The British Columbia Chiropractic Association (BCCA) invited Dr Tommy Gerschman from Fortius Sport & Health to present an update on pediatric concussions for their members. It was one of the better webinars I have attended in a while and Dr Gerschman - a board-certified pediatric rheumatologist with multiple certifications and designations in pediatric sports medicine - did a fabulous job putting together a succinct and practical presentation. (If you want to take an hour to watch the whole presentation, it has now been uploaded to YouTube.)
Overall, I'm really excited about this update. It is the first one in all the years I have been following this topic that there are some really useable clinical guidelines to follow. I believe this will be very helpful for practitioners, parents and coaches (and for them all to be on the same page). Before this consensus, the general recommendation was to find a practitioner who knows what they are doing... but there was not a lot of consistency or guidance for practitioners providing the care.
The most recent gathering of the international Concussion in Sport Group (CISG) was last year (2016) in Berlin. This group gets together every few years to do an extensive systematic review of the research regarding concussions identification and management. This was the 5th such consensus meeting. The last one, held in Zurich in 2012, was a major update and this one very much fed off of the progress made there, including reducing rest periods and identifying risk modifiers. Following the international update, the Canadian organization Parachute published a document on Canadian Guidelines on Concussion in Sport to provide a harmonized plan for practitioners, parents, and coaches in Canada.
Enough background. Here is the information update you need:
- Children have a high incidence of concussions than adults, as well as an increased time to normalization.
- Consider that they have less neck strength, a larger head to body ratio, and their brains are rapidly developing.
- Males twice as likely to be hospitalized due to sports-related concussion than females.
- Most common sports involved in hospitalizations were cycling, playground activities, hockey, and skiing/snowboarding.
- Concussions are regarded as widely under-reported. This is partially because most concussions do not require extensive medical attention, but it is very important that those who do need attention get it.
- Consider also that often times the people supporting children's activities are volunteers and may not have concussion training.
- Children are also more likely to under-report symptoms, but up to 50%.
- The age-range with the highest incidence of concussions also coincides with the timeline for other issues to develop, including migraines, headaches, and mood disorders, which can confuse concussion identification.
- Loss of consciousness is actually not a primary diagnostic criterion.
- Possible momentary "loss of attention" or being "stunned" actually carries more weight.
- It is important to consider concussion for any blow to the head, as well as injuries that include a whiplash or rotation movement of the head, even if there is no physical contact to the outside of the head. (Concussions are actually caused by the impact of the brain against the inside of the skull, so they do not require outside impact trauma.)
- It is important to check in with a health practitioner within 72 hours of the original injury.
- Preseason Screening and Baseline Testing: There was a lot of focus on this previously, but now it is clear that their real-life application was not as useful as we had hoped. There was a noted ceiling effect for athletes who did multiple screens and there was a tendency for immature athletes to throw their early season scores. The testing environment also proved to have a variable impact on scoring. The downside to the cessation of baseline testing is the lost opportunity to educate parents and players on concussion awareness, but there are certainly ways to overcome that.
- Prolonged Periods of Rest: I will cover this more below, but I wanted to emphasize here that extended and complete periods of rest are NOT recommended.
- Grading System: There is not more grading system. You may say mild, moderate, or severe concussion, but overall you are going to treat on such an individual basis that a grading system does not outcomes and adds needless complexity.
- Waking kids up from sleep. This has been out for a while, but I put it here in case you missed that boat. Brains need their rest to heal!
A nice way to keep everything sorted in your mind is to use the Rs Approach.
- Recognize & Remove
1- Recognize & Remove
Step one! Recognize when a child POTENTIALLY has a concussion and remove them from the current activity. I say potentially because it is OK if we remove kids without concussions from playing the current game. They will be back next game after properly assessed. It's not the end of the world and it is far more important to avoid the second hit for those who are concussed. Symptoms may begin immediately or onset may be delayed by up to 24 hours, so it is not always obvious at the time of injury. The CRT can be used at this time to support on-filed assessment.
Once removed from the field, there should be an attempt to reassess. This is where the SCAT5 comes in to play. It helps discriminated between concussion and not-concussion. Use is best within 3-5 days. You should also check in with your health provider within 72 hours because it is within that period that they can do the most accurate assessment of an acute concussion.
As a good rule, institute 24-48 hours of reduced cognitive load. This does not mean sitting alone in a quiet, dark room. It DOES mean no school, organized activities, or work. (I would also add no screens, but that is getting more specific into brain rehab.) After 48 hours, there is a noted benefit to attempting to get back into regular routine and schedule, even if there are still some symptoms. Holding kids back longer tends to prolonge overall length of symptomology. This return after 1-2 days of rest may require some modification, such as no testing, no homework, and longer time for assignments. They should be allowed to put head down and zone out if they start getting symptoms while at school. If that doesn't help, they should be allowed to leave classroom environment. If they need to go home and rest, fine. Try again the next day. Obviously, this will require teachers, parents, and kids to all be in open communication and supportive of the process. The goal is to pace back into the school environment with as much support as possible. I will note too that it is equally important to slow down the over-achievers. Each child will have their own happy medium pace of progress.
4 - Recover
The ultimate intended outcome is a complete Return to Learn and Return to Play. After 24-48 hours of rest, there should be a gradual integration into normal routines with continual challenge and progression. For adults, recovery from an acute concussion takes at least 7-10 days; for children, it is longer. 80% of children will recover within 3-4 weeks. We notice in children, and I have seen in-office, a delay in neurological symptoms. Inability to concentrate, frustration, sleeplessness, fatigue, emotional irregularity, and aggression are all very easily overlooked.
Risk factors (modifiers) for prolonged recovery include:
- More numerous and more severe symptoms
- Previous concussions
- Parental anxiety
- History of headaches, neck pain, or mood disorder
You want your child to be able to attend a full school day (and cope well with it) before they return to sport. They can actually return to activity before returning to full play, but the goal is to not get hit in the head again. Ideas for safe activities include jogging and the stationary bike. Start with 60-70% effort for 30 minutes after first 2 days of rest. This early return for activity is especially important for very active children as it is part of their normal routine. If symptoms do come up, rest for the rest of the day and then try again tomorrow. Return to exercise progression starts early, but not return to potential contact. And Return to Learn is prioritized over Return to Play.
There are some really great resources and videos for Return to Learn and Return to Play on the Concussion Awareness Training Tool online.
There is no strong evidence for medication in the treatment and recovery of concussions, especially in children. NSAIDs may provide short-term symptom relief and aid in early return to school, but if your child is taking any medications, they should NOT be allowed to move on to the next stage of return to play. Medications should also be avoided within the first few hours after injury. We need to know if symptoms are worsening. If you give medications on-field, they are definitely not allowed to return to play that day.
Cervical (neck) and vestibular rehabilitation are recommended for both acute and chronic concussions, especially for those with headaches symptoms. Finding a chiropractor or physical therapist with experience in these areas is key to a complete recovery.
Mental health status should be monitored and addressed. As I mentioned earlier, the age range with the highest incidence of concussions in children coincides with common progressions of headache, migraine, and mood disorders. It is not always easy to distinguish whether such presentations are symptoms of a recent concussion or an independent issue, so it is worth checking in with a professional and ensuring that your child is receiving the care they need, either way.
On an individual level, cervicogenic and vestibular rehab have the best support for reducing susceptibility to recurrent concussions. There may also be a role for visual tracking and training in treatment and prevention.
On a bigger level, there are also some systematic implementations that would aid in reducing the rates of concussions in children.
- Removing body checking for younger ages has dramatically reduced concussion in younger age groups. Not all provinces have the same policies, but this is worth advocating for.
- Wear your brain bucket. OK, moment of truth: Helmets are very good at reducing catastrophic head injuries, but the results are inconclusive on concussion and they may actually increase soft tissue damage (especially in the case of a heavy helmet and a whiplash movement). But you should still wear them! Proper fit is important. Bigger is not better. There is a lot of work going toward developing new technologies to make helmet better at reducing whiplash, so keep an eye out in this area.
- Put your mouthguard back in! For a while, it looked like they were not helping reduce concussions, but more recent research is showing they're worth it. Custom-fit mouthguards only.
- Do not allow "heading the ball" for younger children. They don't know how to do it right yet and the risk of concussion and injury is high for them. (Yes, there is a proper way to do it that can be taught to older teens and adults.)
- Actively participate in and encourage awareness during preseason preparations and throughout the year. Concussion care for children is definitely a team sport. It requires players, coaches, parents, teachers, and healthcare practitioners to all play well together.
Areas to Keep Watching
- Nutrition - In the last few years, we have seen a big impact on nutrition on overall brain health. Concussion specific information is just starting to make headway, but there is enough understanding to pay attention to inflammatory load and healthy fats during recovery.
- Genetics - It is considered likely that there are some predetermined genetic risk factors for concussions, but these are being deemphasized for now because they are unlikely to modify treatment and identification.
- BioPsychoSocial Model of Pain - This is the current riding pain theory (and it is a good one). It takes into consideration how your chemistry, your environment, your stress load, your sleep, and just about everything else impacts your perception and capacity to cope with pain. Very similar theories are likely to hold up with concussions as well.
- King-Devick Test - This screening tool is showing promise, but still needs to demonstrate reliability in monitoring children as further studies are completed.
- Biomarkers & Imaging for Diagnosis - There is some really interesting work being done in these fields, but we're not quite there yet.
Well, there is your update! I hope you find it useful for caring for your kid or players. If in doubt, get them assessed and cared for by a healthcare practitioner with experience in pediatric concussion, ideally within 3 days of injury. It's kids' brains we are talking about here. Let's set our next generation up for success!
The forms for assessment and tracking concussions have all been updated as of the 5th consensus. Here are the updated forms are:
- NO SCAT 4, skipped to 5 to keep in line with conference number
- Child SCAT5
- Child SCAT5 for 5-12 YO.
- CRT5 meant for parents and coaches to help identify red flags and use on site.
- Full CISG consensus statement on concussion in sport.