CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Sport-Related in Children and Adolescents Mark E. Halstead, MD, FAAP, a Kevin D. Walter, MD, FAAP, b Kody Moffatt, MD, FAAP, c COUNCIL ON SPORTS MEDICINE AND FITNESS

Sport-related concussion is an important topic in nearly all sports and abstract at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion’s definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health aWashington University School of Medicine, St Louis, Missouri; bDepartment of Orthopaedic Surgery, Pediatric Sports Medicine, care providers should have a good understanding of diagnostic evaluation Medical College of Wisconsin, Milwaukee, Wisconsin; and cCreighton and initial management strategies. Effective management can aid recovery University School of Medicine, Omaha, Nebraska and potentially reduce the risk of long-term symptoms and complications. Drs Halstead, Walter, and Moffatt served as coauthors of the manuscript and provided substantial input into its content and Because concussion symptoms often interfere with school, social life, revision; and all authors approved the final manuscript as submitted. family relationships, and athletics, a concussion may affect the emotional This document is copyrighted and is property of the American well-being of the injured athlete. Because every concussion has its own Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy unique spectrum and severity of symptoms, individualized management of Pediatrics. Any conflicts have been resolved through a process is appropriate. The reduction, not necessarily elimination, of physical and approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial cognitive activity is the mainstay of treatment. A full return to activity and/ involvement in the development of the content of this publication. or sport is accomplished by using a stepwise program while evaluating Clinical reports from the American Academy of Pediatrics benefit from for a return of symptoms. An understanding of prolonged symptoms and expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of complications will help the pediatric health care provider know when to Pediatrics may not reflect the views of the liaisons or the organizations refer to a specialist. Additional research is needed in nearly all aspects or government agencies that they represent. of concussion in the young athlete. This report provides education on The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking the current state of sport-related concussion knowledge, diagnosis, and into account individual circumstances, may be appropriate. management in children and adolescents. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

DOI: https://doi. org/ 10. 1542/ peds. 2018- 3074 INTRODUCTION Address correspondence to Mark E. Halstead, MD, FAAP. E-mail: [email protected]

Over the last several decades, sport-related (SRCs) have been PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). recognized as a major health concern in young athletes. Exposure to contact Copyright © 2018 by the American Academy of Pediatrics sports at younger ages, long-term exposure to repetitive head trauma, and consequences of the immediate effect on an athlete’s daily life are continued concerns among parents, athletes, and health care providers.1, 2 To cite: Halstead ME, Walter KD, Moffatt K. Sport-Related Research about SRCs is being published at a robust pace with the hope of Concussion in Children and Adolescents. Pediatrics. 2018; 142(6):e20183074 identifying the best ways to diagnose, treat, and (ideally) prevent SRCs.

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018:e20183074 FROM THE AMERICAN ACADEMY OF PEDIATRICS Many organizations have published elsewhere on the body with an GRADING SCALES position statements or clinical impulsive force transmitted to the More than 25 grading scales for SRC reports on SRCs, including the head. and mTBI have been published.21 American Academy of Pediatrics Because these grading scales are (AAP), National Athletic Trainers’ 2. SRC typically results in the rapid based on expert opinion alone, Association, American Medical onset of short-lived impairment of the 2001 Vienna Concussion in Society for Sports Medicine, neurologic function that resolves Sport Group recommended the American College of Sports Medicine, spontaneously. However, in some discontinuation of their use in American Academy of Neurology, cases, signs and symptoms may describing SRC or guiding return to and National Academy of Medicine evolve over a number of minutes play. Current recommendations are (formerly Institute of Medicine).3 – 8 to hours. to diagnose the SRC without labels Despite these publications as well as 3. SRC may result in neuropathologic such as mild, moderate, or severe or existing legislation throughout the changes, but the acute clinical as simple versus complex and to use United States mandating education signs and symptoms largely reflect current consensus protocols to guide about concussions, knowledge of a functional disturbance rather return to play. concussions by athletes, parents, than a structural injury, and as coaches, and health care providers such, no abnormality is seen on 9–17 can be improved. This report standard neuroimaging studies. PATHOPHYSIOLOGY serves as an update the 2010 AAP clinical report for pediatric health 4. SRC results in a range of clinical The biokinetics that induce SRC care providers on the current state signs and symptoms that may consist of forces of acceleration, of knowledge and guidance for or may not involve loss of deceleration, and rotation of the the diagnosis and management of consciousness. Resolution of the head.22 – 24 SRCs are usually caused by pediatric and adolescent SRC. clinical and cognitive symptoms a direct blow to the head; however, typically follows a sequential SRCs may also be caused by a blow course. However, in some cases, elsewhere on the body with a DEFINITION symptoms may be prolonged. secondary force transmitted to the 18,19 There is currently no universally head. Weaker neck muscles, 5. The clinical signs and symptoms accepted definition of SRC. A which are more frequently seen in cannot be explained by drug, universally accepted definition is the pediatric population, may impair alcohol, or medication use; other important when discussing the the attenuation of force to the head injuries (such as cervical injuries, 25,26 injury with patients and their and increase SRC risk. peripheral vestibular dysfunction, parents, for health care providers etc); or other comorbidities (eg, Neurologic signs and symptoms of in making the diagnosis correctly, psychological factors or coexisting SRCs are not related to macroscopic and for researchers to have uniform medical conditions). neural damage; they are believed to standards when conducting studies be a functional or microstructural about SRCs. Debate still exists as In 2014, a systematic review was injury.18, 19, 27 The pathophysiology of to whether the term concussion or published by an expert panel concussion, as described in animal mild traumatic injury (mTBI) attempting to develop an evidence- models and some recent human should be used to describe the injury. based definition of concussion.20 This studies, involves a neurometabolic Often, concussion is considered study found the following prevalent cascade of events.27– 29 to be a subset of mTBI and will be and consistent indicators of a considered as such for this report. concussion: After the biomechanical injury to the brain, there is potassium efflux Several international symposia on • observed and documented from the neurons and a dramatic concussion in sport have been held disorientation or confusion increase in extracellular glutamate.29, 30 since 2001.18, 19 In the Concussion in immediately after the event; Glutamate, an excitatory Sport Group, a consensus of experts neurotransmitter, activates the defined SRC as “a traumatic brain • impaired balance within 1 day N-methyl-D-aspartate receptor. injury induced by biomechanical after injury; This leads to neuronal depolarization forces.” This consensus statement • with further potassium efflux and also includes 5 common features of slower reaction time within 2 days calcium and sodium influx, which concussive : after injury; and/or depresses neuronal activity.27, 29 1. SRC may be caused by a direct • impaired verbal learning and In an attempt to restore homeostasis, blow to the head, face, neck, or memory within 2 days after injury. there is upregulation of the

Downloaded from www.aappublications.org/news by guest on November 12, 2018 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS sodium-potassium ion pumps, which estimated that 1.1 million to 1.9 an increase in the true incidence depletes intracellular energy million recreational concussions and with more opportunity for sport reserves as a result of the increased SRCs occur annually in the United participation, leading to increased use of adenosine triphosphate and States in children 18 years of age or injury exposure risk, and with the hyperglycolysis.27, 30 Pediatric and younger.43 This large range highlights increasing size, strength, and adolescent studies have revealed the challenges of understanding speed of young athletes over the reduced cerebral blood flow after the true epidemiology of SRCs: years.40, 49, 51, 52 SRC, which, when coupled with the variable definitions used in research, Underreporting by athletes with SRCs increased energy demand, leads to the lack of a widespread injury remains a large concern, especially “ ”27,30 –32 a proposed energy crisis. In surveillance system, different entry because in most cases, SRC is not an attempt to normalize increased points for athletes with concussion a visible injury to an observer, so intracellular calcium levels, neurons into the health care system, and identification relies on self-reporting. 8,44 –46 sequester calcium into mitochondria, underreporting of the injury. When surveyed in 2013, 70.6% of leading to mitochondrial dysfunction Many epidemiologic studies are high school athletes indicated they and impaired oxidative metabolism, based on emergency department would report their SRC, which is an 27 worsening the energy crisis. After visits, but a recent study showed that increase from 2002 data indicating the increase in glucose metabolism, 75% of 5- to 17-year-old patients that only 47.3% indicated they there is an ensuing hypometabolic with SRCs entered the health care would report their injury.44, 45 state that may persist for up to 4 system through their primary care Unfortunately, athletes still attempt 33,34 47 weeks. provider. To further complicate to hide their injury.16 A recent study finding the true epidemiology, some Structurally, the intracellular calcium of high school athletes found only patients may never seek medical care flux can damage the cytoskeleton and 40% to 45% of high school athletes for their injuries. A pediatric study also cause axonal injury; however, reported their SRC.53 A study of estimated that between 511 590 and axonal injury primarily occurs youth rugby players revealed that 1 240 972 (45%–65%) patients with from shear and tensile forces of 80% of athletes either did not report concussion were not seen in health trauma.27, 30 This damage can reduce a concussion or returned to play care settings, and an adult-based conductive velocity through the before full recovery.54 Other surveys study revealed that 42% of patients neuron and could be correlated with indicate that 66% of high school with an mTBI did not seek medical the cognitive impairments seen in athletes would play through their care.43, 48 SRC. Findings suggest that the young SRC, with the primary reasons being brain may be more vulnerable to that they did not want to be removed Concussion incidence and reporting axonal injury because myelination from play and that they were fearful have increased over the last 2 is an ongoing maturational change of approaching their coach, in decades. Many studies report SRC throughout brain development.27, 35– 37 addition to a lack of recognition by rates using athletic exposures Although all the postinjury changes coaches, athletes, and parents.55, 56 (AEs). An AE means that an athlete can lead to cell death, there There is evidence that female high has participated in some or all of 1 appears to be little cell death after school athletes are more likely than practice or 1 game. Studies of high a concussion.27 –30 Currently, it is male athletes to report concussive school athletes show an overall unclear how chronic structural symptoms to an authority figure increase in SRCs from 0.12 in 1000 changes and cognitive dysfunction despite having similar knowledge AEs in 1997–1998 to 0.51 in 1000 may evolve over time. about SRC symptoms.57 AEs in 2011–2012.40, 49 Studies have also demonstrated increased On the basis of a compilation of several large epidemiologic studies, EPIDEMIOLOGY emergency department visits over the last decade for recreational the high school sport with the highest Historically, it is reported that up concussions and SRCs ranging from risk of concussion remains American 49,58 –60 to 3.8 million recreational and increases of 57% to more than tackle football (Table 1). The ’ SRCs occur annually at all ages in 200% in the 8- to 19-year-old age high-contact boys sports of lacrosse, the United States.38 –42 Because of group.50, 51 This increasing rate is ice hockey, and wrestling also carry ’ the large number of participants likely explained by increased overall high concussion risk. In girls sports, in youth and high school sports, awareness because of medical, soccer carries the highest risk of concussions in the pediatric and coaching, and lay public education concussion, followed by lacrosse, adolescent age groups account for the and increased media exposure, field hockey, and basketball. majority of SRCs. A recent study that leading to improved reporting In comparable sports played by those evaluated 3 national injury databases and diagnosis. There may also be of both sexes, such as basketball and

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 3 TABLE 1 Concussion Rates in High School higher (1.76 in 1000 AEs) than in TABLE 2 Signs and Symptoms of a Concussion Sports high school athletes, with a nearly 2.5 Category Symptoms Sport Concussions per times higher concussion risk in 11- to Somatic Headache 1000 AEs 12-year-olds when compared with 8- Nausea and/or vomiting Boys’ tackle football 0.54–0.94 to 10-year-olds.68 A study of youth ice Neck pain Girls’ soccer 0.30–0.73 hockey players 12 to 18 years of age Light sensitivity Boys’ lacrosse 0.30–0.67 revealed a similar concussion rate to Noise sensitivity Boys’ ice hockey 0.54–0.62 Vestibular Vision problems that in the tackle football study (1.58 Boys’ wrestling 0.17–0.58 and/or Girls’ lacrosse 0.20–0.55 in 1000 AEs), but in contrast to the oculomotor Girls’ field hockey 0.10–0.44 pattern seen in other contact sports, Hearing problems and/or Girls’ basketball 0.16–0.44 the younger athletes (12–14 years) tinnitus Boys’ soccer 0.17–0.44 had a 2.4 times higher concussion Balance problems Girls’ softball 0.10–0.36 Dizziness risk than the older athletes (15–18 Boys’ basketball 0.07–0.25 Cognitive Confusion 69 Girls’ volleyball 0.05–0.25 years). No studies of young children Feeling mentally “foggy” Cheerleading 0.06–0.22 that reported SRC incidence by AE Difficulty concentrating Boys’ baseball 0.04–0.14 were identified; however, a study Difficulty remembering Girls’ gymnastics 0.07 evaluating athletes ages 4 to 13 years Answers questions slowly Boys’ and girls’ track 0.02 Repeats questions seen in the emergency department and/or field Loss of consciousness Boys’ and girls’ 0.01–0.02 revealed tackle football to be the Emotional Irritable swimming and/or most likely sport to cause athletes More emotional than usual diving to sustain a concussion, followed by Sadness Nervous and/or anxious Data compiled from Gessel et al,39 Lincoln et al,40 basketball, soccer, and baseball.70 Sleep Drowsiness and/or fatigue Rosenthal et al,49 Marar et al,58 Meehan et al,59 O’Connor The youngest athletes in this study, et al,60 Currie et al,61 and Castile et al.62 Feeling slowed down 4- to 7-year-olds, were also found to Trouble falling asleep be more likely to sustain SRC from Sleeping too much soccer, girls have a higher concussion player–to–other-object contact than Sleeping too little 49,58 –60 risk when compared with boys. were their older counterparts.70 Girls’ ice hockey data specific to high school are limited, but in college- In general, the concussion incidence to 96%) is the most frequently aged female ice hockey players, the is higher in competition than reported SRC symptom, followed by concussion rate is higher than in male practice for both male and female dizziness (65% to 75%), difficulty ice hockey players and is similar to athletes across nearly all sports.8, 58, 60 concentrating (48% to 61%), and 60,62, 72 football rates.8, 63 The reason behind For boys, the concussion rate in confusion (40% to 46%). the sex differences in concussion competition when compared with Loss of consciousness is not a rates remains unclear, although some practice is more than 7 times higher requirement to diagnose concussion have theorized that female athletes in lacrosse and soccer, about 3 times and is reported to occur in less than 62,72 have weaker neck musculature or higher in tackle football, and over 5% of SRCs. Recent studies that estrogen may play a role.25 It twice as high in wrestling.60,71 have also demonstrated high rates has also been suggested that female In girls, the concussion rate in of vestibular and oculomotor athletes may report symptoms more competition when compared with dysfunction in athletes after SRC, frequently than male athletes.64 practice is about 5 times higher in including accommodative disorders, lacrosse, soccer, and basketball.60, 71 convergence insufficiency, and Most studies classify youth athletes 73,74 The exception to this is cheerleading, saccadic dysfunction. as anyone younger than 18 years, but which showed a higher concussion the majority of these include only It is important for the clinician rate in practice (0.14 in 1000 high school athletes. Recent research to recognize that symptoms of AEs) than in competition and/or has shown that middle school tackle a concussion are not specific to performance (0.12 in 1000 AEs).58, 61 football has the highest concussion that diagnosis and may mimic rate (2.6–2.9 in 1000 AEs), followed preexisting problems of an athlete. ’ – by girls soccer (1.2 2.2 in 1000 SIGNS AND SYMPTOMS Specific attention to athletes with AEs).65 – 67 Cheerleading (0.68–1.1 migraine and/or headache disorders, in 1000 AEs) and girls’ basketball Signs and symptoms of SRCs can be learning disorders, attention-deficit/ (0.88 in 1000 AEs) had the next- classified into 5 categories, including hyperactivity disorder (ADHD), highest rates. A study of youth tackle somatic, vestibular, oculomotor, mental health conditions (such football players 8 to 12 years of age cognitive, and emotional and as depression or anxiety), and revealed concussion rates that were sleep (Table 2). Headache (86% sleep disorders is critical to not

Downloaded from www.aappublications.org/news by guest on November 12, 2018 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS falsely attributing those symptoms TABLE 3 Postconcussion Symptom Scale (Ages 13 and Older) to the concussion, although it is Symptoms No Mild Moderate Severe important to realize that an SRC may Symptoms temporarily worsen the symptoms Headache 0 1 2 3 4 5 6 the athlete experiences with these “Pressure in head” 0 123456 conditions. Neck pain 0 1 2 3 4 5 6 Nausea or vomiting 0 1 2 3 4 5 6 A postconcussion symptom checklist Dizziness 0 1 2 3 4 5 6 Blurred vision 0 1 2 3 4 5 6 is useful in assessing an athlete after Balance problems 0 1 2 3 4 5 6 an SRC and often is a component of Sensitivity to light 0 1 2 3 4 5 6 sideline assessment tools (Table 3). Sensitivity to noise 0 1 2 3 4 5 6 Several variations are available, and Feeling slowed down 0 1 2 3 4 5 6 “ ” it is helpful to use an age-appropriate Feeling in a fog 0 123456 “Don’t feel right” 0 123456 symptom questionnaire in athletes Difficulty concentrating 0 1 2 3 4 5 6 younger than 12 years (Table 4). Difficulty remembering 0 1 2 3 4 5 6 These tools typically use a 7-point Fatigue and/or low energy 0 1 2 3 4 5 6 Likert scale graded from 0 (no Confusion 0 1 2 3 4 5 6 symptoms) to 6 (severe symptoms) Drowsiness 0 1 2 3 4 5 6 More emotional 0 1 2 3 4 5 6 for athletes older than 12 years, Irritability 0 1 2 3 4 5 6 although tools for athletes 5 to Sadness 0 1 2 3 4 5 6 12 years of age often use 4-point Nervous or anxious 0 1 2 3 4 5 6 Likert scales. A graded scale permits Trouble falling asleep 0 1 2 3 4 5 6 the assessment of the severity of Use of the Postconcussion Symptom Scale: The athlete should fill out the form, on his or her own, to give a subjective value ’ symptom burden and may minimize for each symptom. This form can be used with each encounter to track the athlete s progress toward the resolution of symptoms. Many athletes may have some of these reported symptoms at baseline, such as concentration difficulties in a the reluctance of an athlete to admit patient with ADHD or sadness in an athlete with underlying depression, and this must be taken into consideration when symptoms if asked verbally about interpreting the score. Athletes do not have to be at a total score of 0 to return to play if they had similar symptoms before the presence or absence of specific the concussion. There are currently no guidelines that determine the severity of a concussion on the basis of these scores. symptoms. Parental questionnaires TABLE 4 Postconcussion Symptom Scale (Ages 5–12 Years) may also be of benefit.19, 75,76 Athletes Not at All A Little or Somewhat or A Lot or Often have been found to report a greater or Never Rarely Sometimes number and severity of symptoms I have headaches 0 1 2 3 than their parents, with better I feel dizzy 0 1 2 3 agreement observed if they are asked I feel like the room is spinning 0 1 2 3 within 1 week of the injury.75 I feel like I’m going to faint 01 2 3 Things are blurry when I look at them 0 1 2 3 I see double 0 1 2 3 Multiple studies have found that girls I feel sick to my stomach 0 1 2 3 typically report a higher symptom My neck hurts 0 1 2 3 burden than boys.77 – 79 The presence I get tired a lot 0 1 2 3 of a higher overall initial symptom I get tired easily 0 1 2 3 burden, and especially a higher I have trouble paying attention 0 1 2 3 I get distracted easily 0 1 2 3 burden of somatic symptoms, has I have a hard time concentrating 0 1 2 3 been found to be the most consistent I have problems remembering what 01 2 3 predictor of a prolonged (>28 days) people tell me recovery after a concussion.80 – 83 I have problems following directions 0 1 2 3 This underscores the importance I daydream too much 0 1 2 3 I get confused 0 1 2 3 of symptom monitoring with a I forget things 0 1 2 3 postconcussion symptoms checklist. I have problems finishing things 0 1 2 3 The presence of ADHD, female sex, a I have trouble figuring things out 0 1 2 3 high cognitive symptom load, loss of It’s hard for me to learn new things 01 2 3 consciousness, dizziness, and early pubertal stage have been suggested ACUTE ASSESSMENT having an SRC involves a neurologic to increase the risk for a prolonged examination and an assessment On the Field and/or Sideline recovery after SRC in some studies; of current symptoms, cognition, however, other studies have revealed Ideally, initial evaluation of a balance, and vision. It is highly no increased risk.81, 82,84 – 87 conscious athlete who is suspected of preferred that this assessment is

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 5 performed by a health care provider The SCAT 5 begins with the such as the King-Devick Test and who is knowledgeable in the observable signs of SRC, which vestibular/ocular motor screening assessment of SRC. It would also be include lying motionless on have demonstrated some usefulness ideal if this assessment is conducted the playing surface, balance in the evaluation of SRC.100 – 103 At this by a health care provider who and/or gait abnormalities or time, there are not enough studies of already knows the athlete because stumbling movements, inability to adequate quality to recommend their he or she may be better suited to appropriately respond to questions inclusion in the SCAT.76, 88 identify subtle changes in his or her or disorientation, blank and/ Sideline assessment tools can function or demeanor. If available, or vacant look, and facial injury. assist health care providers in a quiet area (such as a locker room) Memory is assessed regarding the the evaluation of SRC but are not would be a preferable place to assess current event through the use of the intended to be used in isolation the athlete instead of on a field and/ Maddocks questions. The Child SCAT for making the diagnosis of SRC. or sideline or in a loud gymnasium. 5 no longer includes the Maddocks These tools can provide additional questions because they have not information, along with the clinical If an athlete is unconscious after yet been determined to be valid in judgement of the assessor, in making 76 a head injury, initial assessment children younger than 13 years. the diagnosis of SRC. However, these “ ” includes the ABCs : airway, The SCAT 5 and Child SCAT 5 also tools, particularly in younger athletes, breathing, and circulation. If the include the Glasgow Scale have not be studied adequately to athlete remains unconscious, the (GCS), a cervical spine assessment, recommend widespread use. Despite athlete must be assumed to have and demographic and symptom the availability of limited normative an associated cervical spine injury, assessments. The Child SCAT 5 also data on the SCAT and Child SCAT, it is and appropriate measures of includes parental assessment of the preferable to be able to compare an stabilizing the cervical spine and child. The Standardized Assessment athlete’s performance with his or her transportation to an emergency of Concussion (which assesses own preinjury status. It is noted that facility should occur. If the athlete cognition), a brief neurologic preinjury assessments are often not regains consciousness, the cervical examination, and a modified version obtained or are not available at the spine can be adequately assessed, of the Balance Error Scoring System time of assessment immediately after and if there is normal function (BESS) are also components of the injury. and sensation in all 4 extremities, SCAT 5 and Child SCAT 5. further assessment may be Because an athlete may not always Studies of previous versions of the conducted on the sideline or, present immediately with symptoms SCAT revealed significant differences preferably, in a quiet location. or deficits on his or her cognitive in performance on testing between or balance assessments, repeat younger and older athletes, which Various sideline assessment assessments are crucial for the led to the development of the Child tools are readily available. The athlete after head trauma. If an SCAT 3 in 2013 with revision to the most frequently used concussion assessment for a concussion has been SCAT 5 in 2017.90 – 92 Younger athletes assessment tool is the Sport initiated, it is better to err on the side perform worse on components Concussion Assessment Tool (SCAT), of caution and keep an athlete from of the Standardized Assessment which is available in both child returning to play on that day, while of Concussion, including ability (ages 5–12 years; Child SCAT 5) and continuing serial assessments, unless to perform months of the year in adolescent and/or adult (13 years the assessor is confident that SRC has reverse and digits in reverse, as well and older; SCAT 5) versions.76, 88 not occurred. as the BESS.91,93 Female athletes, These tools are updated with each When evaluating an athlete after in general, perform better than Concussion in Sport Group meeting suspected head trauma, there are their male counterparts on most on the basis of research published several red flags that warrant urgent components of the SCAT.90, 93 – 95 in previous versions between referral to an emergency department. Several studies have published meetings.19, 76,88 To complete a full These red flags include weakness or normative data and reliability assessment using the entire tool tingling in the arms or legs, severe or assessments for the BESS in young requires a minimum of 10 minutes. progressively increasing headache, athletes, although the BESS has not The Acute Concussion Evaluation loss of consciousness, deteriorating been demonstrated to consistently is an additional history-taking and level of consciousness, repeated reveal balance deficits greater than 3 assessment tool produced by the episodes of vomiting, a combative days after SRC.93, 96 – 99 Centers for Disease Control and state, and seizures or convulsions. Prevention that may be useful to The assessment of visual deficits after These findings may indicate that pediatricians.89 SRC is drawing more interest. Tools a more serious and potentially

Downloaded from www.aappublications.org/news by guest on November 12, 2018 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS life-threatening head injury has athlete becomes symptom free or significant intracranial hemorrhaging occurred and may require further is minimally symptomatic after his after 6 hours without deterioration evaluation with neuroimaging. or her injury, return to play on the in level of consciousness is extremely Tonic posturing and convulsive day of injury is not permissible if the rare: 0.03% of patients.110 Therefore, movements may immediately follow diagnosis of SRC has been made. All CT for delayed diagnosis of a concussion. Fortunately, these are 50 states and the District of Columbia in patients often benign and self-limited and have enacted laws requiring an without deterioration in level of do not portend long-term deficits individual who is suspected of consciousness after 6 hours is and generally can be addressed sustaining a concussion to be unlikely to be helpful, although past through routine SRC management. removed from play and evaluated by studies have recommended CT to be If seizure or seizure-like activity has a medical provider before returning performed in the first 48 hours after occurred minutes to hours following to play. injury.105, 111 CT is easier to perform head trauma, further evaluation and more cost-effective to obtain in an emergency department is when compared with MRI. However, warranted.104 NEUROIMAGING CT exposes children to the potentially Results of conventional harmful effects of ionizing radiation, In-Office and/or Emergency neuroimaging are typically normal which increases the risk for benign Department Assessment – in SRC. Computed tomography and malignant neoplasm.112 115 When assessing a patient in the office (CT) or MRI of the brain contribute Therefore, criteria to guide after an SRC, obtaining a history little to concussion evaluation neuroimaging decisions have been of the injury as well as relevant and management except when developed, but none are sensitive past history, including previous there is suspicion of a more severe enough to diagnose all intracranial – head injuries and any preexisting intracranial injury or structural pathology.116 119 conditions (eg, ADHD, depression, lesion (eg, skull fracture or anxiety, migraine headaches, and hemorrhage).19, 105, 106 Despite a In a 2009 prospective study, more learning disabilities), is important.89 decrease in reported injury severity than 42 000 patients were evaluated The use of a postconcussion and conventional neuroimaging regarding who may be at high risk symptom checklist is helpful in often yielding normal results, of structural brain injury and had facilitating the history taking and emergency department head CT use a CT scan performed through the reminding the health care provider for concussions increased 36% from emergency department.118 In patients to ask about all relevant symptoms. 2006 to 2011.107 older than 2 years, approximately A physical examination may include a 7% of the injuries were sport related. Concussion may be associated neurologic examination, a head-and- Patients with a GCS score less than with a significant cervical spine neck evaluation, an ocular evaluation 15, signs of basilar skull fracture, injury, skull fracture, or any of the (such as the vestibular and/or ocular or signs of altered mental status 4 types of intracranial hemorrhage motor screening assessment), a (agitation, somnolence, repetitive (subdural, epidural, intracerebral, balance assessment (which may questioning, slow response to verbal or subarachnoid).106 Signs and include the BESS, Romberg test, and/ communication) were found to be symptoms that increase the index or tandem gait), and an assessment at the highest risk for structural of suspicion for more serious of cognitive function. It is currently brain injury, and CT scanning intracranial injury include severe unclear whether the use of sideline was recommended. Patients with headache, seizures, focal neurologic tools, such as the SCAT, are as useful a GCS of 15 in the emergency deficits, loss of consciousness after SRC when assessed multiple department but with a history of for over 30 seconds, significant days after the original injury.19 If loss of consciousness, history of mental status impairment, repeated evaluation occurs immediately after vomiting, severe headache, or severe emesis, significant irritability, and the injury, monitoring the athlete mechanism of injury (falls >3 feet, worsening symptoms.19, 108 Normal for deterioration may be needed. motor vehicle or bicycle crash, or neuroimaging in the acute phase It is important to also assess for head struck by high-impact object) of injury may not absolutely rule findings on the history or physical carried a 0.9% risk of structural brain out a chronic , examination that may be concerning injury, and the authors recommended nor does it help predict subsequent for a structural injury (eg, cervical CT instead of observation. In this neurobehavioral dysfunction or spine injury, skull fracture, or study population, 58% did not fall recovery time.109 intracranial hemorrhage) that into those categories, and CT was not would require further evaluation Recent literature has shown that recommended because the structural with neuroimaging. Even if an the likelihood of finding clinically brain injury risk was less than

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 7 0.05%. A 2010 Canadian study came used for research purposes to expand To be efficient when baseline testing to similar conclusions and found knowledge about concussion and multiple teams at a school, many that acutely worsening headaches validate management strategies. schools use a group setting. It has elevated the risk of structural brain been demonstrated that performance injury, and CT was recommended.119 in a group setting will result in lower NEUROCOGNITIVE TESTING baseline scores than performance in MRI is superior to CT in the detection those tested individually, although of cerebral contusion, petechial Neurocognitive testing may be 1 study revealed an elimination of hemorrhage, and white matter performed in the assessment these differences when standardized injury.120 MRI is believed to be the of an athlete with SRC to help test instructions were used and test of choice if neuroimaging is provide objective information a trained administrator was needed outside of the emergency about recovery from the injury. present.151 – 153 A baseline CNT period. Patients who are clinically Traditional pencil-and-paper is ideally performed in a quiet worsening or not improving over neurocognitive testing often environment, free of distractions, time may benefit from MRI to assess takes several hours to administer before the athlete’s season, while the for other structural problems that and requires interpretation by athlete is well rested, and following may cause a similar symptom profile a neuropsychologist. Several the recommendations of the test (eg, Chiari malformation or tumor). computerized neurocognitive tests manufacturers. Repeating invalid These findings may have implications (CNTs) are available that allow for baseline tests more than once has for long-term outcomes and return- rapid and uniform testing of large been shown not to be beneficial to-play decisions. However, only numbers of athletes. There have been because the individual has a low 0.5% of pediatric patients with numerous studies evaluating the likelihood of obtaining a valid test persistent symptoms after SRC reliability of various CNT platforms; result.154 had findings on an MRI that were however, studies conducted compatible with traumatic injury, independently of the developers of Concerns have been raised about whereas another 14.3% were found the tests have questioned the overall athletes “sandbagging” their to have abnormal findings unrelated reliability of testing from year to baseline CNTs, which means to trauma, with the majority of those year.125 – 138 The reliability of pencil- intentionally performing poorly findings being benign.121 and-paper testing has also been to be able to have an easier goal to questioned.139 reach on their testing after an SRC. Emerging neuroimaging modalities Although there was initial concern hold promise for identifying imaging It is important for the individual about this possibility, the majority biomarkers that may improve interpreting the results of baseline of these sandbagging results can diagnosis, management, and and postinjury CNTs to be be detected.155 – 157 Studies have prognosis; however, further research knowledgeable about the modifiers demonstrated that 11% to 35% of is needed before these modalities that may affect performance on the athletes could successfully avoid can be recommended for clinical test. Sleep has frequently been cited detection when intentionally care.105, 122, 123 These modalities as a modifier for performance on performing poorly on CNTs, but include diffusion tensor imaging with baseline and postinjury CNTs.140 – 143 experience in test interpretation tractography, magnetic resonance History of concussion, regardless of can help identify those who may be spectroscopy, functional MRI, sex, did not affect performance on sandbagging.155– 157 positron emission tomography, and CNTs.144, 145 Individuals with ADHD single-photon emission CT. Research tend to have lower baseline scores on It must be acknowledged that has shown postinjury changes using CNTs than those without and perform when using a group setting for these modalities.32,122 – 124 The worse on CNTs if they do not take baseline testing, most schools identification of biomarkers through their medication before testing.146, 147 and organizations will have neuroimaging and the measurement Athletes with musculoskeletal great difficulty in creating the of metabolic and hemodynamic injuries were found to have impaired proper testing environment with changes in the brain through CNT results similar to those of administrators who have the time functional imaging will likely provide athletes with concussion.148 The and are appropriately trained a more accurate picture of the injury mechanism of the hit that produces to review all baseline results and provide a biologic basis for an SRC has not been shown to alter individually. The ideal methodology concussion symptoms while potentially performance on CNTs.149 Athletes for baseline and postinjury improving management strategies found to be more severely depressed testing may be impractical for and recovery predictions.8, 122 performed worse than those who most schools and organizations. Currently, these modalities are best were considered mildly depressed.150 Careful consideration is necessary

Downloaded from www.aappublications.org/news by guest on November 12, 2018 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS when schools or organizations used as the sole determining factor there may be negative consequences are considering using CNTs as in return-to-play decisions. If an of extremes of rest in an athlete’s part of their concussion program. athlete is suffering from prolonged recovery from SRC. Several recent Providing baseline and postinjury symptoms over several months or studies have demonstrated that CNT results in isolation for athletes has had multiple concussions with athletes who are recommended is not considered to be an adequate cognitive or emotional concerns periods of strict rest, regardless of concussion program for the school believed to be related to the symptom severity, typically take or organization seeking to use concussion, a formal assessment by a longer to recover and often continue these tools. If a school chooses neuropsychologist may be beneficial. to report higher symptom burdens to implement CNTs as part of its than athletes who rest for only concussion program, a plan should a few days.164 – 169 A study of the be in place to include proper ACUTE MANAGEMENT role of cognitive rest after an SRC administration and interpretation The management of an athlete with demonstrated that athletes who did of the baseline and postinjury test concussion involves the education not reduce their cognitive load at all results. of the athlete and his or her family after injury did take the longest to There is no agreed-on time at which about concussions and expectations improve, but even mild reductions to conduct CNTs after SRCs. Given for recovery, assessing for injuries in their cognitive load resulted in that CNTs cannot be used to predict or deficits that may benefit from similar recovery times as in those 170 the length of recovery, it is likely rehabilitation, and guiding the athlete who had extreme rest. prudent to perform postinjury testing back to school and physical activity. In light of recent research, a on an athlete when he or she is free Because each patient and concussion reasonable approach to physical of concussion symptoms. Ideally, is unique, it is important to proceed rest includes immediate removal comparison is with an athlete’s own with an individualized approach to from play and, while the athlete is baseline because several studies managing the athlete. having consistent symptoms, limiting demonstrate improved identification Athletes who are suspected to have physical exertion to brisk walking of cognitive impairment when an a concussion should be removed but avoiding complete inactivity. ’ athlete s own baseline is used for from play and not be allowed to Allowing some light cardiovascular comparison rather than population- return the same day. Athletes who activity, such as brisk walking, 158,159 based norms. continued to play immediately after although not allowing a return to Ideally, neurocognitive testing a SRC were found to have worse full sports participation, seems is performed and interpreted by symptoms and CNT scores than those prudent and is supported by recent a neuropsychologist. However, who were removed immediately research.171 This exercise is intended given the large number of athletes from play.162 The athletes who to be subsymptom exercise, meaning participating in sports and the continued to play were also 8.8 the intensity of the exercise is limited relative scarcity of and limited times more likely to have a recovery to a level that does not increase or access to neuropsychologists, a longer than 21 days.162 Another provoke symptoms. This may be widespread CNT program would study demonstrated that athletes self-monitored or through a formal not be practical or possible.160 who sustained an additional head physical therapy program. Further Ideally, if a nonneuropsychologist impact within 24 hours of the first research is needed to determine the is using CNTs, collaboration with had a greater symptom burden and optimal time to initiate this type of a neuropsychologist to aid in test a longer recovery time (52.3 vs 36.9 exercise after an SRC as well as the administration and interpretation days) than those who did not sustain most beneficial type and duration of may be beneficial.161 an additional head injury.163 These exercise. studies reinforce the importance Currently, it is not recommended When returning an athlete to school of immediate removal from play to that routine mandatory baseline and after a concussion, it is beneficial reduce the likelihood of a longer postinjury CNTs be conducted.19 for the student to receive academic recovery and worse symptoms or CNTs, when used, should be adjustments to reduce his or her exposure to additional head trauma. conducted by individuals with workload and environmental triggers appropriate training in the The previous clinical report that may exacerbate symptoms. administration, interpretation, and emphasized the role of physical Communication with teachers and limitations of the specific test. Ideally, and cognitive rest.3 Although there working with school staff who will the tests should be interpreted is a role for reducing physical and be implementing these adjustments against a patient’s individual cognitive activity after an SRC, is important for a smooth transition baseline. These tests should not be recent research has revealed that back into school. Prolonged school

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 9 removal or absence is discouraged. A is discouraged because they may RETURN TO SPORT AND/OR PLAY more detailed discussion of returning contribute to medication overuse Determining when an athlete returns 178 to learning after a concussion can headaches. There are currently no to play after a concussion should be found in the AAP clinical report medications that are specific to treat follow an individualized course, “ Returning to Learning Following a concussion. Despite the widespread because each athlete recovers at ”172 Concussion. prescription of medications by a different pace. Return to sport Because many young athletes are physicians caring for patients with after an SRC is best accomplished highly socially connected through SRCs, there is no evidence-based by following a graduated stepwise their electronics and social media, research to support their use in the program updated by the Berlin blanket recommendations to have management of SRCs. Concussion in Sport Group 19 athletes with SRCs completely avoid Because many SRCs occur through a (Table 5). Return-to-sport the use of electronics, computers, whiplash-type mechanism, cervical recommendations for children television, video games, and texting is strains are commonly associated with have been extrapolated from adult discouraged. To date, no research has a concussion. A cervical strain may consensus guidelines, and further documented any detrimental effect also lead to cervicogenic headaches. research is required to refine a of electronic use in SRC recovery. If a cervical strain is diagnosed, pediatric- and adolescent-specific Individuals with light sensitivity or physical therapy can be considered to program. Studies reveal a longer oculomotor dysfunction may find help facilitate recovery.179 recovery period for adolescents and their symptoms worsen while using younger athletes compared with electronics and may need to limit Athletes may also experience college-aged athletes; therefore, their overall screen time, adjust vestibular injuries or oculomotor a more conservative approach brightness levels, or increase font dysfunction after an SRC. to deciding when pediatric and sizes to reduce episodes of symptom Rehabilitation of these injuries adolescent athletes can return to full worsening. A complete elimination may also be of benefit, although it sport is warranted.181 – 186 of electronics may result in feeling is unclear when the appropriate No athlete should be allowed to socially isolated from friends, which time is to initiate therapy for these return to play on the same day as the may lead to depressive or anxious problems because many cases are injury.162, 163 The phrase, “When in 8 symptoms. mild and may resolve spontaneously. doubt, sit them out!” is paramount Several studies have demonstrated Persistent symptoms of dizziness in the management of pediatric and deficits in the reaction time to and and balance problems may benefit adolescent concussion.18 Despite judgment of road hazards in adults from vestibular rehabilitation by the existence of state laws and the with concussion attempting a driving appropriately trained physical AAP, American Medical Society for 179 simulator in the first 24 hours after therapists. Sports Medicine, American Academy 173,174 injury. Similar deficits likely It is important to counsel patients of Neurology, and Concussion in exist in adolescent athletes after regarding their expected recovery Sport Group all having published an SRC, so it is worthwhile to avoid and provide reassurance that they statements recommending not driving for the first few days after an are expected to improve. Each returning to play on the same day of SRC. concussion is unique, and there are the injury, literature reveals that 10% Reported recommendations for the currently no diagnostic tests, physical to 38% of young athletes reported use of medications after a concussion examination findings, or historical returning to play on the same day as 187,188 are common among primary elements that can definitively predict the injury. Additional education care, emergency department, and how long it will take for a patient to of all stakeholders in SRCs remains sports medicine physicians.175 – 177 recover. Studies on recovery time an important task. Acetaminophen and nonsteroidal have reported that the majority of Athletes should not be allowed to anti-inflammatory medications were pediatric and adolescent athletes return to contact, collision, or high- the most commonly used.175– 177 with SRCs recover between 1 and risk activities until symptoms of Emergency department physicians 4 weeks.180 – 186 Not all athletes the concussion have resolved and reported high rates of use of with SRCs will recover within that a return-to-sport progression has ondansetron.176 Primary care time frame, however. Athletes who been completed. Premature return physicians also report a frequent sustain a second concussion within to contact increases the risk of more recommendation of melatonin and 1 year after recovery from the first severe injury, repeat injury, and amitriptyline.175, 177 The chronic use concussion were not found to have a prolonged recovery.189, 190 Cognitive of acetaminophen or nonsteroidal longer recovery time than that of the and noncontact physical exertion anti-inflammatory medications initial concussion.180 might increase symptoms, but it

Downloaded from www.aappublications.org/news by guest on November 12, 2018 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 5 Graduated Return-to-Sport Program Stage Aim Activity Goal of Step 1 Symptom-limited activity Daily activities that do not provoke symptoms Gradual reintroduction of work and/or school activities 2 Light aerobic exercise Walking or stationary cycling at slow-to-medium pace; Increase heart rate no resistance training 3 Sport-specific exercise Running or skating drills; no activities with risk of Add movement head impact 4 Noncontact training drills Harder drills (eg, passing drills and team drills); may Exercise, coordination, and increased thinking during begin progressive resistance training sport 5 Full-contact practice After medical clearance, participate in full, normal Restore confidence and allow coaching staff to assess training activities functional skills 6 Return to sport Normal game play Full clearance/participation Recommend 48 h of relative physical and cognitive rest before beginning the program. No more than 1 step should be completed per day. If any symptoms worsen during exercise, the athlete should return to the previous step. Consider prolonging and/or altering the return-to-sport program for any pediatric and/or adolescent patient with symptoms over 4 wk. is unlikely to worsen the injury symptoms do not return. A return of concussion. These materials or outcomes, whereas prolonged symptoms may indicate incomplete should be provided on an annual inactivity is known to result in a recovery from the concussion. If basis, and all stakeholders should higher symptom level and prolonged symptoms return while the athlete sign the forms acknowledging recovery.164, 168,191 Although is in the program, the athlete should their participation and beginning symptom-limited aerobic wait 24 hours, and if the symptoms understanding. activity may be appropriate in some have resolved, he or she may then 2. Any athlete suspected of young athletes with a concussion, attempt the previous step that sustaining a concussion should be children and adolescents should not was completed without symptoms immediately removed from play fully return to sports until they have and continue the progression if and cannot return to play on the also successfully returned to full symptoms do not recur. Reevaluation same day. academics. by a health care provider is indicated for any athlete who has a continued 3. Any athlete with a suspected The graded return-to-sports return of symptoms with exertion. concussion cannot return to program was initially proposed An athlete who has a history of participation until written medical by the Canadian Academy of Sport multiple concussions or who had a clearance is received from a health and Exercise Medicine in 2000 prolonged recovery (over 4 weeks) care provider who is trained in and endorsed by the first meeting may need a longer period of time to the evaluation and management of of the Vienna Concussion in Sport progress through each step of the concussion. Group in 2001.18, 192 Children and program. A specialist with experience adolescents should not advance States may vary on the type of in concussion management may be beyond step 2 until they return education, frequency of signed needed to create an appropriate to their preinjury symptom levels certification, return-to-play content, return-to-activity program. and are fully participating in and type of health care provider who 194,195 school. Ideally, the progression is can provide written clearance. monitored by a licensed health care Every health care provider should LEGISLATION ’ professional who is knowledgeable understand his or her state s law in concussion management; however, By 2014, every state and the District and how it affects the patients and a parent or coach may monitor the of Columbia had passed youth sports practice. 193 progression through the return- concussion laws. Most laws consist Research indicates that concussion to-sport program if he or she is of the 3 key components found in laws have had a positive impact by ’ given proper instructions and can Washington state s 2009 Zackery increasing the reporting of symptoms 193 monitor for the return of symptoms. Lystedt Act : by athletes and decreasing instances Athletic trainers are also licensed 1. Organizations operating sports in which coaches allow athletes health care professionals who can programs for athletes younger who are symptomatic to return to supervise a return-to-sport program than 18 years, both schools and play.195 – 197 Before all states passed once they are instructed to do so. youth sports organizations, must concussion legislation, states Each step should take at least 24 provide educational materials that had laws had a 10% higher hours, and it may take the athlete and/or programs to inform concussion-related health care use just under a week to resume full coaches, athletes, and parents rate compared with states that did game participation, provided that about the nature and risks of not have laws, indicating a positive

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 11 effect.198 However, education to a concussion specialist for further with no clinical problems to reduce does not seem to be spread evenly evaluation. the bias of convenience samples. across the athletic community. A Two studies revealed no increased There is still no consensus agreement study performed 3 years after the risk of dementia, Parkinson disease, on the definition of postconcussion passage of the Washington state law amyotrophic lateral sclerosis, or syndrome (PCS). The World Health revealed that although nearly all high cognitive or depressive problems in Organization’s definition of PCS school football and soccer coaches former high school football players includes the presence of 3 or more received education through 2 or of the following symptoms after a compared with classmates who did more modalities (written, in-person, 204,205 head injury: headache; dizziness; not play football. video, and slide presentation), only fatigue; irritability; difficulty with 34.7% of the athletes and 16.2% of concentrating and performing mental Second-impact syndrome is a parents were exposed to that much tasks; impairment of memory; condition that is still contested in the education.199 In addition, a recent insomnia; and reduced tolerance medical community.206 This injury study in Illinois showed that although to stress, emotional excitement, or is believed to be the result of an pediatricians had good knowledge alcohol.201 There was no minimum individual sustaining a second head about concussion diagnosis and time frame for these symptoms injury before fully recovering from initial management, only 26.6% provided by the World Health the first, which can result in cerebral were “somewhat familiar” or “very Organization to diagnose PCS. The vascular congestion, progressing to familiar” with a recently passed Diagnostic and Statistical Manual diffuse cerebral and death.207 state law.12 A pediatric health of Mental Disorders, Fourth Edition Particular attention to this condition care provider can have a positive included a definition of PCS, but this impact by incorporating concussion in the young athlete is important was removed in the fifth edition education for both parents and because the vast majority of cases because of confusion and a lack of athletes into the young athlete annual have been reported in individuals consensus regarding the disorder.202 208 examination. of high school age and younger. Fortunately, this is believed to Long-term Effects be a rare phenomenon but lends PROLONGED SYMPTOMS AND/OR Significant attention in the medical support to the recommendation to LONG-TERM ISSUES community and media has been given immediately remove an athlete from Although the vast majority of young to the concern of potential long- play after a suspected SRC and to athletes will have a resolution of their term effects of SRC and repetitive not allow premature return to play, symptoms within 4 weeks, some will head trauma. The most emphasis is particularly while symptomatic. have symptoms that linger beyond on the condition known as chronic that time. In athletes with persistent traumatic encephalopathy (CTE). Retirement symptoms, it is important to evaluate There is currently not a way to for associated injuries that may conclusively diagnose CTE in a The decision to retire an athlete from benefit from rehabilitation or other living individual; this is exclusively a a particular sport or sports after treatments, including cervical strains; postmortem pathologic diagnosis. In vestibular injuries; oculomotor a recent convenience sample study of an SRC is often a difficult decision. disorders; sleep cycle disturbances; former football players who donated No evidence-based criteria exist to and developing depression, anxiety, their for evaluation after their help guide the clinician in making a or problems with attention.8 Because deaths, 3 of 14 high school (21%) and decision concerning the appropriate the majority of these possible 0 of 2 pre–high school players were time to retire. Several expert opinion coexisting conditions can mimic found to have CTE on analysis.203 publications have offered some 209,210 symptoms of concussion, providers The 3 athletes who only played in considerations for retirement. may attribute persistent symptoms high school were noted to have stage It is likely prudent to refer an to the concussive injury itself and 1, the mildest form of CTE. Nearly athlete to a specialist with expertise miss an opportunity to potentially all of the professional athletes were in SRC if a clinician is contemplating improve a treatable problem. Several found to have evidence of CTE, the retiring an athlete from a particular studies have also demonstrated majority of them with evidence of sport. There is no “magic number” young athletes with prolonged severe pathology. Further research of concussions that an individual symptoms have a higher likelihood of is necessary to correlate pathologic has sustained that can be used to high preinjury somatization.87, 200 It findings with clinical manifestations, determine when an athlete should no is reasonable to consider referral of including larger-scale evaluations of longer be allowed to participate in a patients with prolonged symptoms the brains of contact-sport athletes particular sport.

Downloaded from www.aappublications.org/news by guest on November 12, 2018 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS PREVENTION In terms of concussion prevention, Headgear football helmet improvements may The prevention of all concussions Soccer headgear has been marketed be reaching a point of diminishing is highly unlikely, and expectations to help reduce the impact associated returns and are not likely to should be focused on efforts to with heading and head hits and be the solution to the issue of reduce the risk and minimize any ultimately the risk for concussion. concussions.226 Properly fitted potential long-term outcomes. Headgear has not been demonstrated football helmets may decrease Concussion prevention efforts to have a benefit for head-to- the likelihood of sustaining more have historically been focused on ball impact or neurocognitive significant intracranial injury and protective equipment, educational performance.243 – 245 Soccer headgear are recommended.227, 228 Helmet fit efforts, rule changes, evaluating may increase the risk of injury is best assessed by individuals with for increased risk, and dietary attributable to possibly increased proper training in this area, such as supplements. rotational forces to the head and an athletic trainers. increased risk for a more aggressive Mouth Guards style of play.246– 248 Headgear has also There are several after-market not been found to provide significant The use of mouth guards in helmet attachments, such as protection from SRC in rugby.249 – 251 sports has been described since bumpers, pads, and sensors. No 211 Given the lack of evidence-based 1930. The potential for mouth studies demonstrate that helmets or research conclusively demonstrating guards to prevent concussion was third-party attachments prevent or benefit, the use or mandating of initially suggested in 1954, with reduce the severity of concussions. headgear for reducing concussion data supporting this notion being These attachments have not been 212,213 risk cannot be supported at this time. published a decade later. tested by the National Operating Since then, several larger studies Committee on Standards for Athletic Education with varying designs have refuted Equipment and may void the helmet 214–218 this assertion. Evidence certification and manufacturer’s Education and awareness of of an advantage in concussion warranty. Data suggesting an concussion are also important when prevention between athletes impact threshold for injury are not trying to reduce SRC as well as wearing custom-made versus supported, and the use of helmet improve diagnosis and management. noncustom-made mouth guards impact indicators has a low positive Several studies have demonstrated 215,216, 219 –221 remains inconclusive. predictive value and may generate the benefit of education efforts in However, the use of mouth guards is unnecessary evaluations.229, 230 The improving concussion knowledge, paramount in reducing maxillofacial use of these sensors does not appear reducing referrals for neuroimaging, 214,217, 222 and dental trauma. to have a role in clinical decision- and increasing the likelihood of 252–255 making but may have a role in reporting SRCs. Although Helmets research regarding rule changes or these particular education efforts Football helmets have evolved improved helmet design.229 –231 The may not directly reduce SRCs alone, significantly over the past 50 years. use of helmet-based or other sensor understanding how concussions Current football helmets are larger, systems to clinically diagnose or occur through education may result heavier, and designed to absorb and assess SRC cannot be supported at in rule changes as well as changes in dissipate impact forces to a greater this time.19 behaviors and attitudes toward SRC. extent than earlier models.223 Since Biomarkers the 1970s, football helmets have Studies in the sports of skiing, been designed to reduce severe snowboarding, lacrosse, Several different biomarkers injuries, such as skull fractures, equestrianism, rodeo, and have been investigated as playing subdural hematomas, and recreational bicycling have a potential role in concussion contusion or hemorrhage.224 The demonstrated a protective effect evaluation, including S100β, glial current goal of reducing concussions of helmet use in limiting impact fibrillary acidic protein, neuron- through helmet design remains forces causing head injury overall specific enolase, τ, neurofilament elusive. Several studies have not but none regarding concussion light protein, amyloid β, brain- demonstrated a difference in specifically.232 –241 Hockey helmets derived neurotrophic factor, creatine concussion symptom severity, have been shown to reduce the kinase and heart-type fatty acid time to recovery, or incidence of impact force from elbow collisions binding protein, prolactin, cortisol, concussion among various brands and low-velocity puck impacts but and albumin.256 Additionally, and models of football helmets, not from shoulder collisions, falls, or apolipoprotein E ε4, apolipoprotein whether new or refurbished.220, 225 high-velocity puck impacts.242 E ε4 promoter G-219T-TT genotype,

Downloaded from www.aappublications.org/news by guest on November 12, 2018 PEDIATRICS Volume 142, number 6, December 2018 13 and τSer53Pro polymorphism have literature regarding rule changes help mitigate the SRC risk are all been suggested as possible risk in American football and provided important SRC reduction goals. factors for a predisposition to recommendations for reducing SRC concussion, potential delayed risk.266 Increasing the age at which recovery, or increased risk for heading is initiated may provide CONCLUSIONS .257, 258 These some reductions in SRCs in soccer Our conclusions are as follows: investigations are preliminary, and in younger age groups, although none of these potential biomarkers greater reductions may be achieved 1. SRCs remain common in youth have advanced to use in the clinical through limiting player-to-player and high school sports. Further setting.259 contact.267 There is likely a benefit of research continues to be needed, encouraging athletes to play by the especially in middle school and Supplements rules and discouraging aggressive younger athletes. playing styles, which may be Similar to biomarkers, numerous 2. Each concussion is unique and has influenced by coaching. nutritional supplements have been a spectrum of severity and types investigated as having potential of symptoms. These symptoms preventive and/or therapeutic roles may overlap with other medical in concussion management, including FUTURE DIRECTIONS conditions. Ω-3 fatty acids, eicosapentaenoic acid, docosahexaenoic acid, Since the original clinical report in 3. Conventional neuroimaging curcumin, resveratrol, melatonin, 2010, there has been an exponential is generally normal after an creatine, Scutellaria baicalensis, increase in the amount of published SRC. Following evidence-based green tea, caffeine, and vitamins C, D, research on SRCs. This research guidelines may significantly and E.260, 261 There are some animal has advanced the knowledge base reduce unnecessary imaging. and understanding of the injury studies to support their possible 4. Various tools exist to evaluate the and has helped guide the evolution benefit, but there is currently no athlete after an SRC. Familiarity in evaluation and management of evidence that these supplements can with these tools and their SRC. There continue to be large help in the prevention or treatment limitations can aid clinicians in – gaps in research, particularly in of concussions in humans.260 263 appropriate evaluation after a the middle school and younger- suspected SRC. Neck Strengthening aged populations. The need exists for furthering our knowledge in 5. The majority of pediatric athletes A simple and somewhat promising the area of diagnosis, especially in with SRCs will have a resolution of form of prevention may come from terms of finding tests or imaging the symptoms within 4 weeks of a cervical muscle strengthening studies to help increase sensitivity the time of injury. program. Poor neck strength was and specificity in truly determining 6. After a concussion, initial found to be a predictor of concussion, what is and is not an SRC. Agreement reductions in physical and and for each additional pound of on a definition of SRC would also cognitive activity can be beneficial strength a player had, the overall further the field. Refining our 25 to recovery, but prolonged risk of SRC was reduced by 5%. approaches to the management of restrictions on physical exertion Improved neck strength, as well as the injury will only benefit athletes or removal from school can have the ability to anticipate and activate as they recover. Much work is negative effects on recovery and the neck muscles, was found to needed to clarify the confusing symptoms. mitigate the kinematic forces from information the general public 264 head impact. receives regarding the absolute 7. The long-term effects of a risk of CTE, what the pathologic single concussion or multiple Rule Changes findings mean in relation to the concussions has still not been Rule changes and a proper clinical picture, what dose response conclusively determined. enforcement of rules by officials may exist, and what modifying Prolonged exposure over may help reduce the likelihood factors may also contribute to the many years to repetitive brain of concussion. The AAP has development of CTE. Continuing to trauma has been associated with addressed the benefits of reducing make and enforce rule changes that pathologic changes in the brain concussion risk by eliminating body reduce the risk of contact, modifying in collegiate and professional checking in youth hockey.265 The practices to eliminate unnecessary athletes but is notably less in AAP policy statement on tackling or extra contact, and determining younger athletes. The exact in youth football reviewed the if equipment modifications may correlation of clinical symptoms

Downloaded from www.aappublications.org/news by guest on November 12, 2018 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS with pathologic findings has not lack of symptom resolution and M. Alison Brooks, MD, FAAP yet been established. may benefit from referral to an Greg Canty, MD, FAAP Alex B. Diamond, DO, MPH, FAAP appropriate health care provider 8. Currently, no medications have William Hennrikus, MD, FAAP been developed to specifically who can evaluate and treat these Kelsey Logan, MD, MPH, FAAP prevent or treat the symptoms of problems. Kody Moffatt, MD, FAAP Blaise A. Nemeth, MD, MS, FAAP 4. All athletes with a suspected SRC SRCs. There are no quality studies K. Brooke Pengel, MD, FAAP at this time that demonstrate should be immediately removed Andrew R. Peterson, MD, MSPH, FAAP benefit in concussion recovery. from play and not returned to full Paul R. Stricker, MD, FAAP sports participation until they 9. Retirement from sports after an LIAISONS SRC is an individualized decision have returned to their baseline level of symptoms and functioning Donald W. Bagnall, LAT, ATC – National Athletic that may benefit from consultation Trainers’ Association with a physician who has and completed a full stepwise experience in recommendations return-to-sport progression CONSULTANTS without a return of concussion for retirement after SRC. Joel Brenner, MD, FAAP symptoms. If injury recovery Gregory Landry MD, FAAP occurs during the academic year, RECOMMENDATIONS a return to the full academic STAFF Our recommendations are as follows: workload is expected before a Anjie Emanuel, MPH return to full sports participation. 1. Neurocognitive testing after an SRC is only 1 tool that may be 5. Although all concussions cannot used in assessing an athlete for be prevented, reducing the risk recovery and should not be used through rule changes, educational ABBREVIATIONS as a sole determining factor to programs, equipment design, and AAP: American Academy of determine when return to play cervical strengthening programs Pediatrics is appropriate. Testing should may be of benefit. Prevention ADHD: attention-deficit/hyperac- be performed and conducted by efforts should be focused on tivity disorder providers who have been trained reducing the risk of long-term AE: athletic exposure in the proper administration and injury after a concussion. BESS: Balance Error Scoring interpretation of the tests. 6. Health care providers should System 2. Athletes who remain unconscious have an understanding of their CNT: computerized neurocogni- after a head injury should be individual state’s laws regarding tive test assumed to have a cervical spine return to play after a concussion. CT: computed tomography injury. Appropriate stabilization CTE: chronic traumatic of the cervical spine should LEAD AUTHORS encephalopathy occur, and the patient should be Mark E. Halstead, MD, FAAP GCS: Glasgow Coma Scale transported to an emergency Kevin D. Walter, MD, FAAP mTBI: mild traumatic brain facility for further evaluation. Kody Moffatt, MD, FAAP injury PCS: postconcussion syndrome 3. Athletes with prolonged COUNCIL ON SPORTS MEDICINE AND SCAT: Sport Concussion symptoms after an SRC should be FITNESS EXECUTIVE COMMITTEE, Assessment Tool evaluated for coexisting problems 2017–2018 SRC: sport-related concussion that may be contributing to the Cynthia R. LaBella, MD, FAAP, Chairperson

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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