Misconceptions common with pediatric concussions

By Kevin D. Walter, MD, FAAP

Sport-related concussion recently has received much attention in medical journals and has become headline news in popular media. Despite the advances in the lay media and the rapidly increasing number of scientific papers, antiquated information still appears in the current medical literature. There are still many misconceptions about concussion, and many physicians remain uncomfortable with diagnosis and treatment.

Every year there are more than 300,000 sport-related concussions reported, and nearly 10 percent of all high school football players sustain a concussion. The true incidence is likely higher, as athletes may not report their injury or symptoms for fear of being withheld from activity or because they feel that transient symptoms are not dangerous. Athletes that have concussions are three times more likely to have subsequent concussions. Thus, to help identify higher-risk athletes, it is important to inquire about a history of concussion during the pre-participation physical.

There are few evidence-based studies that can help define and manage concussions. This article focuses on the Prague Guidelines, which is a consensus statement created by a panel of international experts. They have defined concussion as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces, which:

• Are caused by a direct blow to the head or neck, or elsewhere on the body with an impulsive force transmitted to the head.
• Typically result in the rapid onset of transient impairment of neurologic function.
• May result in neuropathologic changes, but these are largely a functional disturbance rather than a structural injury. Thus, concussion is associated with grossly normal neuroimaging studies.
• May result in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of symptoms usually follows a typical course.

There are several common signs and symptoms of concussion. (See Table 1.) Although signs and symptoms usually appear immediately, they can be delayed for days after the injury. The diagnosis must be made clinically, using a timeline to associate the injury with the patient's symptoms. With a history of a head injury, all you need is one symptom to make the diagnosis of concussion, as the presentation is quite variable. The differential diagnosis for concussion includes heat illness, dehydration, hypoglycemia and exertional headaches. This may cause some confusion, like when a soccer player gets elbowed in the head while practicing on a hot day. Headache and dizziness are symptoms of both concussion and heat illness. However, if there is doubt with your diagnosis, always err on the side of caution and assume that the symptoms are related to concussion.

Table 1. Common signs and symptoms of concussion
Physical	Emotional	Cognitive
Headache.	Nervousness.	Confusion.
Dizziness.	Anxiety.	Disorientation.
Lightheadedness.	Sadness.	Amnesia.
Nausea/emesis.	Irritability.	"Head in a fog."
Clumsiness.	Personality changes.	Slow to answer questions and follow commands.
Impaired balance.	Inappropriate behavior.	Easily distractible.
Sleep problems.	Emotionally labile.
Blurry vision.
Double vision.
Poor coordination.
Intolerance of light or sound.
Loss of consciousness.
Tinnitus.

The Prague Guidelines abandon the previous grading scales for two classifications for concussion. Simple concussion is a first concussion without any focal neurologic findings that spontaneously resolves without complication over 7 to 10 days. Complex concussions encompass the athlete with persistent symptoms, specific sequelae (concussive convulsions, loss of consciousness longer than 1 minute) or athletes that have suffered multiple concussions, especially if the repeat concussions are caused by progressively less force. The duration of symptoms after the initial concussion are felt to be the best indicator of concussion severity, so it is important to review the concussion course with each visit.

The complications of concussion are very serious. Second impact syndrome occurs when an athlete is still symptomatic from a concussion and then sustains a second head injury, which may be minor. It is believed to cause malignant brain edema and vascular engorgement, which leads to brain stem herniation. It has a mortality rate of 50 percent, underscoring the importance of never letting a symptomatic athlete return to play. Post-concussion syndrome occurs when an athlete suffers symptoms lasting longer than 1 to 2 weeks after a concussion. It may manifest with impaired memory and attention, headaches and fatigue, and also emotional lability. Intracranial hemorrhage, while unusual, can be associated with concussive events. Finally, recurrent concussions are thought to cause permanent damage or disability.

On the field, management of an athlete with a head injury begins with the ABCs (airway, breathing and circulation) and making sure the athlete does not have a neck injury or intracranial hemorrhage. Sideline evaluation should include assessment of cognitive function, memory and a neurologic exam. There are validated tools like the Standardized Assessment of Concussion that can be used. These athletes never should be allowed to return to play or practice that day. The player should be monitored regularly though the remainder of the event. Any athletes that have worsening symptoms or a focal deficit on neurologic exam should be transported immediately. Neuroimaging is recommended for athletes with loss of consciousness, worsening mental status deterioration, dramatically worsening headache, focal neurologic findings, seizure activity or persistent post concussion symptoms lasting more than a week.

Concussion in the pediatric and adolescent athlete is very different from concussion in the adult athlete. The young athlete is actively developing and will have different needs regarding care and treatment. Neuropsychological testing, while controversial in young athletes, reveals that professional athletes return to baseline functioning within 2 to 3 days, but adolescent athletes average 10 to 14 days. Thus, young athletes with concussion need more conservative management for concussion.

Return-to-play guidelines should follow the protocol in Table 2. No athlete should begin the return-to-play protocol while still symptomatic physically, cognitively or behaviorally. The athlete only should progress if asymptomatic at the current level and may progress only one level per day. Any recurrence of symptoms indicates that the athlete should alert his or her physician and fall back to the previous step.

Table 2. Return-to-play guidelines

1. No activity, complete rest until completely asymptomatic. 2. Light aerobic exercise, like walking or stationary biking. No resistance training. 3. Sport-specific solo drills (skating for hockey, running for soccer, etc.). 4. Noncontact drills. May begin light resistance training. 5. Full contact practice after medical clearance. 6. Game play.

It is important to keep in mind that young athletes suffering from concussion may have difficulty with school. It is helpful to send a note to the school indicating that a patient with concussive symptoms will need extra time and assistance with assignments. They also may be more distractible and fatigued. It is important to hold them out of recess and gym class.

Sport-related concussion is a common injury in the pediatric population. No athlete should return to play while symptomatic. A simple rule to use is "when in doubt, hold the player out." Referral to a physician with experience treating concussion is essential for complex concussion, recurrent concussions or if there are any concerns. It is important to spend time educating athletes and their families and helping correct their misconceptions about concussion. Outside of enforcing rules and wearing proper equipment, there is no true prevention of concussion. However, educating young athletes can help them recognize the importance of reporting concussions quickly and treating them appropriately.

Kevin D. Walter, MD, FAAP, is a pediatric sports medicine specialist at Children's Hospital of Wisconsin. He also is an assistant professor of Orthopedics at the Medical College of Wisconsin and a member of Children's Specialty Group.

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