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doi:10.1111/jpc.12967
REVIEW ARTICLE
Diagnosis and management of paediatric concussion Silvia Bressan1,2 and Franz E Babl1,3,4 1 Murdoch Childrens Research Institute, 3Emergency Department, Royal Children’s Hospital, 4Department of Pediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia and 2Department of Women’s and Child’s Health, Department of Pediatrics, University of Padova, Padova, Italy
Abstract: Heightened recognition of concussions and concerns about their sequelae in children has become an increasing community and public health concern. Biomarkers and clinical tests are being explored, but the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. While the majority of children go on to recover from post-concussive symptoms within 2 weeks, it is unclear which patients with concussion will go on to develop short- or long-term sequelae. A number of more or less evidence-based guidelines have become available which seek to guide clinicians on how to manage children post-concussion. In general, care after the emergency department is focused on reducing the risk of re-injury and rest until cerebral recovery with a graduated return to school and then play. Key words:
child; concussion; post-concussive syndrome.
Concussions have seemingly reached epidemic proportions, with nearly 4 000 000 sports-related concussions reported each year in the Unites States alone,1 and a fourfold increase in the incidence of diagnosed concussions in high school athletes over a 10-year period.2 The dramatic rise in number of concussion diagnoses in recent years may be due, in part, to increased awareness regarding the potential for complications and long-term sequelae, rather than a true increase in incidence.3 Previously, concussions were viewed as minor mishaps to be shaken off and thought not to interfere with daily activities or cause long-term sequelae. However, recent research describing chronic and degenerative brain changes following concussion has been influential, despite methodological flaws and lack of corroborating evidence.4 Heightened community concern has also translated into public health concerns, policy changes and legal requirements in
many US states, which specify details of child concussion management.3,5
Definition Concussion is a traumatically, or biomechanically, induced alteration of brain function. Current guidelines emphasise ‘the pathophysiological process, or functional disruption, as opposed to anatomic, structural or tissue injury’.6–9 However, debate remains about the distinction between ‘mild traumatic brain injury (TBI)’ and ‘concussion’; many authors use these terms interchangeably, while others consider mild TBI more severe than concussion.6,10 The most commonly used definition in clinical practice and research is the one provided by the 2012 Zurich Consensus Statement on Concussion in Sport9 (Box 1).
Diagnosis Key points • While biomarkers and clinical tests are being explored, the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. • At this time, we are unable to predict which patients with concussion will go on to develop short- or long-term sequelae. • Post-discharge care is focused on reducing the risk of re-injury and avoiding prolonged symptoms through a planned return to school and play. Correspondence: Dr Silvia Bressan, Murdoch Children’s Research Institute, 52 Flemington Road, Parkville, Vic. 3052, Australia. Fax: +613 9345 5938; email: [email protected] Conflict of interest: None declared. Accepted for publication 8 June 2015.
After excluding intracranial injury, based on neuroimaging or clinical presentation, the diagnosis is made when typical symptoms and signs are present immediately after or within hours following head trauma (Table 1). Symptoms and signs can change rapidly and may evolve over time. Diagnosis may be challenging as many of the symptoms are non-specific and no reliable test or marker is currently available. A graded symptom checklist may help in the diagnosis because it measures symptom severity and can be used to monitor recovery. The latest Zurich Consensus Statement includes a comprehensive Sport Concussion Assessment Tool, 3rd edition (SCAT3) for children >13 years old.9,12 This tool, primarily designed for sideline assessment on the sports field, is also useful to monitor recovery. Its key components are the Glasgow Coma Scale, the Post-Concussive Symptom Scale,13 a
Journal of Paediatrics and Child Health 52 (2016) 151–157 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
151
Paediatric concussion
S Bressan and FE Babl
Box 1 Definition of concussion as per Zurich Consensus Statement of Concussion in Sport9 Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘impulsive’ force transmitted to the head. 2. Concussion typically results in the rapid onset of shortlived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases, symptoms may be prolonged.
Table 1 Typical signs and symptoms of concussion (adapted from Marshall et al.11) Physical
Cognitive
Emotional/ behavioural
Headache Nausea Vomiting Blurred or double vision Balance problems Dizziness Sensitivity to light or noise Fatigue Sleep disturbance Drowsiness Loss of consciousness Balance disturbance
Feeling ‘slowed down’ Feeling ‘in a fog’ Difficulty concentrating Difficulty remembering Amnesia
Irritability Anxiety Sadness Depression
cognitive test (the standardised assessment of concussion), a balance (balance error scoring system), and co-ordination tests.12 A modified version of the child-SCAT3 has been developed for children aged 5–12 years9 to take into account the different development of younger children. The symptom checklist in the child-SCAT3 is the Health Behavioural Inventory and includes a parent and child scale.13,14 Many other symptom scales are avail152
able; however, their psychometric properties are not fully defined, especially in the younger age group.13,15 Numerous studies have provided evidence that serum biomarkers of brain damage can be used in diagnosis and risk stratification of TBI in adults, but paediatric research is more limited.16–18 The most studied biomarkers in children are neuron-specific enolase, S-100 calcium binding protein B (S-100B) and glial fibrillary acidic protein (GFAP).17,19 The need for age-corrected normal values, difficulty obtaining blood samples, especially from younger children, and small study sample sizes are important limitations to paediatric research. Despite increasing interest, there is a lack of reliable serum biomarkers for routine use in diagnosing concussion in children. Although traditional neuroimaging is typically normal, recent research using advanced magnetic resonance imaging (MRI) techniques has found more subtle abnormalities in brain structure and function that seem to correlate with physical and cognitive post-concussive symptoms.20–22 However, studies in paediatrics are still very limited. Although advanced imaging provides additional insight into the pathophysiological mechanisms of concussion and holds promise as a potential contributor to diagnosis, it has no current role in routine clinical practice.
Clinical implications As for adults, children may experience short-term and longterm sequelae following concussion. However, their developing brain and their younger age at the time of cerebral insult have different implications compared with adults.15 Duration of postconcussive symptoms may vary with age. The malignant cerebral oedema that seems related to a second impact close to a previous concussion has only been reported in children and young adults. In addition, they have a larger ‘window of opportunity’ for repeat concussion during the prolonged recovery compared with persons who do not sustain their first concussion until their twenties, and may have increased susceptibility to the long-term effects of cumulative damage,15 so caution is warranted until more definitive data are available.
Post-concussive symptoms Recent research has highlighted that a substantial minority of children with concussion suffers from a constellation of longterm physical, cognitive, emotional and behavioural symptoms, known as post-concussive syndrome (PCS),23–26 Table 1. Two major definitions of PCS differ mainly in definition of concussion, timing of post-concussive symptoms onset and duration. The International Classification of Diseases, 10th revision (ICD-10) refers to head trauma with loss of consciousness and symptoms that should appear within 4 weeks, with no mention of duration27 (Box 2). According to the Diagnostic and Statistical Manual of Mental Disorders 5th edition, symptoms should occur shortly after the trauma and last at least 3 months, while loss of consciousness is not an absolute requirement for concussion28 (Box 3). The lack of consensus on defining PCS limits research, contributing to study heterogeneity and preventing between-study comparisons. The process of recovery varies from person to person and injury to injury. In adults, symptoms generally resolve in 7–10
Journal of Paediatrics and Child Health 52 (2016) 151–157 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
S Bressan and FE Babl
Box 2 ICD-10 diagnostic criteria for post-concussive syndrome27 A. History of head trauma with loss of consciousness preceding symptom onset by a maximum of 4 weeks. B. Symptoms in three or more of the following symptom categories: • headache, dizziness, malaise, fatigue, noise intolerance; • irritability, depression, anxiety, emotional lability; • subjective concentration, memory or intellectual difficulties without neuropsychological evidence of marked impairment; • insomnia; • reduced alcohol tolerance; and • preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role.
Box 3 Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 8 diagnostic criteria for postconcussional disorder28 A. A history of head trauma that has caused considerable cerebral concussion.* B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recall of information). C. Three (or more) of the following occur shortly after the trauma and last at least 3 months: • becoming fatigued easily; • disordered sleep; • headache; • vertigo or dizziness; • irritability or aggression on little or no provocation; • anxiety, depression or affective instability; • changes in personality (e.g. social or sexual inappropriateness); or • apathy or lack of spontaneity. D. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of pre-existing symptoms. E. The disturbance causes considerable impairment in social or occupational functioning and represents a considerable decline from a previous level of functioning. In school-aged children, the impairment might manifest as a substantial worsening in school or academic performance dating from the trauma. F. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (e.g. amnestic disorder due to head trauma, personality change due to head trauma). *The manifestations of concussion include loss of consciousness, posttraumatic amnesia and, less commonly, post-traumatic onset of seizures. The specific method of defining this criterion needs to be established by further research.
Paediatric concussion
days.29,30 Estimates of post-concussive symptoms duration in children range widely.31 Most children’s symptoms resolve within 2 weeks.31 However, approximately 25–35% will still be symptomatic at 1 month, a smaller proportion at 3 months and
doi:10.1111/jpc.12967
REVIEW ARTICLE
Diagnosis and management of paediatric concussion Silvia Bressan1,2 and Franz E Babl1,3,4 1 Murdoch Childrens Research Institute, 3Emergency Department, Royal Children’s Hospital, 4Department of Pediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia and 2Department of Women’s and Child’s Health, Department of Pediatrics, University of Padova, Padova, Italy
Abstract: Heightened recognition of concussions and concerns about their sequelae in children has become an increasing community and public health concern. Biomarkers and clinical tests are being explored, but the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. While the majority of children go on to recover from post-concussive symptoms within 2 weeks, it is unclear which patients with concussion will go on to develop short- or long-term sequelae. A number of more or less evidence-based guidelines have become available which seek to guide clinicians on how to manage children post-concussion. In general, care after the emergency department is focused on reducing the risk of re-injury and rest until cerebral recovery with a graduated return to school and then play. Key words:
child; concussion; post-concussive syndrome.
Concussions have seemingly reached epidemic proportions, with nearly 4 000 000 sports-related concussions reported each year in the Unites States alone,1 and a fourfold increase in the incidence of diagnosed concussions in high school athletes over a 10-year period.2 The dramatic rise in number of concussion diagnoses in recent years may be due, in part, to increased awareness regarding the potential for complications and long-term sequelae, rather than a true increase in incidence.3 Previously, concussions were viewed as minor mishaps to be shaken off and thought not to interfere with daily activities or cause long-term sequelae. However, recent research describing chronic and degenerative brain changes following concussion has been influential, despite methodological flaws and lack of corroborating evidence.4 Heightened community concern has also translated into public health concerns, policy changes and legal requirements in
many US states, which specify details of child concussion management.3,5
Definition Concussion is a traumatically, or biomechanically, induced alteration of brain function. Current guidelines emphasise ‘the pathophysiological process, or functional disruption, as opposed to anatomic, structural or tissue injury’.6–9 However, debate remains about the distinction between ‘mild traumatic brain injury (TBI)’ and ‘concussion’; many authors use these terms interchangeably, while others consider mild TBI more severe than concussion.6,10 The most commonly used definition in clinical practice and research is the one provided by the 2012 Zurich Consensus Statement on Concussion in Sport9 (Box 1).
Diagnosis Key points • While biomarkers and clinical tests are being explored, the diagnosis of concussion in the emergency department continues to be based on clinical signs and symptoms. • At this time, we are unable to predict which patients with concussion will go on to develop short- or long-term sequelae. • Post-discharge care is focused on reducing the risk of re-injury and avoiding prolonged symptoms through a planned return to school and play. Correspondence: Dr Silvia Bressan, Murdoch Children’s Research Institute, 52 Flemington Road, Parkville, Vic. 3052, Australia. Fax: +613 9345 5938; email: [email protected] Conflict of interest: None declared. Accepted for publication 8 June 2015.
After excluding intracranial injury, based on neuroimaging or clinical presentation, the diagnosis is made when typical symptoms and signs are present immediately after or within hours following head trauma (Table 1). Symptoms and signs can change rapidly and may evolve over time. Diagnosis may be challenging as many of the symptoms are non-specific and no reliable test or marker is currently available. A graded symptom checklist may help in the diagnosis because it measures symptom severity and can be used to monitor recovery. The latest Zurich Consensus Statement includes a comprehensive Sport Concussion Assessment Tool, 3rd edition (SCAT3) for children >13 years old.9,12 This tool, primarily designed for sideline assessment on the sports field, is also useful to monitor recovery. Its key components are the Glasgow Coma Scale, the Post-Concussive Symptom Scale,13 a
Journal of Paediatrics and Child Health 52 (2016) 151–157 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
151
Paediatric concussion
S Bressan and FE Babl
Box 1 Definition of concussion as per Zurich Consensus Statement of Concussion in Sport9 Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘impulsive’ force transmitted to the head. 2. Concussion typically results in the rapid onset of shortlived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases, symptoms may be prolonged.
Table 1 Typical signs and symptoms of concussion (adapted from Marshall et al.11) Physical
Cognitive
Emotional/ behavioural
Headache Nausea Vomiting Blurred or double vision Balance problems Dizziness Sensitivity to light or noise Fatigue Sleep disturbance Drowsiness Loss of consciousness Balance disturbance
Feeling ‘slowed down’ Feeling ‘in a fog’ Difficulty concentrating Difficulty remembering Amnesia
Irritability Anxiety Sadness Depression
cognitive test (the standardised assessment of concussion), a balance (balance error scoring system), and co-ordination tests.12 A modified version of the child-SCAT3 has been developed for children aged 5–12 years9 to take into account the different development of younger children. The symptom checklist in the child-SCAT3 is the Health Behavioural Inventory and includes a parent and child scale.13,14 Many other symptom scales are avail152
able; however, their psychometric properties are not fully defined, especially in the younger age group.13,15 Numerous studies have provided evidence that serum biomarkers of brain damage can be used in diagnosis and risk stratification of TBI in adults, but paediatric research is more limited.16–18 The most studied biomarkers in children are neuron-specific enolase, S-100 calcium binding protein B (S-100B) and glial fibrillary acidic protein (GFAP).17,19 The need for age-corrected normal values, difficulty obtaining blood samples, especially from younger children, and small study sample sizes are important limitations to paediatric research. Despite increasing interest, there is a lack of reliable serum biomarkers for routine use in diagnosing concussion in children. Although traditional neuroimaging is typically normal, recent research using advanced magnetic resonance imaging (MRI) techniques has found more subtle abnormalities in brain structure and function that seem to correlate with physical and cognitive post-concussive symptoms.20–22 However, studies in paediatrics are still very limited. Although advanced imaging provides additional insight into the pathophysiological mechanisms of concussion and holds promise as a potential contributor to diagnosis, it has no current role in routine clinical practice.
Clinical implications As for adults, children may experience short-term and longterm sequelae following concussion. However, their developing brain and their younger age at the time of cerebral insult have different implications compared with adults.15 Duration of postconcussive symptoms may vary with age. The malignant cerebral oedema that seems related to a second impact close to a previous concussion has only been reported in children and young adults. In addition, they have a larger ‘window of opportunity’ for repeat concussion during the prolonged recovery compared with persons who do not sustain their first concussion until their twenties, and may have increased susceptibility to the long-term effects of cumulative damage,15 so caution is warranted until more definitive data are available.
Post-concussive symptoms Recent research has highlighted that a substantial minority of children with concussion suffers from a constellation of longterm physical, cognitive, emotional and behavioural symptoms, known as post-concussive syndrome (PCS),23–26 Table 1. Two major definitions of PCS differ mainly in definition of concussion, timing of post-concussive symptoms onset and duration. The International Classification of Diseases, 10th revision (ICD-10) refers to head trauma with loss of consciousness and symptoms that should appear within 4 weeks, with no mention of duration27 (Box 2). According to the Diagnostic and Statistical Manual of Mental Disorders 5th edition, symptoms should occur shortly after the trauma and last at least 3 months, while loss of consciousness is not an absolute requirement for concussion28 (Box 3). The lack of consensus on defining PCS limits research, contributing to study heterogeneity and preventing between-study comparisons. The process of recovery varies from person to person and injury to injury. In adults, symptoms generally resolve in 7–10
Journal of Paediatrics and Child Health 52 (2016) 151–157 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
S Bressan and FE Babl
Box 2 ICD-10 diagnostic criteria for post-concussive syndrome27 A. History of head trauma with loss of consciousness preceding symptom onset by a maximum of 4 weeks. B. Symptoms in three or more of the following symptom categories: • headache, dizziness, malaise, fatigue, noise intolerance; • irritability, depression, anxiety, emotional lability; • subjective concentration, memory or intellectual difficulties without neuropsychological evidence of marked impairment; • insomnia; • reduced alcohol tolerance; and • preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role.
Box 3 Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 8 diagnostic criteria for postconcussional disorder28 A. A history of head trauma that has caused considerable cerebral concussion.* B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recall of information). C. Three (or more) of the following occur shortly after the trauma and last at least 3 months: • becoming fatigued easily; • disordered sleep; • headache; • vertigo or dizziness; • irritability or aggression on little or no provocation; • anxiety, depression or affective instability; • changes in personality (e.g. social or sexual inappropriateness); or • apathy or lack of spontaneity. D. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial worsening of pre-existing symptoms. E. The disturbance causes considerable impairment in social or occupational functioning and represents a considerable decline from a previous level of functioning. In school-aged children, the impairment might manifest as a substantial worsening in school or academic performance dating from the trauma. F. The symptoms do not meet criteria for dementia due to head trauma and are not better accounted for by another mental disorder (e.g. amnestic disorder due to head trauma, personality change due to head trauma). *The manifestations of concussion include loss of consciousness, posttraumatic amnesia and, less commonly, post-traumatic onset of seizures. The specific method of defining this criterion needs to be established by further research.
Paediatric concussion
days.29,30 Estimates of post-concussive symptoms duration in children range widely.31 Most children’s symptoms resolve within 2 weeks.31 However, approximately 25–35% will still be symptomatic at 1 month, a smaller proportion at 3 months and
