Management Strategies and Medication Use for Treating Pediatric Patients with Concussions
Kinnaman KA, Mannix RC, Dawn Comstock R, Meehan WP. Acta Paediatr, 2013 Jun 10. [Epub ahead of print]
Take Home Message: A vast majority of pediatricians who care for patients with concussions follow available treatment guidelines, use medications as part of their treatment plan, use neuropsychological testing, and desire additional training in the management of sports-related concussion.
Despite an overall increased incidence of sports-related concussion, we know little regarding how clinicians manage sports-related concussion. Recent evidence has shown that some clinicians may have inadequate training and use outdated concussion grading-scales – and there is even less information on medication use in concussion management. The sports medicine community in turn, must fully understand how clinicians are practicing concussion management to promote safe treatment practices and improve clinician education. Therefore, Kinnaman et. al surveyed pediatric primary care providers nationwide to assess management strategies for patients diagnosed with sports-related concussion, including the use of medications. Two hundred and twenty physician members of American Academy of Pediatrics Sections on Adolescent Health, Sports Medicine and Fitness, Community Pediatrics and School Health completed the questionnaire. Among these physicians, 202 (92%) responded that they treated patients with concussions. 89% of the respondents use medications to manage symptoms. The most common medications were over-the counter; such as, acetaminophen (62%), nonsteroidal anti-inflammatory medications [NSAIDs] (54%) and melatonin (20%). The physicians most commonly prescribed antidepressants (23%), amantadine (10%), and methylphenidate (8%). Physicians who saw more than 16 concussion patients per year were more likely to use prescription medication but were less likely to recommend the use of NSAIDs. Very few physicians (5%) allowed their patients to return to sports while still taking medication for concussion symptoms. 89% of the respondents had access to at neuropsychologist and 68% used neuropsychological testing – with ImPACT™ as the most commonly used product for computerized testing (92%). 84% used published guidelines or criteria to guide their management with the consensus statement from the 3rd International Conference on Concussion in Sport as the most commonly cited. Finally, the majority of responding physicians (81%) reported interest in additional training in concussion management strategies.
The results of this survey study show that a vast majority of responding pediatricians who care for patients with concussions use medications despite the lack of high-quality evidence to support the use of pharmacological agents in concussion management. Most pediatricians surveyed also use neuropsychological testing or have access to a neuropsychologist, which encouragingly reflected the recommended use of multifaceted diagnostic tools and multi-disciplinary approach to concussion management. Of note, the results of this study were collected prior to the consensus statement from the 4th International Conference on Concussion in Sport. However, guidelines were readily available from the 3rd International Conference on Concussion in Sport, which stated that athletes should be symptom-free and off of “any pharmacologic agents or medications that may mask or modify the symptoms of concussion” prior to being returned to play. The fact that 5% of respondent allowed athletes to return to play while still on medications coupled with the reported desire for additional training reflects a concerning potential knowledge gap among primary care pediatricians who care for patients with concussions. Additionally, respondents to the survey were members of special subgroups of the American Academy of Pediatrics and may not accurately represent the general primary care pediatrician population. With the newly available guidelines from the 4th International Conference on Concussion in Sport, additional research is necessary which should include concussion management providers from multiple specialties.
Questions for Discussion: Do you provide concussion management as part of you sports medicine practice? Would you like more training in concussion management? Do you regularly use medications as part of your concussion treatment strategy?
Written by: Stephen Stache, MD
Reviewed by: Jeffrey Driban
Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich,November 2012
National Association of School Nurses Position Statement: Concussions – The Role of the School Nurse
Kinnaman KA, Mannix RC, Dawn Comstock R, & Meehan WP 3rd (2013). Management strategies and medication use for treating paediatric patients with concussions. Acta Paediatrica (Oslo, Norway : 1992) PMID: 23750873