Concussions are considered to be among the most complex injuries in sports medicine and primary care to diagnose assess, and manage

Concussions are considered to be among the most complex injuries in sports medicine and primary care to diagnose assess, and manage A conoussion is a traumatic injury to the brain, generally characterized by rapid onset of a constelation of symptoms or cognitive impaiments 0tcher Gira, & Alessi 2010) The 4th International Conference on Concussion in Sport recognizes concussion as a subset of traumatic brain injury (McCrory, 2013) Imaging Management of the Chdwth Conouson toPy Second impact Syndrome Batum to Lea Pracie Management Concussion Couneng Concussion is a biomechanically induced aiteration in the unction of the brain, rather than e sthuctr o anatomic iniury, Concussions are ohen the result of low-velocity injunies with symptoms that are ce associated wth pathologic structural injury Loss of conscouaness occursin less than 10% of concussions (Scorza, Ralegh &O’Connor 2012) A concussion can be caused by a biow to the headd, or a blow to the neck or oher body part with a force that transmits to the head, resulting in rapid movement or rotaticn of Clnica Implicatons insuctions for Taking the CB Test Onine Conusn Ev onnd Maragement the brain (Halstead & Water, 2010). Sports concussion in vouth has received much attention in recent years because research sbows at improperly managed conoussion can lead to long-berm cognitive deficits and mental health probiems and even contribute to death. The American Academy of Neurology acknowledges that variability in provider experience and training, ooupled with an explosion of concussion-related iterature, has led to uncertant and inconsistency in dagnosis and management of these injuries (Giza et al, 2013). Pedatrics References IMAGE GALLERY ain purpose of is article is to provide an update on the most curent pediatnc standarts and guidelines in concussion evaluation and manageement. This information will promote evidence-based practioe standards that are consistent with “Retum to Play” legislation that has been adopted by most states, Knowiedgeable nurses can educate patents, parents, the public, and other providers on rsks and prevention strategies for concussion, as well as approaches for detection and promotion of best outcomes following this common brain injury. Back to Top Incidence, Prevalence, and Cost to Society Though it is now improving, the public’s knowledge of concussion has varied widely, resulting in gross underreporting of this common brain injury (McKinlay, Bishop, & McLellan, 2011) It has been estimated that up to 3.8 million sports and recreation-related ooncussions occur yearly in the United States (Langlois Ruland-Brown, & Wald, 2006). Approximately 1 in 10 high school sports injuries is a concussion (Hastead, 2010) The difficulty in obtaining a better estimate of this number relates to undermeporting which occurs for several reasons. Wthout loss of consciousness, medical evaluation may not be sought following a concussion-inducing injury. Other times, care may be sought in a setting that does not use an injury surveilance system. An athlete may be reluctant to report head injury or seek medical attention for fear of being removed from his sport (Halstead, 2010, McCrea, Hammeke, Osen, Leo, & Guskiewicz, 2004) Finaly, accurate concussion estimates may be hampered by the use of incomect International Classifcation of Diseases codes (West & Marion, 2014) The cost of concussion to society is even more elusive, as it is diffoult to differentiate between costs for functional and structural brain injuries. In 2010, the Centers for Disease Control and Prevention (CDC) estimated that the cost of traumatic brain injury in the United States was approximately $76.5 billon including both direct and indirect costs (Faul, Xu, Wald, Coronado, & Dellinger, 2010) Direct costs include expenses incumred for neurologic evaluation, management, and follow up. Persisting symptoms and long- term sequelae impose significant burden to individuals, families, and society, and produce enormous indirect costs related to lost or impaired productivity, school and work absence, and altered interpersonal relationships (Faul et al 2010). Back to Top Consensus Statements and Standardization of Care Many new or updated clinical practice guidelines and position statements have been recenty published by stakeholder onrganizations to address growing interest in concussion identification and management. These guidelines have been compared and contrasted to identity points of agreement and opportunities for further clariication. A 2013 comparison of guidelines from the American Society for Sports Medicine, the American Academy of Neurology, and the Zurich Consensus Working Group (West &Marion, 2014) revealed important simiarities. Among these points of agreement are the following Concussion is a clinical diagnosis to be made by a licensed healthcare professional who is familiar with the signs and symptoms of this injury There is no single test that can be used to determine whether a concussion has occurred “Computerized tomography (CT) scans of the head are not routinely recoommended and should be reserved for cases where intracranial hemonhage is suspected Graded symplom and cinical sign checkists can be uatdn dagnosng concussion and monitoring for resolution. This is especialy true for athletes in whom a preseason checkst is avalable for comparison with postinjury results A general, stepwise inorease in physical activity, followed by increase in sports-relaed activty recommended prior to retum to ful play Medications, such as anaigesics tat mask cinical symptoms should not be used while advancing activites It is important to pedietric providers that there is uniform consenus among majpr organzations that a ghad or adolescent should not be aliowed to participate in sports while symplomatic from gnoussion, or on the same day that a concussion has occurred, regardless of duration of symptoms The key ecommendaions require that a pediatric patient with suspected concussion not be allowed to retum to ull play un evaluation and clearance by a loensed healthcare provider A more conservative approach for rehum to activies has been proposed for children and adolescents, as compared to aduts Proorams of indiviualized, stepwise increases in physical activity have largely replaced algonths for asonic grade and activity expectations to concussions (Gomez &Hergenoede 203 tn s013 he Gideline Development Subcommtee of the American Academy of Neurology reviewend idence from 1955 to 2012 to revise its position statement on concussion management in sports iGaa al, 2013) Athough specific interventions to improve outoomes were not identfed. the suboommitee’s practice recommendations specific to children and adolescents included the following Individuals supervising student athletes should retuning to practice/play untl a licensed healthcare provider has determined that the concussion has resolved and that the student is asymptomatic without medication ohibit a student with a conoussive-ke injury from Concussive injuries in children and adolescents should be managed more conservatively than in adits Licensed healthcare providers can help in developing individualized graded plans to rebum to physical and coanitive activity, guided by a carefuly monitored, clinicaly based approach to minimize exacerbation of symptoms There has been a national response to the impact of concussion on youth. As of 2014, all 50 states and the District of Columbia have enacted some type of legislation to address traumatic brain injury For the majority of states, there has been enactment of “Return to Play” legislation to prevent concussion and im injury to students or student athlettes (State Laws on Traumatic Brain Injury, 2014). In general, these laws required school districts to develop programs to affect education of parents, coaches and administrators about concussion, removal of students suspected of having a concussion from sports participasion, and clearance of students with concussion to retun to play by a licensed healthcare professional who is qualified to assess fitness for play. Currently, although most states have “Retun to Play” legislation, not all of these states require healthcare professionals to receive specific training in concussion management, although there is movement in this direction. Many providers stll rely upon reputable published resources to guide their practice. For example, the CDC (2014) has developed a Web site of concussion resources for students, athletes, parents coaches, and healthcare professionals. Back to Top Risk Factors for Developing Concussion History of a previous concussion has been established as one of the most significant risk factors for subsequent concussion (Covassin & Elbin, 2010; West & Marion, 2014). There are several other notable risk factors affecting incidence and severity of concussion in school-age children and adolescents These risk factors can be broadly understood in terms of sport, age, sex, and special population groups Back to Top Sport Athletes who participate in contact or collision sports are at great risk for concussion. This risk is highest during competition (Boden, Breit, Beachler, Wiliams, & Mueller, 2013, Scorza et al, 2012). The American Academy of Neurology reports sports commonly associated with concussion include football, soccer, lacrosse, and basketball. Nontraditional sports that also pose risk for concussion include sledding. skateboarding, and motor oross (Giza et al, 2013) Back to Top- Age Adolescents from age 10 to 19 are more vulnerable to head injunes compered to younger chidren Cogntive recovery from sports-related concussion in tis age group also seems to requre a longer period than that required of college or professional athletes Ma et a 2012) Back to Top Sex Sex dfference as a risk factor for concussion is controversial (Grady, 2010, Wst &Maron 2014), Males have a higher overall incidence of concasion relative to their higher aes of particpaion in contact sports Females, however, have almost a two-fold susceptibility to concussion in any sport where the ues of piay are simlar among males and females (Covassin, Elbin, Kontos&Larson 2010 Femaes seemto be more prone to concussion folowing collision with playing surtaces or equipment whereas maes are more prone to concussion after player-to-player collision (Scorza et al, 2012) Back to Top Special Population Groups Students with attention-deficit and/or hyperacttivity disorder, depression, or leaming disabilites are at greater risk for concussion than those without these conditions (Grady, 2010) Student athletes with an increased body mass index seem to be at increased risk (Giza et al, 2013) Back to Top Suspected Concussion At present there is no single tool or test to rely on for diagnosis of concussion Concussion is a cinical diagnosis (McCrory et al., 2013). Because healthcare professionals are infrequently available to perform immediate assessment at the exact time of head injury, clinicians who practice in outpatient setings may be evaluating children and adolescents for concussion shortly after an injury for evaluation, in follow-up several days after primary evaluation in an emergency department, or when the athlete seeks help for persisting symptoms following an injury that was not yet evaluated Back to Top Initial Evaluation: History and Physical Examination Initial evaluation ater a direct or indirect blow to the head involves ruling out cervical spine injury and serious traumatic brain injury, and addressing other urgent first-aid issues. After ruling out injuries that require immediate intervention, the next step in the assessment of a possible concussion is obtaining a complete history. This history includes a description of events leading up to the injury, location of any forcble impact to the body, whether there was loss of consciousness, and completion of a symptom checklist (Guskiewicz & Broglio, 2011). Loss of consciousness occurs in less than 10 % of concussions (Soorza et al, 2012), The physical examination should include a thorough assessment of mental status, gait, and balance. Accordingly, recommendations for use of the Sport Concussion Assessment Tool 3 (SCAT 3) or another appropriate sideline assessment tool were- made at the Zurich Conference (Guskiewicz et al, 2013, McCrory et al, 2013) Sideline assessment tools generally incorporate these important points, and can be administered by nonmedical trained providers (Table 1). TABLE 1 Instruments Back to Top- Assessment Tools There are dozens of concussion management and assessment tools available today. Generally, these tools are identified as either concussion assessment tools or concussion management tools, and can be further categorized as symptom checklists, sideline assessment tools, balance assessment tools, or computerized neurocognitive examinations (Dziemianowicz et al, 2012). An example of a sideline assessment instrument can be found in Supplemental Digital Content, Figure 1, http// Use of neurocognitive assessment tools in conjunction with symptom checkis has been shown to merove sensitvity, specificty, and both positive and negaive predictive value oft estmating proacted recovery when compared to using any instrument alone (Lau Colins & Lovel 2011 De recommendations and findings, no tools have been developed specificaly for sideine asesmet of chidren, and no curently available instrument has been validated for sideline use through all stages of a child’s recovery (Davis & PPurcell, 2014) Moreover, there is insuficient evidence to support appraisals developed using neuropsychological assessment tools in preadolescent groupe Athough validty and reliability testing is ongoing to support use of adut instruments in pediatric pateents it s practica and appropriate that clinicians incorporate these instruments into their practice in accordance with local guidelines Back to Top Imaging Concussions cannot be diagnosed by a CT scan or magnetic resonance imaging (MRI), nor can they be rued out by a negative CT scan or MRI. Imaging contributes ittle to the management of concussion oher than ruling out serious traumatic brain injuries (eg, intracranial hemonthage, subdural or epidur hematomas), contusions, skul fracture, or cervical spine injuries (Scorza et al. 2012). There are guidelines available to cinicians to help quide these types of decisions For example, a 2010 cinical report on spots. related concussion in children and adolescents from the American Academy of Pediatrics recommends that children who present with loss of consciousness greater than 30 seconds, evidence of skull fracture, or focal neurological or ophthalmologic findings following head injury be considered for imaging (Halstead & Walter, 2010) Back to Top Management of the Child with Concussion Evidence is currently lacking to show that any specific intervention enhances recovery or diminishes long- term sequelae postconcussion (Giza et al 2013, Grady, Master, & Giola, 2012). Until more evidence emerges, cognitive and physical rest are comerstones in concussion management of pediatric patients Concem about long-term injury to the child’s developing brain merits a more conservative approach than for adults Greater than 80 % of concussions in children resolve with conservative management in the first 3 weeks postinjury (Collins et al, 2003). To achieve cognitive and physical rest during this period, demands on the child or adolescent must be reduced Recommendations should be made for increased rest or sleep, time off from school or work, limitation of homework, minimal use of visually stimulating electronic activities, no unnecessary travel, and restriction of exercise and athletics. For older teens, driving should be prohibited pending medical clearance (Moser, Glatts, & Schatz, 2012; Moser & Schatz, 2012, Schneider et al, 2013) Best practice includes a multidisciplinary team that actively involves the student, family, medical providers, and relevant school and sports staff (McAvoy, 2009, 2012) Specific recommendations to achieve cognitive and physical rest must be individualized and targeted to achieve optimal compliance. For example, if a child or adolescent finds television viewing to be relaxing and it does not exacerbate symptoms, it may be permited in limited quantity, with modifications to reduce light and noise. There are currently no known interventions to speed recovery postooncussion in pediatric patients. Low levels of physical activity are being examined for benefit of those individuals who are slower to recover (McCrory et al, 2013) Back to Top Return to Play A gradual retun-to-play protocol can be implemented once a chid or adolescent has recovered from the concussion injury across physical, cognitive, emotional, and sleep domains. The decision to return to play should never be made by one individual, or by using one assessment tool rather, multiple data points from mutiple sources should be considered. During graduated return-to-olay activities, the student should not ber taking medications that may mask the symptoms of conoussion. A sample return-to-play protocol can be found in Figure 2 Athletes between the ages of 10 and 18 years appear to be more symptomatic after concussion, and may take longer than adults to become asymptomatic (McAvoy, 2009, 2012). Evidence suggests that postconcussion headache persisting 7 days. ater injury in high school athletes is associated with incomplete recovery from Egure 2 concussion (Colins et al, 2003). If symptoms are increasing at any point, not improving by 2 weeks, or persisting beyond 3 weeks, a multidisciplinary rehablitation strategy may be warranted, including referral to a specialized concussion management team (Makdissi, Cantu, Johnston, McCrory, & Meeuwisse, 2013). Ovid ta wters u Supon&Trinng F c Coe Instrume Casegorys Considertion Assessment and -20-minute assesment Tests memonry, performance, reaction time, and speed of cognitive procesing and othe areas of neurocognitive function ImPACT Management Tool Symptom Checklist Online version available Originally developed to provide information to athletes, physicians, and athit trainers on the resolution of concussive symptoms 22em scale Assessment and Management Tool Symptom Checklist PCS Post Concussion Symptom Scale Subjective rating of 0-6 for each item One of the most widely used tools for sideline injury assessment Test battery consisting of initial injury assessment with Glasgow Coma Scale, followed by observationidocumentation of concussive signs, followed by symptom endorsement and rating of severity Assessment Tool SCAT Sport Conoussion Assessment Tool, 3rd Edition Sideline Assessment Tool Standardized tool specific for assessing children aged 5-12 years of age Assessment Tool Sideline Assessment Tool ChildSCAT Recommended for use by the Centers for Disease Control and Prevention as pat of the “Heads Up” campaign to enhance evidence-based concussicn management Includes injury characteristic assessment, symptom checkist, and screening for high-risk factor Assessment and ACE Acute Concussion Evaluation Management Tool Sideline Assessment Tool -5-7-minute assessment Designed to assess acute impainment by nondinicians Component of SCAT Measures orientation, memory, concentration, and recall Assessment Tool Sideline Assessment Tool SAC Standardized Assessment of Concussion -3-5-minute assessment Postural stabilty assessed using three ddferent stances, completed on both hard and soh se Balance Assessment Tool BESS The Balance Emror Scoring System Component of SCAT Assessment inwalidated by ankleleg injury Widely accepted telemedicine tool Management Tool Intemet-Based Neurocognitive Assessment Tool CRP -30-minute assessment HeadMinder Concussion Resolu- Objective measures of reaction time, visual recognition, and speed of information process tion Index ‘Ehin Schat, & Covassin (2011) and hverson, Lovell, & Collins (2005) Lau et al. (20111, Lovell & Collies (1, and Lovell et al (2006 McCrea et al About Us Guskiewic (6Elanger ot (2003) King Bghe et al 2013 Tem Privacy Policy Hume, & Gissane (2014) Cohen Gioia, Atabaki &Teach (2009 and Gloia, Collins, & Isquith (200 McCrea et al (2003) Contact Us OvidUl, SourcelD118528 2019 Ovid Technologies, Inc. All rights reserved sack to Tops Second Impaet Syndrome It a child or adolescent retums to full activises andior sports betore fu resclutign of conoussion, the bram may be more susceptible to reinjury from a repeated injury, This rare conditon is called “second impact syndrome” and its devastating consequences have been reported aimost exclusively in toens (Boden Tacchet, Cantu, Knowles, & Mueller, 2007, McCrea, Pemne, Niog & Hars, 2013, Weinsbein Tumer Kuzma, & Feuer, 2013). Unsl more is known about the increased wineratility to injury following concussion, it is widely accepted tat chidren and adolescents not be permited to reum to ul play wi sll symptomatic Back to Top “Return to Learn Problems in the classroom setting have also been repoted following conoussion and are related to the signs and symploms associated with this injury (Table 2) Paraleing gradual retum-to-play recommendations, gradual retun to cognitive exertion may be necessary to reduce symptoms during recovery Folowing concussion, students have been found to have cognitive deficits such as dificulty remembering previously learned material and dficulty leaming new maerial These students may beneft from individualzed accommodations developed by a multidisciplinary team (Halstead et al, 2013) JABLE 2 Concussion Several terms should be tamiar to the heathcare provider when requesting assistance from the school following concussion in a student 0Halstead et al 2013) These include academic adjustments (nonformalized adusmentsto the sudent envinonment during a shon up to 3 weeks recovery penod and should not significanty aher curiculum requirements), academic accommodations (more formalized adjustments, in the form of a 504 plan for symptoms lasting beyond 3 weeks, may include schedule adustments and testing reanangementa) and academic modifications (prolonged and more permanent changes to the curriculum that are usually in the form of an Individualized Education Plan Back to Top Proactive Management: Concussion Counseling In their 2013 guideline updates, the American Academy of Neurology recommends processes to support preparticipation concussion counseling for student athietes (Gza et a, 2013) srecommended that healthcare providers educate designated school-based professionals so that they can provide accurate conqussion information to parents and athetes, and healthcare providers inform athtes and their famles of concussion risk factors For pediatric paients, the majority of concussions that bring children to an emergency department do nat occur during competitive ahietics, but rather are related to fails, bicycle and motor vehicle accidents and other mechanisms (Meehan &Mannix, 2010) Anticipatory guidance about concussion is relevant to all children and their parents. This information should be reasonably included as part of wel-child counseling Because prior concussion is a significant risk factor for uture injury as well as a risk factor for neurocognitive impaiment, ascertaining concussion history can also be made a part of the annual visit For children and adolescents who report events suggestye of an interim goncussion, but who may not have been formaly evaluated at the Sme of injury, neuropsychological testing should be considered in cases where residual effects are suspected For children and adolescents who have a history of mutiple concussions, formal neurocognitve testng may help guide decisions for withdrawal thom compettve sports (Giza et al, 2013) Sports preparticipation baseline neuropsychological testing has not shown substantial utity in helping to diagnose postinjury concussion (Echemenda et al, 2012) but the American Academy of Neurology emphasizes that such tests are only an adjunct in the evaluation of head injury, and cannot be used alone to diagnose concussion (Giza et al, 2013) Back to Top- Clinical Implications Incidence and impact of conoussion are of increasing concem to the healthcare, athletic and educational communities. Guideines for assessment and management of children and adolescents who have sustained a concussive injury support the following concussion severity should be determined by ther degree of functional impairment andior the duration of symptoms rather than by the mechanism of injury concussion management shouid be individualzed and is dependent upon multiple factors including sign/symptom presentation, previous history of concussion, neurocognitive assessment, and reports from parents, coaches, and teachers, concussion management should be driven by concem for long-derm cognitive impairment and concussive injuries in children and adolescents should be managed more conservatively than in adults. Systems are needed to improve early delection of this brain injury and trackong of mptoms from time of dagnosis. For children and adolescents, an active plan of cognitive and physical rest pending neuropsychological recovery and symptom resolution is the mainstay of treatment, followed by a graded program of exertion prior to medical clearance for return to full activites Student athletes should never retum to play on the same day as a suspected concussion, regardless of symptoms Current evidence for concussion management in pediatrics is based mostly upon consensus and usual practioe Rigorous evidence for clinical recommendations for children and adolescents is greaty needed Web resources for clinicians are isted in Table 3 Table 2 W Resours Back to Top Instructions for Taking the CE Test Online Concussion Evaluation and Management in Pediatrics Read the article. The test for this CE activity can be taken online at . Tests can no longer be mailed or faxed You will need to create a free login to your personal CE Planner account before taking online tests. Your planner wil keep track of all your Lippincott Wilams&Wkins online CE activites for you There is only one corect answer for each question A passing score for this test is 13 comrect answers. I you pass, you can print your certiicate of eamed contact hours and the answer key. f you fal, you haver the option of taking the test again at no additional cost For questions, contact Lippincott Wliams & Wilkins: 1-800-787-8985 Registration Deadine: April 30, 2017 Disclosure Statement The authors and planners have disclosed that they have no financial relationships related to this article Provider Accreditation Lippincoft Wliams & Wikins, publisher of MCN, The American Jounmal of MatemalChld Nursing, will award 2.5 contact hours for this continuing nursing education activity Lippincott Williams & Wikins is accredited as a provider of continuing nursing education by the Amenican Nurses Credentialing Center’s Commission on Accreditation This activity is also provider approved by the California Board of Registered Nursing. Provider Number CEP 11749 for 2.5 contact hours. Lippincott Williams & Wikins is also an approved provider of continuing nursing education by the District of Columbia and Florida CE Broker #50-1223. Your certificate is valid in al states Payment The registration fee for this test is $24.95 For additional continuing nursing education activites on pediatric topics, go to nursingcenter.comice Back to Top References Boden B. P. Breit L Beachler J. A, Wliams A. Mueller F. O. (2013) Fatalities in high school and college football players. American Joumal of Sports Medicine, 41(5), 1108-1116 dot 10.1177/0363546513478572 Context Link Boden B. P. Tacchetti R. L, Cantu R. C, Knowles S. B., Mueller F. O. (2007). Catastrophic head injuries in high school and colege football players. American Joumal of Sports Medicine, 35(7), 1075-1081. doi 10.1177/0363546507299239 IContext Link Centers for Disease Control and Prevention (2014) Injury prevention and control Traumatic brain injury Retrieved from www.adc.goviconoussion?

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