Diagnosing and managing paediatric concussion: Key recommendations for general paediatricians and family doctors

Abstract

Concussion in children and adolescents is an important health concern. Most paediatric patients fully recover in 1 month or less following an acute concussion. However, some experience prolonged or persistent concussion symptoms for months. Those with prolonged post-concussion-related symptoms may have impaired quality of life, and limited involvement in social, academic, and physical activities with associated mental health implications. In this review, we share key updated clinical recommendations from the Living Guideline for Diagnosing and Managing Pediatric Concussion that will improve the way general paediatricians and family doctors diagnose and manage paediatric patients with suspected concussion.

WHAT’S NEW

1. A comprehensive medical examination is required to diagnose concussion. No single physical test or functional test can rule out or diagnose concussion.

2. After 24–48 hours of complete rest, low-risk physical activities should be resumed in a step-wise manner at an intensity that does not worsen concussion symptoms.

3. Participation in cognitive and social activities 24–48 hours after an acute concussion should gradually resume at a level that does not worsen concussion symptoms.

4. Medical clearance is required before full-contact sport and game play can be resumed. Medical clearance is not required to return to school.

5. Those at high-risk of prolonged recovery should be referred to an interdisciplinary concussion team for targeted care, including potential prescribed aerobic exercise.

The number of children and adolescents seeking initial care and follow-up for concussion is increasing across Canada (1). Although the reason for this increase remains unknown (e.g., more risky behaviour versus increased awareness of concussion and what to do if you think you have a concussion), there is an urgent need for increased implementation of standardized diagnosis and management protocols for the primary care setting (1). To fill this need, a North American team of 43 paediatric concussion experts created a living clinical guideline resource based on current research and expert consensus (2,3). The guideline shares recommendations and validated clinical algorithms for the full spectrum of paediatric clinical care, including concussion recognition, diagnosis, acute management, persistent symptom management, clinical utility of advanced radiologic and serologic biomarkers, and telemedicine. The clinical guideline website and recommendations are updated on a quarterly basis with experts considering all new research as it is published.

Key clinical recommendations relevant for general paediatricians and family doctors are shared in this review article and include the following: 1) guidance and a clinical algorithm for medical assessment and diagnosis; 2) guidance on rest and resuming activities, school, work, devices with screens, and driving after concussion; 3) guidance on managing symptoms and recovery following concussion; 4) guidance on what to include in the written medical assessment and medical clearance letters; and 5) information about when and where to refer children/adolescents for specialized care.

MEDICAL ASSESSMENT AND DIAGNOSIS OF CONCUSSION

Youth who sustain any direct or indirect impact to their head or neck and experience concussion-like signs and symptoms may have a concussion (4). Concussion signs and symptoms can be nonspecific and include physical, cognitive, sleep-related, and emotional symptoms. The onset of symptoms may be immediate or may be delayed. A medical examination by a physician or nurse practitioner is required for all patients who have suspected concussion (3). This in-office assessment should include an extensive medical history and physical examination in order to consider a thorough differential diagnosis and rule out severe traumatic brain injuries, cervical spine injuries, and other medical, mental health, or neurological conditions. Figure 1 shares an acute and prolonged concussion clinical algorithm that includes a link to a comprehensive physical examination tool. No single physical, functional, advanced neuroimaging, or blood test exists to rule out or diagnose concussion or monitor recovery (5,6). Neuroimaging is not required to diagnose a concussion. Patients who may have structural intracranial injuries or an injury to their cervical spine should be referred to an emergency department for diagnostic imaging (3,7–9).

Figure 1.

Algorithm for the management of actute and chronic symptoms for pediatric concussion with risk modifiers that may delay recovery.

When diagnosing concussion, a range of signs and symptoms such as headache, vestibular/visual/oculomotor disturbances, sleep problems, mental health problems, cognitive difficulties, and fatigue should be considered. A review of the child/adolescent’s pre-injury physical and mental health should be conducted. Early identification of mental health disorders and identifying those at risk for a mental health disorder is imperative to help prevent exacerbation of mental health problems while the patient recovers from concussion. Early identification of any potential interactions between pre-existing symptoms/conditions and new symptoms related to concussion are important to clarify and will help determine appropriate supportive care and may help prevent additional difficulties.

Following the initial assessment, children/adolescents with a confirmed concussion should return for a medical follow-up visit in 1 to 2 weeks. Children/adolescents who experience worsening symptoms should return earlier for a medical follow-up (Figure 1) (3).

RETURNING TO PHYSICAL AND COGNITIVE ACTIVITIES AFTER CONCUSSION

Rest, activity, school, and work

A period of complete physical and cognitive rest for the first 24 to 48 hours following the acute injury is required. Complete rest longer than 24 to 48 hours after a concussion is no longer recommended and may prolong recovery (10,11). Physical and cognitive activity should be gradually resumed after 24 to 48 hours at an intensity that does not make symptoms worse or give rise to new symptoms. These activities should be modified if symptoms worsen. Any activity for which there is a risk of sustaining another concussion (falling, head/body contact, or collision) must be avoided during recovery.

Patients should be encouraged to return to school as soon as they are able, and should be provided with a step-wise ‘Return-to-School’ plan and a ‘Return-to-Sport/Activity’ plan that can be used by the patient, family members, teachers, and coaches to manage and track returning to activity and school. See Supplementary Appendix 1—List of Resources—for return to activity/sport and school step-wise protocols. These plans can be started at the same time; however, a successful return to school, without accommodations related to the concussion, should be completed before medical clearance to return to sport is provided (3). For adolescents that are employed, returning to school should be prioritized.

Social activities, devices, and screen time

Following the 24 to 48-hour period of complete rest, children/adolescents with concussion symptoms should be encouraged to take part in enjoyable social activities to help promote their recovery and decrease the risk of being socially isolated. Changes may be required to these social activities to ensure that the activities do not result in symptom exacerbation, symptom recurrence, or have any risk of additional physical impact or injury. Examples of modifications include a quiet environment/activity and limiting the number of people at one time. Electronic device use such as cell phones and computer screens can gradually begin 24 to 48 hours after the acute injury at a level that does not make symptoms worse (3). Devices with screens should not be used in the hour before bedtime.

High-risk activity and game-play

Returning to activities and sports for which there is a risk of concussion or repeat injury requires medical clearance (3). If the level of return to play is competitive/highly active or the child/adolescent has a complex medical history, consider referral to a physician-supported interdisciplinary concussion team for return to gameplay and high-risk activity decisions. Encouraging healthy youth athletes to complete concussion tests before participating in sports (pre-season baseline testing), is not required and does not provide a benefit when diagnosing or managing a concussion later in the season (12). Referral to an interdisciplinary team may also be useful for those who have persisting post-concussion symptoms (e.g., >4 weeks post-injury), are struggling to gradually return to physical or cognitive activity, are usually highly active, or are in competitive sports. They can arrange for testing to determine their sub-symptom threshold aerobic exercise level to prescribe low-risk aerobic exercise treatment (13,14).

Driving

Adolescents should not drive for at least the first 24 to 48 hours following an acute concussion. Adolescents should only resume driving when their symptoms have improved, they can concentrate adequately to feel safe while driving, and driving does not exacerbate their symptoms (3). Driving is a challenging cognitive task. The risks of driving too early following concussion should be shared with patients and their parents or caregivers in order to prevent a potential motor vehicle accident (15).

MANAGING SYMPTOMS AND RECOVERY FOLLOWING CONCUSSION

Headache

Headache is the most common post-concussion symptom. Most headaches resolve within 1 to 4 weeks as part of the natural progression of concussion. However, children/adolescents with severe or persistent headaches require a focused medical follow-up, identification of co-morbid headache disorders, and classification of their headache (16). A focused physical exam that includes the neck, jaw (temporal-mandibular joint), vision, and vestibular and autonomic systems may help identify the origin of the headache and guide treatment (3). Acute headaches can be treated with over the counter pain medications such as ibuprofen or acetaminophen. Over the counter medications should not be taken more than 15 days in a month. Unlike with other types of pain, patients with concussion should not be using over the counter medications at regularly scheduled intervals. A medication and headache journal may be suggested and patients with headache should continue participating in low-risk cognitive and physical activities under a threshold that does not worsen the headache (3).

Sleep and fatigue

Problems falling asleep or staying asleep and fatigue or drowsiness are common following a concussion and also generally resolve spontaneously. The patient should be advised to maintain a regular sleep routine and to use evidence-based sleep management strategies and energy conservation techniques to handle fatigue and sleep issues. These energy conservation techniques may include planning (when engaging in activities), prioritizing (what activities to engage in), pacing (how long you engage in an activity and taking breaks), and/or positioning (in what environment does the activity takes place). See Supplementary Appendix 1 for a link to a Sleep Strategies handout. Alcohol and recreational drugs should be avoided following a concussion and not used to relieve symptoms (3).

Cognition

Problems with speech, mental processing, memory, or attention following concussion require a focused medical follow-up. Identifying pre-existing cognitive problems and understanding the interaction between concussion-related and pre-existing problems is imperative. If problems with cognition are prolonged or interfere with daily activities, a referral to an experienced professional may be required to assess the cognitive difficulty (3).

Visual, oculomotor, vestibular systems

Symptoms such as dizziness, vertigo, visual problems, or balance problems are normal concussion symptoms and often resolve as part of the natural recovery process in the first 4 weeks following a concussion. Problems with the visual, vestibular, or oculomotor functioning systems should be identified early in order to provide suggestions for physical activity and academic accommodations. Children/adolescents with these symptoms require a focused medical examination at the 1–2 week follow-up. Additional diagnostic testing may be required and/or referral to a specialist. Examples of diagnostic tests include visual testing, screening for paroxysmal positional vertigo (Dix-Hallpike), assessment of the central vestibular system (i.e., saccades, vestibular ocular reflex) and an assessment of the patient’s postural stability and balance. Directions for how to conduct these tests can be found in the Living Guideline (See Supplementary Appendix 1) (3).

WHAT TO INCLUDE IN THE WRITTEN MEDICAL ASSESSMENT

A medical assessment note should be provided to all patients following an assessment for concussion. The note should include information about the patient’s diagnosis and common concussion symptoms, how much to rest, a return to activity and school plan or strategy, a list of warning signs (red flags) to prompt an emergency medical assessment, nonpharmaceutical strategies and activity modifications to manage acute symptoms, and information about medical clearance to return to high-risk activities and gameplay. When a patient has been medically assessed and has been cleared to participate in impact and full contact sports-related activities, a medical clearance letter must be provided to the patient to share with teachers and coaches. See Supplementary Appendix 1 for a link to templates for a medical assessment and a medical clearance letter (17,18).

WHEN AND WHERE TO REFER CHILDREN/ADOLESCENTS FOR SPECIALIZED CARE

The majority of patients fully recover within 1 to 4 weeks following a concussion, however, up to 30% of paediatric patients experience a prolonged recovery (19). After 4 weeks, patients who have not returned to school and activities or continue to experience symptoms including headache, sleep problems, fatigue, cognitive, vestibular/oculomotor/visual problems, or mental health-related problems, should be referred to an interdisciplinary concussion team (15).

Strong evidence suggests that a prolonged recovery is most likely in older adolescent girls, those with a high symptom burden, and those with previous mental health problems or headaches (Table 1) (19,20). A clinical risk score should be used to determine the risk of a prolonged recovery (see Supplementary Appendix 1—5P Clinical Risk Score). Patients who have higher risk for a prolonged recovery warrant early referral to an interdisciplinary concussion team (3).

Table 1.

A list of risk modifiers that may delay recovery from concussion in paediatric patients

Risk modifier
Age (older)
Sex (female)
Slow recovery from a previous concussion
Severity of pre-injury symptoms
Symptom burden at assessment
Vestibular or oculomotor dysfunction
Migraines
Learning or behavioural difficulties
Mental health conditions
Lower family education level or socioeconomic status

Modified from http://www.5pconcussion.com/en/scorecalculator.

Summary

Most paediatric patients with concussion can be managed in primary care settings. However, early identification and referral for higher-risk patients and those who have prolonged recovery is important to ensure that they get appropriate specialized treatment and support. Recommendations within this clinical guideline resource are reviewed and updated as soon as new evidence is published in order to ensure that the most recent evidence is considered for each clinical recommendation. Providing paediatricians and family doctors with free access to an up to date and clear resource for managing paediatric concussion is essential for improving quality of care. The Living Guideline for Diagnosing and Managing Pediatric Concussion can be accessed at https://braininjuryguidelines.org/pediatricconcussion/.

Living Guideline for Diagnosing and Managing Pediatric Concussion- Expert Panel Members. https://braininjuryguidelines.org/pediatricconcussion/committees-and-stakeholders/expert-panel/

Funding: The Living Guideline for Diagnosing and Managing Pediatric Concussion is funded by the Ontario Neurotrauma Foundation.

Potential Conflicts of Interest: RZ: I, Roger Zemek, hold competitively funded research grants from Canadian Institutes of Health Research (CIHR), Ontario Neurotrauma Foundation (ONF), Physician Services Incorporated (PSI) Foundation, CHEO Foundation, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), and the National Football League (NFL) Scientific Advisory Board. I also hold Clinical Research Chair in Pediatric Concussion from the University of Ottawa, and am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity). I am a co-owner and Scientific Director of 360 Concussion Care. NR: I, Nick Reed, have been awarded and associated with research grants from Canadian Institutes of Health Research (CIHR), Ontario Neurotrauma Foundation (ONF), Public Health Agency of Canada, Holland Bloorview Kids Rehabilitation Hospital Foundation, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), the National Football League (NFL) Scientific Advisory Board, Scotiabank and the Greater Toronto Hockey League. I hold a Canada Research Chair in Pediatric Concussion from the Canadian Institutes of Health Research, and I am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity). I am a co-owner and Lead of Knowledge Translation and Allied Health Engagement at 360 Concussion Care. SB: I, Shannon Bauman, have a competitively funded research grant from the Ontario Neurotrauma Foundation (ONF); I am on the concussion advisory board for Parachute Canada (a non-profit injury prevention charity) and ONF. I hold a copyright for the “Concussion North Treatment Passport.” I am the Medical Director of Concussion North. There are no other disclosures from the authorship team. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. See https://braininjuryguidelines.org/pediatricconcussion/committees-and-stakeholders/conflicts-of-interest/ for conflict of interest disclosures from members of the ONF Pediatric Concussion Living Guideline expert panel.