Pediatric Concussion Management by Farhad Sahebkar, M.D., and Rebecca Gologorsky
Concussion is a brain injury caused by biochemical reaction to physical trauma, and is generally characterized by the rapid onset of particular neurological symptoms, or cognitive impairment. The injury is typically self-limited and resolves spontaneously. Concussion commonly arises from sports injuries, which account for between 1.6 and 3.8 million concussions annually in the United States; about 10 percent of all U.S. high school sports injuries involve concussions. A small percentage of concussions can be serious, and may lead to prolonged symptom course, significant morbidity, or even death.
Sports concussion has recently entered the medical spotlight due to increasing media coverage and government regulation of concussion management. The heightened public awareness of this prevalent and potentially serious condition requires clinicians to learn about their states’ laws concerning concussion management. On October 4, 2011, the governor of California approved bill AB 25, which requires all school districts offering athletic programs to immediately remove an athlete from play if he or she is suspected of having a concussion. The bill also dictates that the athlete be evaluated by an appropriately trained health care provider before he or she returns to play, and that the athlete and parent/guardian sign a yearly concussion information sheet.The current American Academy of Neurology guidelines, developed through expert opinion, date back to 1997, and use a grading system for acute concussion symptoms (See reference 8). Because this grading system does not predict long-term symptom occurrence or outcome, a multidisciplinary panel examining the best available evidence for concussion management has proposed updated guidelines that are at press.
Symptom-Based Approach to Care
The new recommendations abandon the use of grading scales in favor of a more individual and symptom-based approach, and focus on determination of return-to-play (See reference 2). The assessment of concussion is a complex process that may be further complicated by patient perception. While the general population typically reports concussion accurately or even overstates symptoms, athletes tend to underreport concussion symptoms, perhaps so that the injured athlete may quickly return to the game (See reference 6). Further, the athlete may not be aware of being concussed because signs and symptoms can be delayed for up to several hours or days.
The pathophysiology of concussion consists of the non-mechanical damage to the brain initiated immediately upon impact.
Decreases in cerebral blood flow, disruption of membrane potential, and altered metabolism characterize the first phase of damage. The accumulation of lactate secondary to anaerobic glycolysis, excess energy (ATP) consumption, and exhaustion of ATP stores begin as the body works to restore ion balance and membrane potential.
This leads to energy crisis, impaired axonal function, and excessive release of excitatory neurotransmitters (See reference 1).
A second impact during the critical period of restoration of homeostasis may lead to diffuse cerebral swelling, brain herniation, and death can occur, as seen in second impact syndrome (See reference 3).
The signs and symptoms of concussion fall into four categories and can present within minutes of the injury or may not appear until the affected person undergoes significant physical or mental exertion. The categories are as follows: physical, cognitive, emotional and sleep.
Loss of consciousness (LOC) occurs in less than 10 percent of cases but is an important sign of more critical damage, and often necessitates further imaging. Concussed patients should also be questioned about the details of events before and after injury to evaluate for amnesia that is suggestive of more serious injury (See reference 7).
Management and Return to Play Decision-Making
Patients with concussion should be removed from play until evaluated by a clinician or other certified medical professional experienced in concussion management. After diagnosis, symptom management becomes key. The injured athlete should be directed to manage physical and mental exertion carefully and to avoid exacerbating activities (See table 1). These include recognizing and treating alternative or aggravating diagnoses, including migraine, medication overuse, and rebound headache.
In addition to a detailed neurological evaluation and physical exam, computerized neuropsychological testing can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play (See references 4 & 5).
At California Pacific Medical Center, we use the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), a widely used and scientifically validated computerized concussion evaluation system to establish a of baseline neurological conditions (e.g., migraines) or other related factors (e.g., overuse of medication). These factors, as well as previous injury, tend to prolong or complicate the period of recovery.
A gradual return to physical activity is recommended. Table 1 outlines the stepwise advance in physical activity that may be followed, provided the patient remains asymptomatic. It is further recommended that athletes be off all medication used to treat their post-concussive symptoms before returning to play. An even more conservative approach is recommended for athletes under 21 years of age.
- Nausea or vomiting (early onset)
- Balance problems
- Fuzzy or blurred vision
- Lack of energy
- Sensitivity to noise or light
- Emotional lability
- Nervousness or anxiety
- Difficulty thinking clearly
- Sluggish cognitive function
- Difficulty concentrating
- Difficulty remembering new information
- Changes in sleeping habits
- Trouble falling asleep
Rehabilitation stage | Functional Exercise at Each Stage of Rehabilitation
- No activity - Complete and cognitive rest
- Light aerobic exercise - Walking, swimming, stationary bike
- Sport-specific exercise - Specific sport-related drills but no head impact
- Non-contact training drills - More complex training drills, may start resistance training
- Full-contact practice - With medical clearance, participate in normal training activities
- Return to play - Normal game play
- H, Kochanek PM, Clark RS: Traumatic brain injury in Infants and children: Mechanisms of secondary damage and treatment in the intensive care unit. Crit Care Clin 2003;19(3):529
- McCory P, Meeuwisse W, Johnston K, et al. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med 2009;19(3):185-200Bayir
- Saunders R, Harbaugh R. The second impact in catastrophic contact-sports head trauma. JAMA. 1984;252:538–539.
- Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clin Sports Med 2004;23:421-41: ix.
- Collins M, Grindel S, Lovell M, et al. Relationship between concussion and neuropsychological performance in college football players. JAMA 1999;282:964-70
- Broglio SP, Macciocchi SN, Ferrara MS. Neurocognitive performance of concussed athletes when symptom free. A Athl Train. 2007 Oct-Dec;42(4): 504-508
- Kelly, J.P., and Rosenberg, J. (1997). Diagnosis and management of concussion in sports. Neurology. 48, 575-80
- Quality Standards Subcommittee. (1997). Practice Parameter: The management of concussion in sports (summary statement). Neurology. 48,
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