(excerpt from needs assessment)

BACKGROUND

A concussion, which is now also termed mild traumatic brain injury (mTBI), is an injury to the brain “characterized by immediate and transient alteration in brain function, including alteration of mental status or level of consciousness, that results from mechanical force or trauma.”¹ There is generally no history of loss of consciousness. This type of injury is concerning for all ages, but children are especially vulnerable, as their brains are still developing. Sports injuries are the most common injury leading to concussion in adolescents, but other, less considered injuries, such as falls, fights, and abuse, must also be taken into account. According to the concussion center at Weill-Cornell Medical Center, as of 2018, over 500 000 children are seen in emergency rooms for TBIs and 80% to 90% of them are concussions, or mTBIs.² The Centers for Disease Control and Prevention (CDC) reports an even higher number of over 800 000.³

The signs and symptoms of mTBI are any combination of the following, as listed on the Acute Concussion Evaluation (ACE), one of the tools used by medical professionals for screening for mTBI. These can be physical (e.g., headache, vomiting, dizziness, fatigue), cognitive (e.g., feeling mentally foggy, and/or sleep related (e.g., drowsiness). This tool, in conjunction with the Post-Concussion Symptom Scale (PCSS), is helpful both for initial evaluation of patients with concussion and for follow-up in the office or even on the phone, to help assess recovery and ability to return to normal activities. These assessments work well for an older child or adolescent but may need to be modified for younger children who are not able to describe these symptoms. Additionally, some behavioral findings may be secondary to other underlying conditions, such as attention deficit disorder, learning issues, or anxiety,² which also complicates diagnosis in young children.

Although most children recover fully and quickly from a single mTBI, the risk and consequences of repeated head injuries with mTBIs cannot be underestimated. To lessen this risk, certain precautions should be taken during recovery and before return to normal school and sports participation. Guidelines have been developed for adults following concussions and for adolescents following sports injuries and return to play. Newer and ongoing research has necessitated updating these guidelines, as well as tailoring them to children, as the recent CDC guidelines have done. These guidelines address initial evaluation, both by history and physical and scoring questionnaires. They also address imaging, follow-up care by the physician, in addition to when to return to school, sports, and other activities.

Physicians’ and other health care providers’ role in educating athletes, children, coaches, parents, and teachers in order to improve recognition of injuries that can put them at risk for concussion cannot be underestimated.⁴ Learning and following these updated guidelines will aid in this important role, in addition to guiding health care providers’ direct role in patient care.

EDUCATIONAL ANALYSIS

Gap #1: Clinicians may be unaware of the current evaluation guidelines for children with head injuries leading to concussion (mTBI).

Learning Objective #1: Describe the current evaluation guidelines for children with mTBI.

The American Academy of Neurology and 2010 National Academy of Sciences methodologies guided the development of the CDC Pediatric mTBI Guideline through a rigorous process. The basis of the Guideline was formed by an extensive review of scientific literature, spanning 25 years of research,^3,5

The new CDC guidelines recommend use of validated age-appropriate symptom scales to diagnose children and assess their recovery. The ones most commonly used are as the Standardized Assessment of Concussion (SAC), the ACE, the PCSS, the Standardized Assessment of Concussion (SAC), and the Standardized Concussion Assessment Tool (SCAT3), which combines the Glasgow Coma Scale (GCS), Maddocks score (specific questions asked of an athlete on the sideline after a head injury), symptom evaluation, cognitive evaluation using SAC, neck examination, balance examination, coordination examination, and a follow-up of the SAC delayed recall task. There is also a pediatric version of the SCAT3, the ChildScat3, as children need different tools for symptom assessment and mental status testing; their balance and coordination also differ from that of older athletes.⁶

Health care providers “…may [also] use validated, age-appropriate computerized cognitive testing, such as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), in the acute period of injury as a component of the diagnosis of mTBI.”³ Patients with head trauma should be evaluated by the GCS to ensure that the patient does not have a more serious TBI with possible structural damage. All scales and other testing should be used in conjunction with a complete physical and neurological exam. Each test has its own pros and cons to its use alone.⁶

Additionally, it is not recommended that imaging be routinely used for diagnosis of mTBI as it exposes children to unnecessary radiation, according to the guidance. “CT imaging should be used when there’s a clinical suspicion based on validated decision rules to look for severe brain injuries but not used in the identification of mild traumatic brain injury,” Dr. Lumba-Brown said.³

Gap #2: Clinicians may be unaware of the current treatment and follow-up guidelines for children with concussions.

Learning Objective #2: Describe the current treatment and follow-up guidelines for children with concussions.

“Health care professionals should use validated symptom scales to assess recovery in children with mTBI. Health care professionals may use validated cognitive testing [ImPACT] (including measures of reaction time) to assess recovery in children with mTBI. Health care professionals may [also] use balance testing to assess recovery in adolescent athletes with mTBI.”³ It may be important to use a combination of these resources. “Health care professionals should closely monitor children with mTBI who are determined to be at high risk for persistent symptoms based on their premorbid history, demographics, and/or injury characteristics.”³ These risk factors are also important during the initial evaluation.

“For children with mTBI whose symptoms do not resolve as expected with standard care (ie, within 4–6 weeks), health care professionals should provide or refer for appropriate assessments and/or interventions. Children with mTBI who are at high risk for persistent symptoms or delayed recovery are more likely to require intervention than children at low risk. Health care professionals can more effectively counsel patients with mTBI when they have assessed prognostic risk factors.”³

One of the symptoms that is often persistent after mTBI is headache. When these children present to the ER with a history of mTBI in the recent past, the patient should be “…clinically observed and [the provider should] consider obtaining a head CT in children seen with severe headache, especially when associated with other risk factors and worsening headache after mTBI, to evaluate for ICI [intracranial injury] requiring further management in accord with validated clinical decision-making rules. Children undergoing observation periods for headache with acutely worsening symptoms should undergo emergent neuroimaging.”³

In the past, the recommendation for treatment of acute mTBI has been total rest—both physical and brain rest—until all symptoms have resolved. Brain rest includes, but is not limited to, avoidance of schoolwork and looking at phones, computers, and television screens. This is still the recommendation for the immediate period following mTBI; however, especially for children, recent evidence has suggested that “…inactivity beyond this period for most children may worsen their self-reported symptoms…”³ and that “…patients in an acute care setting randomized to 5 days of strict rest from cognitive and physical activity experienced symptoms longer than the usual care group. However, both the strict rest and usual care groups reported lower levels of cognitive activity in the first 5 days after a concussion, leading to the conclusion that current usual care endorsing modest physical and cognitive rest after injury is an effective strategy for recovery.”⁷

These more recent studies have led to the recommendation that “health care professionals should counsel patients to observe more restrictive physical and cognitive activity during the first several days after mTBI in children. Following these first several days, health care professionals should counsel patients and families to resume a gradual schedule of activity that does not exacerbate symptoms, with close monitoring of [number and severity] symptom[s]. After the successful resumption of a gradual schedule of activity, health care professionals should offer an active rehabilitation program of progressive reintroduction of noncontact aerobic activity that does not exacerbate symptoms, with close monitoring of [number and severity of] symptom[s]. Health care professionals should counsel patients to return to full activity when they return to premorbid performance if they have remained symptom free at rest and with increasing levels of physical exertion.”³

Social support is also important in enhancing improvement in children. Assessing and emphasizing this support are also key parts of the guidelines.³

Regarding returning to academics following mTBI, “[t]o assist children returning to school after mTBI, medical and school-based teams should counsel the student and family regarding the process of gradually increasing the duration and intensity of academic activities as tolerated, with the goal of increasing participation without significantly exacerbating symptoms. Return-to-school protocols should be customized based on the severity of postconcussion symptoms in children with mTBI as determined jointly by medical and school-based teams. For any student with prolonged symptoms that interfere with academic performance, school-based teams should assess the educational needs of that student and determine the student’s need for additional educational supports. Postconcussion symptoms and academic progress in school should be monitored collaboratively by the student, family, health care professional(s), and school teams, who jointly determine what modifications or accommodations are needed to maintain an academic workload without significantly exacerbating symptoms. The provision of educational supports should be monitored and adjusted on an ongoing basis by the school-based team until the student’s academic performance has returned to preinjury levels. For students who demonstrate prolonged symptoms and academic difficulties despite an active treatment approach, health care professionals should refer the child for a formal evaluation by a specialist in pediatric mTBI.”³

For pain, specifically for headaches, health care providers should recommend nonopioid pain relievers, such as ibuprofen or acetaminophen, with a warning regarding overuse, due to the possibility of rebound headaches. Additionally, if the headaches are chronic, there may be other factors contributing that need to be addressed.³ Vestibulo-oculomotor dysfunction may also persist; if that is the case, patients should be referred to a program of vestibular rehabilitation.

As previously mentioned, sleep disturbance is not uncommon after mTBI; sleep hygiene should be discussed with patients and parents. If the disturbances persist, consideration should be made for referral to a sleep disorder specialist.

Cognitive impairment, common after mTBI, should resolve within a limited period of time. If it does not, the health care provider should consider referral for a formal neuropsychological evaluation.³

Gap #3: Clinicians may be unaware of the predictive evaluations for children with concussions being studied.

Learning Objective #3: Review possible predictive evaluations under investigation for children with concussions.

In addition to the standards of care and current guidelines, there are recent and ongoing investigations into possible predictive evaluations for children with mTBI.

Postconcussive symptoms, which are persistent somatic, cognitive, physical, psychological, or behavioral changes lasting more than one month following injury, can impact a child’s and family’s life significantly. The ability to predict these symptoms and the time frame of persistence would be extremely helpful. A clinical risk score for children presenting to the emergency department with concussion and head injury within the previous 48 hours was studied. The investigators found a modest discrimination to stratify PPCS risk at 28 days. Although this is a promising finding for predictive evaluations, before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.⁸

CONCLUSION

Management of concussions/mTBIs in children is an evolving science. The traditional treatment of total physical and brain rest differs from the current recommendations and is an ongoing subject of research. The CDC’s guidelines are the current standard of care and should be followed by pediatricians, ER physicians, and other health care providers; patients and parents should also be educated as to these guidelines. Further research should aid in improving the evaluation and treatment of mTBIs and health care providers should also continue to be aware of future changes.

REFERENCES

1. Agarwal N, Thakkar R, Than K. Concussion. American Association of Neurological Surgeons. Accessed April 6, 2020. https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Concussion

2. Weill Cornell Medicine. Concussion and Brain Injury Clinic. Children and Concussions. Accessed April 6, 2020. https://concussion.weillcornell.org/about-concussions/kids-and-concussions

3. National Center for Injury Prevention and Control. Traumatic Brain Injury & Concussion: CDC Pediatric mTBI Guideline. Center for Disease Control and Prevention; 2018. Accessed April 6, 2020. https://www.cdc.gov/traumaticbraininjury/index.html

4. Kerr HA Concussion risk factors and strategies for prevention. Pediatr Ann. 2014;43(12):e309-e315. doi:10.3928/00904481-20141124-10

5. Jenco M. CDC releases new guidance on diagnosing, managing concussions. AAP News. September 10, 2018. Accessed April 6, 2020. https://www.aappublications.org/news/2018/09/10/concussion091018

6. Dessy AM, Yuk FJ, Maniya AY, et al. Review of assessment scales for diagnosing and monitoring sports-related concussion. Cureus. 2017;9(12):e1922. doi:10.7759/cureus.1922

7. Thomas DG, Apps JN, Hoffman RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135 (2):213-223. doi:10.1542/peds.2014-0966

8. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014-25. doi: 10.1001/jama.2016.1203

9. Biochemical diagnostics of mild traumatic brain injury (TBI) and concussion in children and adolescents. https://clinicaltrials.gov/ct2/show/NCT04288167?term=children&cond=concussion+in+children&age=0&draw=2&rank=1. Accessed April 6, 2020.

10. Interhemispheric anterior delta desynchronization in children who present to the emergency department with acute concussion: a proof of concept study. Rambam Medical Center. https://clinicaltrials.gov/ct2/show/NCT02916108?term=children&cond=concussion+in+children&age=0&draw=2&rank=7. Accessed April 6, 2020.

11. McCarty CA, Zatzick D, Stein E, Wang J, Hilt R, Rivara FP; Seattle Sports Concussion Research Collaborative. Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial. Pediatrics. 2016;138(4):e20160459. doi:10.1542/peds.2016-0459

12. Multicentre, randomised clinical trial of paediatric concussion assessment of rest and exertion (PedCARE): a study to determine when to resume physical activities following concussion in children. https://clinicaltrials.gov/ct2/show/NCT02893969. Accessed April 6, 2020.

13. Effects of ketone supplementation on functional outcomes in adolescents post-concussion; University of Alabama. https://clinicaltrials.gov/ct2/show/NCT04079907?term=children&cond=concussion+in+children&age=0&draw=2&rank=21. Accessed April 6, 2020.