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A review of how to manage a patient with a concussion from the initial injury to postinjury follow-up.
BY PAT F BASS III, MD, MS, MPH
You sit down between morning and afternoon clinic to review phone calls from concerned parents. A father is not sure what to do. His 14-year-old daughter has an annoying headache. The patient had head-to-head contact at soccer practice several days ago. There was no loss of consciousness, vomiting, or amnesia. The dad treated her mild headache with over-the-counter pain meds. He did not think there was any reason to seek medical care, and she returned to school the next day.
The father is now concerned that, although not significantly worse, his daughter continues to ask for medication for her headache. She seems to be more irritable, and today a teacher e-mailed a note that the girl is having difficulty completing work and paying attention in class.
According to the Centers for Disease Control and Prevention, concussion is synonymous with mild traumatic brain injury (MTBI) and can be defined as: ". . . a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (ie, CT scan, MRI)."1
Concussion may involve physical, cognitive, emotional, and sleep-related symptoms. Symptoms can be highly variable from patient to patient, lasting only minutes in some patients and months in others. Rather than structural damage to the brain, the pathophysiology of a concussion is thought to be neuronal dysfunction resulting from metabolic and physiologic changes (Table 1).2 These changes may result in a constellation of physical symptoms (Table 2).1
There are 1.6 to 3.8 million concussions per year in the United States with falls, motor vehicle accidents, and assaults being the most common etiologies.1 One in 5 concussions is sports related, but the percentage is higher in adolescents.3 One in 10 sports concussions involves some loss of consciousness.1
The child in this scenario is displaying symptoms of a postconcussive syndrome. In most cases, patients recover in 7 to 10 days with 85% to 95% recovering in 3 months. A small minority of patients will have a complicated recovery. When patients experience persistent symptoms, factors not related to the injury appear to play an increasingly significant role.
Often students can look and even feel normal, giving concussion the moniker invisible injury. Likewise, medical and neuropsychiatric testing may not show significant impairment. Many highly motivated adolescents, sometimes helped through peer pressure, expect themselves to “get over it” and “get back in the game.”
Certain groups of patients may have a more complicated or longer recovery following a concussion, such as patients with prior concussions; previous headache history, especially migraines; or prior psychiatric/developmental problems such as attention-deficit/hyperactivity disorder, depression, or mood disorders.
If your patient had more significant symptoms and was brought to the emergency department (ED) or clinic, or if you were performing a sideline evaluation, how would you assess your patient assuming emergent care (problems with the airway, breathing, and circulation) is not needed?
Your history should focus on the injury and symptoms immediately following the injury (Table 3). Your physical exam should look for specific signs of trauma such as abrasions, lacerations, or hematomas of the scalp. Additionally, you should look for hemotympanum (blood behind the tympanic membrane); Battle sign (bruising over the mastoid); and raccoon eyes (blood in periorbital tissues). Neurologic exams should be performed, but focal neurologic findings are extremely uncommon in concussion.4
It is also essential to assess mental status in any patient with a head injury.4 This can be done with the Glasgow Coma Scale (Table 4), one of the most common instruments used clinically and in head injury research. Whether or not to perform neuroimaging is beyond the scope of this article, but there are several good reviews on the subject.4-6
If you are present on the sideline when a suspected concussion has occurred, the following protocol is recommended by the Sports Concussion Institute: 1) remove from play; 2) sideline assessment; and 3) reevaluations.
Although required by law in some states, removal from play is the most important factor because of potential complications, prolonged recovery, and second impact syndrome, which can lead to long-term brain damage or even death. Sideline assessment tools such as the Sports Concussion Assessment Tool 2, the American College of Sports Medicine assessment tool, or the Concussion Recognition & Response app can help you systematically and reliably assess patients after a concussion. Finally, reassessment is essential because symptoms can change rapidly after a concussion and any new or worsening symptoms may warrant a visit to the ED.
Initially all patients will require frequent follow-up and parents will need to be educated for signs and symptoms that should trigger them to seek medical care. Follow-up in the office is appropriate for patients who seem to be improving. Consider referral to a concussion specialist for complicated presentations, questions about returning to school or play, concern over symptoms, or if your patient is not improving as you would expect.
Although many physicians will use assessment tools to monitor progression or improvement of symptoms, a recent study in JAMA Neurology suggests the injury biomarker T-tau may be useful in monitoring concussions.7 The biomarker was found to be elevated compared with baseline in hockey players experiencing a concussion. Levels peaked 12 hours after injury and remained elevated for up to 6 days, but decreased as the hockey players improved. Additional study is needed in order to develop blood biomarkers useful in the treatment of the postconcussive patient for return-to-school and return-to-play decisions.
Because of the previously mentioned issues related to concussion, it can be difficult for friends, parents, and teachers to understand or identify the extent of a child’s invisible injury. Patients experiencing a concussion should avoid reinjury and avoid both physical and mental overexertion.
Lacking research demonstrating harm, cognitive rest (avoiding cognitive stressors such as video games, school work, texting, and television) has been recommended by several clinical guideline statements.8 It probably is not surprising that a head injury might have a direct impact on learning, and a number of recent studies have demonstrated that intense cognitive activity may actually worsen concussive symptoms,9,10 as they did for your patient.
The cognitive activities are thought to stress the already metabolically altered brain and result in worsening symptoms. Although returning to a normal routine is good for an adolescent, one of the main goals in management of the postconcussive patient is to limit cognitive activity at the point where it begins to reproduce or worsen symptoms. Returning to school will require communication and coordination between parents, school, and physician.
Your role in the initial evaluation of the concussion is to determine severity and to determine when the adolescent will be able to return to physical activity. Parents and caregivers will need to make sure the adolescent gets enough rest and decreases his or her cognitive stress. Ultimately the parents and caregivers will decide when the adolescent is ready to return to school. One recommendation is that adolescents should remain home as long as symptoms prevent concentration for up to 30 minutes. When able to tolerate symptoms for 30 to 45 minutes, parents can consider home tutoring or in-school instruction.8
Most students will return to school while still having some symptoms from their concussion. Certain academic adjustments need to be made to the adolescent's regular schedule and may need to be negotiated among school, parent, and physician. These adjustments should be individualized to both student and school (Table 5).9
Most students will recover within 3 weeks and the academic adjustments can be discontinued. When students require longer-term assistance, this is generally referred to as “academic accommodation” or “academic modification.” These are usually official plans and may include extra time for work and tests that are formalized in a written 504 plan (mandated by the Rehabilitation Act of 1973). In academic modification, changes are usually longer term and may involve altering grade level educational plans through an Individualized Educational Program (IEP). These comprehensive plans developed by parents, teachers, and school staff outline the unique educational needs of students and address any accommodations.
Patients must be back to their academic baseline before returning to sports and other full physical activities. The American Academy of Pediatrics recommends a 6-step process allowing for gradual return to play (Table 6), and some sports may have specific protocols.11 The protocol generally progresses every 24 hours as long as symptoms do not occur. If the athlete experiences any symptoms of concussion (Table 2), the patient is returned to the previous phase.
Symptoms should be monitored at each phase and athletes should not progress if they begin to experience symptoms. Symptoms indicate the need for additional rest. When the athlete is not experiencing symptoms for a minimum of 24 hours, he or she may begin at the previous step where symptoms occurred. Individual athletes will progress through the phases differently and it may take some several weeks to complete all 6 phases.
Consider a referral to a concussion specialist for any of the following: parental concern; worsening symptoms; symptoms that persist after 3 weeks; multiple concussions (especially if occurring with less impact); or risk factors for prolonged recovery.
While many pediatricians are uncomfortable with the management of concussion, guidelines and available tools can provide you with the appropriate knowledge base and assistance to manage your next patient with a concussion.
1. Centers for Disease Control and Prevention. Heads Up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). Available at: http://www.cdc.gov/concussion/headsup/pdf/facts_for_physicians_booklet-a.pdf. Accessed July 29, 2014.
2. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228-235.
3. Bazarian JJ, McClung J, Shah MN, Cheng YT, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998-2000. Brain Inj. 2005;19(20:85-91.
4. Schunk JE, Schutzman SA. Pediatric head injury. Pediatr Rev. 2012;33(9):398-410.
5. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.
6. Blackwell CD, Gorelick M, Holmes JF, Bandyopadhyay S, Kuppermann N. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med. 2007;49(3):320-324.
7. Shahim P, Tegner Y, Wilson DH, et al. Blood biomarkers for brain injury in concussed professional hockey players. JAMA Neurol. 2014;71(6):684-692.
8. Halstead ME, McAvoy K, Devore CD, et al; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957.
9. Howell D, Osternig L, Van Donkelaar P, Mayr U, Chou LS. Effects of concussion on attention and executive function in adolescents. Med Sci Sports Exerc. 2013;45(6):1030-1037.
10. Sady MD, Vaughan CG, Gioia GA. School and the concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am. 2011;22(4):701-719.
11. May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014;9(2): 242-255.
Dr Bass is chief medical information officer and associate professor of medicine and pediatrics, Louisiana State University Health Science Center–Shreveport, Louisiana. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.