What’s New With Pediatric Sport Concussions? Free

In this issue of Pediatrics, Davis et al¹  review the updated recommendations from the sixth International Consensus Conference on Concussion in Sport held in October 2022 in Amsterdam by the Concussion in Sport Group.²  Since the last American Academy of Pediatrics clinical report on sport-related concussions (SRC) was published in 2018,³  research published on SRC has continued at a remarkable pace and is likely the most published topic in sports medicine. The challenge for sport concussion specialists and all clinicians who care for concussed athletes is not only staying abreast of the science but translating it into clinical care. With evolving guidelines and the development of new assessment tools, keeping up can be overwhelming.

Gone are the days of complete physical and cognitive rest. “Cocooning,” in which a patient is kept in a darkened environment with little stimulus, not only lacks benefit but may be harmful by slowing recovery. Now, the recommendation is for light cardiovascular activity below the level that increases symptoms, referred to as “sub symptom threshold training,” as soon as 48 hours after injury.² 

Several decades ago, most thought that concussions in children and adolescents resolved in 7 to 10 days. Now we know that only approximately one-half of patients recover in this time frame, with 30% taking 1 month or longer to recover.^4,5  Although we cannot yet predict the time course of recovery for individual athletes, recognizing risk factors that place an athlete at risk for a longer recovery can be helpful. Davis et al provide a useful summary of risk factors for a prolonged recovery, including (1) high initial symptom burden, (2) continuing to play immediately after the concussion, (3) delay in medical care, (4) little reduction in physical or cognitive activity after the concussion, (5) prolonged cognitive rest, and (6) female patients with migraines. Understanding these risk factors can help with counseling and point to interventions to help reduce the time to full recovery. Other strategies for the primary prevention of SRC include reducing risky activities (eg, body checking in hockey and collision practices in American football) and neuromuscular training, such as specific warm-up exercises focused on strength, balance, and agility, including neck strengthening.

Updated tools for acute and longer-term concussion assessments have also been introduced, including the Sport Concussion Assessment Tool 6 and a Child Sport Concussion Assessment Tool 6.^6,7  Both include small updates from the previous version. These updates include longer word and digit recall lists, an increased emphasis on the assessment of the cervical spine, the addition of the dual-task gait assessment, and the reintroduction of the timed portion of the months in reverse. The Sport Concussion Office Assessment Tool 6 and Child Sport Concussion Office Assessment Tool 6 are newer tools to help with assessment >1 week after the injury.^8,9  These 2 new assessments help clinicians identify areas in a concussed athlete that may be amenable to rehabilitation, including cervical strains, oculomotor dysfunction, mental health concerns, disordered sleep, and vestibular dysfunction.

Although we have made significant strides in concussion management over the last 2 decades, additional research is still sorely needed in athletes aged ≤12 years. Because of the lack of research in this age group, the tools previously discussed are no longer recommended for patients aged <8 years and our guidance in this group is largely based on expert consensus. Additional research is also needed focused on female concussed athletes because the majority of studies on sport concussion have focused on male athletes.

Keeping up to date with sport-related concussions can be daunting. It is for me, even as a sports medicine clinician practicing daily in the concussion world. Pediatricians can use this updated information from Davis et al to improve their concussion diagnosis and management skills and feel confident that they have the latest evidence-based recommendations and tools available.

SRC

sport-related concussion