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Concussion

Sue Kirelik, MD and Solomon Behar, MD
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Concussion management continues to be controversial and ever-evolving. Sue and Sol discuss current concepts in definition and management of concussions in children.

Pearls

  • Not all children that present with symptoms of concussion have concussion. Providers should take a detailed history and physical to not miss other etiologies such as idiopathic intracranial hypertension or brain tumors.

  • The optimal timing for return to school and activity is not well known in children. Some degree of exercise is helpful as is return to school with accommodations. Complete rest may cause more problems than it solves.

  • Oculomotor and vestibular testing are important parts of the evaluation of a child with concussion and cervicovestibular therapy can improve recovery time.

 

  • What is a concussion? This is not as straightforward as you might expect. The American Academy of Neurology says, "It is  biomechanical forces causing a pathophysiologic disturbance in neurologic function. It's characterized by specific clinical symptoms..."

    • The gist of it is you hit your head, you have a neurometabolic cascade, and as a result, you have a number of symptoms develop.

  • What symptoms can we expect with concussion? Headaches is common but not universally seen. Loss of consciousness is seen only rarely. A variety of other neurologic symptoms including dizziness, visual changes, double vision, blurry vision and cognitive problems. These cognitive changes can be sleep state disturbances, difficulty focusing, amnesia, and emotional symptoms like anxiety.

  • What is the typical course? In adolescent the average time to recovery is two to three weeks. Adults recover more quickly in a week to 10 days. In younger kids data is not as good quality but some will have longer lasting symptoms. With any given child it is very difficulty to predict the course to expect.

  • There has been controversy in the literature about what we should be doing for rest after concussion what do you tell people to do for post-concussion rest? The latest data is suggesting that extreme cognitive rest might be overdoing it.

    • In the first 24 to 48 hours, most of these kids are pretty miserable, and we do know that anything that basically burns glucose in your brain makes you feel worse. In time getting back to school becomes important and asking children to sit in a dark room until symptom free causes more problems than it solves.

    • This can lead to school avoidance and anxiety.

    • More recent data is showing that only moderate cognitive rest early on may be best. Children should be transitioning back to activities of daily life and  transitioning back to school with adjustments in place. You can lighten your but not eliminate your cognitive load.

  • What practical guidance do you give families? We use a booklet called Reduce, Educate, Accommodate and Pace(REAP) that describes how to transition back to activities and school for children with concussion. Link to REAP booklet.

    • If a kid is able to be up and about for 20 to 30 minutes focusing on light things, then they can start to transition back to school, and usually that happens within 24 to 48 hours.

    • This booklet describes adjustments that can be done in school by teachers specific to symptoms.

    • More information can be found on Dr. Kirelik’s webpage at the Rocky Mountain Center for Concussion.

  • If you are attending a sporting event how do you address an acute injury that could be concussion? If a child take a big hit or is not acting appropriately on the field they should be assessed for concussion. If there are any signs or symptoms of concussion they should not return to play. This is important because we do know that you have neurometabolic changes that make your brain more vulnerable to an addition hit until you are fully resolved from that concussion.

  • What should we do in the emergency room when children come in asking for clearance to return to play? In an emergency room or an acute care setting you do not have enough data to confidently know if someone has resolved their concussion.

    • When we clear someone to return to play we are looking to see a few things.

      • Are they symptom free?

      • Are they off of all medications used to treat concussive symptoms?

      • Do they have a normal physical exam including ocular motor function and vestibular function?

      • Do they have evidence of neurocognitive recovery? Some children will  feel as if they have recovered but will still have symptoms that can be seen based on neurocognitive testing. Teachers are a great source of data on when the kid is back to normal.

  • Is there a validated objective neurocognitive test that we can use in practice? This is tough because there's controversy about these tests. There's the SCAT3 and there's the pediatric SCAT. Those were developed by the International Consensus on Concussion to assess concussions and are not well validated in kids.

    • One of the problems is we do not know a child's baseline when we use these tools. If you can  assess these kids before they have a concussion these are more useful. Again teachers may be your best source of the neurocognitive status.

  • How do you use physical symptoms for return to play?  This is a really evolving area because the return-to-play steps are not evidence based. They were developed to fit a professional sports schedule. You hit your head on Sunday in the football game. You rest on Monday. You go through the steps in time to be done by Saturday and you play again on Sunday.

    • They were never designed for kids and they have not been studied in children but they are still what's recommended by the International Guidelines on Concussion, which is a consensus group that meets about every four years to give us some recommendations.

    • These steps were also designed before we allowed exercise in concussion recovery. We now know that getting these kids physically active with safe cardio exercise can actually help your recovery, so graduated return-to-play does not make sense when we used exercise for concussion recovery.

    • We still feel obligated to use them.

  • What's the shortest amount of time you could get back? Typically, we do not clear kids before a week post-injury because we want to see how things are going to evolve. It takes four days to get through the graduated return to play steps. The four physical steps have the goal of challenging brain cells and make sure they do not develop symptoms with exertion.

  • What are the four steps? The first is really light cardio. The second is more hand-to-eye coordination. The third are more sports specific drill, and the fourth is technically a contact practice. Contact practice does not always make sense for a specific child. For example non-athletes we're trying to clear to go back to physical education or children who play non-contact sports. In these cases we use more vigorous sports specific workout for the fourth step.

  • What is second impact syndrome? Second impact syndrome is extremely controversial. Not everybody agrees that it exists.

    • The theory that there is a period of metabolic vulnerability during which a minor hit can cause severe complications. The thought is players can no  longer auto-regulate cerebral blood flow leading to massive cerebral edema and herniation. There are 10 or 11 roughly cases per year in the United States mostly in football. There is discussion about whether truly this is second impact syndrome or are these perhaps genetically vulnerable kids with channelopathy who are more prone to swell? Some of these cases are frank subdural, epidural bleeds.

    • Second impact syndrome is not the only thing to worry about repeated injury. Much more often will lead to prolonged recovery with persistent neurocognitive deficit, chronic headaches, depression, or anxiety.

  • Is there a duration of time after the first concussion happens where we stop worrying second impact syndrome? We really do not know the answer to that. We base kids clearance on clinical assessment. A few studies in adults where they can do MRI spectroscopy to look at the neurometabolism of the brain have found is those neurometabolic changes persist long beyond symptom resolution, normal physical exam, neurocognitive resolution.

  • What are the long term concerns? One concern that is still being investigated is chronic traumatic encephalopathy (CTE). We know that when you look at retired athletes, some of their brains will show on autopsy findings of CTE with tau protein deposition. There athletes may have had cognitive issues, memory problems, substance abuse, emotional difficulties, but what we don't know is how much trauma do you need to get it and who is at risk.

  • Are there any serum or blood tests that we can do to decide how severe a concussion is or to predict their prognosis?  A lot of study being done in this area on serum biomarkers or cerebrospinal fluid biomarkers where your brain releases a certain protein and you can measure that. SB100 is one of these. So far none really panned out to be sensitive or specific enough to help us.

    • Eye-tracking devices might help us. There's a lot of study being done in that area.

  • Where specialty concussion care is available who should be referred? Kids who have the potential for a very difficult recovery probably should be referred for specialty care. Risk factors like learning disability, ADD, ADHD, past depression, anxiety can lead to longer recovery. Other reasons to refer may be:

    • Multiple concussions.

    • Severe presentation with severe symptoms.

    • Dizziness and visual disturbances can be from vestibular and ocular motor dysfunction, which is treatable through physical therapy.

    • If there a question of having to retire them from sports.

  • What happens at that first visit with a child with a concussion in your clinic? We first want to confirm the diagnosis.

    • Not all headache after playing football is a concussion. Idiopathic intracranial hypertension can present in this fashion. Kirelik has seen this present to concussion clinic three times. Fundoscopic exam is very important. Cardiac lesions and brain tumors have also been identified in concussion clinic so they start with detailed history and physical exam.

    • The exam is comprehensive and includes. Eye movement screening, vestibular testing, cervical spine evaluation.

    • Oculomotor and vestibular testing is important and primary care providers should learn to do this testing.

Mucha A et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American journal of sports medicine. 2014;42(10):2479-2486. PMC 4209316

  • Each child is also seen by a psychologist to education the patient on school adjustments, screening for anxiety and depression and to help watch out for issues with secondary gain.

  • After evaluation comes treatment for those with prolonged recovery. The number one treatment is exercise and the second is vestibular therapy. In vestibular therapy they do certain exercises to help desensitize the vestibular system helps the dizzy kid with recovery. Cervicovestibular therapy is one modality with evidence supporting earlier return to play.

Schneider KJ et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014 Sep;48(17):1294-8. PMID 24855132

  • How long do you usually follow patients? With uncomplicated recovery, 80 to 90% of patients recovery within three weeks and get cleared from the concussion. Kirelik has followed some for nine months to a year until they finally resolved.

How can we advise parents on long term sequelae? We think that if you have one, two, maybe even three uncomplicated concussions in childhood long-term, you're going to be fine.  We do know that the earlier you start contact football if you are professional football player, the more likely you are to have neurocognitive complications, so repetitive sub-concussive blows may be concerning. Overall the risks are not well understood.

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