Letters from Maine

The fog may be lifting


 

One of the common symptoms described by postconcussion patients is that their heads feel a bit foggy. It may not be simply by chance that “foggy” is the best word to describe the atmosphere surrounding the entire field of concussion diagnosis and management.

A boy is having his head wrapped following a concussioin. KatarzynaBialasiewicz/Thinkstock

Back in the Dark Ages, when the diagnosis of concussion was a simpler binary call, the issue of management seldom created much discussion. If the patient lost consciousness or was amnesic, he (it was less frequently she) could return to activity when his headache was gone and he could remember what he was supposed to do when the quarterback called for a “Red 34, Drive Right Smash” play. That may have even been during the second half of the game in which he was injured.

As it became more widely understood that the diagnosis of concussion didn’t require loss of consciousness and that repeated concussions could have serious sequelae, management became a bit fuzzier. No one had thought much about the recuperative process. Into this vacuum came a wide variety of researchers and providers. Concussion management blossomed into a cottage industry, populated by neurologists, orthopedists, trainers, sports medicine specialists, and physical therapists. Not surprisingly, much of their advice was based on unproven assumptions, including the concept of “brain rest.”

It has taken time, but fortunately, folks with patience and wisdom have questioned these assumptions and begun collecting data. The result of these investigations and others has prompted the American Academy of Pediatrics to publish an updated set of guidelines on concussion management that includes the observation that extended school absence may slow the rehabilitation process (Pediatrics. 2018 Dec. doi: 10.1542/peds.2018-3074).

It is becoming clear that management of concussion can be rather complex and must be individualized to each patient. In my experience, the postconcussion period can unmask behavioral, cognitive, and emotional problems that were preexisting but had received little or no attention. For example, the trauma of the event may trigger anxiety about further injury or exacerbate depression that had been building for years. The student who “couldn’t do algebra” following a head injury may have had a lifelong learning disability that had gone unnoticed. The student athlete with prolonged postconcussion symptoms may indeed have another more serious problem. Hopefully, the new guidelines from the AAP will be a first step toward a more thoughtful and scientifically driven approach to concussion management.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

It would be nice if that approach could filter down to the management of the more common but less dramatic pediatric injuries. There is hope. Choosing Wisely – a patient/parent–targeted initiative by the American Board of Internal Medicine Foundation in cooperation with the AAP – points out that, although half of the pediatric head injury patients seen in emergency departments received CT scan, only a third of those studies were indicated. Parents are encouraged to learn more about the risks of CT scans and question the physician when one is recommended.

But, doctors’ habits and old wives’ tales die slowly. I hope that you no longer recommend that parents keep their children awake after a head injury, or wake them every hour to check their pupils. Those counterproductive recommendations make about as much sense as staying out of the swimming pool for an hour after eating a chocolate chip cookie.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

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