom-free is not necessary, as this may take several more days to occur. Short amounts of cognitive activity are recommended, resting when symptoms worsen, and then resuming when symptoms have lessened. It is important to keep in mind that after concussion, cognitive stamina is decreased, and the student may not tolerate a full day of school initially.

Once the child is able to tolerate more prolonged periods of cognitive activity at home, they are ready to return to school. The PCP can write for academic accommodations to support the student during concussion recovery. Occasionally, specific accommodations are needed and may include limited eye tracking (copy of class notes, limited reading and writing), additional time for testing and assignments, and breaks when needed. Most students will be able to return to school within 1 to 2 weeks, and then gradually advance back to a full academic work load by 2 to 3 weeks. In the adult population, neurocognitive testing has been used in decision-making for return to play; however, in the pediatric and adolescent population, where academics are the focus, it has been shown to be of great use in determining readiness of return to school.

PAGE BREAK

It is no longer necessary for concussed patients to sit in a dark room and do nothing until symptoms remit. In fact, early on in the concussion, daily light activity, such as a brisk walk, is permitted as long as it does not provoke or worsen symptoms. Once the student is tolerating a full day of school without symptoms, a full academic workload, and is caught up in school, the student may start a step-wise return-to-play protocol. This should be guided by the PCP and can be carried out by a certified athletic trainer or athletic coach. The Zurich Consensus Statement from 2013 contains the definitive return-to-play protocol that is the model for return to play across the country and around the world.

Role of medications

Within the first 3 to 4 weeks after a concussion, medications to alleviate concussion-related symptoms are typically not recommended. Acetaminophen and ibuprofen have not been reported to be helpful in relieving concussion-related headaches and may mask symptoms, causing patients to overexert themselves. Prolonged daily use of these medications also may result in rebound medication-associated headaches. Melatonin (3 mg to 6 mg), taken 1 hour before bedtime, is safe in this population and is a useful adjunct to help initiate sleep.

It is important that PCPs have the knowledge and skill set to recognize and diagnose pediatric and adolescent concussion. Accurate and prompt diagnosis and initiation of appropriate management strategies can result in timely resolution of symptoms. Followed by a gradual increase of cognitive and physical activity, this care plan may prevent a protracted recovery from concussion, requiring further medical, educational and rehabilitative interventions.

Disclosure: Robinson reports no relevant financial disclosures.