For Medical Providers
These are general thoughts from the literature as of 8/2013. This is not intended to impose standards of care or to prevent the medical provider from considering the individual needs of his or her patient.
Initial patient evaluation of head injury/concussion.
The goal of the initial visit after a patient has suffered a head injury is
- to rule out severe TBI and assess for the need for urgent neuroimaging
- to diagnose or rule out concussion
- provide recommendations for the management of a concussion
A comprehensive history is helpful in the evaluation of a patient with a head injury, including:
- Details about the mechanism of injury
- Signs and symptoms at the time of the injury
- Evolution of signs and symptoms since the injury.
History should also include concussion risk factors:
- Prior concussions
- Burden of prior concussions including how recent the concussions were, how much force was required to cause a concussion, the severity and duration of symptoms and if the patient had any permanent residual symptoms.
Risk factors for concussion:
- Mental health diagnosis or concerns
- Learning concerns or diagnosed learning disabilities
- Past speech therapies
- Past strabismus and/or vision therapies
- Underlying medical problems
Review of Systems
A complete head to toe physical exam should include:
- Head: Inspect for signs of fracture, such as scalp swelling, bogginess, crepitus, battles sign, raccoon eyes
- Eye: Pupils, EOM, Oculomotor/vestibular exam including evaluating pursuits, saccades, vestibulo ocular reflex testing, vestibulo ocular cancellation, accommodation and convergence assessment.
- Ear: hemotypanum
- Neck: c-spine injury, cervical strain
- Neurologic: Cranial nerves, Motor strength, sensory exam, Balance testing using BESS (Balance Error Scoring System), Gait and stability testing, Cerebellar testing
Many guidelines suggest that formal neurocognitive testing may be helpful in the management of concussion. Research suggests that neurocognitive recovery may lag behind symptom resolution and normalization of the physical exam, therefore neurocognitive assessment is an important part of the evaluation. In some circumstances it may not be feasible to do neurocognitive testing. In this situation feedback from the student’s teachers is important to document neurocognitive function prior to clearance for Return-to-Play
Although CT is useful in ruling out intracranial injury it is rarely helpful in concussion. Children and teens are at increased risk for future cancers when exposed to medical radiation therefore it is important to be thoughtful about obtaining a CT. Several studies have show decision rules to be helpful in determining when urgent neuroimaging is indicated in the acutely injured patient.
Observation for 4-6 hours after injury in an appropriate medical setting with providers who are trained to assess pediatric patients is a viable alternative to obtaining a CT scan in certain patients. Patients may be referred to an RMHC/HealthONE ED.
Initial Treatment Recommendations
Treatment for the first few days after a concussion includes both physical and cognitive rest. Patients with severe symptoms may be held out of school for the first few days after an injury. We do not recommend “cocoon therapy” or removing a child from school until they are asymptomatic. Patients should resume “ADL’s” (activities of daily living) as soon as possible. They should avoid screens, especially texting, video and computer games, electronic readers and computers after injury. As the patient recovers the focus should be on returning to school as soon as symptoms allow. A patient does not have to be asymptomatic to return to school (but must be asymptomatic to return to play).
Our “Return to learn” handout may be helpful to the primary care provider in providing recommendations for academic adjustments to the school.
The REAP booklet is helpful in educating parents and patients about concussion and concussion recovery and may be downloaded by parents. Copies are available for purchase by organizations by contacting Karen Romero.
Return to play occurs after return to learn and only once the concussion is resolved.
Follow-up Patient Visit
At the follow-up visit the patient should be assessed for concussion resolution vs. ongoing post-concussion symptoms.
Return-to-Play: In order to begin the Return-to-play steps a patient must be:
- Free of all symptoms attributed to concussion
- Have a normal physical exam including no provocation of symptoms with vestibular, oculoomotor or balance challenges
- Demonstration of normal neurocognitive function (back at school with no adjustments, documentation of baseline function based on teacher feedback and/or neurocognitive testing)
- Off all medications used to manage and/or treat post-concussion symptoms
A patient who is still suffering post-concussion symptoms may additional treatment and/or therapies. Complications that may require treatment include:
- Worsening or severe symptoms warranting MRI
- Vestibular and/or oculomotor dysfunction
- Neck strain with or without cervicogenic headache
- Acute or chronic post-traumatic headache
- Cognitive dysfunction
- Disordered sleep
- Depressive symptoms
- Autonomic dysfunction with postural intolerance
- Improvement but incomplete recovery
We are happy to see any patient within 3 months of an acute concussion. At this time we do not have the resources to manage those with remote injury and prolonged post-concussion syndrome.
Patients who often benefit from referral to the Center for Concussion are:
- Patients who are not recovering in a typical time frame (symptoms for more than 1-2 weeks)
- Patients with severe symptoms including headache, dizziness, balance difficulties, postural symptoms.
- Patients with underlying risk factors: ADD/ADHD, Mental Health concerns, learning disabilities, prior concussion
- Patients who may need to retire from sport due to severe or multiple concussions
We feel that actively management a concussion early in the course of the injury may significantly benefit the recovery. We like to intervene with these patients as soon after the injury as possible and recommend early referral.
Please call the Center for Concussion at (720) 979-0840 to speak with a medical provider if you would like to discuss and/or refer a patient.