Concussion – Primary Steps for Primary Care

Primary Steps for Primary Care | October 8, 2018 | cookchildrens

A concussion is a trauma-related pathophysiological process that affects the neurometabolic function of the brain. Concussions are quite prevalent; the CDC reports 3.8 million sport-related brain injuries occur annually. It is estimated in middle school and high school children, up to 20% of children have suffered a concussion. In the majority of patients, post-concussive symptoms resolve within 10 days. By 1 month, 72% of patients recover; by 3 months, 97% recover. Post-concussive symptoms can cause significant disability affecting function in both the home and school environment; therefore diagnosis and recognition of post-concussive symptoms is important in order to manage the symptoms appropriately.

What should the initial evaluation of concussion entail?

Usually performed by an athletic trainer in the sporting environment
Should be conducted in a standardized fashion
There is no evidence to support a specific tool
A multi-modal assessment tool, such as the Sport Concussion Assessment Tool (SCAT, currently in the 5th edition) or Standardized Assessment of Concussion (SAC) is recommended
If suspicion for sports-related concussion, the athlete should not return to play that day and should be cleared for gradual return to play by a physician (primary care provider) comfortable with concussion

What are the typical symptoms of concussion:

Somatic
- Headache
- Sleep disturbance (sleeping too much or insomnia or frequent awakenings)
- Nausea
- Balance impairment/dizziness
Cognitive
- Difficulty with attention and concentration
- Confusion
- Feeling in a fog
- Difficulty with short term memory
Emotional
- Irritability
- Sadness
- Anxiety
- Emotional lability

What role can the primary care provider play in concussion management?

Counsel about avoidance of additional head injury.
Initial symptom management.
- Cognitive and physical rest and pacing are the primary interventions.
- Physical rest for 1-2 days, and then slowly increase using graduated return to play protocol (described below).
- Cognitive rest for 1-2 days.
- Limit exposure to screen time and video game in the first few days after injury. Initially start with no screen time at all (TV, phone, texting, computer) and then increase gradually by starting activity in small chunks of time (5-15 minutes) and increasing as tolerated; if symptoms start or worsen, then take a break. Slowly increase the work period and shorten the break period.
Headache: most headaches resolve in the first few days after injury.
- Treat with Ibuprofen as needed. Avoid overuse by limiting to 3 days/week or less.
- If headache lasts longer than 2 weeks, consider starting a preventive therapy while waiting to get into a pediatric neurologist. Amitriptyline is often the first choice while we try to avoid topiramate due to possible exacerbation of post-concussive symptoms with cognitive slowing.
- Consider magnesium supplementation – 250-400mg daily.
Nausea
- Consider treating in the first few days with ondansetron as needed.
Sleep Disturbance:
- Emphasize appropriate sleep hygiene.
- Trial melatonin – start at 3mg and titrate up to 6-9mg as needed.
Return to school:
- Typically require 1-2 days of cognitive rest before returning to school.
- Return when able to tolerate 30-45 minutes of concentration, visual stimulation and auditory stimulation.
- May need modifications or 504 plan initially.
  - Limited course load.
  - Shortened classes or school day.
  - Rest breaks.
  - Aids for learning (class notes, tutoring, etc.).
  - Reduce exposure to computers, smart boards, videos.
Return to play protocol
- For all sports related concussions: brief period of physical rest for 24-48 hours, followed by graduated return to play protocol. Physical rest means performing simply ADLS: eat, sleep and bathing.
- Only consider return to play if there has been successful return to school first.
- Graduated return to play protocol/active rehabilitation:
  - Symptom limited activity – daily activities that do not provoke symptoms (gradual reintroduction of work/school activities.
  - Light aerobic exercise – walking, stationary cycling. Goal is to simply increase heart rate
  - Sport-specific exercise – for example, running drills.
  - Non-contact training drills – progressive resistance training, harder training drills.
  - Full contact practice – only after medical clearance; participating in normal training activities.
  - Return to game – normal game play.
- If symptoms such as headaches, nausea, balance difficulty, fatigue, or dizziness return, then patient should return to last tolerated step.

When is referral to other specialists considered?

Referral beyond initial management is typical only needed for persistent post-concussive symptoms lasting 10 days or longer.

Physical therapy for vestibular therapy or for management of tension headache and cervicogenic headache.
Sports medicine physician for post-concussive symptoms.
Pediatric neurologist for post-concussive headaches.
Pediatric sleep specialist for sleep disturbances unresponsive to melatonin.
Neuropsychology for post-concussive syndrome.
Psychiatry and Psychology for mood or emotional lability.

Related information:

References:

McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51: 838.
Arthur T, Kacperski J. Management of Post-traumatic Headaches in Children and Adolescents. Headache December 2015; 56: 36-48
CDC Heads Up

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