Clearing up confusion over concussion identification and management

A concussion can sideline a player, but it shouldn’t intimidate pediatricians.

Providers and the public have a lot of misconceptions about concussion management, but experts say the need for extreme treatment is rare, with rest and gradual return to activities being the key.

“We want to make pediatricians comfortable in managing and safely returning patients back to sports following a concussion,” says Mark Halstead, MD, FAAP of the Washington University School of Medicine and St. Louis Children’s Hospital in Missouri.

Halstead discussed concussion management in a session titled, “Hitting a Moving Target: Office Concussion Evaluation,” with Kevin D. Walter, MD, program director for pediatric and adolescent sports medicine at the Children’s Hospital of Wisconsin and associate professor at the Medical College of Wisconsin in Milwaukee, on October 26, 2019 and repeated on October 27, 2019 at the 2019 American Academy of Pediatrics (AAP) Annual Conference and Exhibition in New Orleans, Louisiana.

The session highlighted guidance from the 2018 AAP clinical report on sports-related concussions to which Drs. Walter and Halstead contributed.

As concussion care is a rapidly evolving field, pediatricians are often somewhat unsure about concussion treatment, Dr. Walter says, and this means that the public is even more confused.

“We are trying to get pediatricians more comfortable with the diagnosis and management of concussion so that they can not only provide better care in their clinics, but they can educate their community,” Dr. Walter says.

Dr. Walter says it’s important to increase awareness about concussions among providers, parents, and coaches.

“It’s a common injury that pediatricians see all the time in their practice, but there’s still a whole lot of misinformation and myths in the media, including the idea that all concussions are going to lead to long-term deficits,” Dr. Walter says.

Part of the problem with concussion management is the multiple entry points into the healthcare system that individuals with concussions use-some go to athletic trainers, some use emergency departments, and others visit the urgent care center or their primary care office, Dr. Walter notes. Some don’t see anyone at all.

“That makes it really hard to truly understand the incidence of concussion,” he says. “The key thing is always a good history and physical exam. You want to make sure the symptoms are consistent with concussion and no other medical reason.”

How many concussions an individual has had plays a big role in how an injury is managed, Dr. Walter says. A standard neurologic exam is necessary in all cases, but the Fifth Edition Sport Concussion Assessment Tool (SCAT5) is also helpful for an immediate assessment at the time of an incident and to evaluate improvement later on.

“It takes you stepwise through a concussion evaluation.  If used on the sideline, there is a recorded score and documentation of what the athlete looked like at the time of injury," Dr. Walter says. “This can help prevent an athlete changing their story and minimizing their symptoms in an attempt to get cleared faster.”

“The first day or two after concussion, the symptoms are usually at their worst, but if symptoms continuously worsen, that’s a problem that may require emergent evaluation,” Dr. Walter says.

Use of computed tomography scans and magnetic resonance imaging should be used only to assess for more serious injury, like skull fracture or intracranial hemorrhage. Concussion will not "show up" on standard neuroimaging, Dr. Walter adds.

“In the end, advanced imaging is for a select few people,” he says. “It’s not a screening tool.”

Clinical judgment is the key in concussion assessment and management, Dr. Walter says.

Recommendations on treatment are also changing, the days of sitting quiet in a dark room-nicknamed "cocoon therapy"- and waking up kids repetitively at night should be things of the past.

Dr. Walter says “They may have to miss a few days of school, but the goal is to get back into school as soon as possible, maybe with a lightened workload.”

Because every school and every student is different, Walter prefers that schools create a workload reduction plan that increases as the student recovers.

“There’s no one better than the school on how to guide the student back to school,” Dr. Walter says. “They know the caliber of the student and the flexibility of the teachers.  This helps school best tailor the adjustments to the students’ needs.”

As far as the clinician’s side of recovery, Dr. Walter says patients may be allowed to do many of their normal activities within reason, but avoiding sports, and contact and collision activity.

“These kids can remain involved with their daily lives. They don’t have to sit around and do nothing, they just should be sure that they don't worsen their symptoms,” Dr. Walter says, adding that electronics don’t necessarily have to be off-limits. “They can be plugged in as long as they do it based on symptoms and do not overstress their brain.” Getting a good night's sleep is important, and kids need to focus on getting their school work done prior to watching YouTube videos for fun.

When it comes to medications, Dr. Walter is more conservative.

“I avoid opioids and narcotics, as their side effect profile mirrors concussion symptoms,” Dr. Walter says. Acetaminophen is the safest best, at least for the first few days, followed by nonsteroidal anti-inflammatory drugs if patients feel that works better for headache control.

Conservative pain management is key to determining if a concussion is worsening, he adds, and too much pain medication can mask symptoms and delay a patient getting the additional care they may need.

When it comes to return to sports guidance, Dr. Walter suggests pediatricians follow the six-step protocol outlined in the 2017 Berlin Concussion in Sport Group Consensus Statement. The guideline maps out the return to play progression accepted by nearly all athletic organizations and governing bodies, Dr. Walter says. Patients and parents must agree that the patient is symptom-free. Medications should no longer be required to manage pain, and the school should agree that the patient is back to their baseline with a full, normal workload. Physicians should then reevaluate the patient's neurologic, cognitive, and balance / coordination to ensure he or she is back to baseline before clearing them to begin the return to sports progression. A gradual return is key, he says, starting with aerobic activity with a gradual return to full game play.

“It’s a step-wise progression,” Dr. Walter says. “If they have a return of symptoms, they should stop and go back to the doctor.”

 Research has shown that pre-high school sports have the biggest risk of not recognizing concussion and allowing kids to return to play too quickly.  Our hope is that pediatricians who attended our session will become a resource for their community to help promote education and awareness on concussion.

“No one should return with symptoms; no one should ever return the same day as a concussion; and we recommend everyone should have medical evaluation prior to clearance,” Dr. Walter says.