March 2016

Concussions’ Unpredictability Underscores Need for Follow-Up Care

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Concussions do not come with easy answers. Michael Nance, MD, director of the pediatric trauma program at The Children’s Hospital of Philadelphia, recently reinforced that lesson with research looking for simple tests to guide follow-up care for youth who come to the emergency department (ED) with these mild traumatic brain injuries.

In CHOP’s clinical care practices, families are encouraged to bring children with suspected concussion to their primary care doctors, who have received comprehensive concussion-related training and who are part of a network-wide, streamlined process for follow-up care.

“The ED is going to be one common portal of entry for kids with concussion who are not in the CHOP system,” said Dr. Nance, who is also an investigator with CHOP’s Center for Injury Research and Prevention (CIRP) and a professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania.

About 80 percent of the 1.7 million Americans who sustain a head injury each year are treated and released from the ED — so if there were a simple predictive test that worked well in the ED to triage these patients and differentiate individuals with greater immediate and future care needs, it could potentially help a large population which commonly receives little post-release guidance beyond “take it easy.”

But Dr. Nance and his colleagues found no such luck with a simple test.

Researchers Analyze Usefulness of Neurocognitive Test in ED

As they reported in the journal Brain Injury earlier this year, they evaluated the use of a widely used and validated neurocognitive test, a computer program called Immediate Post-concussion Assessment and Cognitive Testing (ImPACT©), to measure performance of youth with blunt trauma head injuries while they are in the ED. They compared these youth to a control group with lower extremity injuries, to rule out the possibility that any poor performance scores could be the result of the stressful experience of ED treatment itself.

They did find that the test was feasible to administer in this setting, and that the youth with head injuries had significantly higher symptom scores and performed worse on neurocognitive measures than the control group, although the difference was statistically significant in only two neurocognitive domains. Plus, they pointed out that the test had potential to be a practical choice because many schools require that student athletes take this test to get personal baseline measurements while they are healthy.

Ultimately, though, they concluded that the test will not become useful as a triage tool in the ED. (This month, a Canadian team published a larger study in the Journal of the American Medical Association, showing only modest success using a more complex predictive scoring measure for the same purpose. They also did not yet recommend clinical use of the predictive scoring tool.)

“The bottom line is that we found all the kids with concussions demonstrated significant abnormalities,” Dr. Nance said. “You probably can’t predict who will have what outcome that early. With the pervasiveness of symptoms in the ED population, our findings strongly argue for structured follow-up after discharge from the emergency department.”

Training Physicians on Front Line of Concussion Care

At CHOP’s primary care practices, structured follow-up for concussion has become part of standard practice in recent years.

“Pediatricians do not receive a lot of concussion-specific training in medical school or residency,” said Christina Master, MD, a sports medicine pediatrician at CHOP and associate professor at Penn.

Recognizing that shortfall in training and the rapid growth in knowledge about concussion care needs, Dr. Master, along with colleagues from CHOP Sports Medicine and CIRP, launched an interdisciplinary, research-basedMinds Matter: Improving Pediatric Concussion Care for Children” program that includes up-to-date training for primary care pediatricians in CHOP’s network.

Through this program, CHOP pediatricians have received education about how to serve as the front line in treatment and monitoring recovery of children and teens with concussions, including concussion-specific training, tools for clinical diagnosis and management, and family education resources. Their offices are equipped to see patients within days after a minor head injury to ensure early diagnosis, adequate rest, and coordination with schools to manage recovery. Most patients seen in the ED at CHOP for concussion now receive discharge instructions to follow up with their primary care pediatrician.

“Part of the reason why primary care pediatricians are well suited to this is that they have existing relationships with these children and families, and can therefore be sensitive to how concussion may present itself for that particular child,” said Kristy Arbogast, PhD, co-scientific director and director of engineering at CIRP and an associate professor at Penn.

Primary care pediatricians are also prepared to use a variety of clinical observation and testing skills to monitor their patients and diagnose and treat concussion-related concerns. Although neurocognitive tests are popular among youth and families because they are conducted in many school sports settings, they are not necessarily required for a clinical diagnosis or clinical planning.

“That testing is one of the tools in the tool box but certainly not the only tool,” Dr. Arbogast said.

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