Pediatricians take front line in management of concussions

In June, a joint study from the CDC and The Children’s Hospital of Philadelphia identified an alarming trend in how the United States evaluates the nation’s pediatric concussion rates: The majority of pediatric concussion counts were based solely on ED visits or on school data, but did not include data from primary care sites.

Analyzing more than 8,000 pediatric concussion diagnoses over a 4-year period, the researchers found that while 11.7% of patients had their first concussion visit within the ED and 5.2% were directed through specialty care, including sports medicine or neurology, 81.9% of patients identified primary care as their point of entry.

Photo by Ann & Robert H. Lurie Children’s Hospital of Chicago

“We learned two really important things about pediatric concussion health care practices,” researcher Kristy B. Arbogast, PhD, director of engineering at the Center for Injury Research and Prevention at The Children’s Hospital of Philadelphia (CHOP) and co-scientific director of the Center for Child Injury Prevention Studies, said in a press release. “First, four in five of this diverse group of children were diagnosed at a primary care practice — not the emergency department. Second, one-third were under age 12, and therefore represent an important part of the concussion population that is missed by existing surveillance systems that focus on high school athletes.”

Recent studies have confirmed a marked increase in concussion injuries in the general population, predominantly driven by a substantial rise among adolescents, an upsurge most likely attributed to heightened media focus on — and therefore, parental awareness of — concussions and their potential adverse effects. As a result, pediatricians and primary care physicians are increasingly becoming the first line of defense in the face of mounting pediatric concussion rates.

To explore the complexities of this issue, Infectious Diseases in Children spoke with concussion experts, sports medicine specialists, pediatricians, and public health and policy experts about the difficulties PCPs face in stemming the tide of adolescent concussion and how new legislation may alter the role of primary care in identifying, diagnosing and managing pediatric concussion.

Concussions by the numbers

In 2009, an estimated 248,418 children aged younger than 19 years were treated in U.S. EDs for sports- and recreation-related injuries, including concussion or traumatic brain injuries, according to the CDC, representing a 57% increase in such injuries among children over the preceding 8 years.

Yet, as the joint CDC/CHOP study from Arbogast and colleagues demonstrated, even this number may still be grossly underestimating the true burden of pediatric concussions in the U.S.

“Eighty-two percent of children in our network saw their pediatrician first for their concussion, rather than the emergency department or sports medicine or other specialist,” co-researcher Christina L. Master, MD, CAQSM, a pediatric and adolescent primary care sports medicine specialist at CHOP, told Infectious Diseases in Children. “It is likely that we are substantially undercounting concussions in this country since most of the data on concussions has been from emergency room visits and high school sports injury databases.”

Despite renewed interest brought on by the media spotlight, recent studies have not been able to account for the noticeable spike in concussions among adolescents over the past decade. In addition, studies that have focused primarily on available statistics of high school sports injuries often ignore the younger pediatric demographics, which constitutes a significant gap in the concussion knowledge base.

In a recent study, Alan L. Zhang, MD, associate professor of the orthopedic department at the University of California, San Francisco Medical Center, and colleagues examined data from administrative health records of 43,884 patients diagnosed with concussions during a 7-year period to conduct a retrospective cohort study on the frequency of and trends in concussions.

During the study period, the researchers determined there was a 160% increase in the incidence of concussion in the general population; 32% of the individuals diagnosed with concussion were aged 10 to 19 years with the largest increase in incidence occurring from 2007 to 2014 in that age group.

“The rates at which concussions are rising may be in part due to the rise in youth sports participation and also better diagnostic skills and training for coaches and sports medicine professionals,” Zhang and colleagues wrote. “This trend is alarming, however, and the youth population should definitely be prioritized for ongoing work in concussion diagnosis, education, treatment and prevention.”

Tackling the obvious offender

When examining concussion incidence and risk, the media focus has consistently settled on youth football. With more than 1.1 million players nationally, football remains one the most popular sports for high school athletes and one of the largest contributors to head and neck injuries, including concussions and catastrophic injuries.

“Football has been in the spotlight because concussion rates tend to be higher for football than for other contact sports, but concussions happen in every sport across both genders,” Cynthia R. LaBella, MD, FAAP, chairwoman of the AAP’s Council on Sports Medicine and Fitness, told Infectious Diseases in Children. “At the high school level, the concussion rates in girls soccer are not that far behind boys football.”

Recent surveys indicated that among male high school/collegiate athletes, football resulted in the most concussion injuries, followed by ice hockey, lacrosse, wrestling and soccer. Among female youth athletes, soccer generated the most concussions, with lacrosse and basketball close behind.

To address the danger posed by sports-related concussions among children, in May 2009, the state of Washington passed the “Zackery Lystedt Law,” becoming the first state to require a “removal and clearance for Return to Play” among youth athletes. Three years earlier, Lystedt, then aged 13, collapsed from a traumatic brain injury after being allowed to re-enter a middle school football game shortly after enduring a concussion that may have been undiagnosed or dismissed. When he returned to the game, an ensuing impact to his helmet resulted in bleeding in Lystedt’s brain.

Today, all 50 states, as well as the District of Columbia, have passed similar “return-to-play” legislation, requiring schools to follow specific protocols for allowing students to return to sports after a concussion.

“These protocols vary slightly by state, but all have, at a minimum, the requirement that any student with a suspected concussion must be pulled from play and not allowed to return without written clearance from a qualified health care professional,” LaBella said.

Examining the influence of return-to-play legislation on concussion-related health care use in states where it was enacted, in 2015, researchers from the University of Michigan and the University of Washington identified a significant rate increase of children seeking medical attention for concussions, even in states that had not yet passed the legislation.

In their study, Gibson and colleagues determined that the rate of health care use was significantly greater in states with “return-to-play” legislation vs. states without such legislation (92% vs. 75%). Moreover, the researchers found no corresponding rise in inpatient or ED visits during the study period, but noted a significant increase in primary care office visits for concussions.

“Fortunately, there is a growing awareness of concussions in children, and visits for concussions seem to be increasing,” Mersine A. Bryan, MD, of the division of general pediatrics at the University of Washington, told Infectious Diseases in Children. “Having laws in place, such as the ‘Zackery Lystedt Law’ in Washington, has raised awareness about the potential severe complications that can result from concussions. Requiring adolescents to have a health care professional clear them to play after a concussion is another important step in prevention of the serious consequences.”

Primary care in a changing landscape

With “return-to-play” legislation funneling more youth athletes into primary care offices — combined with skyrocketing concussion rates and increased parental awareness of concussion risk — it may seem as though the landscape of concussion management has changed overnight for pediatricians and PCPs on the front lines.

“The pediatrician’s role in adolescent concussion assessment/management has definitely shifted in recent years,” LaBella said in an interview. “More than ever before, pediatricians are being called upon to make the diagnosis of concussion and determine clearance for ‘return to sports.’ This is because there has been intense media focus on concussions and the potential adverse effects, which has resulted in parents being better at identifying signs and symptoms and being concerned enough to bring their child to the pediatrician for evaluation.”

While PCPs are considered to be integral to facilitating proper care among children with concussions, there remains some question about whether these physicians are adequately prepared to handle the recent uptake in pediatric concussion numbers.

In a 2012 study published in Pediatrics, Zonfrillo and colleagues surveyed 276 emergency medicine and PCPs from the same pediatric care network. The researchers found that 90% of surveyed providers had cared for at least one patient with a concussion within the previous 3 months, 16% expressed they were inadequately trained to educate others about concussions, 15% noted they did not have time to educate others, and 96% expressed the need for a concussion provider decision support tool.

“The pediatrician is on the front line with this injury, as many parents take their children to the pediatrician for an initial examination following a suspected concussion. As a result, the pediatrician needs to be trained in assessing concussion and have access to a referral network of concussion specialists that can provide more focused care as needed,” Anthony P. Kontos, PhD, research director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, told Infectious Diseases in Children.

The majority of surveyed providers expressed that there was inadequate time and training to complete neurocognitive testing in their setting; however, PCPs were more likely to consider neurocognitive testing within their role while emergency medicine physicians were more likely to refer their patients to a concussion specialist.

“When the only treatment option was rest, pediatricians may have managed this injury without outside assistance,” Jeffrey J. Bazarian, MD, MPH, professor of emergency medicine, neurology, neurosurgery, and public health science at the University of Rochester, said in an interview. “But now that a variety of treatment options have emerged, their role may be more to identify and refer early concussion patients who are not likely to recover with rest alone.”

Diagnosis and management in the office

Concussion assessment in primary care must be comprehensive, as there are numerous clinical profiles — vestibular, ocular, migraine, cognitive, mood/anxiety — associated with this injury, and each one may require a different approach to treatment.

“Concussion diagnosis is still clinical, including a history of a force, whether direct or indirect, to the head resulting in new symptoms afterward, the most common of which are headache, dizziness and balance issues,” Master said. “Loss of consciousness and memory loss may occur in some cases, but are not necessary for diagnosis. We also know now that a targeted physical examination that assesses balance, eye tracking and vestibular issues may often identify physical examination deficits in concussion.”

According to specialists, physical examination for concussion should consist of a complete head, neck and neurologic evaluation, including a test of cognitive function (mini-mental status examination or SCAT-3), tests for balance (Romberg’s test, tandem gait, Balance Error Scoring System) and vestibular/oculomotor screening to ascertain whether these tests can be performed without provoking headache, dizziness or blurred vision.

“There is no single objective test that can diagnose a concussion with 100% specificity and 100% sensitivity,” LaBella told Infectious Diseases in Children. “Some of these tests can aid in the diagnosis or management when used in conjunction with the history and physical examination, but none is a stand-alone test that can replace the history and physical examination for making the diagnosis.”

With expanded media focus and attention, as well as larger studies assessing younger demographics, even the common hallmarks of concussion diagnosis continue to change. Concussions can occur without a direct blow to the head, for example, and can occur if there is a hit to the body that causes a significant jolt to the head. Additionally, loss of consciousness is not required to make a diagnosis of concussion, as less than 10% of concussions are associated with an individual losing consciousness.

“Previously, it was thought that loss of consciousness and/or memory loss were predictors of concussion severity, so ‘return-to-play’ time frames were based on length of loss of consciousness or degree of memory loss,” LaBella noted. “However, we have learned that these do not correlate with recovery time, so we no longer follow a cookbook approach for return to sports.”

In a recent study published in Neurosurgery, Luke C. Henry, PhD, of the department of neurological surgery at the University of Pittsburgh Medical Center Sports Medicine Concussion Program, and colleagues determined that sports-related concussion recovery outcomes were found to be between 21 and 28 days for most participants in a cohort of adolescent and young adult athletes. This recovery period was longer than the commonly reported time frame of 7 to 14 days.

The researchers emphasized the importance of a comprehensive assessment of sports-related concussion including symptoms, neurocognitive testing and vestibular-oculomotor outcomes “because each component may have a different recovery trajectory that might be missed by focusing on only one or two assessments.”

The landscape of concussion management has continued to change at a rapid pace, leaving behind even the time-honored tenets of concussion management on shaky statistical ground. Conservative rest was another hallmark of concussion rehabilitation, prohibiting children from returning to play and all other physical activities until all concussion symptoms had abated. However, recent studies have indicated approaches that relied on prescribed rest alone may not be effective for all patients and may actually exacerbate symptoms in some patients.

“There has been research showing benefits of sub-symptom threshold aerobic exercise as a treatment strategy for concussions,” LaBella said. “As a result, we are no longer recommending complete physical rest until all symptoms are resolved. In most cases a graded aerobic exercise program can be initiated as soon as symptoms start to subside, and may, in fact, facilitate recovery.”

‘Shaking off’ a concussion culture

In 2013, a report released by the Institute of Medicine and National Research Council noted that youth athletes in the U.S. face a “culture of resistance” in reporting when they might have a concussion and to complying with treatment plans, both of which could endanger their health.

Bazarian noted that helmets, state concussion laws affecting public schools, game officials enforcing rules in contact sports and coaches limiting the number of full contact practices were among the best methods available for preventing concussion among youth athletes. Such preventive measures, however, are unlikely to impact concussion rates if youth athletes continue to underreport their signs and symptoms of concussion, he and others suggested.

“Although we can never fully prevent concussion, wearing appropriate safety gear such as a helmet for skateboarding or skiing can go a long way in mitigating the effects of head injuries and prevent more serious injury to the brain,” Kontos said. “However, prevention for concussion is more about making sure children report a suspected concussion and then preventing the secondary effects once a concussion has occurred — the real challenge lies in changing behavior and getting children to report their injuries.”

Countering a well-established culture of resistance in which youth athletes have been previously encouraged to “shake off” injuries and significant physical impacts in order to stay in the game requires the creation of an environment where children can feel comfortable reporting their symptoms.

Particularly in sports like football, wrestling and ice hockey, Kontos said, children need to be able to report their possible concussion to a parent, coach or athletic trainer, who should ensure that the athlete receives proper evaluation and follow-up care by health care professionals.

Educating the public on concussion

To provide parents, coaches, and athletes with a plethora of information aimed at recognizing, preventing and responding to head injuries, the CDC launched its “Heads Up Concussion in Youth Sports” educational initiative in 2003. While initial “Heads Up” materials focused on the role of health care providers in diagnosis and management of concussions, more recent initiatives have turned attention to sports programs and schools in an effort to share vital concussion information and raise awareness in environments where children spend the most time.

Unfortunately, disseminating “up-to-date” knowledge on concussion that could potentially avert a devastating pediatric injury is not always an easy task. Intermediaries such as news organizations and social media can be useful tools for offering guidance for parents, but accurate information often can be lost in the commotion of public discourse. Meanwhile, the transition of complex data into digestible public health messages continues to be an obstacle, even for the most knowledgeable experts.

“Concussions have received a large amount of media attention in recent years, which, in general, has been a good thing,” LaBella said in an interview. “Parents, athletes, coaches are now better informed about the signs and symptoms of concussion and the importance of resting from sports until the injury is evaluated and symptoms fully cleared.”

However, LaBella noted, the media has also focused on the extreme cases, in which symptoms have been severe and lasting many months or years.

“It is important to know that the overwhelming majority of people with concussions — 85%-90% — recover completely and in a relatively short period of time — 1-2 weeks — without any long term effects,” she said.

Mainstream and social media often exploit certain avenues in relaying information to acquire more viewers and hold the reader’s attention. However, in the midst of a possible emergency when a parent suspects their child may have a concussion, parents may not only lack direction, but could also be unable to contextualize the information even if from a reputable source.

According to Kontos, pediatricians should provide “accurate empirically based information about concussion to counter the hype and misinformation that is often presented in the media. Parents and children look to their pediatrician as someone they trust as a source of accurate information. Pediatricians should help increase awareness about concussion without feeding the fear associated with this injury.”

Furthermore, despite the stigma and concerns often voiced by parents, a significant proportion of concussions each year were unrelated to sports. LaBella noted that if there is any suspicion for a concussion, regardless of the environment, the child should be pulled from the activity and rest until an evaluation by a qualified health care provider is conducted. The sooner the injury is identified and proper treatment initiated, LaBella said, the lower risk for severe symptoms and/or a prolonged recovery.

“There is always concern about the risk for injury while playing sports, and certainly every effort should be made to reduce injury risk,” LaBella said. “However, it is important to remember that the benefits of sports participation for kids — overall health, physical fitness, strength, stronger bones, peer socialization, less risk-taking behaviors — still far outweigh the risks for injury. We should encourage children and adolescents to be physically active and to participate in organized sports. Even football is an excellent way to achieve this goal.” – by Suzanne Reist and Bob Stott

• References:
• Arbogast KB, et al. JAMA Pediatr. 2016; doi:10.1001/jamapediatrics.2016.0294.
• Gibson TB, et al. JAMA Pediatr. 2015; doi:10.101/jamapediatrics.2014.2320.
• Henry LC, et al. Neurosurgery. 2016; doi:10.1227/NEU.0000000000001041.
• Zhang AL, et al. Orthop J Sports Med. 2016; doi: 10.1177/2325967116662458.
• Zonfrillo MR, et al. Pediatrics. 2016; doi: 10.1542/peds.2012-1431

• For more information:
• Jeffrey J. Bazarian, MD, MPH, can be reached at the University of Rochester Medical Center School of Medicine and Dentistry, 601 Elmwood Ave, Box 655, Rochester, NY 14642. Email: Jeff_Bazarian@URMC.Rochester.edu.
• Mersine A. Bryan, MD, can be reached at the Division of General Pediatrics, University of Washington, 2001 8th Ave, Suite 400, Seattle, WA 98121. Email: mersine@u.washington.edu.
• Anthony P. Kontos, PhD, can be reached at the UPMC Sports Medicine Concussion Program, University of Pittsburgh, UPMC Rooney Sports Complex, 3200 South Water St., Pittsburgh, PA 15203. Email: akontos@pitt.edu.
• Cynthia R. LaBella, MD, FAAP, can be reached at Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611. Email: clabella@luriechildrens.org.
• Christina L. Master, MD, CAQSM, can be reached at the Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104. Email: masterc@email.chop.edu.

Disclosures: Bryan, Kontos, LaBella and Master report no relevant financial disclosures. Bazarian reports being on the Medical Advisory Board for BlackBox Biometrics, which makes a head impact sensor; receiving research support from BrainScope, which makes an EEG-based concussion diagnostic device; and receiving research support from Banyan Biomarkers, which makes a blood-based concussion diagnostic test.