Morbidity by Injury Severity
Concussions
A concussion is the transient and immediate change in neurologic function due to a mild TBI, with or without a brief loss of consciousness (240). A concussion is often referred to as getting “dinged” or having your “bell rung.” Neuroimaging is typically normal following a concussion (241), and the diagnosis is made clinically.
Symptoms of concussion usually resolve within 20 minutes, but postconcussive symptoms can last for days and weeks. Common concussive symptoms include headache, memory lapses, cognitive problems, confusion, feeling dazed or “foggy,” dizziness, sleep problems, behavioral changes, bizarre statements, poor attention span, photophobia, diplopia, and sadness (242).Common causes of concussions in children are sports injuries, falls, bicycle accidents, and automobile accidents (243). Yearly in the United States, more than 300,000 TBIs, mostly concussions, occur due to youth sports (244). Female athletes have a higher rate of concussions than males, thought to be secondary to their relatively weaker neck muscles being less able to absorb head and neck trauma (245). Concussions are graded by severity (Table 10.4), and return to activities depends on the concussion severity. Postconcussive symptoms (246) may resolve before cognitive functioning returns to normal (247). Neuropsychologic testing can detect these persistent cognitive changes. Many youth sports programs use cognitive assessment tools such as ImPACTTM (248) prior to participation and will not allow a return to activities until cognition returns to baseline (249). In general, a person should be symptom-free for one week before returning to activities.
In the days and weeks after a concussion, the injured brain cells are vulnerable to repeat injuries, which can cause extensive neuronal loss (240). For this reason, the brain should be rested following a concussion until all symptoms have resolved.
Symptoms can be exacerbated and recovery slowed by strenuous physical and cognitive activities. During this “cognitive rest,” physical and academic activities should be limited. Once symptoms have resolved, the patient should gradually return to activities as tolerated (250).Repeated concussions over months or years can lead to long-term cognitive deficits (60) and increase the risk of neurodegenerative disorders such as Alzheimer’s disease (251). So activities that have a higher risk of concussions, such as football, boxing, and ice hockey, should be restricted if a person has suffered several concussions. Persons who have had previous concussions may be more susceptible to recurrent concussions and slower brain healing (60). Repeat concussions over hours, days, or weeks can lead to catastrophic changes, such as second impact syndrome, previously described in the pathophysiology section.
Mild to Moderate Injury
Children who sustain minor TBI may demonstrate few, if any, consequences, or they may complain of subjective complaints such as headaches, mild memory impairment, and fatigue. This constellation of symptoms is consistent with postconcussive syndrome. Although the child with a mild TBI may not require a prolonged hospital stay on the rehabilitation unit, they may still have difficulty returning to school. The challenges these children may encounter include difficulty with timed tasks, impaired attention, and impaired memory. Subtle language dysfunction and impaired prosody of speech may be notable, as well as behavioral and personality changes. For these children, neuropsychological testing to identify any deficits is imperative, lest they be allowed to fall behind in their academic progress as the effect of the injury on their cognitive function goes unnoticed (166). It is encouraging, however, to note that by one year after injury, children who sustained a minor TBI rarely have impairment that continues to challenge them academically (252). In 2004, Hawley et al.
identified a group of 67 school-aged children who sustained TBI (35 mild, 13 moderate, 19 severe) and gathered 14 control subjects as well. They reported that two-thirds of the children with TBI exhibited significant behavioral problems and 76% of the children with behavioral problems also had difficulties with schoolwork (253). Another study has noted that children with mild TBI also demonstrate difficulties compared to typically developing peers in some areas of metacognition— specifically in their ability to recognize semantic anomalies in spoken sentences (254). These findings suggest that although it is encouraging that so many children do well academically after sustaining mild TBI, caution must be taken to not overlook behavioral concerns or higher executive functions that may affect academic performance.10.4
When to Return to Play
| GRADES OF CONCUSSION | GRADE 1 | GRADE 2 | GRADE 3 |
| Definitions | 1. Transientconfusion 2. No loss of consciousness 3. Concussion symptoms last 15 minutes | 1. Any loss of consciousness | |
| Management recommendations | 1. Remove from activity 2. Examine immediately and every 5 minutes for change in status, at rest and with exertion 3. May return to activity if symptoms clear within 15 minutes | 1. Remove from activity for remainder of day 2. Examine immediately and frequently for signs of deteriorating neurologic status 3. Trained person reexamine the next day 4. Full neurologic exam by physician to OK return to activity after asymptomatic for one full week at rest and with exertion | 1. Transport to nearest emergency department if still unconscious or other concerning signs 2. Thorough neurologic exam on emergent basis and appropriate neuroimaging, if indicated. 3. Hospital admission if pathology detected or mental status abnormal |
| When to return to play (period of time being asymptomatic with normal neurologic exam at rest and with exertion) | 1. One grade 1 concussion: 15 minutes 2. Multiple grade 1 concussions: 1 week | 1. One grade 2 concussion: 1 week 2. Multiple grade 2: 2 weeks | 1. Grade 3 with brief loss of consciousness (seconds): 1week 2. Grade 3 with prolonged loss of consciousness (minutes): 2weeks 3. Multiple grade 3: 1 month or longer, as per evaluating physician |
| Source: Adapted from Quality Standards Committee of the American Academy of Neurology. The Management of Concussion in Sports (practice parameter). Neurology. 1997;48:581-585. | |||
Moderate to Severe Injury
Outcome studies regarding children who sustained significant TBI have demonstrated overall fair recovery. One such study evaluating 30 subjects noted that only 1 out of the 30 subjects failed to become ambulatory by two or more years post-injury, and 6 out of the 30 subjects ultimately attended college. The evaluators found that 13 out of 30 of those subjects returned to their previous level of functioning (255). Another study in 1980 by Brink et al. (63) noted 73% of pediatric survivors of severe TBI were able to demonstrate independence in ambulation and self-care within 1 year post-injury.
The literature regarding academic outcomes for children after severe TBI is less encouraging. These children demonstrate lower scores on standardized tests (199). Ewing-Cobbs (224) reported these children have lower reading recognition, spelling, and arithmetic scores compared with patients who sustained only a mild to moderate brain injury. Two years post- TBI, 39% of these patients had failed a grade and 73% of them needed special education assistance. Ewing-Cobbs (256) also reported that moderate to severe TBI sustained prior to the age of 6 had adverse persistent consequences for intellectual and academic development.
These children were assessed five years after injury and were found to have continuing deficits with no further recovery of function, demonstrating a persistent performance gap with no “catch up” phenomenon. They also found that children with focal nonprogressive brain injury demonstrated relatively good intellectual and academic outcomes. They concluded that there appeared to be significant limits on neurologic and cognitive plasticity. An interesting note was that the older children did fairly well on achievement testing but demonstrated poor functional academic recovery by failing a grade and needing ongoing support services. It seems that contributing components to success at school are the comorbid behavioral problems that almost two-thirds of children display after TBI and approximately three-quarters of those children demonstrate difficulties with schoolwork (253).Profound Injury
Children with profound brain injury and unconsciousness that lasted for greater than 90 days demonstrated a less favorable prognosis for recovery. In a series evaluating profoundly injured children by Kriel, only 1 of the 36 subjects had a normal motor outcome and no children demonstrated a normal cognitive outcome. Two-thirds of the patients recovered some language function, and one-quarter recovered independent ambulation with or without assistive devices (238).
Anoxic Brain Injury
Generally speaking, the children who sustain an anoxic brain injury tend to demonstrate a worse outcome than those with TBI. In a study that evaluated children who were unconscious for greater than 90 days secondary to an acquired brain injury, 75% of the subjects who had a TBI eventually regained consciousness. Only 25% with anoxic brain injury ultimately regained consciousness. One-quarter of children with TBI became ambulatory, and most of them regained some language function. Children with anoxic brain injury who were unconscious for more than 60 days did not regain language skills or become ambulatory. A greater percentage of the children who had anoxic injuries died during the years of follow-up (257).