Office Management of Pediatric

Concussions

Donna K. Broshek, Ph.D., ABPP-CN

Co-Director, Acute Concussion Evaluation Clinic

Director, Neurocognitive Assessment Lab

John Edward Fowler Professor

Psychiatry & Neurobehavioral Sciences

Disclosures• Funding from Virginia Department of Aging & Rehabilitative

Services for community TBI screening project

• Immediate Past President, Sports Neuropsychology Society

– The NFL & NHL are key sponsors of SNS conference.

– Not involved in our scientific program.

• Member of NBA/WNBA Concussion Committee

(uncompensated)

• Member of multiple concussion advisory panels for local schools

& UVA (uncompensated)

Objectives

• Understand the acute symptoms of concussion and typical

recovery for children & adolescents

• Become familiar with evidence based recommendations

for clinical management of concussion

• Understand the importance of identifying, diagnosing, &

treating specific prolonged post-concussion symptoms

Concussions…

Not just football…

Not just contact sports…

Not just males…

Not just sports…

Concussion definition (Berlin, 2017)

• Sport related concussion (SRC) is a traumatic brain injury

induced by biomechanical forces. Common features include:

– May be caused either by a direct blow to the head, face, neck or

elsewhere on the body with impulsive force transmitted to head.

– Typically results in rapid onset of short-lived impairment of

neurological function that resolves spontaneously. However, in

some cases, signs and symptoms evolve over a number of

minutes to hours.

– May result in neuropathological changes, but the acute clinical

signs and symptoms largely reflect a functional disturbance

rather than a structural injury and, as such, no abnormality is

seen on standard structural neuroimaging studies.

Concussion definition (Berlin, 2017)

• SRC results in a range of clinical signs and symptoms that

may or may not involve loss of consciousness.

• Resolution of the clinical and cognitive features typically

follows a sequential course. However, in some cases

symptoms may be prolonged.

• The clinical signs and symptoms cannot be explained by

drug, alcohol, or medication use, other injuries (such as

cervical injuries, peripheral vestibular dysfunction) or other

comorbidities (e.g., psychological factors or coexisting

medical conditions).

CDC Pediatric Guidelines (2018)

• Recommends the term mTBI

• One or more of:

– Confusion or disorientation

– LOC for 30 minutes or less

– Post-traumatic amnesia for less than 24 hours

– Other transient neuro findings: focal signs, symptoms,

or seizure

• Glasgow Coma Scale (GCS) score of 13-15

CDC mTBI Includes:

• GCS scores of 13-15

• “With or without the complication of

intracranial injury on neuroimaging”

• “Regardless of potentially requiring a

hospital admission and/or neurosurgical

intervention”

• Very different definition….

Expected Recovery• 70-80% of children with mTBI recover within 1-3

months (CDC)

• Vast majority recovery from SRC and return to

play or school within 1 month (Davis et al, 2017)

– Significant proportion experience symptoms > 1 month

– Adolescents may take longer to recover than younger

or older

• Individualized concussion management

for all ages is key.

AAN Guidelines (2013)

• Immediate removal from play if concussion

suspected

• Discarded concussion grading system:

• Focus on individual management

• No set timeline for return to play

• Concussion is a clinical diagnosis– Checklists, computerized testing, & balance assessments

are tools.

AAN Guidelines (2013)

• No return until assessed by a licensed health

care professional trained in concussion.

• Return to play slowly after acute symptoms

resolve.

• High school and younger – manage more

conservatively due to longer recovery.

• First 10 days after a concussion is the period of

greatest risk for another concussion.

Virginia Senate Bill 652 (2010)

• Mandates concussion education in all public high schools for coaches, student-athletes, & parents, as well as policies and procedures

• Student-athletes & parents to receive annual education

Virginia Senate Bill 652 (2010)

• Any athlete with suspected concussion shall be removed from play/activity– Shall not return the same day

– MUST be evaluated by health care professional• Licensed physician, physician assistant, osteopath, athletic trainer,

neuropsychologist, or nurse practitioner

– Must be asymptomatic with increasing exertion (Zurich)*

– Requires written clearance for return to activity

Virginia Senate Bill 172 (2014)

• Board of Education shall amend its

guidelines for school division policies

and procedures on concussions in

student-athletes to include a "Return to

Learn Protocol“

Virginia Board of Education

Guidelines for Policies on

Concussions in Student-Athletes

• Premature return to learn/play may

delay and/or impede recovery.

• Return-to-play should not occur before

the student-athlete has managed to

return to a full day of academic

activities.

Audience Question

• Should children with concussions

routinely undergo neuroimaging?

1. Yes

2. No

CDC Evidence Based Guidelines

for Pediatric mTBI (2018)

CDC Key Recommendations

1. Do not routinely image patients to diagnose mTBI.

2. Use validated, age-appropriate symptom scales to

diagnose mTBI.

3. Assess evidence-based risk factors for prolonged

recovery.

4. Provide patients with instructions on return to

activity customized to their symptoms.

5. Counsel patients to return gradually to non-sports

activities after no more than 2-3 days of rest.

Tipsheet for HCPs

• On Presentation/What are the red flags?

• On Discharge – What do we tell parents and/or caregivers?

• On Interim Assessment– When can the child or adolescent return to learn/play?

• On Re-Assessment after 1 month– What do we do next if symptoms still present.?

On Presentation – Red Flags

• Assess & treat symptoms

• Determine need for CT imaging or

observation/admission– Most do not need CT

• Treat acute headaches

• Prescribe physical & cognitive rest

On Presentation

• Headache (CDC/ONF)

– Nonopiod analgesia (ibuprofen, acetaminophen)

– Counsel family on analgesic overuse & rebound headaches

• Physical & cognitive rest– Initial 24/48 hour rest period; ask parents to check for

symptoms in 24 hour intervals (ONF)

– Observe more restrictive activity during the first several

days (CDC)

– Rest within first 3 days beneficial, but greater inactivity may

prolong symptoms (CDC)

Rehabilitation

StageAim Activity Goal of each step

1. Symptom-limited

activity

Daily activities that do not provoke symptoms Gradual reintroduction of work/school

activities

2. Light aerobic

exercise

Walking or stationary cycling at slow to medium

pace. No resistance trainingIncrease heart rate

3. Sport-specific

exercise

Running or skating drills. No head impact activities Add movement

4. Non-contact

training drills

Harder training drills, e.g., passing drills. May start

progressive resistance trainingExercise, coordination, and increased

thinking.

5. Full contact

practice

Following medical clearance, participate in normal

training activitiesRestore confidence and assess

functional skills by coaching staff

6. Return to play Normal game play

On Discharge

• Provide education & reassurance (ONF)

– Current symptoms are expected and common

– Expected positive recovery

• “Parents need to know that most patients recover

fully from concussion even though the recovery

rate is variable and unpredictable….Providing

information reduces anxiety and helps set realistic

expectations, promote recovery, and prevent re-

injury.”

“Post-Concussion Syndrome”

• Non-specific symptoms

• Unclear time frames

• Wide variability in use of term

• Does not provide diagnostic or

treatment information

• Not helpful to patient

Concussion & Post Concussion

Syndrome as Red Herring

• Many symptoms are misattributed to concussion

• Misattribution of symptoms results in inadequate

evaluation & treatment

• Treatable symptoms & conditions go untreated

• Post concussion syndrome is inappropriately

diagnosed at the time of initial concussion diagnosis or

within the expected recovery curve

• Over-prescription of cognitive & physical rest, causing

iatrogenic effects of isolation & inactivity

Time to Retire:

“Post-Concussion Syndrome”

• Non-specific symptoms & unclear time frames

• Wide variability in use of term

• Results in misattribution by health care providers

• Does not provide diagnostic or treatment information

– Delays or denies appropriate treatment

– Not helpful to patient

Audience Question

• Which of the following is the most

common symptom after concussion?

1. Drowsiness

2. Irritability

3. Headache

4. Dizziness

Common Factors Affecting

Recovery

• Headaches

• Visual Disturbance

• Vestibular Dysfunction

• Anxiety

Headache is a (the most) common

symptom reported following mTBI

Meehan III et al, 2010

Vision: Convergence Insufficiency

• Common binocular vision disorder

– Eyestrain

– Headaches

– Blurred vision, diplopia [double vision]

– Sleepiness

– Difficulty concentrating

– Reading difficulties Archives of Ophthalmology. 2008;126(10):1336-1349

Vestibular Dysfunction

Vestibular system & central nervous system

work together to control eye, head & body

movements to maintain balance.

Symptoms of vestibular dysfunction:

• Vertigo

• Dizziness

• Imbalance

• Spatial disorientation

Predicting Psychological Distress

after Pediatric Concussion (Brooks et al., 2019)

• Prospective, multi-center study

– Ages 6-17, n=311

• Pre-injury anxiety is a significant predictor

of psychological distress at 4 weeks

• Screen for anxiety & manage proactively

A word about insomnia…

• Disrupted sleep is common

• Sleep deprivation can reduce reaction time,

cognitive processing speed

• Insomnia can further add to depression &

anxiety

• Poor sleep hygiene further exacerbates

insomnia and adds to lengthy recovery

Expectation as EtiologyMittenberg et al (1992, 1998)

“Beliefs about the probable effects of

concussion may well result in selective

attention to normal affective, cognitive, and

somatic responses to stress and reattribution

of those symptoms to brain injury.”

• “Most sports related head injury is minor,

and although most athletes who have a

concussion recover within a few days or

few weeks, a small number of individuals

develop long lasting or progressive

symptoms.”

• “The precise incidence of CTE after

repetitive head injury is unknown…”

The Benefits of Physical Activity

and Sport Powell et al. (2011)

Brief Interventions for Recovery

In Office Interventions

• Education & expectancy

– Symptoms are typical and expected

– You will get better

• Treat stress & sleep disturbance

– Prescribe phone apps: CBT-I Coach, Sleep

Genius, Calm, HeadSpace

In Office Interventions

• Anxiety:

• Education about anxiety as a risk factor

• Autonomic arousal in anxiety triggering

situations

• Focus on anxiety reduction

– Smart phone apps

· Diaphragmatic breathing (Breathe2Relax)

· Relaxation strategies/mindfulness

(Progressive Muscle Relaxation)

• Return to Activity • Return to Life

Concussion TreatmentDiagnose & Treat Specific Symptoms