Pediatrics

Nicole D. Reams, MD, on the Challenges of Diagnosing mTBI in Youth

Traumatic brain injury (TBI) is the cause of death and disability for thousands of people each year and is a top public health concern in the United States. TBI affects people of all ages and can be caused by a variety of factors, including falls, motor vehicle accidents, and sports-related activity.

Children are a high-risk group for mild TBI (mTBI) not only because they are prone to falls but also because participation in recreational sports may result in head injuries.

To answer our questions about the challenges associated with diagnosing and managing mTBI among children, Neurology Consultant reached out to Nicole D. Reams, MD, who is a sports neurologist and the director for the Sports Concussion Program at NorthShore University HealthSystem in Glenview, Illinois. She is also an independent neurologic consultant for the Chicago Bears, Chicago Fire, Chicago Blackhawks, Northwestern University Athletics, Dominican University Athletics, Chicago Lions Rugby, and Rockford Ice Dogs.

NEURO CON: What are the current challenges surrounding diagnosing concussion in youth?

Nicole Reams: The biggest current challenge is that there are no objective tests for concussion that diagnose this injury with certainty. Although clinicians often use additional standardized testing like computerized neurocognitive testing, balance assessments, and oculomotor scoring, they are tools to assist with the provider’s clinical diagnosis and cannot be used alone to confirm or refute a diagnosis of concussion, nor determine when the concussion is over and when an athlete may be ready to return to play, or a student to return to normal classwork or physical education participation. This is further challenging just based on the nature of the injury: concussion symptoms are nonspecific and can be present in non-injured healthy individuals on a normal day or can be caused by other conditions such as cervical strain, sleep deprivation, and migraine. The symptoms of concussion can also be mildly delayed in onset and can evolve over the first approximately 48 hours, making acute assessment challenging as well.

NEURO CON: How have you, personally, overcome these challenges?

NR: Experience certainly increases a provider’s confidence in diagnosis of concussion and its mimics. Additionally, using both detailed subjective reporting and objective testing can be a helpful way to provide a comprehensive assessment for an individual. For example, I feel more confident about a concussion diagnosis when I can detect balance abnormalities and oculomotor dysfunction during my examination, and I feel more confident about returning an athlete to play if he or she has a normal neurologic examination and has performed neurocognitive testing that is back to his or her pre-injury baseline.

NEURO CON: How might technology impact the diagnostic tools currently in practice?

NR: Our field is hopeful that technology—including electroencephalogram (EEG), event-related potential (ERP), advanced imaging, and biomarkers—will be game-changing in regards to diagnosis, return to play, and ultimately for prognostic indicators for development of syndromes like post-concussion syndrome and possibly traumatic encephalopathy syndrome (the clinical correlate to chronic traumatic encephalopathy). There are some promising tools and biomarkers being studied and published about, but currently no tool is accurate or reliable enough to take the place of the clinical assessment, nor even be heavily relied on.

NEURO CON: What role does the electronic medical record play in improving patient outcomes after concussion?

NR: We utilize the electronic medical record to standardize the visits for each individual as well as between individuals. Every patient seen at my practice will provide a subjective history of the present illness but also will answer the same questions regarding past medical history, risk factors for prolonged recovery, symptom scales for concussion, depression, anxiety and insomnia, current work or school status, current athletic status and duration of involvement overall in contact sports, history of prior concussions, if imaging was performed and the results, and numerous physical examination parameters. This allows us to track recovery for a patient over time more objectively. This also allows us to analyze patient risk factors and presenting features as they compare to patient outcomes (intensity and duration of concussion symptoms, when the patient returned to school, athletics, and so on) with the goal that we may be able to counsel our patients about the potential prognosis at the initial presentation.

NEURO CON: In your opinion, are current concussion guidelines adequate for diagnosing, treating, and managing concussion in youth? If not, what do you think needs to be amended?

NR: I think there has been very good work directed at defining concussion, emphasizing immediate removal from play when there is concern for injury, allowing for academic accommodations in the school setting during acute recovery, and the return to exercise/athletics process. We may start to see the process evolve to direct more complicated or protracted patients to a specialist or multidisciplinary clinic when that option exists—some preliminary research suggests that these patients have better outcomes in a concussion clinic setting. Also, ideally, there would be more athletic trainer coverage for youth sports and primary schools. Athletic trainer coverage at the high school level is such a huge benefit, allowing for acute assessment, removal from play  by a medical professional (rather than the onus falling on the coach, parents, or athlete themselves), and supervised recovery including return to play. In younger age groups as well as in more rural or underserved areas, athletic trainers are not typically available, which can be more challenging.

 

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