Managing Concussions and Choosing Wisely

By: Linda Harder

Photography by: Tracey Brown

Maryland children are benefiting from national and local initiatives that promote better treatment of concussions and that limit unnecessary tests and procedures. Our Maryland medical experts explain.

Better Management of Concussions in the Young

As the medical community becomes increasingly aware of the possible effects of even minor trauma to the brain, and as Maryland became the 18th state to pass laws addressing concussion management in 2011, programs to treat concussions are mushrooming. The Kennedy Krieger Institute now offers one such center, the Neurorehabilitation Concussion Clinic, as  the newest arm  of their Pediatric Brain Injury Program, which now addresses the full spectrum of brain injury severity.

Stacy Suskauer, M.D., the center’s medical director, also was appointed by the CDC to a work group developing national clinical diagnosis and management guidelines for concussions in children and teens. She explains, “Our program at Kennedy Krieger is unique – every child sees both a neuropsychologist and physician at every visit. The physician may be a pediatric neurologist, physiatrist, or pediatric sports medicine physician, depending on the child’s needs.  For example, those with co-existing cervical injuries may be directed to the pediatric sports medicine specialist.”

The clinic treats patients aged three to 18; not surprisingly, more than half are athletes, and the majority are teens. Perhaps less obvious, however, is that a minority of these children have lost consciousness. Also surprising is that experts now know that helmets may do little to protect against some concussions, as helmets don’t stop the rotational forces that cause most concussions.

“We know that pediatricians may not have time in their busy schedules to manage these patients,” Dr. Suskauer says. “That’s why we’re here.”

Diagnosis

No one diagnostic test can evaluate concussions. Dr. Suskauer states, “MRIs are not typically ordered.  Neurocognitive tests are useful if there’s a history of trauma, whether or not  symptoms are noted immediately after injury. If parents think the child’s memory is not quite right, or if a straight A student is suddenly performing as an average student, that’s cause for evaluation.”

All of those evaluated by the clinic receive neuropsychological testing, and the clinic providers reach out to the child’s school with recommendations for accommodations.

Current Treatment Approaches

Dr. Suskauer notes, “Cognitive rest is a hot topic now. Is rest best? Yes, at least for the first few days. We avoid an approach of strict confinement until the child is 100% better, because that can lead to additional stress and mood concerns. Instead, we take a symptom-based approach and minimize whatever aggravates the child. Texting, television and other activities can be undertaken to the child’s tolerance. Some children like to listen to, rather than watch, television.

“We try to keep the child moving ahead without slowing their recovery,” she continues. “Families often don’t realize that, during the first few days, symptoms can evolve rather than improve. In the first two weeks, there is a metabolic mismatch; the brain needs more glucose but glucose delivery is impaired. Data suggests that DHA (docosahexaenoic acid) can be helpful for brain injury recovery. We recommend a moderate dose based on weight.”

After about three to four weeks, many children are ready for a second phase of treatment, with increased safe physical activity. Dr. Suskauer recommends, “Start with just five minutes of walking, and stop before or as symptoms emerge. Especially in athletes, safe exercise may be a critical intervention to improve cerebral blood flow.”

Children with cognitive deficits may also benefit from amantadine. It increases dopamine, which drops after brain injury, and blocks the NMDA receptor, a glutamate receptor that controls synaptic plasticity and memory function. “We don’t know yet which of these mechanisms is helpful,” observes Dr. Suskauer. “We also may prescribe melatonin if the patient’s sleep is disrupted, as sleep is vital for recovery.”

Dr. Suskauer concludes, “One problem physicians should be aware of is that teens underreport symptoms because they feel pressured to be on the field. The bottom line is – when in doubt, sit it out. If there’s any question, that’s why we’re here.”

Choosing Wisely: When More is Less

An initiative launched by the American Board of Internal Medicine (ABIM) Foundation in 2012 called Choosing Wisely® encourages conversations between physicians and patients to promote appropriate testing. The foundation states that its goal is to help patients choose care that is:

▪     Supported by evidence

▪     Not duplicative of tests/procedures already received

▪     Free from harm

▪     Truly necessary

The initiative aims to keep the message succinct and simple enough to be useful to patients. To that end, each medical society that participates has been asked to develop a list of “Five Things Physicians and Patients Should Question.” In April 2012, nine medical societies participated in the first release of these lists. In February 2013, another 18 societies added their lists, including The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP) and the Society of Hospital Medicine – Pediatric Hospital Medicine. The AAFP’s list does not contain any items pertaining to pediatrics, however.

Neil Siegel, M.D., clinical assistant professor of Family and Community Medicine at University of Maryland School of Medicine, observes, “I’ve been attuned to this conservative mode of practice since my residency training, but Choosing Wisely is giving me additional tools to use when talking to my patients. It also helps to start conversations with my colleagues or anyone who is suspicious that you have an ulterior motive if you don’t recommend undertaking a procedure or test. It helps make the case that you’re not trying to cut costs or save money.”

He adds, “I can use this list to tell my patients that I’m doing this to keep them safer. Doing more is not always better. Sometimes extra tests don’t help, and sometimes they even cause harm. For example, antibiotics can cause an allergic reaction, or unnecessary imaging tests emit radiation that can be harmful when it accumulates.”

Dr. Siegel describes the wide variability of pre-op testing practices among hospitals and physicians. “One hospital will send me evidence-based guidelines, where only certain patients need an EKG, for example. Other hospitals will require ordering everything on the pre-op list, regardless of the patient’s age and health. It’s more convenient for the doctor to get everything because they know there won’t be a delay. But it can lead to unnecessary testing.”

Another major area of concern in recent years is the overuse of antibiotics. Recent guidelines have been issued to discourage prescribing antibiotics for many ear infections or sinus infections, for example.

“My advice to doctors,” says Dr. Siegel, “is to become familiar with your own specialty’s list. Make sure you’re implementing those recommendations in your own practice. Also review the lists from any related specialties. Really own your own society’s measures and become familiar with the broader campaign. All of us serve as public health information sources for our neighbors, family and friends. When they ask us, we should tell them that sometimes less is better. Our specialty societies also have an obligation to publicize the campaign in their medical meetings. Hopefully, media attention will help to generate awareness among consumers.”

We have a TV screen in our waiting room that we can use for educational purposes such as this Choosing Wisely campaign,” he continues. “We prefer to customize our messages, though, so that patients only get messages appropriate to their personal situation.”

Consumer Reports also is helping to educate consumers, with a series of reports and eventually a series of videos on Choosing Wisely. The AARP, the Leapfrog Group, the National Partnership for Women & Families, Wikipedia and others, are among a long list of other organizations working to educate the general public about these guidelines. Visit www.choosingwisely.org for more information.

The AAP’s list of five things to question is shown in the sidebar on page xxx. Other societies’ lists also include various pediatric tests and procedures to question, such as:

  1. Don’t diagnose or manage asthma without spirometry. (American Academy of Asthma, Allergy and Immunology)
  2. Don’t prescribe oral antibiotics for uncomplicated acute external otitis. (American Academy of Otolaryngology)
  3. Don’t do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. (American College of Radiology)
  4. Don’t perform ultrasound on boys with cryptorchidism. (American Urologic Association)
  5. Don’t order chest x-rays in children with uncomplicated asthma or bronchiolitis.
  6. Don’t routinely use bronchodilators in children with bronchiolitis.
  7. Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.
  8. Don’t routinely treat gastroesophageal reflux in infants with acid suppression therapy.
  9. Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. (the last five are from the Society of Hospital Medicine)

Five Things Pediatricians and Patients Should Question

  1. Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
  2. Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
  3. CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
  4. Neuroimaging is not necessary in a child with simple febrile seizure.
  5. 5CT scans are not necessary in the routine evaluation of abdominal pain.

Adapted from the American Academy of Pediatrics Choosing Wisely® list.

________________________________________________________________

Stacy Suskauer, M.D., medical director, Neurorehabilitation Concussion Clinic at Kennedy Krieger Institute and assistant professor of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine.

Neil Siegel, M.D., assistant professor of Family Medicine at University of Maryland School of Medicine, medical director of  UniversityCare and physician at UniversityCare at Edmondson Village


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