New treatments for concussion: the next millennium beckons

Controversies in the evaluation and management of minor blunt head trauma in children

PURPOSE OF REVIEW

We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma.

RECENT FINDINGS

Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome.

SUMMARY

Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population

Athletic concussion is a growing focus of attention for pediatricians. Although numerous literature reviews and clinical guidelines are now available pertaining to athletic concussion, few have focused on the pediatric athlete in particular. Sport-related concussions occur relatively frequently in children and adolescents, and primary health care providers are often responsible for coordinating clinical management. Here we summarize the scientific literature pertinent to the care of young athletes. We examine how concussion affects younger and older athletes differently at biomechanical, pathophysiological, neurobehavioral, and contextual levels. We also discuss important issues in clinical management, including preparticipation assessment, concussion evaluation and recovery tracking, and when and how to return pediatric athletes to play sports. We also briefly cover non-sport-related interventions (eg, school support). With proper management, most children and adolescents sustaining a sport-related concussion can be expected to recover fully.

Return to play after concussion: principles and practice

OBJECTIVE

The sport medicine team is increasingly being asked to manage concussed athletes and to provide written clearance for return to play postconcussion, making it critical to have a good understanding of concussion recognition, assessment, and management.

DATA SOURCES/SYNTHESIS

A handy way to think of concussion management is the four Rs: recognition, response, rehabilitation, and return.

RESULTS

Athletes, coaches, parents, therapists, and physicians need a thorough understanding of concussion signs and symptoms. An athlete suspected of having sustained a concussion should be removed from the game or practice and assessed by a member of the sideline medical team. All athletes who sustain a concussion should be evaluated by a medical doctor. Rehabilitation has similarities to but also differs from the traditional orthopedic model in that the first step is rest, both physical and cognitive. Once asymptomatic at rest, a step-wise return to activity is undertaken.

CONCLUSIONS

This protocol has been adapted for various sports. It may be used for children, although it is prudent to be more conservative and to progress more slowly than in an older age group.

Rotational acceleration measurements--evaluating helmet protection

PURPOSE

Current helmet testing standards do not address the rotational components of an impact to the head. We describe a new testing paradigm used to measure the rotational acceleration of a headform and a protective helmet following an impact to the head in the horizontal plane. This impact simulation allows for the testing of currently available head protection devices in conditions thought to be important for the generation of cerebral concussion. The degree to which a particular helmet dampens rotational acceleration, and thus protects against concussion, can be assessed.

METHODS

Our testing device consists of a pneumatic piston that provides a measured impact to a standard headform. Four different helmets were tested using the described paradigm.

RESULTS

Acceleration curves for each helmet and the corresponding headform are presented.

CONCLUSIONS

Clear differences in rotational acceleration were demonstrated. Possible avenues of further investigation are discussed.