New Concussion Guidelines for Pediatric Patients
By Alan G. Kulberg, M.D.
Not so long ago, in our very own galaxy, when a football player was slow to rise from the turf after a tackle and stumbled to the sideline muttering incomprehensibly, we in the medical field would say he was “seeing stars” or “got his bell rung.” Or, when a person was whiplashed in a car accident and had a severe throbbing headache, the next day we would attribute it to neck strain. In fact, we now know these people had a concussion. Defined simply, a concussion is an alteration of brain function caused by trauma and occurs when the brain is stretched and distorted by direct or indirect forces.
Concussions span the spectrum from loss of consciousness to more subtle slowed mental processing. Thanks to a popular movie and the findings that some professional athletes involved in collision sports can develop dementia associated with post-mortem brain abnormalities, the general public is far more aware and concerned about concussions these days. However, in the absence of good long-term data, we must be careful not to overgeneralize from the NFL experience to young recreational athletes.
In this relatively young field of medicine, with the knowledge that concussions must be taken seriously, what do we really know about how to make the diagnosis of concussion in children and adolescents and how to best manage our patients?
On September 4th, the CDC, with the help of concussion experts across the United States, published a set of guidelines based on available evidence to help medical providers provide the best care for pediatric and adolescent patients. Their research generally agreed with the consensus of an international panel of concussion experts that convened in Berlin, Germany, in October, 2016 and produced some important findings and recommendations. These include:
1) Brain imaging such as CT scans and MRI’s “should not routinely be used” for diagnostic purposes but rather the decision to image a brain should be based on published clinical “rules” which define those at risk for more serious injury such as intracranial bleeding. Physicians, particularly those who work in the emergency setting, are familiar with these rules.
2) There are no reliable blood tests currently available for the diagnosis of concussion, though research in this area is ongoing.
3) Rest, or reduction in both cognitive (thinking) and physical activity is appropriate for about two days following a concussion. Accordingly, the CDC and Berlin groups recommended a gradual increase in activity beginning several days after a concussion as long as the patient is monitored and activities do not worsen symptoms. Contrary to the often-provided instruction in the past of no activity until symptoms resolve, early gradual reintroduction of physical activity probably benefits recovery. Complete rest and sensory isolation known as “cocooning” beyond a few days may put the patient at greater risk for later mood difficulties such as anxiety or depression. In a related manner, the ability to be resilient and cope successfully with the challenges following a concussion are influenced by the nature of those psychological qualities that existed in a person prior to the injury. In other words, characteristics that defined a person before a concussion still apply after the injury. This is something I have commonly observed in my own practice.
4) The CDC and Berlin workgroups found there is no one test available to clinicians that can be used as a “stand-alone” tool in assessing recovery. Rather, a combination of tools like validated symptom scales, computerized testing, and balance testing can be helpful. In my clinic, I use the popular ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) which can be very helpful but I emphasize to my patients and parents that it is just “one piece of the puzzle” in the overall assessment.
5) It is important to identify patients who are at risk for more prolonged symptoms. While most patients will experience resolution of their symptoms within 1-3 months after injury (also corroborating what I have seen), those with higher initial symptom burdens, learning difficulties, or a history of prior concussions, for example, often take longer to recover and may require referral to other specialists such as physical or speech therapists.
6) The CDC workgroup was also emphatic about the need for a team-based approach to assist students during their re-entry into academic life. These teams should include medical caregivers, educational personnel, the patient, and her/his family. The team would serve to identify the student’s educational needs and to ”jointly determine what modifications or accommodations are needed to maintain an academic workload without significantly exacerbating symptoms.”
Though it was not addressed in the CDC document, students who are also competitive athletes must return-to learn effectively before they can return-to-play. Historically, the emphasis on concussions in students have been referenced to safely returning them to athletic play. The CDC guideline serves to shift the focus of concussion care to cognitive needs and will serve as an important template in assisting medical providers and informing the public about the optimum strategies for managing pediatric concussions.
I am often asked how many concussions should disqualify a student from competitive athletics and what are the long-term risks. There are no easy answers to these questions; more evidence is required to make such predictions though better information and monitoring have rendered the “three strikes and you’re out” antiquated. Many factors must be taken into consideration and it should be recognized that sports provide numerous benefits to students, both physical and cognitive. Still, at the end of the day, we must remember that a concussion is a brain injury and can have long-term consequences. Caution should rule the day.
Alan G. Kulberg, MD, is Medical Director of the Berkshire Medical Center Concussion Clinic
(This column was originally published in The Berkshire Eagle on 9/16/18)