Dr. Gliksman of Hackensack University Medical Center, Hackensack Meridian Health School of Medicine has no relevant financial relationships to disclose.)
Dr. Johnston of Johns Hopkins University School of Medicine and Chief Medical Officer at Kennedy Krieger Institute has no relevant financial relationships to disclose.)
This article includes discussion of cerebral concussion in childhood, closed head injury, mild traumatic brain injury, minor head trauma, and pediatric concussion. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
The incidence of concussion, or mild traumatic brain injury, has reached epidemic proportions. The author describes features of concussion in the pediatric population, noting that these injuries occur in the context of the developing brain. Concussion results from a biomechanical force to the head or body inducing a series of neurometabolic changes that reflect a functional disturbance rather than a structural injury (McCrory et al 2017). Differences in stature and nervous system physiology of children lead to unique susceptibility to concussive injury. Similar to adults, symptoms indicate disruption of global brain function, including cognitive, emotional, physical, and sleep dysfunction; however, the recovery time is often prolonged in the pediatric population. Management of pediatric concussion is also distinctive given the cognitive demands of children in school. Management of pediatric concussion includes immediate removal from play, a brief period of cognitive and physical rest, evaluation by a provider trained in concussion management, return to learning with appropriate academic accommodations, and, once clearance is provided, return to sports/physical activities following a supervised gradual return to play program. Proper management at the time of injury is essential given the risk of second impact syndrome or diffuse cerebral swelling, unique to the younger population.
• Concussion results from biomechanical forces leading to temporary neurometabolic alterations that reflect a functional disturbance rather than a structural injury.
• Concussion in children is unique, occurring within the context of neurodevelopment.
• Core symptoms of concussion in children are similar to adults, including abnormalities in physical, cognitive, emotional, or sleep domains; however, resolution of symptoms is often longer in children.
• Management of pediatric concussion includes a brief period of physical and cognitive rest. If involved in sports, immediate removal from play is essential followed by a supervised, gradual return to physical activity when cleared by a provider.
• Assessment and management should be individualized in pediatric concussion.
Historical note and terminology
The term “concussion” is derived from the Latin concutere meaning “to dash together, shake violently,” and the terminology has been noted back to times of Ancient Greece in 1 short Hippocratic text (Pearce 2008). Current definitions of concussion vary in both literature and practice. Mild traumatic brain injury (mTBI), minor head trauma, closed head injury, and concussion are often used to describe similar constructs, though currently no consensus exists on which 1 term, or precise definition, to use. In the most recent Consensus Statement on Concussion in Sport (McCrory et al 2017), sports-related concussion was defined as
“A traumatic brain injury induced by biomechanical forces… may be caused by a direct blow to the head, face, neck or elsewhere on the body with an ‘impulsive force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously… the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury, and, as such, no abnormality is seen on standard structural neuroimaging studies. Concussion results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical symptoms typically follows a sequential course. However, in some cases symptoms may be prolonged.”
The Centers for Disease Control and Prevention (CDC) has developed a website devoted to traumatic brain injury, including concussion in sports. This website provides concussion-related educational material, including concussion training for health care providers and clinical documentation forms (Heads Up and the Acute Concussion Evaluation (ACE) checklist and care plan). This material can be accessed for free at www.cdc.gov/concussion.
Concussion “grading scales” attempting to stratify concussion severity were utilized in the past, but are no longer recommended (McCrory et al 2009). The SCAT5 (Sports Concussion Assessment Tool, Version 5) is utilized at most sidelines if there is a concern for a concussion in a player. This tool utilizes Maddocks questions as well as the Standardized Assessment of Concussion (SAC) (Maddocks and Dicker 1989; Maddocks et al 1995; McCrory et al 2017).
The management of concussion in young athletes has reached the public health domain, with all 50 states and the District of Columbia passing legislation modeled after the “Lystedt Law” (Washington State, House Bill 1824, 2009). This legislation mandates the following: concussion education for coaches, athletes, and parents; immediate removal of a child from play if a concussion is suspected; same-day return to play is prohibited; and written clearance from a medical professional with expertise in brain injury for return to play.
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