Management of Concussion in the Pediatric Patient
Management of Concussion in the Pediatric Patient
A significant amount of research has been conducted recently on the diagnosis and management of concussion. A position statement was published by McCrory and colleagues (2009) after the Third International Conference on Concussion in Sport (CIS) was held in 2008; however, the statement did not specifically address pediatric patients (Halstead & Walter, 2010; McCrory et al., 2009). The American Academy of Pediatrics published a report in 2010 that outlined the most recent knowledge on pediatric and adolescent sport-related concussion (Halstead & Walter, 2010). More recently, the Canadian Pediatric Society provided updated guidelines on the management of concussion among pediatric patients in 2012 (Purcell, 2012). This discussion will provide a summary of the most recent literature with regard to management and follow-up of mTBI in pediatric patients.
The pediatric nurse practitioner (PNP) must consider a number of diagnoses when a patient presents with a headache, fatigue, mental fogginess, and poor concentration immediately after a head injury. Diagnoses other than concussion include contusion and skull fracture. Red flag diagnoses to keep in mind are SIS, intracranial hemorrhage or hematoma, and cervical spine injury (see the Box). SIS, which has only been documented in children and adolescents, is described as cerebral congestion that occurs when a patient has sustained a second head injury before having fully recovered from a previous concussion (Halstead & Walter, 2010; Purcell, 2012). This rare condition is believed to be caused by a loss of cerebrovascular autoregulation, resulting in diffuse cerebral edema (Purcell, 2012). SIS often leads to coma and death (Purcell, 2012).
History taking is an important step not only in identifying and ruling out potential diagnoses but also in determining factors that may affect recovery. Karlin (2011) suggests taking a history of the concussive event, including type of sport (if any), mechanism of injury, loss of consciousness, amnesia, and events after the concussion. It is imperative to obtain an accurate history from the patient and from someone who observed the injury and patient's response immediately after the event. This information will help further clarify the diagnosis, rule out red flag diagnoses, and give the care provider a sense of the severity of the injury. Inquiring about neurologic deficits will aid in ruling out red flag diagnoses such as SIS and intracranial bleeding. Having the patient's previous concussion history is necessary to determine the potential for SIS and poorer prognosis (Karlin, 2011). A postconcussive symptom inventory should be taken, including progression of symptoms and response to mental and physical exertion (Karlin, 2011). Determination of a premorbid personal history of headaches, psychiatric illness, learning disabilities, attention-deficit/hyperactivity disorder, sleep disorder, and seizure disorder is important, because these factors predict the potential for a prolonged prognosis (Cohen et al., 2009; Karlin, 2011; Purcell, 2012). Identifying such modifying factors will assist the PNP in formulating an individualized management and follow-up plan.
The diagnosis of concussion is made on the basis of common signs and symptoms that occur after a head injury. The signs and symptoms are organized into four categories: physical, emotional, cognitive, and sleep-related (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Headache is the most common symptom (Halstead & Walter, 2010). Other physical signs include nausea, vomiting, dizziness, visual changes, fatigue, phonophobia, photophobia, numbness, and tingling (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Cognitive signs consist of mental fogginess and difficulty with concentration and memory (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Irritability, sadness, and nervousness are common emotional changes, whereas sleep disturbances such as drowsiness, increased sleep, or decreased sleep are other signs of mTBI (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Typically, symptoms will resolve in 7 to 10 days after the injury (Purcell, 2012).
In terms of the physical examination, experts recommend conducting a head and neck examination, as well as a neurologic examination that incorporates assessment of gait, balance, coordination, cognition, and cranial nerves (Halstead & Walter, 2010; Karlin 2011; Purcell, 2012). If any neurologic deficits are noted during the physical examination, further evaluation such as diagnostic imaging is warranted to rule out a structural brain or cervical spine injury (Purcell, 2012).
A number of assessment tools have been developed for medical evaluation of the concussed athlete. The Sport Concussion Assessment Tool 2, developed by the CIS group, provides a comprehensive evaluation including neuropsychological testing, use of the balance error scoring system, and use of the Glasgow Coma Scale (McCrory et al., 2009). The Sport Concussion Assessment Tool 2 was designed to be used on the field of play to evaluate athletes 10 years of age and older (McCrory et al., 2009). Purcell (2012) suggests that although this tool has not been validated for use off the playing field, it may be considered for use in the office setting. The practitioner in the case presented was unaware of the existence of such assessment tools at the time and therefore did not use one when evaluating the patient.
Neuroimaging The consensus among experts is that neuroimaging, including skull radiographs, computerized tomography (CT) scans, or magnetic resonance imaging, is generally not indicated after an mTBI (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2009; Purcell, 2012). Neuroimaging usually shows no abnormality because a concussive injury results in functional damage, not structural damage (Halstead & Walter, 2010; Karlin, 2011). In fact, care providers are advised to ensure judicious use of CT scans because of the carcinogenic risk of radiation, especially among the pediatric population (Sun, Nq, & Sarji, 2010). If structural damage is suspected, as evidenced by focal neurologic deficits, seizure activity, or prolonged unconsciousness, neuroimaging such as a CT scan should be obtained (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Functional imaging modalities such as functional magnetic resonance imaging, positron emission tomography, magnetic resonance spectroscopy, and single-photon emission CT may be more useful than structural neuroimaging in determining the extent of brain injury, but more research is required before use of such modalities can be recommended (Halstead & Walter, 2010). In this case, no structural damage to the brain or spinal cord was suspected because the physical examination revealed no neurologic deficits, and thus no imaging was required.
Neuropsychological testing has been shown to be a useful tool in evaluating patients with mTBI because it provides an objective measure of brain function (Halstead & Walter, 2010; Purcell, 2012). Neuropsychological testing should not be used in isolation to diagnose brain injury or to direct the treatment plan, but it should be used in conjunction with clinical assessment to help guide decisions about when the patient is fit to return to sports (Halstead & Walter, 2010; Purcell, 2012). The results of the neuropsychological test also can be used to guide recommendations for school-based interventions (Karlin, 2011). Computer-based neuropsychological testing programs are available, such as ImPACT and CogSport (Purcell, 2012). More traditional paper-pencil tests are also available and are typically performed by neuropsychologists (Halstead & Walter, 2010).
Although neuropsychological testing can be a helpful tool, it is not recommended in every case of mTBI. Neuropsychological testing should be considered when the concussion lasts longer than the expected time frame of 7 to 10 days (Purcell, 2009). Neuropsychological testing also should be considered in children with premorbid conditions, including learning disabilities and behavior disorders, who have experienced a concussion (Karlin, 2011). It is important to note that neuropsychological testing among pediatric patients poses a number of challenges because a child's cognitive function continues to mature and develop. As a result, serial tests will show normal improvements as the child develops, which can potentially confound postinjury assessments (Purcell, 2012). Having a baseline with which to compare postconcussive results is ideal but not always feasible because testing may be required as often as every 6 months to account for a child's normal cognitive growth (Purcell, 2012). Therefore Purcell (2012) does not recommend routine neuropsychological testing in the pediatric age group because of financial costs, time, and resources required to implement frequent baseline testing.
Because the patient presented in the case did not have a history of premorbid conditions, symptoms lasting longer than 10 days, or a baseline neuropsychological test to be used for comparison, neuropsychological testing was not performed. If he continued to have difficulty concentrating or has problems with learning at school, a formal neuropsychological test may be considered in the future.
Cognitive and PhysicalRrest The mainstay of treating a concussion is cognitive and physical rest. Patients with active symptoms should be advised to limit activities that require mental concentration such as reading, watching television, and computer work (Halstead & Walter, 2010; Purcell, 2012). Some students may need to miss class to avoid exacerbating symptoms that occur as a result of increased mental effort required to perform in school (Halstead & Walter, 2010; Purcell, 2012). Care providers need to be cautious when restricting patients from returning to school because prolonged absences from school can result in delayed psychosocial development (Karlin, 2011). In such cases, a graduated approach to returning to school can be organized with the help of the child's teacher. Informal academic accommodations should be made such as open-book testing, tutoring, decreased time with computers, and reduced work load (Halstead & Walter, 2010; Karlin, 2011).
In terms of physical rest, no evidence-based guidelines currently outline when it is safe for pediatric patients with concussion to return to play (RTP; Karlin, 2011). Most guidelines are based on adult models, but experts encourage a more cautious and conservative approach among children and adolescents (Halstead & Walter, 2010; Karlin, 2011; Purcell, 2009). Athletes should absolutely not be allowed to RTP the same day as the injury and should be symptom free for 7 to 10 days before beginning any physical activity (Halstead & Walter, 2010; Karlin, 2011; Purcell, 2012). A graduated RTP protocol was developed by the CIS group to prevent negative consequences and further injury ( Table ; McCrory et al., 2009). Each step in the protocol should take a minimum of 24 hours, and if the patient remains symptom free throughout, he or she can move to the next step (Halstead & Walter, 2010; Karlin, 2011; McCrory et al., 2009; Purcell, 2012). If symptoms recur during a particular step, the patient must resume physical and cognitive rest until he or she is asymptomatic for at least 24 hours. If symptoms do not recur, the patient can resume the last step of the graduated RTP protocol that was last tolerated (Halstead & Walter, 2010; Karlin, 2011; McCrory et al., 2009; Purcell, 2012).
Pharmacotherapeutics The role of pharmacotherapy is very limited in terms of concussion management. The use of medication for treating concussion in children has not been studied (Halstead & Walter, 2010; Purcell, 2012). Acetaminophen and ibuprofen may help to reduce symptoms, but no evidence is available at present to support this assumption (Purcell, 2012). Athletes must keep in mind that they should be medication-free upon returning to play because medications may mask signs and symptoms of concussion (McCrory, 2009; Purcell, 2012). The patient in the case study was cautioned that acetaminophen or ibuprofen should not be used before he begins the graduated RTP protocol.
Follow-up Monitoring a child's recovery is an essential part of managing a concussion. In the acute phase, it is important that the practitioner monitor the patient throughout varying steps of the graduated RTP protocol (Purcell, 2012). Cohen and colleagues (2009) suggest that all concussion cases be managed on an individual basis, and depending on the severity of symptoms, more frequent monitoring may be required.
Evidence suggests that a child's developing brain is more susceptible to injury than the adult brain (Purcell, 2009). Children appear to take longer to recover from concussion and have more significant neurologic and cognitive effects (Halstead & Walter, 2010; Purcell, 2009). Therefore long-term monitoring and follow-up is critical to the child's health and development. Potential sequelae to concussion that must be monitored include disrupted sleep, learning disabilities, anxiety, and depression (Karlin, 2011). Karlin (2011) states that postconcussive syndrome may rarely develop in young athletes after a single concussion. Postconcussive syndrome is characterized by persistent cognitive, physical, or emotional difficulties that last 1 to 6 weeks after an mTBI (Jotwani & Harmon, 2010). The patient in the case was encouraged to attend routine follow-up appointments to evaluate the presence of postconcussive syndrome and other potential sequelae.
Referral Referral to a specialist is generally not indicated. Cohen and colleagues (2009) suggest that if symptom reduction is not seen within 3 to 5 days or if the symptoms are of concern in terms of type or severity, then referral to a specialist is warranted. In this case, the provider chose not to refer at this point because the patient did not have any alarming symptoms or premorbid conditions and his symptoms had shown much improvement in the 3 weeks after the injury.
Discussion
A significant amount of research has been conducted recently on the diagnosis and management of concussion. A position statement was published by McCrory and colleagues (2009) after the Third International Conference on Concussion in Sport (CIS) was held in 2008; however, the statement did not specifically address pediatric patients (Halstead & Walter, 2010; McCrory et al., 2009). The American Academy of Pediatrics published a report in 2010 that outlined the most recent knowledge on pediatric and adolescent sport-related concussion (Halstead & Walter, 2010). More recently, the Canadian Pediatric Society provided updated guidelines on the management of concussion among pediatric patients in 2012 (Purcell, 2012). This discussion will provide a summary of the most recent literature with regard to management and follow-up of mTBI in pediatric patients.
Differential Diagnoses
The pediatric nurse practitioner (PNP) must consider a number of diagnoses when a patient presents with a headache, fatigue, mental fogginess, and poor concentration immediately after a head injury. Diagnoses other than concussion include contusion and skull fracture. Red flag diagnoses to keep in mind are SIS, intracranial hemorrhage or hematoma, and cervical spine injury (see the Box). SIS, which has only been documented in children and adolescents, is described as cerebral congestion that occurs when a patient has sustained a second head injury before having fully recovered from a previous concussion (Halstead & Walter, 2010; Purcell, 2012). This rare condition is believed to be caused by a loss of cerebrovascular autoregulation, resulting in diffuse cerebral edema (Purcell, 2012). SIS often leads to coma and death (Purcell, 2012).
Initial Evaluation
History taking is an important step not only in identifying and ruling out potential diagnoses but also in determining factors that may affect recovery. Karlin (2011) suggests taking a history of the concussive event, including type of sport (if any), mechanism of injury, loss of consciousness, amnesia, and events after the concussion. It is imperative to obtain an accurate history from the patient and from someone who observed the injury and patient's response immediately after the event. This information will help further clarify the diagnosis, rule out red flag diagnoses, and give the care provider a sense of the severity of the injury. Inquiring about neurologic deficits will aid in ruling out red flag diagnoses such as SIS and intracranial bleeding. Having the patient's previous concussion history is necessary to determine the potential for SIS and poorer prognosis (Karlin, 2011). A postconcussive symptom inventory should be taken, including progression of symptoms and response to mental and physical exertion (Karlin, 2011). Determination of a premorbid personal history of headaches, psychiatric illness, learning disabilities, attention-deficit/hyperactivity disorder, sleep disorder, and seizure disorder is important, because these factors predict the potential for a prolonged prognosis (Cohen et al., 2009; Karlin, 2011; Purcell, 2012). Identifying such modifying factors will assist the PNP in formulating an individualized management and follow-up plan.
The diagnosis of concussion is made on the basis of common signs and symptoms that occur after a head injury. The signs and symptoms are organized into four categories: physical, emotional, cognitive, and sleep-related (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Headache is the most common symptom (Halstead & Walter, 2010). Other physical signs include nausea, vomiting, dizziness, visual changes, fatigue, phonophobia, photophobia, numbness, and tingling (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Cognitive signs consist of mental fogginess and difficulty with concentration and memory (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Irritability, sadness, and nervousness are common emotional changes, whereas sleep disturbances such as drowsiness, increased sleep, or decreased sleep are other signs of mTBI (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Typically, symptoms will resolve in 7 to 10 days after the injury (Purcell, 2012).
In terms of the physical examination, experts recommend conducting a head and neck examination, as well as a neurologic examination that incorporates assessment of gait, balance, coordination, cognition, and cranial nerves (Halstead & Walter, 2010; Karlin 2011; Purcell, 2012). If any neurologic deficits are noted during the physical examination, further evaluation such as diagnostic imaging is warranted to rule out a structural brain or cervical spine injury (Purcell, 2012).
A number of assessment tools have been developed for medical evaluation of the concussed athlete. The Sport Concussion Assessment Tool 2, developed by the CIS group, provides a comprehensive evaluation including neuropsychological testing, use of the balance error scoring system, and use of the Glasgow Coma Scale (McCrory et al., 2009). The Sport Concussion Assessment Tool 2 was designed to be used on the field of play to evaluate athletes 10 years of age and older (McCrory et al., 2009). Purcell (2012) suggests that although this tool has not been validated for use off the playing field, it may be considered for use in the office setting. The practitioner in the case presented was unaware of the existence of such assessment tools at the time and therefore did not use one when evaluating the patient.
Diagnostic Testing
Neuroimaging The consensus among experts is that neuroimaging, including skull radiographs, computerized tomography (CT) scans, or magnetic resonance imaging, is generally not indicated after an mTBI (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2009; Purcell, 2012). Neuroimaging usually shows no abnormality because a concussive injury results in functional damage, not structural damage (Halstead & Walter, 2010; Karlin, 2011). In fact, care providers are advised to ensure judicious use of CT scans because of the carcinogenic risk of radiation, especially among the pediatric population (Sun, Nq, & Sarji, 2010). If structural damage is suspected, as evidenced by focal neurologic deficits, seizure activity, or prolonged unconsciousness, neuroimaging such as a CT scan should be obtained (Cohen et al., 2009; Halstead & Walter, 2010; Purcell, 2012). Functional imaging modalities such as functional magnetic resonance imaging, positron emission tomography, magnetic resonance spectroscopy, and single-photon emission CT may be more useful than structural neuroimaging in determining the extent of brain injury, but more research is required before use of such modalities can be recommended (Halstead & Walter, 2010). In this case, no structural damage to the brain or spinal cord was suspected because the physical examination revealed no neurologic deficits, and thus no imaging was required.
Neuropsychological Testing
Neuropsychological testing has been shown to be a useful tool in evaluating patients with mTBI because it provides an objective measure of brain function (Halstead & Walter, 2010; Purcell, 2012). Neuropsychological testing should not be used in isolation to diagnose brain injury or to direct the treatment plan, but it should be used in conjunction with clinical assessment to help guide decisions about when the patient is fit to return to sports (Halstead & Walter, 2010; Purcell, 2012). The results of the neuropsychological test also can be used to guide recommendations for school-based interventions (Karlin, 2011). Computer-based neuropsychological testing programs are available, such as ImPACT and CogSport (Purcell, 2012). More traditional paper-pencil tests are also available and are typically performed by neuropsychologists (Halstead & Walter, 2010).
Although neuropsychological testing can be a helpful tool, it is not recommended in every case of mTBI. Neuropsychological testing should be considered when the concussion lasts longer than the expected time frame of 7 to 10 days (Purcell, 2009). Neuropsychological testing also should be considered in children with premorbid conditions, including learning disabilities and behavior disorders, who have experienced a concussion (Karlin, 2011). It is important to note that neuropsychological testing among pediatric patients poses a number of challenges because a child's cognitive function continues to mature and develop. As a result, serial tests will show normal improvements as the child develops, which can potentially confound postinjury assessments (Purcell, 2012). Having a baseline with which to compare postconcussive results is ideal but not always feasible because testing may be required as often as every 6 months to account for a child's normal cognitive growth (Purcell, 2012). Therefore Purcell (2012) does not recommend routine neuropsychological testing in the pediatric age group because of financial costs, time, and resources required to implement frequent baseline testing.
Because the patient presented in the case did not have a history of premorbid conditions, symptoms lasting longer than 10 days, or a baseline neuropsychological test to be used for comparison, neuropsychological testing was not performed. If he continued to have difficulty concentrating or has problems with learning at school, a formal neuropsychological test may be considered in the future.
Treatment Plan
Cognitive and PhysicalRrest The mainstay of treating a concussion is cognitive and physical rest. Patients with active symptoms should be advised to limit activities that require mental concentration such as reading, watching television, and computer work (Halstead & Walter, 2010; Purcell, 2012). Some students may need to miss class to avoid exacerbating symptoms that occur as a result of increased mental effort required to perform in school (Halstead & Walter, 2010; Purcell, 2012). Care providers need to be cautious when restricting patients from returning to school because prolonged absences from school can result in delayed psychosocial development (Karlin, 2011). In such cases, a graduated approach to returning to school can be organized with the help of the child's teacher. Informal academic accommodations should be made such as open-book testing, tutoring, decreased time with computers, and reduced work load (Halstead & Walter, 2010; Karlin, 2011).
In terms of physical rest, no evidence-based guidelines currently outline when it is safe for pediatric patients with concussion to return to play (RTP; Karlin, 2011). Most guidelines are based on adult models, but experts encourage a more cautious and conservative approach among children and adolescents (Halstead & Walter, 2010; Karlin, 2011; Purcell, 2009). Athletes should absolutely not be allowed to RTP the same day as the injury and should be symptom free for 7 to 10 days before beginning any physical activity (Halstead & Walter, 2010; Karlin, 2011; Purcell, 2012). A graduated RTP protocol was developed by the CIS group to prevent negative consequences and further injury ( Table ; McCrory et al., 2009). Each step in the protocol should take a minimum of 24 hours, and if the patient remains symptom free throughout, he or she can move to the next step (Halstead & Walter, 2010; Karlin, 2011; McCrory et al., 2009; Purcell, 2012). If symptoms recur during a particular step, the patient must resume physical and cognitive rest until he or she is asymptomatic for at least 24 hours. If symptoms do not recur, the patient can resume the last step of the graduated RTP protocol that was last tolerated (Halstead & Walter, 2010; Karlin, 2011; McCrory et al., 2009; Purcell, 2012).
Pharmacotherapeutics The role of pharmacotherapy is very limited in terms of concussion management. The use of medication for treating concussion in children has not been studied (Halstead & Walter, 2010; Purcell, 2012). Acetaminophen and ibuprofen may help to reduce symptoms, but no evidence is available at present to support this assumption (Purcell, 2012). Athletes must keep in mind that they should be medication-free upon returning to play because medications may mask signs and symptoms of concussion (McCrory, 2009; Purcell, 2012). The patient in the case study was cautioned that acetaminophen or ibuprofen should not be used before he begins the graduated RTP protocol.
Follow-up Monitoring a child's recovery is an essential part of managing a concussion. In the acute phase, it is important that the practitioner monitor the patient throughout varying steps of the graduated RTP protocol (Purcell, 2012). Cohen and colleagues (2009) suggest that all concussion cases be managed on an individual basis, and depending on the severity of symptoms, more frequent monitoring may be required.
Evidence suggests that a child's developing brain is more susceptible to injury than the adult brain (Purcell, 2009). Children appear to take longer to recover from concussion and have more significant neurologic and cognitive effects (Halstead & Walter, 2010; Purcell, 2009). Therefore long-term monitoring and follow-up is critical to the child's health and development. Potential sequelae to concussion that must be monitored include disrupted sleep, learning disabilities, anxiety, and depression (Karlin, 2011). Karlin (2011) states that postconcussive syndrome may rarely develop in young athletes after a single concussion. Postconcussive syndrome is characterized by persistent cognitive, physical, or emotional difficulties that last 1 to 6 weeks after an mTBI (Jotwani & Harmon, 2010). The patient in the case was encouraged to attend routine follow-up appointments to evaluate the presence of postconcussive syndrome and other potential sequelae.
Referral Referral to a specialist is generally not indicated. Cohen and colleagues (2009) suggest that if symptom reduction is not seen within 3 to 5 days or if the symptoms are of concern in terms of type or severity, then referral to a specialist is warranted. In this case, the provider chose not to refer at this point because the patient did not have any alarming symptoms or premorbid conditions and his symptoms had shown much improvement in the 3 weeks after the injury.
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