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]

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use outdated concussion grading-scales – and there is even less information on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.

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

Related posts:

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