Monday, October 26, 2015

Concussions…Ding dong…Not as simple as getting “your bell rung”

Part 3 – treatment, complications, and follow up

By: Ann L. Contrucci, MD, Director, Risk and Patient Safety, MagMutual Patient Safety Institute  

This article will discuss the treatment, recovery process, and complications that can arise from a concussion, as well as follow-up - a crucial step in the overall recovery process for adolescents and children who have sustained concussions.

Risk factors can complicate and prolong the recovery process from a concussion. The risk of cumulative effects from a history of multiple concussions is real, especially if they occur over a shortened period of time. This is why we emphasize taking a detailed neurological history that includes a personal or family history of migraines, depression, mood disorders, anxiety, learning disabilities and ADHD. Any of these morbidities can prolong a patient’s recovery time. As always, signs of deteriorating neurologic function should be promptly evaluated and treated.

The management of concussions

As a part of your initial evaluation, include a general discussion of the steps involved in concussion recovery with the patient and family, and the importance of patient/family compliance with your recommendations, such as the need for the patient to avoid physical and cognitive exertion, especially in the acute stages of recovery. Highlight the fact that some symptoms may not be noticed for several days after injury and that they must monitor the patient for those types of changes and notify you or the attending physician immediately.

The good news is that most patients recover fully without sequelae. The bad news is that the management can become quite complex and cumbersome. Individualize patient management and monitor the patient’s physical and cognitive activities closely. Typically, if symptoms resolve within 7-14 days, treatment and follow up may be done in the primary care office setting. If seen initially in the ED, that treating physician should ensure proper follow up either through the PCP or with a concussion specialist. ED physicians should not allow return to play the same day and should not give a date to return to play when discharging a concussion patient.

All evaluating/treating physicians should refer the child or adolescent to a concussion specialist if symptoms persist after 10-14 days, if they worsen, if there is a history of multiple concussions or if other risk factors exist that could prolong recovery. At that point, neuropsychological testing may be considered to validate persistent subjective symptoms, especially symptoms related to reaction time, executive functioning, etc. However, neuropsychological testing should not be used exclusively to diagnose, treat, or make return to play decisions.

What about returning to school?

Often parents and patients will ask these questions as soon as the injury occurs. A recovery plan must be individualized to the particular patient. Memory, concentration, and focusing issues can and do occur. This is why “cognitive rest” is crucial, especially in early management and recovery – examples include avoiding computer work, watching TV, texting, video games, and even reading. Teachers can be a vital set of “extra eyes” upon a concussed student’s return to school by watching out for the following: difficulty concentrating or remembering new information, taking longer to complete tasks, complaining of increased headache or fatigue while doing school work, or poorer academic performance than baseline. Accommodations may be required temporarily as the child or teen transitions back, including a shortened school day or taking rest breaks during class or during the day as well as allowing for more time to complete work and providing the student with accommodations in testing situations.

What about returning to play?

The physician should make an unpressured decision as to when a child may return to play, not the family or coach. The challenge is to individualize each patient’s plan, based on his or her symptoms. A good rule of thumb is the younger the athlete, the more conservative the treatment. As we mentioned in Part 2 of this article, children’s brains are still developing and the neurometabolic cascade of injury is very different than in the adult’s brain.

There is a 5-step process of increasing activity that may take days, weeks or months. Symptoms and cognitive function should be evaluated during each increase in activity level. This is best done in a team approach as it requires a fair amount of follow up. The 5-step process reintroducing activity is as follows:

1. Step 1: Start with light aerobic exercise, which is defined as increasing heart rate for 5-10 minutes such as with an exercise bike or light walking. However, Step 1 should not occur until at “baseline” and there are no physical or cognitive symptoms for a minimum of 24 hrs.
2. Step 2: Next introduce some moderate exercise and limited body and head movement but for a time that is less than the “typical routine.” Examples include moderate jogging, biking, or weight lifting.
3. Step 3: Gradually move closer to a “typical routine” with some non-contact exercise, which includes running, regular weight lifting routine and sports specific drills.
4. Step 4: The athlete is allowed back to practice.
5. Step 5: Return to competition.

If symptoms return at any of these steps, rest for minimum of 24 hours and return to previous step. There will most likely be resistance from patients and families at this point. Reiterate that the rest period will help them return sooner than if they “try to push through”.

Post concussive syndrome occurs when symptoms continue for several weeks to months after injury. It occurs in approximately 5-8% of patients with a history of previous concussions. Students may be eligible for a “504 plan” in school which is a plan to accommodate those with a disability (temporary or permanent) that affects academic performance.

Can we prevent concussion injuries?

Realistically, can concussions be prevented? Planning during the pre-season can be important so all team members understand the roles they play – who will be responsible for the field response, the emergency assessment of the athlete, the observation on the sideline and deciding about disposition. This can be difficult as there is not always an actual trainer available on the sidelines especially for the younger children. These tips will help:

• Know where trauma centers are in the area.
• Educate coaches and athletes on concussions.
• Consider conducting baseline assessments during the pre-season especially in contact sports.
• Ensure the league or school has a concussion plan in place – numerous resources are available.
• Use common sense regarding appropriate techniques of play, following the rules, conducting good sportsmanship, and correctly wearing protective equipment Keep in mind that helmets themselves are not “concussion proof” – they are there to prevent catastrophic injuries only.

In conclusion, remember children and teenagers have different brains and should be treated differently than adults. Reach out for help when needed. Concussions can create long-lasting complications and should be taken seriously. Numerous resources are available for clinicians including checklists for symptoms and guidelines for return to play and school. The CDC has a specific toolkit which includes CME credit. The AAP and American Academy of Neurology have guidelines as well. The good news is that concussions can be successfully treated to full recovery with the end result being a team of happy physicians, parents, coaches, children and teenagers.


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