CLINICAL PRESENTATION
Initial assessment of pediatric athletes with suspected concussive injuries can be particularly challenging because of the variability and evolving nature of associated signs and symptoms, resulting in a wide range of clinical presentations.3 These presenting signs and symptoms can, however, provide vital clues to the location of the injury within the brain because the consequences of concussion arise from injury to the brain’s cortical and subcortical systems (see Table 1).9
The cortical systems are located within the frontal, temporal, parietal, and occipital lobes, each of which houses control centers for specific learned skills and functions. The subcortical systems include the hypothalamus, trigeminal system, basal ganglia, and cerebellum. While a concussion most often causes diffuse harm rather than localized trauma, familiarity with the functions associated with specific brain locations aids in initial identification of the injury and allows for individualized concussion management.13
After a concussion occurs, it is essential to evaluate all domains of the child’s functioning through a comprehensive physical assessment, including a detailed concussion history and review of preinjury risk factors.3 In addition, there may be unobservable symptoms about which a child is unable to communicate due to his or her stage of emotional and cognitive development and restricted capacity to serve as a primary reporter.14
Signs and symptoms
The four categories of concussion signs and symptoms include physical, cognitive, emotional, and sleep (see Table 2).15 A concussed patient may experience any variation or combination of these signs and symptoms.
It is important to recognize that, although loss of consciousness is a serious sign of a concussion, it occurs in only about 10% of concussive injuries.5,15 In fact, current concussion guidelines no longer advocate the use of grading scales, which assessed the severity of a concussion based primarily on the presence or absence of a brief loss of consciousness. Evidence now shows that loss of consciousness does not predict clinical course or cognitive long-term impairment after a concussion.16
Duration of symptoms
The duration of concussion symptoms can vary, but in most cases symptoms last seven to 10 days, with 10% to 15% of patients reporting symptoms for more than 10 days.3,5 While recovery duration has not been studied sufficiently in children younger than 15, younger children require longer recovery periods. The resolution of symptoms, however, does not necessarily correlate with absolute cognitive recovery.5,17
Modifying and complicating factors
In addition to the patient’s presenting signs and symptoms, factors that may modify or complicate recovery from a concussion should be identified (see Table 3).3 These factors include preexisting conditions or disorders and the use of certain prescription drugs. Each factor should be assessed individually, taking into account the patient’s age.2
Some presenting symptoms may overlap with symptoms of common disorders in this group. It is important to note if symptoms of such conditions as attention-deficit/hyperactivity disorder (ADHD), sleep disorders, learning disabilities, and mood disorders were present prior to the concussion.5
Modifying factors provide essential information that can help predict the individual patient’s anticipated recovery process and must be taken into account throughout the process. They are particularly important when assessing the differences between a child’s preconcussion and postconcussion functioning.3,4
POST INJURY EVALUATION OF COGNITIVE FUNCTIONING
Concussion is diagnosed clinically, based on the mechanism of the sustained injury, and is supported primarily by reported and observed signs and symptoms. The ability to systematically evaluate the patient for manifestations of concussion is essential to pediatric concussion management.3,18
To aid in appropriately evaluating symptoms and assessing functional damage, many standardized assessment tools and neuropsychological tests have been developed. These tools have been modified for younger athletes due to differences in children’s neurocognitive development and in their ability to be symptom self-reporters.
Concussion assessment tools
The tools most commonly used to assess the effects of concussion in younger athletes are listed in Table 4. It was not until 2012, with the release of the Child Sport Concussion Assessment Tool Version 3 (Child-SCAT3), that an appropriately adapted and valid concussion assessment tool became available for children younger than 10.3
Assessment tools are useful but are not diagnostic. They do not take the place of a clinician’s thorough neurocognitive evaluation of a potentially concussed child.
Neuropsychologic testing
In order to properly manage pediatric concussions, postconcussion status must be assessed relative to preconcussion status in order to ensure optimal resolution of symptoms and cognitive recovery.19
The American Medical Society for Sports Medicine supports baseline testing for high-risk athletes, defined as those with a prior history of concussions or “confounding” conditions (learning disability, mood and attention disorders, migraine headaches).5 The International Consensus Statement on Concussion in Sport states that there is insufficient evidence to recommend routine baseline testing, but its early use after pediatric concussion may provide helpful information for determining when the child may return to school. The American Academy of Neurology suggests that clinicians “… might utilize baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/ADHD, as doing so fosters better interpretation of postinjury scores.”4
Assessment tools can provide essential insight into the cognitive functional state of a concussed child athlete, even after symptom resolution.3,5,20 They are not stand-alone measures of recovery but can be useful components of the pediatric concussion evaluation and management process and an aid to clinical decision making.3,13
Paper-and-pencil or computerized neuropsychologic tests provide objective measures of brain-behavior relationships and are more sensitive in detecting subtle cognitive impairments than a clinical examination.5 Although neuropsychologic testing has not been validated as a diagnostic tool, it may be useful for both baseline (preinjury) testing of athletes and for monitoring recovery from a concussive event.5,20 (For more information on motor control assessment, see Dirks RP, McLeod TCV. Sport-related mild traumatic brain injury. Clinician Reviews. 2008;18[9]:22. http://bit.ly/1mjizIa.)
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